Surgical Management Of Aneurysms Research Articles

Clinical Features and Surgical Management of Aneurysms at the Proximal Segment (A1) of the Anterior Cerebral Artery

Clinical Features and Surgical Management of Aneurysms at the Proximal Segment (A1) of the Anterior Cerebral Artery

Treatment of Recurrent Intracranial Aneurysms After Neck Clipping: Novel Classification Scheme and Management Strategies.

BACKGROUNDRecurrent aneurysms after initial clipping have been discussed as an important issue in the surgical management of aneurysm.OBJECTIVETo report our experience with recurrent cerebral aneurysms after neck clipping and to discuss classification and recommended management.METHODSAneurysm treatments from a single institution over a 20-year period were retrospectively reviewed. Twenty-three recurrent aneurysms in 23 patients were managed during the study period. Recurrent aneurysms were classified using the concepts of closure line and closure plane, as follows. Type 1: neck situated in an almost different site from the previous clip. Type 2: existing closure plane and reconstructive closure plane are almost the same. Type 3: existing closure plane and reconstructive closure plane cross (type 3a); in rare cases, the existing closure line is sufficiently distant from the neck (type 3b). Type 4: no reconstructive closure line is identifiable.RESULTSNine patients presented with subarachnoid hemorrhage at recurrence. The mean interval to recurrence was 15.0 years. Management comprised clipping with elective subsequent old-clip removal (n = 7), clipping with preceding old-clip removal (n = 2), bypass occlusion (n = 1), coating (n = 1), combined surgery (n = 1), endovascular surgery (n = 4), and observation (n = 3). Therapeutic intervention was not indicated in 4 patients. Types 3a and 4 required more complex surgical procedures or coil embolization. Procedural complications were observed in 2 patients.CONCLUSIONA small but definite propensity toward recurrence after neck clipping exists, and most recurrent aneurysms require some form of retreatment. The novel classification scheme may provide conceptual clarity and therapeutic guidance for decision making.

Surgical management of recurrent aneurysms after coiling treatment

Objective: Aneurysms that recur after coiling treatment are difficult to manage. The microsurgical technique in these cases differs significantly from that in regular aneurysm clipping. We present our experience in surgical management of aneurysms that recurred more than 1 month after coiling in a series of 19 patients.Materials and methods: Between January 2004 and December 2014, 1437 patients were treated surgically for intracranial aneurysms in our institution. We performed a retrospective review of the clinical records, operation videos, and cerebral angiograms. We focused on patients in whom the initial aneurysm was treated by coiling, but the results were incomplete or the aneurysm recurred.Results: Nineteen patients underwent surgical clipping for recurrent aneurysm more than 1 month after initial coiling treatment. The sex ratio (male:female) was 0.9, and the average age was 51.3 years (range 35–72 years). One aneurysm was classified as giant (≥ 25 mm), two as large (10–25 mm), and 18 as small (≤ 10 mm). A good outcome (Glasgow Outcome Scale 4 or 5) was observed in 16 of 19 patients (84.2%).Conclusion: Microsurgical clipping can be safe and effective in the management of previously coiled residual and recurrent aneurysms.

Cutting-Edge Treatment of Unruptured Aneurysms

Although technical advances in the surgical management of aneurysms are limited, microsurgery can still be used to create elegant and anatomical bypasses in the hands of a skilled neurosurgeon. The evolving trends in the field include more minimally invasive approaches; more use of direct clipping, clip reconstruction, and bypass procedures; and less brain retraction and skull base surgery. Circulatory arrest as part of the aneurysm surgical process is no longer used.

