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Temporary arterial occlusion during the surgical treatment of intracranial aneurysms
Monday, 7 July 1997 occluded simulating VAocclusion andthe histological changes werechronoiogicallyinvestigated to evaluate lts efficacy. We performed unilateral VAocclusion therapy for three patients with ruptured OA.The resultwas compared with that of the simulation study. Results: In simulation study, intimal thickening was observed in the areas of stagnant flow, luminal obliteration was not observed, however, within 2.9 ± 0.6 (mean ± SO) times of the tubular diameter (TD) from the union. The aneurysms became invisible after VA occlusion therapy in all three patients. Theseaneurysms were located morethan 2.9 TO awayfrom the VAunion. Discussion and Conclusions: The angiographical findings after VA occlusion therapy grossly corresponded with the result of the simulation study. The value of 2.9TO is one of the guidelines in considering the usefulness of therapeutic VAocclusion therapy.
IP-1-4SI
Effect of temporary clipping and division of the posterior communicating artery on the surgical result in cases of ruptured basilar bifurcation aneurysms
S. Yagi, H. Nukui, S. Mituka, T. Hosaka, T.Kakizawa, T.Horikoshi, N. Miyazawa, H. Nishi. Dept. of Neurosurgery, Yamanashi MedicalUniversity, Tamaho-Machi, Yamanashi, Japan The aim of this study was to evaluate the effect of temporary clip (TC) and division of posterior communicating artery (PComA) on the surgical results in cases with ruptured basilar bifurcation aneurysms. Fifty-five cases were analyzed. Timing of operation (within 3 daysafter SAH: A, over 4 days: B) and clinical grades by Hunt and Kosnik's classification were as follows: In A-group, I-II 7, III-IV 8. In group B, HI 34, III-IV 8. We ordinarily use TC for lessthan to min. and dividedPComA if necessary. TC was used in 26 cases (T-group). According to the aneurysmal size, 12 of 33 in small size (less than 9 mm) and 14 of 24 in large size (morethan 10 mm). According to the aneurysm position, t5 of 37 in low position (lessthan 9 mm over AC-PC line)and 1t of 20 in highposition (more than 10 mm). PComA was dividedin 16 cases. According to the size, 9 of 33 casesin smallsize and 7 of 24 in largesize. According to the position, 11 of 37 in low position and 5 of 20 in high position. Favorable outcomes were obtained as follows: In T-group, I-II 87%, III-IV 53% and in non-T-group, I-II 86% III-IV 64%. In D-group, I-II 70%, III-IV 50% and in non-O-group, I-II 92% III-IV 47%. Intraoperative hemorrhage or surgical procedure didn't cause unfavorable outcomes. • Based on these results which has shown no effect of TC and division of PComA on surgical results, it can be concluded that these procedures should be seriously considered in caseswithruptured basilarbifurcation aneurysms for safe and easy operations.
IP-1-46!lntraoperative SEP monitoring in giant aneurysm surgery
I. Berisavac, V. Bojovi6, A.M. Carano ClinicalHospitalZemun, Belgrade, Opt. of Neurosurgery, Belgrade, Yugoslavia
Radical surgery of giant aneurysm is seldompossible without a temporary clip of the carrierartery. The periodof temporary arterial occlusion is usuallylonger dueto the possible relations of aneurysmal bodyto the othervascular and neural elements, which make the operation more difficult. In these operations, intraoperative somatosensitive evoked potentials (SEP) monitoring has a special value. We reporttwo casesof operated giant aneurysms, wheretemporary occlusionof the carrierartery was unusually long. In the first case a giant aneurysm of left medial cerebellar artery (MCA) with diameter of 35 mm, without bleeding was diagnosed by CT as a tumor. Temporary occlusion of MCA at the bifurcation lasted for 9 minutes. Central conduction time (CCT)registrated by SEPwas prolongated over the reference values. Afterthe occlusion we noticedfast normalization of CCT. In the postoperativeperiodthe patientwas withoutneurological deficit. Control angiography confirmed complete clipping of the aneurysm. In the secondcase of an aneurysm with diameter of 30 mm in the supraclinoidalsegment of internal carotidartery(ICA), we haveexposed ICAin theneck and put an temporary clip for the periodof 14 min. SEPshowed a prolongation of CCT whichwas normalized when we stopped the occlusion. Postoperatively, the patientwas withoutneurological deficit. Control angiography confirmed total clipping of aneurysm. Intraoperative SEP monitoring provides a good operative outcome even though the occlusion of the carrier artery was quite long. We noticed a kind of "physiological readiness" of the brain tissue for a longerperiod of the blood deficit,due to the collateral bloodflow.
