Microcirugía asistida por endoscopia en el clipado de aneurismas gigantes y del segmento carotídeo comunicante posterior / Endoscopic assited microsurgery for clipping of giant aneurysms and carotid portion of posterior communicating aneurysms

Objetivo. Describir la utilidad de la endoscopia en el clipado microquirúrgico de aneurismas cerebrales. Descripción: Paciente de 62 años de edad con diagnóstico de aneurisma gigante de la arteria carótida interna (ICA) asociado amúltiples aneurismas, uno de ellos en el segmento carotídeo comunicante posterior (Pcom). Intervención. Se resolvió el aneurisma gigante carotídeo y el comunicante posterior con técnica microquirúrgica mediante el clipado,y éste último se clipó con la asistencia del endoscopio. Conclusión. En casos con aneurismas de ICA gigantes y aneurismas ICA-PcomA la microcirugía asistida por endoscopia provee acceso a las áreas ocultas al microscopio, permitiendo una apropiada oclusión del cuello aneurismático con preservación de perforantes

Objective. To describe the importance of the aid of the neuroendoscopein the microsurgery of cerebral aneurysms. Description. 62 years old female patient with an internal carotidartery giant aneurysm (ICA) and multiple aneurysms, one of them in the posterior communicant carotid segment (pcom). Intervention. Both of them were treated with microsurgery, and the pcom aneurysm was clipped with the assistance of endoscopy. Conclusion. In cases with giant and pcom aneurysms the endoscope assisted microsurgery is useful, providing good access to hidden fields to microscope, allowing a properlyocclusion and preservation of perforators branches.

Clipado de aneurismas grandes y gigantes asistidos por técnicas de compresión por succión retrógrada / Assisted clipping of giant and big aneurysms by the technique of decompression by retrograde suction

Objetivo. Presentar la experiencia del Hospital Fujita Health University en el clipado de aneurismas cerebrales de tamaño grande y gigante asistida por descompresión por succión retrógrada, analizando sus ventajas y desventajas.Material y método. Análisis retrospectivo de 30 pacientes con diagnóstico de aneurismas cerebrales grandes y gigantes tratados por clipado asistido por descompresión succión retrógrada tratados entre Noviembre 2005 y Junio 2010. La técnica quirúrgica y el pronóstico fueron revisados. Resultados. Todos los aneurismas fueron clipados correctamente, y posteriormente se realizaron angiotomografías 3D o angiografías con sustracción digital, demostrando permeabilidad de ramos perforantes, y clipado aneurismático sin cuello remanente. En esta serie no hubo mortalidad postoperatoria. Conclusión. La técnica de descompresión por succión retrógrada es de gran utilidad en el tratamiento definitivo de aneurismas grandes y gigantes.

Decompressive hemicraniectomy for malignant MCA territory infarction

A number of patients with ischemic cerebrovascular stroke suffer a progressive deterioration secondary to massive cerebral ischemia, oedema, and increased intracranial pressure [ICP]. The evolution is often fatal. Stroke is the second leading cause of death worldwide. Life-threatening, complete middle cerebral artery [MCA] infarction occurs in up to 10% of all stroke patients, and this may be characterized as massive hemispheric or malignant space-occupying supratentorial infracts[35-50] Malignant, space-occupying supratentorial ischemic stroke is characterized by mortality up to 80%, several reports indicated a beneficial effect of hemicraniectomy in this situation, converting the closed, rigid cranial vault into a semi open. The main cause of death encountered in these patients is severe postischemic brain oedema leading to raised ICP, clinical deterioration, coma, and death [20-44]. The result is dramatic decrease in ICP and a reversal of the clinical and radiological signs of hemiation. For these reasons, decompressive craniectomy has been increasingly proposed as a life-saving measure in patients with large, space-occupying hemispheric infarction. Recent successes with intra-venous [52] and intra-arterial[11] thrombolytic therapy have resulted in an increased awareness of stroke as a medical emergency[52] Thus, increasing numbers of patients are being evaluated in the early hours following the ictal event. In the process of gaining more experience in the early management of patients with acute ischemic stroke, it has become clear that in a number of these patients a progressive and often fetal deterioration secondary to mass effect from the oedematous, infarcted tissue occurs. An increasing body of experimental and clinical evidence suggests that some of these patients may benefit from undergoing a decompressive craniectomy but the timing and indications for this potential lifesaving procedure are still debated. Early hemicraniectomy based on radiographic and clinical criteria, but before signs of brainstem hemiation, has been proposed as a means of improving outcomes. The objectives of the review are to help better define the selection criteria for performing the surgery in case of supratentorial infarctions, to asses the immediate outcome in terms of time conscious recovery and survival and to assess long term outcome using standard and functional assessment scales

