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Surgical treatment of thrombosed giant aneurysm
SI24
Tuesday, 8 July 1997
Cerebrovascular Disorders
Tuesday, 8 July 1997
14:00-16:30
V-4 Cerebrovascular Disorders
IV-4-46I
Silastic sheet wrapping with clip reinforcement for aneurysmal neck avulsion and unclippable small aneurysms
Lee Je Hyuk, Park Jong Keun, Jung Shin, Kim Jae Hyoo, Kim Soo Han, Kang Sam Suk. Department of Neurosurgery, Chonnam University, Kwang Ju, Korea Intraoperative neck avulsion of an aneurysm is a catastrophic accident which may take place when the neck is thin or friable and occurs during dissection or clip placement. In such cases the use of Sundt-Kees or Heifetz encircling patch clips have been advocated. In cases of unclippable small aneurysms, where clipping was difficult due to slippage, some authors have recommended coagulation of the lesion but the efficacy of such measures are questioned. In the recent 2 years, the authors have experienced four cases of aneurysmal neck avulsion during aneurysmal surgery and two cases of unclippable small aneurysms. Of the cases of neck avulsion, three were of ICA (Internal carotid artery) aneurysms and one from an anterior communicating aneurysm. In all cases, the lesion was wrapped with microfibrillar collagen (Avitene) and silastic sheets, reinforced by clips. Two cases of unclippable small aneurysms were of ICA aneurysms, in both cases the lesions were wrapped with Bernsheet and reinforced with silastic sheet and clip. Postoperative course was uneventful in all cases and no known complications due to the procedure was noted per se. We are of the opinion that in cases of catastrophic neck avulsion during aneurysmal surgery and unclippable small aneurysms, Avitene or Bemsheet covering followed by stlastic wrapping and reinforcement clipping is a good alternative procedure.
IV-4-47!
Operations for medially projecting intracranial carotid artery aneurysms. Morbidity and the relation to perforating arteries
Kunio Nakai, Tomoaki Terada, Ekini Nakai, Toru ltakura, Departement of
Neurological Surgery, Wakayama MedicalCollege, Wakayama 640, Japan Introduction: Although laterally projecting aneurysms from the intracranial carotid artery (e.g. IC-PCom aneurysm) can easily be clipped through a conventional pterional craniotomy, those projecting medially or purely posteriorly from the carotid artery are often difficult to clip to its ideal part of the aneurysmal neck due to the presence of the small branches (including the anterior choroidal artery) supplying important structures such as optic nerve, optic tract, midbrain, thalamus or hypothalamus. Method and Cases: We have operated 42 aneurysms along the intracranial internal carotid artery (IC) among 153 intracranial aneurysms operated on from Jan. 1994 to Oct. 1996. All aneurysms were operated within 48 hours from the SAH (Hunt & Kosnik Grade 0 to IV). Neck clipping was performed through pterional craniotomy with or without orbitotomy. Results: Several factors (preservation of the perforating arteries, duration of temporary clipping of the IC and brain retraction, preoperative Grade, age etc.) were evaluated in relation to the additional postoperative neurological deficit. Among the factors examined, preservation of the perforating artery is most importantly related to the postoperative neurological deficit. Discussion: Among the 42 IC aneurysms, we have experienced 11 aneurysms that have perforating arteries or anterior choroidal arteries along their dome or neck. Most of those aneurysms projected medially or posteriorly (seven) or were large in size (four). Our surgical experience and strategy for such relatively unusual cases of IC-aneurysms will be presented by video.
IV-4-48I
tomy, and trapping of the vertebral artery are thought to be reasonable operations for these aneurysms. In particular, trans-condyle approach was very useful in all cases. When the aneurysm is embedded in the brain stem, only a partial aneurysmectomy should be performed, otherwise the brain stem will be injured and serious complications will occur. To reduce severe complications, we use the following procedure. 1) Precise diagnosis before operation by using MRI and 3D-CT is very useful for knowing not only the relation between aneurysm and parent artery but also the location of thrombus. 2) Trans-condyle approach Is necessary to widen the operative field and to comfirm of contralateral and distal vertebral artery. 3) Intraoperative continuous monitoring of SEP is important to know the brain stem function during operation. 4) Miniture doppler probe and micro-optic fiberscope are useful aids.
