Surgical Management of Pseudoaneurysm

OBJECTIVES: Surgical experiences of pseudoaneurysms such as traumatic, mycotic and ill-defined unknown causes of aneurysms are rare. The authors have studied the results of surgical management from such cases in our series. PATIENTS AND METHOD: In the last 17 years, 1320 patients with cerebrovascular aneurysms were managed surgically. Among these, 16 patients showed the pseudoaneurysms. The authors analyzed retrospectively the clinical characteristics, treatment methods, management outcomes and problems in the managements. RESULTS: There were 6 patients with traumatic aneurysm, 4 mycotic aneurysms and 6 ill-defined unknown causes of aneurysm. The sites of traumatic aneurysms were cavernous portion of the internal carotid artery(n=3), distal portion of the anterior cerebral artery (n=2) and vertebral artery(VA: n=1). Good outcomes in 5 cases could be obtained by extracranial - intracranial bypass followed by parent vessel occlusion or resection of aneurysm followed by re-anast-omosis of parent vessel. The sites of mycotic aneurysm were peripheral portions of middle cerebral artery(MCA: n=3) and posterior cerebral artery(PCA: n=1). The outcomes of the patients with a mycotic aneurysm were relatively poor. It was partially due to the development of new aneurysm after treatment in one. The sites of ill-defined unknown causes of aneurysm were extracranial carotid artery(n=3), V2 portion of the VA(n=1), peripheral portion of the PCA (n=1) and MCA(n=1). Good outcome in all cases could be obtained by resection of aneurysm with or without saphenous vein graft. CONCLUSION: For the treatments of cerebrovascular pseudoaneurysm, combinations of aggressive medical, endovascular and surgical managements seem mandatory. Insertion of stent for a extracranial carotid artery aneurysm and coiling for a peripheral mycotic aneurysm can be option in future.

Remote Epidural Hematoma Following the Removal of Brain Tumors: Report of Three Cases

OBJECTIVES: The authors present three cases of brain tumors in which epidural hematomas(EDHs) were developed postoperatively in the remote areas from craniotomy sites. The preventive tactics as well as possible mechanisms of development of remote EDH are discussed. MATERIAL AND METHODS: The magnetic resonance imagings of three patients revealed a left lateral ventricular mass located just aside of foramen Monro in a 27-year-old male, a large cystic mass in the temporal lobe in a 35-year-old male, and a partially calcified pineal mass in a 27-year-old male patient. The surgical removals of these tumors were performed without any noticeable events during surgery via left frontal transcortical transventricular approach for lateral ventricular tumor, left temporal craniotomy for cystic temporal tumor, and right occipital transtentorial approach for pineal tumor. RESULTS: Postoperative EDHs remote from the sites of craniotomy were detected by the immediate postoperative computerized tomographic scans. We obtained good outcomes without any morbidity in all three patients with emergent evacuation of the hematoma. The pathologic diagnoses were lateral ventricular ependymoastrocytoma, temporal craniopharyngioma and mixed germinoma of the pineal region. CONCLUSION: It is postulated that a sudden reduction of intracranial pressure(ICP) at the time of tumor removal may strip the dura from the inner table of the skull to cause EDH from the remote site of craniotomy. Gradual reduction of ICP with slow drainage of cerebrospinal fluid before tumor removal as well as lowering the head position of patient during surgery might be helpful for preventing this unusual complication.

Surgical Management of Large and Giant Aneurysm

OBJECTIVES: The goal of the surgical management of large and giant aneurysm is complete extirpation of the aneurysms with preservation or reconstruction of the parent artery. To improve the surgical management results of those aneurysms in the future, we review our experience and discuss technical maneuvers and strategies used to avoid potential complications of those aneurysm surgery. MATERIAL AND METHODS: During the past 12 years, thirty six cases of large and giant aneurysms(diameter>19mm) were managed by surgery. The clinical characteristics, treatment methods, surgical complications and outcome of those cases were analyzed and, based on the review of the literatures, the preventive methods of surgical complication related to the clipping of those aneurysms were discussed. RESULTS: The locations of those aneurysms were anterior circulation in 34 cases and posterior circulation in 2 cases. The most frequent site of aneurysmal location was a paraclinoidal region of the anterior circulation. The aneurysms were managed surgically by direct clipping of aneurysmal neck in 31 cases, aneurysmal trapping followed by extracranial-intracranial bypass in 2 cases, proximal clipping of parent artery, aneurysmorrhaphy, and excision of aneurysm followed by end to end anastomosis of parent artery in each one case. Surgical complications occurred in 13 cases. A parent vessel occlusion by thrombus formation and parent vessel stenosis after clipping of aneurysm were the main complications. We obtained good outcome in 27, fair 5, poor 1 and dead in 3 case(s). CONCLUSION: We conclude that selection of suitable management method for each case, high quality of surgical technique and prevention of complication during operation are important key points for the successful treatment of large and giant aneurysm. The heparinization prior to application of temporary clip on parent vessels, aneurysmal decompression during dissection and clipping of aneurysm, complete closing of the aneurysmal neck and avoiding the narrowing of parent vessel after clipping of aneurysm were the main technical maneuvers used to avoid complications of those aneurysm surgery.