Cerebrovascular Disorders - Surgical Treatment ofAneurysms
549
IP-1-47! The "trapping-evacuation" technique in the treatment of large and giant paraclinoidal aneurysms S.S. Eliava, YM. Filatov, A.Y. Lubnin, A.S. Kheireddine. Burdenko Neurosurgical Institute, Moscow, Russia The purpose of this investigation was to evaluate the efficacy of retrograde suction decompression of largeand giantparaclinoidal aneurysms. Methods: 4 patients underwent surgical treatment for large and giant paraclinoidal aneurysms utilising the '1rapping-evacuation" technique. 3 patients werefemale and one male, ages were between 26 and 46 years (mean 37). In all four casesaneurysm clipping was performed aftertemporary trapping of the aneurysm and retrograde suctiondecompression via exposure of the cervical internal carotid artery. All patients underwent control angiography. Results: The aneurysms were completely clipped in all 4 cases (100%), which wasconfirmed by angiographic studies. 3 patients (75%)weredischarged without any change in the neurological status. One patient (25%) developed severevisualdeficiton the side of the aneurysm, whichwas due to mechanical compression of the opticnerveby the clip intraoperatively. Conclusion: Retrograde suction decompression of large and giant parac1inoidal aneurysms is a safe and effective technique to control the proximal segment of the internal carotid artery duringsurgery. It allows to reduce significantlythe amount of blood in the aneurysm and decrease the tension of the walls, whichhelpsto clip the aneurysm morequicklyand safely.
IP-1-48I
Long-term follow-up stUdy of giant tc aneurysm treated by trapping
Kiyoshi Matsumoto, K. Oshida, T. Iwata, H. Izumiyama, H. Ikeda, K. Sasaki, Y Suzuki, H. Jimbo, M. Shimazu, T. Sawa, T.Okino1 . Departmentof Neurosurgery, Showa University Schoolof Medicine, Tokyo, Japan, 1 Hatanodai Neurosurgical Hospital, Tokyo, Japan Introduction: Radical operation of giant IC aneurysm is very difficult,because there is no working spacefor clipping of thesehugeaneurysm. Evenif it seems to be possible, the clip slipsout mostly, because of the giant size. Now, the main method of treatment of giant aneurysm is intravascular embolization. Patients and Methods: The cases were: males, 3; females 3. Age from 12~65 yearsold, average 43 year, follow-up average 12 years. Matastest was carried out for investigation of cross circulation before operation. At first we tried neck clipping but it was impossible to clip the aneurysms because of the wide and hard neck. So we abandoned clipping of neck and executed trapping between proximal and peripheral side of IC aneurysm. Results: 5 among 6 patients completely recovered, they make their living withoutany neurological deficit. Discussion: Giant aneurysms occupy the important location of hypothalamus and midbrain. It is difficultto separate the aneurysm from surrounding perforating arteries and brain tissue. The outcome is generally very poor. According to a report, 6 among8 casesoperated by clipping of IC giantaneurysm's neck died.The mortality was 75%. Therefore, they should not be operated by clipping. The trapping method is superior to clipping in giant aneurysm.
IP-1-49I
Temporary arterial occlusion during the surgical treatment of intracranial aneurysms
B. Petrovic 1, S. Ojuric 2 , M. Zivkovi6 2 , V. Novikl , 1 Neurosurgical Clinic, Clinic, University of Nis, Nis, Yugoslavia
2 Neurology
Temporary intracranial arterial occlusion is often utilised during the surgical treatment of intracranial aneurysms, but it remains controversial whether it is safeto usetemporary occlusion. Wetherefore conducted a systematic review of 392consecutive patientswho where hospitalised with intracranial aneurysmatic haemorrhage in the period 1988-1996. Out of this number 271 patients were operated on during which temporal occlusion wasusedin 119patients. The mortality ratein thisgroupof patientsas 5% (6 patients) in comparison with 29% (44 patients) in groupwithouttemporal occlusion. The degree of brain dysfunction was assessed by electrophysiological method of evoked potentials in 36 patients. Our results show that temporary occlusion has significant advantages in intracranial aneurysm surgery.