IV-4-49/
Treatment of a growing partially thrombosed intracranial giant aneurysm by excision and trapping with STA-MCA bypass
S. Abiko, 1. Okamura, Y. Kurokawa, N. Ikeda, K. Watanabe. Department of Neurosurgery, Ube Industries CentralHospital, Ube, Japan Introduction: Treatment of a partially thrombosed intracranial giant aneurysm is very difficult because of the mass effect of the aneurysm, thrombus in the aneurysmal sac, and the anatomical relationships. Here we present two cases of a growing giant aneurysm and discuss the operative method as well as the mechanism of giant aneurysm growth from the surgical findings and specimens. Case: The first patient was a 67-year-old man who underwent STA-MCA bypass with intraaneurysmal embolization by detachable balloons for a partially thrombosed giant aneurysm of the right carotid bifurcation that manifested with ischemic events. He was discharged with left hemiparesis and followed at our outpatient clinic. One year later, there was exacerbation of the left hemiparesis. CT scans and cerebral angiography showed hydrocephalus, a growing giant cerebral aneurysm with thrombus, and agenesis of the right AI. Permanent clips were placed proximal and distal to the aneurysm. The aneurysm was then opened and the intraluminal thrombus and detachable balloons were removed for decompression. The second patient was a 77-year-old woman who had a left sided infarction three years before her second admission with progressive right hemiparesis and speech disturbance. CT scans and cerebral angiography revealed a growing partially thrombosed giant aneurysm of the left middle cerebral artery. Permanent clips were placed proximal and distal to the aneurysm, followed by aneurysmectomy and STA-MCA bypass.
IV-4-50 I Transclinoid approach for aneurysms of distal basilar artery and it's neighborhoods Koji Saito, Tohru Okuyama, Akira Hirano, Akira Takahashi, Yuji Hashimoto, Tohru Inagaki. Kushiro Neurosurgical Hospital, Kushiro, Japan Surgical management of aneurysms of distal basilar artery and its neighborhoOd is still very difficult. The pterional approach is one of the popular approaches but the approach has limitations because of its narrow working space, so we used to do clipping with long sized clip. The transclinoid approach can give wider working space, so proper clipping can be done with suitable clip or clips without obstruction of the field by the clip holder. The 1st step of transclinoid approach is the removal of anterior clinoid process. This procedure provides a wider space lateral to the carotid artery, and exposes the proximal part of the basilar artery in the early stage, so that temporary clipping can be performed at anytime. The second step is retraction of the temporal lobe laterally without damage of the sylvian veins bridging to the sphenoparietal sinus. The arachnoid membrane between 3rd nerve and temporal lobe must be cut, whereafter the 3rd nerve can be followed and the PCA and SCA identified. This step provides further space and a good angle of approach, making it possible to clip the aneurysm. We tried this approach since 1992, and 5 cases with basilar bifurcation aneurysms (3 cases SAH), 13 cases with BA·SCA aneurysms (4 cases SAH), 3 cases with PCA (P1~P2) aneurysms (1 case SAH), and 1 case with basilar trunk and SCA aneurysms have been operated. The operative results were excellent.
Surgical treatment of thrombosed giant aneurysm
T. Shima, M, Nishida, K. Yamane, Y. Okada 1. Dept of Neurosurgery. Chugoku RousalHospital, 1-5-1. Hirotagaya, Kuro, 737-01, 1 Dept of Neurosurgery, ShimaneMedicalUniversity, 2-89. Enye-cho, tzumo. Shimane, 893, Japan Neurological signs due to the mass effect of a giant aneurysm in the posterior circulation are more severe than those in the anterior circulation. Direct surgical treatment involving trapping of giant thrombosed vertebral aneurysms and aneurysmectomy are often difficult. The authors present three cases of surgically treated thrombosed giant vertebral aneurysm, who presented with mass effect signs without subarachnoid hemorrhage. Two of them were managed with partial aneurysmectomy after trapping the vertebral artery, and one case was treated with trapping and aneurysmectomy. All cases showed satisfactory results after operation. Internal decompression by thrombectomy, aneurysmec-
I V-4-51
I A combined trans-sylvian and subtemporal approach for basilar bifurcation aneurysms
Hiromi Goto, Kazuo Watanabe. Southern Tonoku Research instltine for Neuroscience, 18 Maebayashi Fukuyama-machi Koriyama-city, Fukushima, Japan A combined trans-sylvlan and subtemporal approach for basilar bifurcation aneurysms has the advantage of preventing perforating artery injury, because the origin of both P1 segments and their associated perforating and choroidal arteries are well visualized. By this approach, we can clip the basilar bifurcation aneurysms as well as perform temporary clipping of the basilar artery, so we can clip the aneurysm without obstruction by the temporary clip. We demonstrate this approach in details by video.