An Analysis of Factors Related to Rebleeding in Patients with Aneurysmal Subarachnoid Hemorrhage / 대한뇌혈관학회지

OBJECTS: To assess risk factors related to the occurrence of rebleeding in patients with aneurysmal subarachnoid hemorrhage (SAH) who had been planned to the early surgery, this study was conducted retrospectively. MATERIAL AND METHODS: During the period from January, 1993 to December, 1995, 258 patients with aneurysmal SAH who admitted within 3 days of their SAH and had been planned to early surgery were selected as study population. Ten variables including age, sex, hypertension history, rebleeding before admission, systolic blood pressure on admission, intracerebral or intraventricular hematoma, clinical grade, computed tomographic (CT) grade, admission time after SAH, hemostatic parameter were analyzed by the univariate and multivariate logistic regression method using the Statistical Analysis System (SAS). RESULTS: Of the 258 patients, 25 (9.69%) patients had rebleeding. Admission within 2 hours after SAH (p=0.001), clinical grade IV-V (p=0.015), rebleeding before admission (p=0.000), and intracerebral or intraventricular hematoma (p=0.04) appeared to be associated with a higher risk of rebleeding on the univariate analysis. Particularly, the patients who admitted to hospital within 2 hours after SAH and who are clinical grade IV or V appeared to be more likely to have early rebleeding. Rebleeding before admission was revealed as a independent factor associated with rebleeding on the multivariate logistic regression analysis. CONCLUSION: The short course use of antifibrinolytics, 3-dimensional CT angiography and endovascular surgery should be considered for the patients with aneurysmal SAH who have rebleeding history before admission, intracerebral or intraventricular hematoma, who admit to hospital within 2 hours after SAH, and who are clinical IV or V to minimize rebleeding in the interval between SAH attack and early surgery.

Clinical Analysis of Management of Spine-injuried Patients: Experince in the Suburban

The incidence of spine trauma has been increasing. To investigate the incidence, characteristics, and difficulty in management of the acute spine-injuried patients in suburban area we analyzed 50 cases treated conservatively or by operative fusion over a recent one-year period. This study comprised of 26 females and 24 males, between 23 and 83 years old patients with injury of whole column of spine. The most frequent cause of injury was traffic accident. The most common lesion was the compression fracture of the first lumbar spine. Most patients complained neck or back pain on admission. In 3 cases, neurological deficits were noted. For six patients, surgical treatment were performed and 44 patients has been conservatively managed with halo brace, neck collars, and thoracolumbar orthoses. The average period of admi-ssion and immobilzation for the conservatively treated patients was 6 weeks. During which time a few complications such as progressive kyphosis, hypoalbuminemia, thrombophlebitis, urinary tract infection, paralytic ileus, bed sore, and alcohol withdrawal syndrome were aroused. In most cases, good outcomes were achieved. Most of geriatric patients, concomitant systemic diseases with cardiovascular and pulmonary dysfunction were usually present and absence of the insight on spine injury made difficulties in managment. On the basis of these results we concluded that most elderly patients with spine fracture coulde be effectively treated by conservative methods, and also careful and systemic management with adequate education for patients and their families were required.

A Morphological Study of Synaptic Reorganization in Mossy Fibers of the Dentate Gyrus according to Hippocampal Sclerosis in Temporal Lobe Epilepsy: A Comparison of Intraoperative ECoG Findings for Tailored Resection

This study was carried out to identify synaptic reorganization by mossy fibers of epileptic dentate gyrus by Timm sulphide silver histochemistry and to investigate degree of synaptic reorganization according to both hippocampal sclerosis and epileptiform discharge in human temporal lobe epilepsy(TLE). The control group was composed of two hippocampal tissues obtained from autopsied brain without neurological abnormalities. TLE group was composed of thirteen hippocampal tissues obtained from surgically resected temporal lobe. Among thirteen hippocampal tissues, five specimens were obtained both of two areas of each hippocampus with or without prominent epileptiform discharges on electrocorticogram(ECoG) for tailored hippocampal resection. Hippocampal cell density was quantitatively analyzed in TLE group and compared with that of control group. A portion of hippocampal tissue was observed under light microscopic and transmission electron microscopes after development with Danscher method. The results were as follows : Hippocampal cell loss was noted in all TLE group. Hippocampal cell loss greater than 30% of control values was found in 12 cases and average hippocampal cell loss was 70%(range 39-88%). The remaining 1 case had 13% hippocampal cell loss. The supragranular Timm granules were noted in inner molecular layer of dentate gyrus and tended to significantly increase in proportion as severity of hippocampal sclerosis. Average of hippocampal cell loss in two areas of five hippocampal tissues with or without prominent epileptiform discharge on ECoG was 73.6%(range 53-90%) and 66.4%(range 50-86%), which showed statistically significant (p<0.05) difference between these two areas and the supragranular Timm granules also tended to increase in the hippocampal tissue with epileptiform discharge. On transmission electron microscope, there showed distinct supragranular Timm granules correspond to mossy fiber synaptic terminals. The results of this study demonstrated that mossy fiber synaptic reorganization seems to play a major role in pathogenesis of human TLE and the development of mossy fiber synaptic reorganization is closely related to severity of hippocampal sclerosis. The result also support the rationale for tailoring the extent of hippocampal resection by intraoperative acute recording(ECoG) according to individual pathophysiology.