IP-1-S0 I Intraoperative hemorrhage in surgical treatment of cerebral aneurysms
G.U.Evzikov, V.V. Krylov, M.S.Gelfenbeyn. Departmentof Neurosurgery, Sklifosovsky Emergency Care Institute, Moscow, Russia Purpose: to determine the dependence of intraoperative hemorrhage (IOH)
IP-1-4SI
Effect of temporary clipping and division of the posterior communicating artery on the surgical result in cases of ruptured basilar bifurcation aneurysms
S. Yagi, H. Nukui, S. Mituka, T. Hosaka, T.Kakizawa, T.Horikoshi, N. Miyazawa, H. Nishi. Dept. of Neurosurgery, Yamanashi MedicalUniversity, Tamaho-Machi, Yamanashi, Japan The aim of this study was to evaluate the effect of temporary clip (TC) and division of posterior communicating artery (PComA) on the surgical results in cases with ruptured basilar bifurcation aneurysms. Fifty-five cases were analyzed. Timing of operation (within 3 daysafter SAH: A, over 4 days: B) and clinical grades by Hunt and Kosnik's classification were as follows: In A-group, I-II 7, III-IV 8. In group B, HI 34, III-IV 8. We ordinarily use TC for lessthan to min. and dividedPComA if necessary. TC was used in 26 cases (T-group). According to the aneurysmal size, 12 of 33 in small size (less than 9 mm) and 14 of 24 in large size (morethan 10 mm). According to the aneurysm position, t5 of 37 in low position (lessthan 9 mm over AC-PC line)and 1t of 20 in highposition (more than 10 mm). PComA was dividedin 16 cases. According to the size, 9 of 33 casesin smallsize and 7 of 24 in largesize. According to the position, 11 of 37 in low position and 5 of 20 in high position. Favorable outcomes were obtained as follows: In T-group, I-II 87%, III-IV 53% and in non-T-group, I-II 86% III-IV 64%. In D-group, I-II 70%, III-IV 50% and in non-O-group, I-II 92% III-IV 47%. Intraoperative hemorrhage or surgical procedure didn't cause unfavorable outcomes. • Based on these results which has shown no effect of TC and division of PComA on surgical results, it can be concluded that these procedures should be seriously considered in caseswithruptured basilarbifurcation aneurysms for safe and easy operations.
IP-1-46!lntraoperative SEP monitoring in giant aneurysm surgery
I. Berisavac, V. Bojovi6, A.M. Carano ClinicalHospitalZemun, Belgrade, Opt. of Neurosurgery, Belgrade, Yugoslavia
Radical surgery of giant aneurysm is seldompossible without a temporary clip of the carrierartery. The periodof temporary arterial occlusion is usuallylonger dueto the possible relations of aneurysmal bodyto the othervascular and neural elements, which make the operation more difficult. In these operations, intraoperative somatosensitive evoked potentials (SEP) monitoring has a special value. We reporttwo casesof operated giant aneurysms, wheretemporary occlusionof the carrierartery was unusually long. In the first case a giant aneurysm of left medial cerebellar artery (MCA) with diameter of 35 mm, without bleeding was diagnosed by CT as a tumor. Temporary occlusion of MCA at the bifurcation lasted for 9 minutes. Central conduction time (CCT)registrated by SEPwas prolongated over the reference values. Afterthe occlusion we noticedfast normalization of CCT. In the postoperativeperiodthe patientwas withoutneurological deficit. Control angiography confirmed complete clipping of the aneurysm. In the secondcase of an aneurysm with diameter of 30 mm in the supraclinoidalsegment of internal carotidartery(ICA), we haveexposed ICAin theneck and put an temporary clip for the periodof 14 min. SEPshowed a prolongation of CCT whichwas normalized when we stopped the occlusion. Postoperatively, the patientwas withoutneurological deficit. Control angiography confirmed total clipping of aneurysm. Intraoperative SEP monitoring provides a good operative outcome even though the occlusion of the carrier artery was quite long. We noticed a kind of "physiological readiness" of the brain tissue for a longerperiod of the blood deficit,due to the collateral bloodflow.