Tuesday, 8 July 1997
Cerebrovascular Disorders
Tuesday, 8 July 1997
14:00-16:30
V-4 Cerebrovascular Disorders
IV-4-46I
Silastic sheet wrapping with clip reinforcement for aneurysmal neck avulsion and unclippable small aneurysms
Lee Je Hyuk, Park Jong Keun, Jung Shin, Kim Jae Hyoo, Kim Soo Han, Kang Sam Suk. Department of Neurosurgery, Chonnam University, Kwang Ju, Korea Intraoperative neck avulsion of an aneurysm is a catastrophic accident which may take place when the neck is thin or friable and occurs during dissection or clip placement. In such cases the use of Sundt-Kees or Heifetz encircling patch clips have been advocated. In cases of unclippable small aneurysms, where clipping was difficult due to slippage, some authors have recommended coagulation of the lesion but the efficacy of such measures are questioned. In the recent 2 years, the authors have experienced four cases of aneurysmal neck avulsion during aneurysmal surgery and two cases of unclippable small aneurysms. Of the cases of neck avulsion, three were of ICA (Internal carotid artery) aneurysms and one from an anterior communicating aneurysm. In all cases, the lesion was wrapped with microfibrillar collagen (Avitene) and silastic sheets, reinforced by clips. Two cases of unclippable small aneurysms were of ICA aneurysms, in both cases the lesions were wrapped with Bernsheet and reinforced with silastic sheet and clip. Postoperative course was uneventful in all cases and no known complications due to the procedure was noted per se. We are of the opinion that in cases of catastrophic neck avulsion during aneurysmal surgery and unclippable small aneurysms, Avitene or Bemsheet covering followed by stlastic wrapping and reinforcement clipping is a good alternative procedure.
IV-4-47!
Operations for medially projecting intracranial carotid artery aneurysms. Morbidity and the relation to perforating arteries
Kunio Nakai, Tomoaki Terada, Ekini Nakai, Toru ltakura, Departement of
Neurological Surgery, Wakayama MedicalCollege, Wakayama 640, Japan Introduction: Although laterally projecting aneurysms from the intracranial carotid artery (e.g. IC-PCom aneurysm) can easily be clipped through a conventional pterional craniotomy, those projecting medially or purely posteriorly from the carotid artery are often difficult to clip to its ideal part of the aneurysmal neck due to the presence of the small branches (including the anterior choroidal artery) supplying important structures such as optic nerve, optic tract, midbrain, thalamus or hypothalamus. Method and Cases: We have operated 42 aneurysms along the intracranial internal carotid artery (IC) among 153 intracranial aneurysms operated on from Jan. 1994 to Oct. 1996. All aneurysms were operated within 48 hours from the SAH (Hunt & Kosnik Grade 0 to IV). Neck clipping was performed through pterional craniotomy with or without orbitotomy. Results: Several factors (preservation of the perforating arteries, duration of temporary clipping of the IC and brain retraction, preoperative Grade, age etc.) were evaluated in relation to the additional postoperative neurological deficit. Among the factors examined, preservation of the perforating artery is most importantly related to the postoperative neurological deficit. Discussion: Among the 42 IC aneurysms, we have experienced 11 aneurysms that have perforating arteries or anterior choroidal arteries along their dome or neck. Most of those aneurysms projected medially or posteriorly (seven) or were large in size (four). Our surgical experience and strategy for such relatively unusual cases of IC-aneurysms will be presented by video.
IV-4-48I
tomy, and trapping of the vertebral artery are thought to be reasonable operations for these aneurysms. In particular, trans-condyle approach was very useful in all cases. When the aneurysm is embedded in the brain stem, only a partial aneurysmectomy should be performed, otherwise the brain stem will be injured and serious complications will occur. To reduce severe complications, we use the following procedure. 1) Precise diagnosis before operation by using MRI and 3D-CT is very useful for knowing not only the relation between aneurysm and parent artery but also the location of thrombus. 2) Trans-condyle approach Is necessary to widen the operative field and to comfirm of contralateral and distal vertebral artery. 3) Intraoperative continuous monitoring of SEP is important to know the brain stem function during operation. 4) Miniture doppler probe and micro-optic fiberscope are useful aids.