COMBINED MICROSURGICAL AND ENDOVASCULAR MANAGEMENT OF COMPLEX INTRACRANIAL ANEURYSMS

The disciplines of microneurosurgery and cranial base surgery have reached maturity, and technical advances in the surgical management of aneurysms are limited. Although most aneurysms can be clipped microsurgically or coiled endovascularly, a subset of patients may require a combined approach. A consecutive series of patients with aneurysms in one surgeon's cerebrovascular practice was reviewed retrospectively to analyze strategies for integrating microsurgical and endovascular techniques in the management of complex aneurysms. Between 1997 and 2001, 596 aneurysms in 491 patients were treated microsurgically by the senior author (MTL) at the University of California, San Francisco, and 77 of these patients (96 aneurysms) were managed with a multimodality approach comprising a total of eight different combinations: selective revascularization and aneurysm occlusion (n = 23), endovascular and surgical trapping (n = 1), clipping of the aneurysm after attempted or incomplete coiling (n = 22), coiling after attempted or incomplete clipping (n = 5), clipping of recurrent aneurysm after coiling (n = 6), coiling of recurrent aneurysm after clipping (n = 1), clipping and coiling of multiple remote aneurysms (n = 13), and coiling after previous surgery (n = 6). A total of 96 aneurysms were treated with combined therapy, of which 43% were large or giant in size and 34% had fusiform or dolichoectatic morphology. Complete angiographic obliteration was achieved in 91 aneurysms (95%). Overall, 66 patients (86%) had good outcomes (Glasgow Outcome Scale score of 4 or 5; mean follow-up, 9 mo). The treatment mortality rate was 9.1% (seven patients), and permanent treatment-associated neurological morbidity rate was 5.2% (four patients). Evolving endovascular technologies need to be integrated into the microsurgical management of aneurysms. Multimodality approaches are best used with complex aneurysms in which conventional therapy with a single modality has failed. Revascularization remains a unique surgical contribution to the overall management of aneurysms with which current endovascular techniques cannot be used. Multimodality management should be considered an elegant addition to the therapeutic armamentarium that, through simplification and increased safety, improves the treatment of complex aneurysms beyond what is achievable by performing clipping or coiling alone.

Interpositional carotid artery bypass strategies in the surgical management of aneurysms and tumors of the skull base

Cerebral revascularization is an important component in the surgical management of complex skull base tumors and aneurysms. Patients who harbor complex aneurysms that cannot be clipped directly and in whom parent vessel occlusion cannot be tolerated may require cerebrovascular bypass surgery. In cases in which skull base tumors encase the carotid artery (CA) and a resection is desired, a cerebrovascular bypass may be necessary in planned CA occlusion or sacrifice. In this review the authors discuss options for performing high-flow anterograde interposition CA bypass for lesions of the skull base. The authors review three important bypass techniques involving saphenous vein grafts: the cervical-to-petrous internal carotid artery (ICA), petrous-to-supraclinoid ICA, and cervical-to-supraclinoid ICA bypass. These revascularization techniques are important tools in the surgical treatment of complex aneurysms and tumors of the skull base and cavernous sinus.

Combined microsurgical and endovascular management of complex intracranial aneurysms.

The disciplines of microneurosurgery and cranial base surgery have reached maturity, and technical advances in the surgical management of aneurysms are limited. Although most aneurysms can be clipped microsurgically or coiled endovascularly, a subset of patients may require a combined approach. A consecutive series of patients with aneurysms in one surgeon's cerebrovascular practice was reviewed retrospectively to analyze strategies for integrating microsurgical and endovascular techniques in the management of complex aneurysms. Between 1997 and 2001, 596 aneurysms in 491 patients were treated microsurgically by the senior author (MTL) at the University of California, San Francisco, and 77 of these patients (96 aneurysms) were managed with a multimodality approach comprising a total of eight different combinations: selective revascularization and aneurysm occlusion (n = 23), endovascular and surgical trapping (n = 1), clipping of the aneurysm after attempted or incomplete coiling (n = 22), coiling after attempted or incomplete clipping (n = 5), clipping of recurrent aneurysm after coiling (n = 6), coiling of recurrent aneurysm after clipping (n = 1), clipping and coiling of multiple remote aneurysms (n = 13), and coiling after previous surgery (n = 6). A total of 96 aneurysms were treated with combined therapy, of which 43% were large or giant in size and 34% had fusiform or dolichoectatic morphology. Complete angiographic obliteration was achieved in 91 aneurysms (95%). Overall, 66 patients (86%) had good outcomes (Glasgow Outcome Scale score of 4 or 5; mean follow-up, 9 mo). The treatment mortality rate was 9.1% (seven patients), and permanent treatment-associated neurological morbidity rate was 5.2% (four patients). Evolving endovascular technologies need to be integrated into the microsurgical management of aneurysms. Multimodality approaches are best used with complex aneurysms in which conventional therapy with a single modality has failed. Revascularization remains a unique surgical contribution to the overall management of aneurysms with which current endovascular techniques cannot be used. Multimodality management should be considered an elegant addition to the therapeutic armamentarium that, through simplification and increased safety, improves the treatment of complex aneurysms beyond what is achievable by performing clipping or coiling alone.

