Cerebral Bypass Surgery for Treating Unclippable and Uncoilable Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Fusiform and dissecting aneurysms cannot be treated with conventional clipping or coiling surgery. Various methods are used for treating these aneurysms, including proximal occlusion of the parent artery or trapping the aneurysms with or without cerebral revascularization. We report here on our experience with treating unclippable and uncoilable aneurysms and we present the clinical and angiographic outcomes. METHODS: Nine patients with unclippable and uncoilable aneurysms were managed during a 5 year period at our institution. We retrospectively reviewed all the patients with aneurysms and who underwent multimodal techniques. The mean age of the 9 patients was 56.5 years. The mean clinical follow-up period was 28.1 months. Six patients presented with subarachnoid hemorrhage and 2 had diplopia. Of these patients, 3 had aneurysms arising from the posterior inferior cerebellar artery (PICA), 2 had vertebral artery (VA) aneurysms, 2 had internal carotid artery aneurysms and 2 had middle cerebral artery aneurysms. Eight aneurysms were fusiform and 1 was a giant saccular aneurysm. RESULTS: The treatment included surgical trapping with bypass in 4 patients, endovascular trapping with bypass in 4 patients and vein graft bypass in 1 patient. Among the bypass surgeries, high-flow bypass was performed for a giant internal cerebral artery (ICA) aneurysm. Trapping of the aneurysms with coil and occipital artery (OA)-PICA bypass were performed for 2 VA aneurysms of the PICA origin. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. CONCLUSION: The cerebral bypass technique is a useful, safe for the treatment of dissecting and otherwise unclippable/uncoilable aneurysms.

Surgical Management of Massive Cerebral Infarction

OBJECTIVE: The aim of this study was to analyze the treatment results and prognostic factors in patients with massive cerebral infarction who underwent decompressive craniectomy. METHODS: From January 2000 to December 2005, we performed decompressive craniectomy in 24 patients with massive cerebral infarction. We retrospectively reviewed the medical records, radiological findings, initial clinical assessment using the Glasgow Coma Scale, serial computerized tomography (CT) with measurement of midline and septum pellucidum shift, and cerebral infarction territories. Patients were evaluated based on the following factors : the pre- and post-operative midline shifting on CT scan, infarction area or its dominancy, consciousness level, pupillary light reflex and Glasgow Outcome Scale. RESULTS: All 24 patients (11 men, 13 women; mean age, 63 years; right middle cerebral artery (MCA) territory, 17 patients; left MCA territory, 7 patients) were treated with large decompressive craniectomy and duroplasty. The average time interval between the onset of symptoms and surgical decompression was 2.5 days. The mean Glasgow Coma Scale was 12.4 on admission and 8.3 preoperatively. Of the 24 surgically treated patients, the good outcome group (Group 2 : GOS 4-5) comprised 9 cases and the poor outcome group (Group1 : GOS 1-3) comprised 15 cases. CONCLUSION: We consider decompressive craniectomy for large hemispheric infarction as a life-saving procedure. Good preoperative GCS, late clinical deterioration, small size of the infarction area, absence of anisocoria, and preoperative midline shift less than 11mm were considered to be positive predictors of good outcome. Careful patient selection based on the above-mentioned factors and early operation may improve the functional outcome of surgical management for large hemispheric infarction.

Saccular Aneurysm of the Azygos Anterior Cerebral Artery: Three Case Reports

The azygos anterior cerebral artery, a rare anomaly in the circle of Willis in which only a single vessel supplies the medial aspects of both anterior cerebral hemispheres, is closely associated with saccular aneurysms. We present three cases of azygos anterior cerebral artery aneurysms among the 781 cerebral aneurysms surgically treated at our institution in an 11-year period. These three cases all involved elderly women who presented with subarachnoid hemorrhage. Conventional cerebral angiography and CT angiography revealed small saccular aneurysms at the distal ends of the azygos anterior cerebral arteries. These aneurysms were clipped successfully using a bifrontal interhemispheric approach. Hence, the pathogenesis of these particular aneurysms relating to hemodynamic change, associated anomalies, and surgical pitfalls is discussed with review of literature.