Trunk Aneurysm Research Articles

Hypothermic circulatory arrest in neurovascular surgery

OBJECTIVE: One of the largest contemporary neurosurgical experiences with hypothermic circulatory arrest was analyzed for trends in patient selection and clinical variables affecting outcome. METHODS: During a 12-year period, 60 patients underwent 62 circulatory arrest procedures: 54 had posterior circulation aneurysms, 4 had anterior circulation aneurysms, and 2 had other lesions (hemangioblastoma and vertebral artery atherosclerosis). RESULTS: The surgical morbidity and mortality rates associated with hypothermic circulatory arrest were 13.3 and 8.3%, respectively. At late follow-up, 76% of the patients had good outcomes (Glasgow Outcome Scale scores of 1 and 2), 5% had poor outcomes (Glasgow Outcome Scale scores of 3 and 4), and 18% had died. After 1992, circulatory arrest was limited to posterior circulation aneurysms and included increasing numbers of basilar trunk aneurysms. Patient outcome correlated with preoperative neurological condition (admission Glasgow Coma Scale score, P < 0.001; Hunt and Hess grade, P = 0.037; and age, P = 0.007). Preservation of perforating arteries was paramount to achieving a good outcome (P = 0.005); duration of circulatory arrest was not. CONCLUSION: Current indications for hypothermic circulatory arrest include only giant and complex posterior circulation aneurysms that cannot be treated using conventional techniques or that recur after endovascular coiling. Surgical morbidity and mortality rates reflect the increasing complexity of the aneurysms treated but are still more favorable than the natural history of these lesions. This experience demonstrates that management in specialized neurovascular centers can minimize the morbidity associated with circulatory arrest so that it remains a viable treatment option for complex posterior circulation aneurysms.

Multiple basilar trunk aneurysms and bilateral internal carotid artery hypoplasia

We describe a case of a 32-year-old woman with bilateral hypoplastic internal carotid arteries who presented with subarachnoid haemorrhage and was found to have two basilar trunk aneurysms. Carotid angiography showed that both internal carotid arteries were narrowed at their origin and terminated at the cervical segment. Vertebral angiography demonstrated a dilated vertebrobasilar system which supplied sufficient blood flow for both cerebral hemispheres through the posterior communicating arteries. The patient was successfully treated by multiple operations.

Hemothorax in type I neurofibromatosis

We report a case of life-threatening hemothorax caused by rupture of a left thyrocervical trunk aneurysm and arteriovenous fistula in a patient with type I neurofibromatosis. This lesion was treated with endovascular coil embolization.

Hypothermic circulatory arrest in neurovascular surgery: evolving indications and predictors of patient outcome.

One of the largest contemporary neurosurgical experiences with hypothermic circulatory arrest was analyzed for trends in patient selection and clinical variables affecting outcome. During a 12-year period, 60 patients underwent 62 circulatory arrest procedures: 54 had posterior circulation aneurysms, 4 had anterior circulation aneurysms, and 2 had other lesions (hemangioblastoma and vertebral artery atherosclerosis). The surgical morbidity and mortality rates associated with hypothermic circulatory arrest were 13.3 and 8.3%, respectively. At late follow-up, 76% of the patients had good outcomes (Glasgow Outcome Scale scores of 1 and 2), 5% had poor outcomes (Glasgow Outcome Scale scores of 3 and 4), and 18% had died. After 1992, circulatory arrest was limited to posterior circulation aneurysms and included increasing numbers of basilar trunk aneurysms. Patient outcome correlated with preoperative neurological condition (admission Glasgow Coma Scale score, P < 0.001; Hunt and Hess grade, P = 0.037; and age, P = 0.007). Preservation of perforating arteries was paramount to achieving a good outcome (P = 0.005); duration of circulatory arrest was not. Current indications for hypothermic circulatory arrest include only giant and complex posterior circulation aneurysms that cannot be treated using conventional techniques or that recur after endovascular coiling. Surgical morbidity and mortality rates reflect the increasing complexity of the aneurysms treated but are still more favorable than the natural history of these lesions. This experience demonstrates that management in specialized neurovascular centers can minimize the morbidity associated with circulatory arrest so that it remains a viable treatment option for complex posterior circulation aneurysms.

