Treatment Of Giant Cerebral Aneurysms Research Articles

Случай успешного хирургического лечения пациентки с разрывом большой церебральной аневризмы

The article presents a clinical case of successful treatment of the female patient with the internal carotid artery (VSA) exploded with a large aneurysm. The relevance of the problem is due to the complexity of the surgical treatment of giant cerebral aneurysm due to the need to have special surgical clips and intraoperative visualization (ultrasound, videoangiography), as well as a high risk of thrombomebole and thromboembolism.

The Use of Flow-Diverting Stents in the Treatment of Giant Cerebral Aneurysms: Preliminary Results

The treatment of giant cerebral aneurysms has always been a challenge for neurosurgeons and neuroradiologists. Flow-diverting stents (Silk; Pipeline Embolization Device) are new endovascular devices introduced for the treatment of intracranial aneurysms without release of intrasaccular coils. They are tubular bimetallic endoluminal devices with low porosity. We have employed these stents in the Neuroradiology Unit of Bellaria Hospital (Bologna, Italy) since the end of 2008, treating nine patients with giant carotid cerebral aneurysms using nine Silk stents as soon as the device obtained the CE mark. All patients were pretreated with dual antiplatelet medications before surgery. The Silk stents were deployed through a 4F Balt introducer, which ensured an uneventful and very quick procedure. Control CT angiography or MR angiography was typically performed at discharge and one, three, six and 12 months after treatment. Post-treatment results were: four complete occlusions, three near complete occlusions (residual neck flow) with reduced volume of the aneurysm and two more than 50% reduction of intra-aneurysmal flow. A fatal hemorrhagic complication occurred in one patient, probably due to the antiplatelet treatment. The Silk stent seems a very interesting curative device to treat giant aneurysms with preservation of the parent artery and small adjacent branches. Technical improvements will certainly reduce the thrombogenic effect with the related risks.

Giant Cerebral Aneurysms: Endovascular Challenges

Giant (>or=25 mm in diameter) cerebral aneurysms have a poor natural history, with high risks of subarachnoid hemorrhage or progressive disability or death caused by mass effect or stroke. Surgical treatment may be effective but carries a high burden of morbidity and mortality. Thus, attempts at endovascular solutions to these complex lesions have been developed to offer therapy at reduced risk. The authors reviewed their clinical experience and the current body of literature concerning giant cerebral aneurysms and present their perspective on the current state of the art in endovascular therapy for these aneurysms. A variety of techniques are described that can be used in an attempt to provide a solution to the wide variety of clinical dilemmas associated with the management of these difficult lesions. Preprocedural planning and periprocedural considerations are discussed briefly. The use of intracranial balloons and stents are described in conjunction with the use of detachable platinum coils. The developing concept of using stents alone to treat aneurysms is discussed. Alternative methods of treating giant aneurysms are discussed. Current endovascular approaches, when properly selected and applied, can provide lower-risk therapies than conventional microsurgical approaches for patients harboring giant cerebral aneurysms. However, endovascular approaches do not, at present, provide results that are as durable as current surgical techniques for giant cerebral aneurysms. Treatment of giant cerebral aneurysms via endovascular therapeutics requires the interventionist to possess an extensive armamentarium. Meticulous preprocedure evaluation, patient selection, and execution of the treatment plan enable safe and effective management. Current therapies do not provide an ideal solution for every patient, so one must consider creative and evolving solutions to these difficult clinical challenges. The procedural morbidity of open surgery versus the decreased durability of current endovascular techniques must be assessed carefully.

Centrifugal pumps and heparin-coated circuits in surgical treatment of giant cerebral aneurysms.

Giant cerebral aneurysms may be untreatable by conventional neurosurgical techniques. Early attempts to use circulatory assistance and deep hypothermia were abandoned due to hemorrhagic complications. More recently, interest in circulatory support for complex neurosurgical procedures has been renewed. A consecutive series of 8 patients were operated on for giant cerebral aneurysms with the combined use of deep hypothermia. The protocol included careful preoperative cardiovascular assessment, perfect intraoperative synergy between neurosurgical and cardiac teams, minimally invasive peripheral vascular access including two femoral vein (21 F) and single arterial (17 F) femoral cannulation, use of total Carmeda coating on BioMedicus pumps in closed circuits, and reduced heparinization without Protamine reversal. All cerebral aneurysms were successfully treated through deep hypothermia (15-18 degrees C) as assessed by intraoperative fluoroscopic controls and Doppler vascular assessment. Mean circulatory support time was 174.2 +/- 29.6 min. Circulatory arrest period was 20 +/- 12 min. All patients survived and were extubated within 48 h. No major deficit was observed clinically or on postoperative CT scan. No hemorrhagic complications occurred (mean transfusions was 2.2 blood units). This work supports an extensive use of heparin-coated surfaces for complex circulatory assist techniques, either for cardiac or extra cardiac complex procedures.

Giant Cerebral Aneurysm Repair: Incorporating Cardiopulmonary Bypass and Neurosurgery

Since our initial experience on April 28, 1989, a total of nine patients have received treatment for giant cerebral aneurysm using cardiopulmonary bypass with deep hypothermia and circulatory arrest. The following data summarize our findings associated with these patients. The average patient's age was 46 years (range: 16 to 59 years of age). Seven patients were female, two were male. The procedure required approximately eight hours to complete with an average cardiopulmonary bypass time of 104 minutes (range: 60 to 140 minutes). Circulatory arrest time averaged 26 minutes (range, 12 to 45 minutes) with an average of 30 minutes (range: 10 to 62 minutes) required to cool the patient to below 18 degrees C (64 degrees F). An average of 54 minutes (range: 28 to 81 minutes) was required to warm the patient to a bladder temperature of 36 degrees C (96.8 degrees F). During the cooling period, five patients went into asystole spontaneously, four patients required bolus of 20 mEq of potassium chloride, and upon rewarming, spontaneous defibrillation occurred in six patients. Three patients were defibrillated without difficulty with external shock. The average number of blood products administered in each of the nine patients was 3.6 units of packed red blood cells, 3 units of fresh frozen plasma, and 6.5 units of platelets. Six patients recovered postoperatively without complication, and the recovery of three patients was affected by the complex anatomical location of the giant aneurysm. Cardiopulmonary bypass with deep hypothermia and circulatory arrest offers an alternative approach to the treatment of giant cerebral aneurysms considered inoperable by conventional techniques. The effectiveness of each procedure depends on the collaborative efforts of every member of the perioperative nursing team, the neurosurgical team, the cardiac surgical team, the neuroanesthesiology team, and the perfusionists. Careful planning and anticipation at every stage of the surgery can reduce surgical time, cardiopulmonary bypass time, and most importantly, circulatory arrest time.

Endaneurysmal microendarterectomy in the treatment of giant cerebral aneurysms

Giant cerebral aneurysms continue to present the surgeon with substantial technical challenges. Operative techniques for managing giant cerebral aneurysms are becoming increasingly sophisticated. We emphasize in this report a technique for direct obliteration of the giant aneurysm with a hard, calcified atheroma at its base that prevents direct clip application without compromise of the parent artery. Temporary trapping of the aneurysm, intramural thrombectomy, and endaneurysmal microendarterectomy allow direct obliteration of the aneurysm neck with preservation of the parent artery. (Neurosurgery 23:674-679, 1988)