IV-4-49/
Treatment of a growing partially thrombosed intracranial giant aneurysm by excision and trapping with STA-MCA bypass
S. Abiko, 1. Okamura, Y. Kurokawa, N. Ikeda, K. Watanabe. Department of Neurosurgery, Ube Industries CentralHospital, Ube, Japan Introduction: Treatment of a partially thrombosed intracranial giant aneurysm is very difficult because of the mass effect of the aneurysm, thrombus in the aneurysmal sac, and the anatomical relationships. Here we present two cases of a growing giant aneurysm and discuss the operative method as well as the mechanism of giant aneurysm growth from the surgical findings and specimens. Case: The first patient was a 67-year-old man who underwent STA-MCA bypass with intraaneurysmal embolization by detachable balloons for a partially thrombosed giant aneurysm of the right carotid bifurcation that manifested with ischemic events. He was discharged with left hemiparesis and followed at our outpatient clinic. One year later, there was exacerbation of the left hemiparesis. CT scans and cerebral angiography showed hydrocephalus, a growing giant cerebral aneurysm with thrombus, and agenesis of the right AI. Permanent clips were placed proximal and distal to the aneurysm. The aneurysm was then opened and the intraluminal thrombus and detachable balloons were removed for decompression. The second patient was a 77-year-old woman who had a left sided infarction three years before her second admission with progressive right hemiparesis and speech disturbance. CT scans and cerebral angiography revealed a growing partially thrombosed giant aneurysm of the left middle cerebral artery. Permanent clips were placed proximal and distal to the aneurysm, followed by aneurysmectomy and STA-MCA bypass.
IV-4-50 I Transclinoid approach for aneurysms of distal basilar artery and it's neighborhoods Koji Saito, Tohru Okuyama, Akira Hirano, Akira Takahashi, Yuji Hashimoto, Tohru Inagaki. Kushiro Neurosurgical Hospital, Kushiro, Japan Surgical management of aneurysms of distal basilar artery and its neighborhoOd is still very difficult. The pterional approach is one of the popular approaches but the approach has limitations because of its narrow working space, so we used to do clipping with long sized clip. The transclinoid approach can give wider working space, so proper clipping can be done with suitable clip or clips without obstruction of the field by the clip holder. The 1st step of transclinoid approach is the removal of anterior clinoid process. This procedure provides a wider space lateral to the carotid artery, and exposes the proximal part of the basilar artery in the early stage, so that temporary clipping can be performed at anytime. The second step is retraction of the temporal lobe laterally without damage of the sylvian veins bridging to the sphenoparietal sinus. The arachnoid membrane between 3rd nerve and temporal lobe must be cut, whereafter the 3rd nerve can be followed and the PCA and SCA identified. This step provides further space and a good angle of approach, making it possible to clip the aneurysm. We tried this approach since 1992, and 5 cases with basilar bifurcation aneurysms (3 cases SAH), 13 cases with BA·SCA aneurysms (4 cases SAH), 3 cases with PCA (P1~P2) aneurysms (1 case SAH), and 1 case with basilar trunk and SCA aneurysms have been operated. The operative results were excellent.
Surgical treatment of thrombosed giant aneurysm
T. Shima, M, Nishida, K. Yamane, Y. Okada 1. Dept of Neurosurgery. Chugoku RousalHospital, 1-5-1. Hirotagaya, Kuro, 737-01, 1 Dept of Neurosurgery, ShimaneMedicalUniversity, 2-89. Enye-cho, tzumo. Shimane, 893, Japan Neurological signs due to the mass effect of a giant aneurysm in the posterior circulation are more severe than those in the anterior circulation. Direct surgical treatment involving trapping of giant thrombosed vertebral aneurysms and aneurysmectomy are often difficult. The authors present three cases of surgically treated thrombosed giant vertebral aneurysm, who presented with mass effect signs without subarachnoid hemorrhage. Two of them were managed with partial aneurysmectomy after trapping the vertebral artery, and one case was treated with trapping and aneurysmectomy. All cases showed satisfactory results after operation. Internal decompression by thrombectomy, aneurysmec-
I V-4-51
I A combined trans-sylvian and subtemporal approach for basilar bifurcation aneurysms
Hiromi Goto, Kazuo Watanabe. Southern Tonoku Research instltine for Neuroscience, 18 Maebayashi Fukuyama-machi Koriyama-city, Fukushima, Japan A combined trans-sylvlan and subtemporal approach for basilar bifurcation aneurysms has the advantage of preventing perforating artery injury, because the origin of both P1 segments and their associated perforating and choroidal arteries are well visualized. By this approach, we can clip the basilar bifurcation aneurysms as well as perform temporary clipping of the basilar artery, so we can clip the aneurysm without obstruction by the temporary clip. We demonstrate this approach in details by video.