Hémorragie digestive par rupture d'un anévrisme des artères viscérales. Présentation de quatre observations

Study aim Gastrointestinal bleeding by rupture of splanchnic artery aneurysms is very rare. The aim of this study is to report four cases observed between 1990 and 1996. Materials and methods In the first case, the celiac trunk aneurysm was revealed by hematemesis due to erosion of the posterior wall of the stomach. Excision of the aneurysm associated with splenopancreatectomy was followed by revascularization of the common hepatic artery with a bypass implanted in the aorta. The second case concerned a splenic artery aneurysm revealed by hemosuccus pancreaticus and intestinal bleeding which was treated by excision and splenopancreatectomy. In the third case, the common hepatic artery aneurysm revealed by hemosuccus pancreaticus and intestinal bleeding was treated by obstructive endoaneurysmorrhaphy. The fourth case concerned a superior mesenteric aneurysm revealed by duodenal erosion causing gastric and intestinal bleeding, which was treated by obstructive endoaneurysmorrhaphy and revascularization of the mesenteric artery by a spleno-mesenteric bypass. Results Surgical treatment was successful in all four patients. In the first case, an acute acalculous cholecystitis required a cholecystectomy after 3 weeks. In the fourth case, a splenic infarction disappeared spontaneously. Conclusion Such observations are rare. The site of the bleeding was located by endoscopy. The aneurysm was recognized by contrast-enhanced computerized tomography (CT) scan and/or celiac and mesenteric arteriography which was performed in all cases and was very useful for the management of such aneurysms. After excision ( n = 2) or obliterative endoaneurysmorrhaphy ( n = 2), revascularization had to be done in two cases for celiac and mesenteric aneurysms.

Aneurysm of the thyrocervical trunk after blunt cervical injury

A healthy, 22-year-old male blacksmith was admitted to the emergency department with a 5-cm-long wound in the right supraclavicular region, having been stuck by a piece of iron weighing I.1 kg. He had paraesthesiae of the inner border of the arm including the three ulnar fingers. The radial and carotid pulses were intact. There was no history of loss of consciousness. X-rays of the shoulder and right clavicle did not reveal a fracture. The wound was cleaned and sutured, and the patient was discharged from hospital after 2 days. There was no follow-up. Four months later he was referred to the orthopaedic department with persistent pain and reduction of movement of the right shoulder and neck. A torticollis towards the right was noted with accompanying reduction of movement of the neck and right shoulder and there were still paraesthesiae in the three ulnar fingers. No other neurological deficits were encountered and physiotherapy was initiated. Five months after the trauma, he developed a right Homer’s syndrome and a facial palsy. MR-scans of the cervical column and right brachial plexus were normal, but angiography of the brachiocephalic trunk revealed an aneurysm of the right thyrocervical trunk near its origin, extending for 2 cm (Fi,r~lrr, 1). Resection of the aneurysm was performed and the Horner’s syndrome gradually subsided over the following 7 days, but the facial palsy and the ulnar pararsthesiae persisted. Discussion

Aneurysm of a Common Celiomesenteric Trunk

Aneurysm of the celiac and/or superior mesenteric arteries are uncommon, accounting for 10% of visceral artery aneurysms. Aneurysms involving a common celiomesenteric trunk are extremely rare. Up to now only two cases have been reported. In this report we describe a saccular aneurysm originating from the bifurcation of a common celiomesenteric trunk. Treatment consisted of resection followed by suture of the aneurysmal neck. This anatomic variation of the visceral arteries probably resulted from a defect in embryonic development suggesting that the aneurysm was congenital in origin. Other etiologies of aneurysms in this location are atherosclerosis, infection, inflammation, and arterial dystrophy. These lesions are almost always surgical indications requiring complete angiographic study of the visceral vasculature.

内視鏡支援下のbsilar trunk aneurysmの手術 : その有用性について

われわれは脳底動脈に発生した破裂脳動脈瘤の症例の手術に対して神経内視鏡を用いることにより, 安全かつ確実に脳動脈瘤のクリッピングを行うことができた.血管撮影所見では径1.2cmの動脈瘤を脳底動脈に認め, 手術はsubtemporal transtentorial approachにより行われた.術中に内視鏡を用いることにより, 脳底動脈の全長にわたる観察が可能であったと同時に, 分岐する穿通枝がないことを確認することができた.このことは, 神経内視鏡が本症例のような稀な深部に存在する病巣に対するアプローチ法のきわめて限られた視野を拡げるものとして注目に値するものと考えられる.