Cerebrovascular Disorders - Surgical Treatment ofAneurysms
549
IP-1-47! The "trapping-evacuation" technique in the treatment of large and giant paraclinoidal aneurysms S.S. Eliava, YM. Filatov, A.Y. Lubnin, A.S. Kheireddine. Burdenko Neurosurgical Institute, Moscow, Russia The purpose of this investigation was to evaluate the efficacy of retrograde suction decompression of largeand giantparaclinoidal aneurysms. Methods: 4 patients underwent surgical treatment for large and giant paraclinoidal aneurysms utilising the '1rapping-evacuation" technique. 3 patients werefemale and one male, ages were between 26 and 46 years (mean 37). In all four casesaneurysm clipping was performed aftertemporary trapping of the aneurysm and retrograde suctiondecompression via exposure of the cervical internal carotid artery. All patients underwent control angiography. Results: The aneurysms were completely clipped in all 4 cases (100%), which wasconfirmed by angiographic studies. 3 patients (75%)weredischarged without any change in the neurological status. One patient (25%) developed severevisualdeficiton the side of the aneurysm, whichwas due to mechanical compression of the opticnerveby the clip intraoperatively. Conclusion: Retrograde suction decompression of large and giant parac1inoidal aneurysms is a safe and effective technique to control the proximal segment of the internal carotid artery duringsurgery. It allows to reduce significantlythe amount of blood in the aneurysm and decrease the tension of the walls, whichhelpsto clip the aneurysm morequicklyand safely.
IP-1-48I
Long-term follow-up stUdy of giant tc aneurysm treated by trapping
Kiyoshi Matsumoto, K. Oshida, T. Iwata, H. Izumiyama, H. Ikeda, K. Sasaki, Y Suzuki, H. Jimbo, M. Shimazu, T. Sawa, T.Okino1 . Departmentof Neurosurgery, Showa University Schoolof Medicine, Tokyo, Japan, 1 Hatanodai Neurosurgical Hospital, Tokyo, Japan Introduction: Radical operation of giant IC aneurysm is very difficult,because there is no working spacefor clipping of thesehugeaneurysm. Evenif it seems to be possible, the clip slipsout mostly, because of the giant size. Now, the main method of treatment of giant aneurysm is intravascular embolization. Patients and Methods: The cases were: males, 3; females 3. Age from 12~65 yearsold, average 43 year, follow-up average 12 years. Matastest was carried out for investigation of cross circulation before operation. At first we tried neck clipping but it was impossible to clip the aneurysms because of the wide and hard neck. So we abandoned clipping of neck and executed trapping between proximal and peripheral side of IC aneurysm. Results: 5 among 6 patients completely recovered, they make their living withoutany neurological deficit. Discussion: Giant aneurysms occupy the important location of hypothalamus and midbrain. It is difficultto separate the aneurysm from surrounding perforating arteries and brain tissue. The outcome is generally very poor. According to a report, 6 among8 casesoperated by clipping of IC giantaneurysm's neck died.The mortality was 75%. Therefore, they should not be operated by clipping. The trapping method is superior to clipping in giant aneurysm.
IP-1-49I
Temporary arterial occlusion during the surgical treatment of intracranial aneurysms
B. Petrovic 1, S. Ojuric 2 , M. Zivkovi6 2 , V. Novikl , 1 Neurosurgical Clinic, Clinic, University of Nis, Nis, Yugoslavia
2 Neurology
Temporary intracranial arterial occlusion is often utilised during the surgical treatment of intracranial aneurysms, but it remains controversial whether it is safeto usetemporary occlusion. Wetherefore conducted a systematic review of 392consecutive patientswho where hospitalised with intracranial aneurysmatic haemorrhage in the period 1988-1996. Out of this number 271 patients were operated on during which temporal occlusion wasusedin 119patients. The mortality ratein thisgroupof patientsas 5% (6 patients) in comparison with 29% (44 patients) in groupwithouttemporal occlusion. The degree of brain dysfunction was assessed by electrophysiological method of evoked potentials in 36 patients. Our results show that temporary occlusion has significant advantages in intracranial aneurysm surgery.
IP-1-S0 I Intraoperative hemorrhage in surgical treatment of cerebral aneurysms
G.U.Evzikov, V.V. Krylov, M.S.Gelfenbeyn. Departmentof Neurosurgery, Sklifosovsky Emergency Care Institute, Moscow, Russia Purpose: to determine the dependence of intraoperative hemorrhage (IOH)