Strategies for surgical management of cerebral aneurysms of special location, size and form--approach, technique and monitoring.

Special strategies are mandatory for optimal surgical management of aneurysms of special location, size and form. Approaches of extradural selective anterior clinoidectomy, partial occipital condylectomy, transpetrosal approach by anterior petrosectomy and supracerebellar transtentorial approach are discussed among them. Furthermore various types of temporary and permanent clipping procedures are discussed along with mention of intraoperative monitoring.

Surgical management of aneurysms at the origin of an aberrant right subclavian artery

An aneurysmal origin of an aberrant right subclavian artery should preferably be closed with a prosthetic patch inserted with the aid of cardiopulmonary bypass with deep hypothermia and circulatory arrest. Three patients were operated on: a transaortic approach was used in two and a transaneurysmal approach in one. This technique allows a single-stage surgical correction of this rare anomaly through a median sternotomy and obviates the need for hazardous and difficult side clamping of the aorta.

Lntracranial Hemorrhage from Aneurysms and Arteriovenous Malformations during Pregnancy and the Puerperium

Intracranial hemorrhage (ICH) from an intracranial aneurysm or arteriovenous malformation is a grave complication of pregnancy and is responsible for 5 to 12% of all maternal deaths. We critically analyzed 154 cases of verified ICH during pregnancy from an identified intracranial lesion, including 2 patients treated at our institution and 152 cases previously reported in the literature in English. Aneurysms were responsible for ICH in 77% of patients, and arteriovenous malformations in 23%. Hemorrhage occurred antepartum in 92% of patients and postpartum in 8%. Women with angiomatous hemorrhage were younger than those with aneurysmal hemorrhage; however, in contrast to previous reports, we found no differences between angiomatous and aneurysmal hemorrhage with respect to parity or gestational age at the time of the initial hemorrhage. Hypertension and/or albuminuria were present at some time during the pregnancy in 34% of patients with documentation, which sometimes made it difficult to differentiate angiomatous or aneurysmal ICH from that associated with eclampsia. In a logistic regression analysis, surgical management of aneurysms, but not arteriovenous malformations, was associated with significantly lower maternal and fetal mortality, independent of other covariants. For those patients with a lesion not operated on, cesarean delivery afforded no better maternal or fetal outcome than did vaginal delivery. We conclude that the decision to operate after ICH during pregnancy should be based upon neurosurgical principles, whereas the method of delivery should be based upon obstetrical considerations. The perioperative and anesthetic management of the pregnant patient with a neurosurgical complication is discussed.

Intracranial hemorrhage from aneurysms and arteriovenous malformations during pregnancy and the puerperium

Intracranial hemorrhage (ICH) from an intracranial aneurysm or arteriovenous malformation is a grave complication of pregnancy and is responsible for 5 to 12% of all maternal deaths. We critically analyzed 154 cases of verified ICH during pregnancy from an identified intracranial lesion, including 2 patients treated at our institution and 152 cases previously reported in the literature in English. Aneurysms were responsible for ICH in 77% of patients, and arteriovenous malformations in 23%. Hemorrhage occurred antepartum in 92% of patients and postpartum in 8%. Women with angiomatous hemorrhage were younger than those with aneurysmal hemorrhage; however, in contrast to previous reports, we found no differences between angiomatous and aneurysmal hemorrhage with respect to parity or gestational age at the time of the initial hemorrhage. Hypertension and/or albuminuria were present at some time during the pregnancy in 34% of patients with documentation, which sometimes made it difficult to differentiate angiomatous or aneurysmal ICH from that associated with eclampsia. In a logistic regression analysis, surgical management of aneurysms, but not arteriovenous malformations, was associated with significantly lower maternal and fetal mortality, independent of other covariants. For those patients with a lesion not operated on, cesarean delivery afforded no better maternal or fetal outcome than did vaginal delivery. We conclude that the decision to operate after ICH during pregnancy should be based upon neurosurgical principles, whereas the method of delivery should be based upon obstetrical considerations. The perioperative and anesthetic management of the pregnant patient with a neurosurgical complication is discussed.