Invasive or noninvasive angiography? The role of "classical" catheter angiography

Within the last decade, diagnostic and interventional angiography have been developed to a high degree of performance, due to the widespread use od DSA, the miniaturisation of the puncture trauma and the introduction sets (catheters, sheaths), the development of high-tech materials (e.g., Nitinol guidewires) and the application of non-ionic, low osmolal contrast media. The specific risks of the procedure, thereby, have been significantly reduced, but could not be totally eliminated. To evaluate vascular diseases non-invasively, special attention was attributed to the progress of colour coded duplex, (spiral) CT-angiography and (CE) MR-angiography, based on the established imaging with US, CT and MRT. The matter is question is whether or not they can substitute the role of conventional angiography as the "gold standard" of vessel imaging. Clinical validity and economic efficiency both determine the indication for the use of invasive or non-invasive methods. In diagnostic procedures, there is a growing tendency for the use of non-invasive techniques, like in imaging of the abdominal and thoracic aorta, the renal, pulmonary and extra- and intra-cranial arteries. Conventional angiography is still reserved for the evaluation of small vessels of the upper and lower extremities, and vessel status in preoperative conditions (carotid, celiac trunk, mesenteric and renal arteries and aneurysms of the cerebral vasculature). Fluoroscopic guiding of catheters and contrast enhancement in interventional procedures, however, cannot be substituted by alternative techniques in the foreseeable future.

The efficacy of transfemoral endovascular aneurysm management: A study on size changes of the abdominal aorta during mid-term follow-up

The aim of this study was to assess efficacy of transfemoral endovascular aneurysm management (TEAM) during mid-term follow-up. Prospective multicentre study. In 26 patients treated by a Tube Endograft, the pre- and postoperative contrast enhanced computed tomography (CT) images were reviewed in a blinded fashion. Aortic diameters were measured at the coeliac trunk, the inferior and superior aneurysm neck and the level of the maximal aneurysm size. The changes in diameter were related to the presence or absence of an endoleak. The median follow-up was 12 months. In 10 patients an endoleak was found. Three endoleaks sealed spontaneously within 30 days after operation. All aneurysms with persistent endoleaks expanded, at a median rate of 0.30 mm per month. Four patients were converted between 9 and 14 months after TEAM. Aneurysms excluded by the endoprosthesis showed a median shrinkage of 0.41 mm per month. The inferior aneurysm neck demonstrated significant growth during follow-up, unrelated to endoleaks. This study demonstrated the efficacy of TEAM in discontinuing the process of aneurysm expansion. Complete seal of the aneurysm sac after TEAM leads to shrinkage or arrest of growth of the aneurysm, while persistent endoleak is associated with progressive expansion.

V-4-52 - A case of giant fusiform thrombosed aneurysm of the vertebrobasilar trunk

V-4-52 - A case of giant fusiform thrombosed aneurysm of the vertebrobasilar trunk

Experiencia con el stent de Palmaz en la estenosis de rama pulmonar

Since 1989, the balloon expandable Palmaz stent (Johnson & Johnson Interventional Systems) has been used for the treatment of congenital heart disease. This study reports the results and the technique used for its implantation in native and post surgical retraction pulmonary branch stenosis. From february 1995 to june 1996, we have performed this technique in 11 symptomatic children/adolescents with pulmonary branch stenosis, the mean age was 11 +/- 2 years. Fourteen procedures were made and 16 stents were implanted. The mean condition of the patients was: 7 with tetralogy of Fallot after a previous complete correction, 1 with Noonan syndrome and a surgically corrected atrial septal defect, 1 with pulmonary trunk aneurysm and a previous surgical correction for pulmonary valve and branch stenosis, 1 with pulmonary atresia and an intact septum who underwent a surgical valvotomy and posterior percutaneous valvuloplasty with a good ventricular development, and final was a tricuspid atresia with a previous Waterston anastomosis which produced a stenosis at the right pulmonary branch who underwent a modified Fontan operation with the result of a severe stenosis at the medial and inferior right pulmonary artery. The branch ostium was affected in five cases, and in one case with diffuse hypoplasia of the right branch, the stenosis was at both sites. The stenosis was native in nine cases and post surgery in the other five (2 Waterston, 1 Blalock-Taussig, 1 Fontan). We used the right and/or left femoral vein in all cases except two, in which we used the internal jugular vein. We followed the technique reported by the Boston-Houston experience, with an extra stiff guide and Mullins sheath towards the site of the stenosis. The procedure was effective in all cases except one. The mean pulmonary branch and balloon diameter was 11 +/- 3 mm and 14 +/- 2 mm, respectively, rate 1.2. The stenosis diameter rose from 4.8 +/- 1 to 11 +/- 2 mm (p < 0.001) with a percentage fall from 63 +/- 5 to 2 +/- 1% (p < 0.001). The pressure gradient fell from 30 +/- 5 to 5 +/- 1 mmHg (p < 0.001) and the right ventricle systolic pressure fell from 77 +/- 6 to 48 +/- 3 mmHg (p < 0.01). The mean followup was 10 +/- 3 months, a symptomatic and pulmonary perfusion improvement was seen. After 8 +/- 4 months, we evaluated six patients/nine stents with angiography, and we excluded thrombosis, aneurysms and occlusion of lobar or segmental branches. One case had a proximal stent re-stenosis as it did not cover the whole stenosis, so a new stent was implanted. Three patients/four stents underwent redilatation getting a slightly higher diameter than previously. One patient had a stent migration and he underwent surgical stent retrieval. Implantation of the Palmaz stent is a useful procedure for the treatment of native or post-operative pulmonary stenosis. It is possible to apply it to hypoplastic and ostial pulmonary stenosis. We confirm the effectiveness of redilatation at mid term.