Surgery of Intractable Epilepsy with Calcified Mass Lesions in the Temporal Lobe

We present 10 patients who underwent temporal lobe surgery for seizure control on our institution between December, 1992 and October, 1994. Preoperative neuroimaging studies of all 10 patients showed calcified mass lesions within the temporal lobe. Among them, 5 cases had mesial temporal calcified mass close to the hippocampus, 3 diffuse mass in the temporal lobe or multilobes and 2 in the temporal tip. All patients presented with complex partial seizure and seven had secondary generalization from their seizures. The duration of epileptic seizure varied between 4 and 23 years(mean 13 year). The patients were refractory to therapeutic levels of anticonvulsant medication. Presurgical evaluations of epilepsy included a detailed clinical history, multiple scalp/shenoidal EEG, prolonged Video-EEG monitoring, neuroimaging, neuropsychological test, WADA test and invasive study with subdural strip electrodes. Anterior temporal lobectomy with lesionectomy were performed in six cases and anterior temporal lobectomy in four cases using intraoperative electrocorticography(EcoG) and/or functional mapping under local or general anesthesia. The extent of resection of amygdala and hippocampus were determined according to electrocorticographic findings. The verified histopathology of the calcified lesions revealed 1 oligodendroglioma, 1 mixed glioma, 1 arterioveous malformation, 1 paragonimiasis, 2 neurocysticercosis, 1 other parasitic granuloma and 3 calcified fibrous nodule. In four patients, severe hippocampal sclerosis with neuronal cell loss and gliosis were observed. After a mean postoperative follow-up of 9 months, 9 patients showed a seizure-free outcome and one patient a significant reduction in seizure activity. We conclude from our studies that temporal lobe surgery for patients refractory to therapeutic levels of long-term anticonvulsant medication can result in excellent postoperative seizure-free outcome in the majority of the patients, and that brain tumors, vascular malformations, and parasitic infections may be considered as etiologic factors of calcified mass lesions in the temporal lobe of such patients.

Angiographically Occult Cerebral Vascular Malformations

In order to obtain more accurate pathological diagosis of the angiographically occult vascular malformations(AOVM) of the brain in the future and to examine the clinical, and radiological characteristics and management outcome of the AOVM, the authors retrospectively reviewed the 30 cases of AOVM in which patients were treated at our instituition during the past 11-year period. The pathological specimens were reexamined, and the lesions were reclassified according to the strict histopathological criteria. The clinical characteristics, radiological features, the difference between the clinical and pathological diagnosis and the management results were studied. There were 15 males and 15 females. The mean age at the time of diagnosis was 31 years, ranging from 3 months to 74 years. The clinical diagnosis were arteriovenous malformation(AVM) in 18 cases, cavernous angioma in 11 and mixed lesion in 1. The pathologic diagnosis was AVM in 14 cases, cavernous angioma in 2, and unclassified lesion in 12. The common presenting symptoms were hemorrhage(53.3%), seizure(20.0%) and mass lesions(20.0%). Twenty four lesions were located at the supratentorial region, 4 at cerebellum and 2 at pons. Most of the lesions were revealed as high density masses with minimal or no contrast enhancement on CT and a core of mixed signal intensity with a peripheral low signal intensity rim on T2-weight MRI. Preoperative clinically significant recurrent hemorrhages were noted in 8 cases and one of them showed marked deterioration of the neurological functions a result of recurrent hemorrhage. Twenty-eight patients underwent surgery and all except one improved neurologically. Six patients initially presented with seizure showed improvement in seizure frequency after operation. One patient who had the lesion at the pons was managed by a radiosurgery and one patient who refused surgery was managed by a conservative method. The conservatively managed patient and another patient who was not found AVM at the hematoma cavity during initial operation rebled about 2 years later following diagnosis and surgery. Thse findings suggest that the complete microsurgical excision, which prevents rebleeding and suppresses seizure activity, represents the treatment of choice for patients with clinically symptomatic AOVM. Avoiding the injury of the vascular mass, obtaining sufficient biopsy specimen during surgery, together with careful histopathological observation of operative specimens through complete clinical-radiological-pathological context are necessary to obtain more accurate pathological diagnosis.