Use of multiple clips for arterial reconstruction in wide neck intracranial anterior circulation aneurysms

Aneurysm clips of different shapes, sizes, fenestrated or non fenestrated can be applied for reconstruction of the arteries in cases of wide necked aneurysms. By fashioning different clips and applying them to the aneurysmal neck in patients with wide necked aneurysms, we describe the method of approximation of the inner walls of the neck of the aneurysm extending to the parent artery leading to complete exclusion of the aneurysm from the circulation. This method also confirms the approximation of the intimae on both the sides of the neck. After exposing the aneurysm, its parent artery and the perforators, the aneurysm neck is carefully dissected; the perforating arteries are also carefully dissected away. Appropriate clip selection is made and clip is applied to the neck of the aneurysm so that the walls of aneurysm which extend into the parent artery are also approximated, thus no remnant of the aneurysm is left behind, in the part extending into the parent vessel. Repeat angiograms done after 3 months of surgery showed no regrowth, or incomplete occlusion of the aneurysm. This method of clip application avoids any recurrence or regrowth of the aneurysm. The greatest advantage of this method of the clip occlusion is that it takes care of the part of the aneurysm which extends into the parent artery, so that even the minimal possibility of any aneurysmal remnant is ruled out

Evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery

The goals of surgical treatment of intracranial aneurysms are to occlude the lesion and maintain blood flow in parent, branching and perforating vessels. We report our experiences in 3 cases using this method for intraoperative blood flow assessment, detection of incomplete clipping of aneurysm and to assess image quality and evaluate the clinical value of this method. A special arrangement of the filters was designed to allow the passage of near-infrared light required for the excitation of the indocyanine green [ICG] fluorescence [700 - 850 nm] from a modified microscope light source into the surgical field and the passage of ICG fluorescence [780 - 950 nm] from the surgical filed back into the optical path of the surgical microscope [Carl Zeiss, Oberkochen, Germany]. Thus, the ICG angiography could be completely performed with a surgical microscope. The reported 3 cases, one female and 2 male, either with incomplete or inadvertent clipping of the branching vessels of unruptured aneurysms were performed using ICG which was excellent in detection of incomplete or inadvertent clipping of the branching vessels

Fundamentals of AVM surgery: an institutional experience

Arteriovenous malformations [AVM] of the brain are congenital lesions and remain dormant for many years but can haemorrhage, cause seizure or impair brain function. Modern therapeutic modalities for AVM include microsurgery, intravascular neurosurgery and stereotactic radiosurgery. There is significant risk of intraoperative haemorrhage due to abnormal vessels as well as due to change in haemodynamic pattern of surrounding brain after excision. Inadequate coagulation of feeding vessels and draining channels, loss of plane between nidus and normal brain, persistent residual or daughter sinus and inadequate intraoperative blood pressure control are the main causes of haemorrhage. The main important aspect in AVM surgery is to identify the plane between the nidus and normal brain and work around the nidus. It is very important to aggressively reduce intraoperative haemorrhage and prevent or minimize the dilation of abnormal capillaries and arteries on the basis of fundamental surgical strategy, i.e., feeder-nidus-drainer. Adequate control is the key factor in prevention and treatment of haemorrhage. In a period of 8 years, from 1994-2003, our department dealt with 290 cases of AVM. In 212 patients, operative removal was performed, which included 89 cases with intracerebral haematoma. In 39 cases, embolisation and/or gamma knife was preferred