Transfacial transclival approach for midline posterior circulation aneurysms.

To evaluate the use of an anterior, transfacial transclival approach to midline posterior circulation aneurysms in five patients. A skin incision is made on the right side of the nose with subsequent bony and cartilaginous disarticulation of the nasal complex. The nose remains attached along the left side and is reflected laterally. Removal of the nasal septum and bilateral ethmoidectomy, medial maxillectomy (usually bilateral), and opening of the sphenoid yield a large triangular exposure of the anterior clivus. After removal of the clivus with a drill, the vertebral and basilar arteries are exposed through a midline dural opening. The approach provided excellent exposure of basilar artery trunk aneurysms with room available for temporary clip placement in three patients. In a fourth patient, a midline posterior inferior cerebellar artery aneurysm was clipped using this technique. A basilar trunk dissection was treated by proximal basilar occlusion through this exposure in a fifth patient. Although three patients developed transient cerebrospinal fluid leaks with symptoms of meningitis, no permanent neurological morbidity resulted from the use of the approach. The transfacial transclival approach to midline aneurysms of the basilar trunk and its branches provided excellent exposure for surgical treatment in five patients. No patient had postoperative palatal dysfunction and cosmetic results were excellent. Cerebrospinal fluid leak and meningitis continue to be the major drawbacks to the use of this approach, although the availability of modern broad-spectrum antibiotics lessens the chance of permanent neurological sequelae.

Posterior transpetrosal approach to aneurysms of the basilar trunk and vertebrobasilar junction

Aneurysms of the basilar trunk and vertebrobasilar junction represent an exceptional challenge to the neurosurgeon. Surgical access to these deep and confined lesions is hampered by the direct proximity of highly vulnerable neural structures such as the brainstem and cranial nerves, as well as by the structure of the petrous bone, which blocks direct surgical approach to these aneurysms. A number of surgical tactics consisting of different supra- and infratentorial approaches have been applied over the years to gain access to these treacherous lesions. Only recently have lateral approaches, such as the anterior transpetrosal, the retrolabyrinthine-transsigmoidal, and the combined supra/infratentorial-posterior transpetrosal approaches, directed through parts of the petrous bone, been reported for surgery of basilar trunk and vertebrobasilar junction aneurysms. Because detailed reports of direct operative intervention using the transpetrosal route for these rare and difficult lesions are scarce, the authors present their surgical experiences in nine patients with basilar trunk and vertebrobasilar junction aneurysms, in whom they operated via the supra/infratentorial-posterior transpetrosal approach. In eight patients, including one with a giant partially thrombosed basilar trunk aneurysm, direct clipping of the aneurysm via the transpetrosal route was possible. In one patient with a giant vertebrobasilar junction aneurysm, the completely calcified aneurysm sac was resected after occlusion of the vertebral artery. In total, one patient died and another experienced postoperative accentuation of preexisting cranial nerve deficits. Two patients had transient cerebrospinal fluid leakage, and the postoperative course was uneventful in the remaining seven. Postoperative angiography demonstrated complete aneurysm clipping in eight patients and relief of preoperative brainstem compression in the patient with the giant vertebrobasilar junction aneurysm. It is concluded that the supra/infratentorial-posterior transpetrosal approach allows excellent access to the basilar artery trunk and vertebrobasilar junction and can be considered the approach of choice to selected aneurysms located in this area.