Intracranial Hemorrhage from Aneurysms and Arteriovenous Malformations during Pregnancy and the Puerperium

Abstract Intracranial hemorrhage (ICH) from an intracranial aneurysm or arteriovenous malformation is a grave complication of pregnancy and is responsible for 5 to 12% of all maternal deaths. We critically analyzed 154 cases of verified ICH during pregnancy from an identified intracranial lesion, including 2 patients treated at our institution and 152 cases previously reported in the literature in English. Aneurysms were responsible for ICH in 77% of patients, and arteriovenous malformations in 23%. Hemorrhage occurred antepartum in 92% of patients and postpartum in 8%. Women with angiomatous hemorrhage were younger than those with aneurysmal hemorrhage; however, in contrast to previous reports, we found no differences between angiomatous and aneurysmal hemorrhage with respect to parity or gestational age at the time of the initial hemorrhage. Hypertension and/or albuminuria were present at some time during the pregnancy in 34% of patients with documentation, which sometimes made it difficult to differentiate angiomatous or aneurysmal ICH from that associated with eclampsia. In a logistic regression analysis, surgical management of aneurysms, but not arteriovenous malformations, was associated with significantly lower maternal and fetal mortality, independent of other covariants. For those patients with a lesion not operated on, cesarean delivery afforded no better maternal or fetal outcome than did vaginal delivery. We conclude that the decision to operate after ICH during pregnancy should be based upon neurosurgical principles, whereas the method of delivery should be based upon obstetrical considerations. The perioperative and anesthetic management of the pregnant patient with a neurosurgical complication is discussed.

Surgical management of aneurysms in the cavernous sinus

A series of 32 patients with aneurysms in the cavernous sinus region is presented. All of them have been operated upon through an intradural pterional approach and the aneurysms directly attacked. Only in 6 patients was the complete dissection of the internal carotid artery and of the aneurysm impossible because of the size of the aneurysms. In these cases the aneurysm has been traped by ligation of the internal carotid artery in the neck and its supraclinoid course and at the same time and extracranial intracranial anastomosis performed. One patient died from massive cerebral infarction after a trapping procedure and another died from a transoperative haemorrhage; another two developed a moderate hemiparesis which resolved within the first six postoperative weeks, and in two patients a preoperative severe visual impairment progressed postoperatively to complete visual loss. All others had a complete resolution of their preoperative symptoms and remained well. The advantages and disadvantages of the different approaches to intracavernous carotid artery aneurysms are discussed and the related literature reviewed.

Surgical Management of Cerebrovascular Disease

This book offers guidelines for the surgical management of cerebrovascular diseases, based on the authors' clinical experience at the Massachusetts General Hospital, Boston. Each of its 25 chapters includes a discussion of clinical signs and symptoms, current diagnostic techniques, illustrative case descriptions, and various treatment options. Complications of treatment and outcome conclude each chapter. Surgical techniques used at Massachusetts General Hospital are described and clearly illustrated. The first nine chapters concern occlusive cerebrovascular disease. The remaining 16 offer concise discussions of the surgical management of aneurysms, arteriovenous anomalies, and brain hemorrhage. The book is thorough but not exhaustive, practical, and up to date. It is well written and nicely illustrated. Color photographs, line drawings, and roentgenograms of excellent quality are featured. Controversial issues, such as carotid endarterectomy for acute stroke and asymptomatic bruit, are presented in an unbiased and well-balanced fashion. Physicians and surgeons who treat patients with stroke would

Surgical management of aneurysm of the ascending aorta with aortic insufficiency

Surgical therapy for aneurysm of the ascending aorta with aortic incompetence consists of replacement with a composite graft valve prothesis and implantation of the coronary ostia over the graft. Four patients underwent this operation with excellent long term results in three patients. The fourth patient died suddenly six months after the operation. The possible cause of this sudden death and modifications in technique which may have prevented this are discussed.