False Aneurysm of the Thyrocervical Trunk

False aneurysm of the thyrocervical trunk as a complication of central venous catheterization is rare. We report a case of this complication in a 63-year-old white man and review the history, diagnosis, pathophysiology, and treatment of these aneurysms.

Surgical approaches for vertebro-basilar trunk aneurysms located in the midline.

Fourteen cases of midline vertebro-basilar trunk aneurysms were operated on by four routes of surgical approach: middle fossa anterior transpetrosal approach (ATP), presigmoid transpetrosal approach (PTP), conventional lateral suboccipital approach (LSO) or suboccipital transcondylar approach (STC). There was no mortality, but the morbidity was different depending on the surgical approach. In basilar trunk aneurysms located higher than the internal auditory canal, excellent results were obtainable by ATP, especially in the case of posteriorly projecting aneurysms. For midline vertebral aneurysms located lower than the internal auditory canal, STC resulted in less surgical complications than LSO. Extradural resection of the jugular tubercle was necessary for aneurysms located on the distal vertebral artery at or close to the vertebro-basilar junction. For vertebro-basilar junction aneurysms located at the level of the internal auditory canal, hearing was preserved by STC, but not by ATP or PTP. However, choice of the surgical approach may depend on the direction of the aneurysm and the technical accessibility of the skull base. All these skull base approaches reduced surgical complications of retraction damage to the cranial nerves and the brain stem. This holds true for all aneurysms arising from the midline vertebro-basilar trunk.

False aneurysm of the pulmonary trunk complicating complete transposition and presenting as pyrexia of unknown origin

SummaryA patient with complete transposition and a ventricular septal defect was clinically improved by an atrial septectomy at nine years but continued sepsis in the thoracotomy scar resulted in blood-stream infection with Staphylococcus aureus at the age of 24 years. A deep nylon suture was found and removed at surgical exploration. Five months later she again became febrile and had a vasculitic skin rash which responded to antibiotic therapy. At that time she was cyanosed and had a restricted exercise tolerance and was found to have aneurysmal dilatation of the pulmonary trunk. A year later she had acute chest pain with increased breathlessness, fever, hepatomegaly and pulmonary regurgitation. The fever did not respond to antibiotic therapy and she died suddenly following removal of a Hickman line. At postmortem examination, there was found to be a false aneurysm in the mediastinum due to rupture of the aneurysmal pulmonary trunk. No evidence of infection was found and it was considered that the low grade pyrexia had been due to the large hematoma within the false aneurysm.

False aneurysm of the thyrocervical trunk: An unconventional surgical approach

There have been reports of neurovascular injuries associated with attempted cannulation of the Central Venous System. 1~ Central venous cannulation has grown with the need to monitor more accuratel)~ cardiorespiratory parameters in the critically ill. We report an unconventional surgical technique required to deal with a false aneurysm arising from attempted cannulation of the subclavian vein. identify the defect, which was plugged with the same finger. The incision was enlarged, the contents evacuated and washed, revealing a 2 mm defect in the underlying artery which was stitched with interrupted 5 / 0 prolene. The aneurysm wall was not resected because of danger to important structures. She made uneventful recovery and was discharged on the 10th postoperative day. At 6 month follow up the lump in the neck had disappeared, with improvement of her Right Horner's syndrome.

Skull Base Approaches for Posterior Circulation Aneurysms

With the emergence of skull base surgery, surgical approaches have been developed and redefined, providing surgeons with accessible avenues to difficult lesions of the cranial base. Although the majority of lesions to which these techniques have been applied have been for tumors, we find that these skull base approaches can equally provide access to difficult vascular lesions, especially complex aneurysms of the posterior circulation. In this report three different skull base approaches were used in four patients for the treatment of posterior circulation aneurysms. A cranio-orbital-zygomatic approach was used for the acute stage of a ruptured basilar tip artery anenrysm and for a giant posterior cerebral artery aneurysm. A petrosal approach was used for a ruptured basilar trunk aneurysm, and the transcondylar approach was used for a vertebral artery aneurysm. Each approach provides a wide field and excellent exposure of vital structures with minimal brain retraction. Neck clipping of the aneurysms was successfully achieved in all cases. We believe that our skull base approaches facilitate the surgical treatment of posterior circulation aneurysms.

Mycotic aneurysm of the pulmonary trunk in a patient with valvar pulmonic stenosis

SummaryA seven-year-old patient with severe valvar pulmonary stenosis developed a mycotic aneurysm of the pulmonary trunk, which was followed closely with echocardiography. The aneurysm increased rapidly in size over a period of three weeks and required surgical removal.