Superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis in treating moyamoya disease: surgical techniques, indications and midterm follow-up results / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Surgical interventions for moyamoya disease include direct and indirect revascularizations. This study aimed to evaluate the therapeutic effect of superficial temporal artery-middle cerebral artery bypass combined with an indirect revascularization procedure, encephalo-duro-myo-synangiosis, in the treatment of moyamoya disease.</p><p><b>METHODS</b>From October 2005 to November 2009, we performed this combined revascularization procedure in 111 patients with different types and stages of moyamoya disease. The superficial temporal artery, middle meningeal artery and the deep temporal artery were evaluated for individualized surgical planning in these cases. The integrity of the deep temporal artery and the middle meningeal artery network, and the pre-existing spontaneous anastomoses of the distal branches of the external carotid artery with the cortical arteries were well preserved. The mean follow-up time was 72.5 months, all clinical and radiological data were retrospectively reviewed.</p><p><b>RESULTS</b>A total of 198 stomas were performed in 122 hemispheres, all remaining patent until the last follow-up. The encephalo-duro-myo-synangiosis resulted in extensive anastomoses of the deep temporal artery (100%), the middle meningeal artery (90.9%), and the sphenopalatine artery (39.8%) with the cortical arteries, respectively. The superficial temporal artery, deep temporal artery, and the middle meningeal artery were significantly thickened in 88 patients as determined by digital subtraction angiography at follow-up. The relative cerebral blood flow increased significantly within one week after the operation. At 6 months post the operation, the relative cerebral blood flow was further increased by 15.5% from the gradual formation of anastomoses as a result of indirect revascularization. Transient ischemic attacks were effectively reduced or totally arrested. The neurological deficits significantly improved in 37 patients, with the National Institutes of Health Stroke Scale scores lowered by 2-8. There was no rehemorrhage in hemorrhagic moyamoya disease patients.</p><p><b>CONCLUSION</b>This study showed that the superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis can achieve good therapeutic effect in the treatment of moyamoya disease.</p>

Surgical treatment for the giant aneurysms of middle cerebral artery / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the surgical treatment of the giant aneurysms of middle cerebral artery.</p><p><b>METHODS</b>Clinical data, surgical methods and outcomes were analyzed in 17 giant aneurysms of middle cerebral artery treated from January 2001 to March 2008. CT scan, CTA, MRA, DSA and 3D-DSA were performed before operations so that we could comprehend the location, size, and shape of aneurysms and compensatory circulation of collateral branches to design the individualized treatment options. All patients had been surgically treated mostly by modified pterional approach, of which, direct clipping of the aneurysms was accomplished in 4 patients, aneurysms trapping or removal after trapping in 4, aneurysms excision or trapping combined with vessels reconstruction in 7, and aneurysms wrapping in 2 cases.</p><p><b>RESULTS</b>CT and MRI revealed the shape and size of aneurysms clearly, while DSA and 3D-DSA could demonstrate the aneurysm's neck and relationship with the adjacent structure. Postoperative neurological function was evaluated according to Glasgow Outcome Scale when patients were discharged. Twelve patients had excellent neurological outcomes. However 4 patients were moderately disabled and one were severely disabled. No patient was dead postoperatively.</p><p><b>CONCLUSIONS</b>It is necessary to perform elaborate imaging before operations for individualized surgical planning. The temporary occlusion of the parent artery and elimination of intra-aneurysmal thrombus are helpful to clipping the aneurysmal neck. Vessels reconstruction is a new and effective method of treating the giant aneurysms of middle cerebral artery.</p>

Clinical experience of 70 cases of cerebral arteriovenous malformations embolization with Onyx, a novel liquid embolic agent / 中华外科杂志

<p><b>OBJECTIVE</b>To report our clinical experience of using Onyx, a new liquid embolic agent, to treat cerebral arteriovenous malformations (AVMs) as well as its efficacy.</p><p><b>METHODS</b>Seventy cases were placed with 6F sheath in the femoral artery after Seldinger puncture and 6F guiding catheter was introduced into the internal carotid artery or vertebral artery, then a microcatheter was navigated into the nidus of AVMs. Slow injection of Onyx under fluoroscopic control was performed to embolize cerebral AVMs using the "plug and push" technique.</p><p><b>RESULTS</b>Thirteen AVM cases (18.6%) were totally occluded by Onyx and 5 cases of which didn't recurrence at 6-month after operation. Thirty-eight cases (54.3%) were subtotally occluded, while another 19 cases (27.1%) were partially embolized. Severe cerebral hemorrhage occurred in 4 cases, 2 of which had mild to severe hemiplegia after operation, and one died. Mild hemiplegia was also found in 1 case due to functional area embolization, and visual field deficit in 2 cases.</p><p><b>CONCLUSIONS</b>Onyx has unique and distinctive superiority in treating cerebral AVMs. Nonetheless, the correct embolization technique should be learned to achieve good clinical results and avoid complications.</p>

Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate clinical strategy and effect of early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm.</p><p><b>METHODS</b>Seventy-five patients presenting with anterior circulating aneurysmal subarachnoid hemorrhage (SAH) underwent early-mid-phase (within 3 days or 3-10 days) microsurgical clipping at Huashan Hospital between January 2001 and August 2004. Glasgow outcome scale (GOS) was conducted to evaluate patients' outcomes.</p><p><b>RESULTS</b>Of 81 intracranial aneurysms, 77 lesions were clipped successfully, and 4 were wrapped. Good outcome was achieved in 53 cases, mild disability in 9 cases, severe disability in 7 cases, persistent vegetative state in 3 cases, and 3 patients (4%) died after surgery. The difference of GOS was statistically significant between patients in Hunt and Hess Grade I-III and Grade IV-V. However, there was no significant difference between early surgery and metaphase surgery.</p><p><b>CONCLUSIONS</b>Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm is considered the feasible opinion.</p>

Risk factors for intracranial aneurysm in a Chinese ethnic population / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Intracranial aneurysm (IAN) is a protruding bubble or a sac on a brain artery that balloons out over time, which may lead to spontaneous subarachnoid hemorrhage (SAH), ultimately disability and mortality. Current research indicates that the disease is due to multiple causes, including environmental factors and various congenital abnormalities of blood vessels. Apart from congenital predisposition, various high-risk factors such as sex, age, hypertension, and atherosclerosis are involved in the formation of intracranial aneurysms. The aim of this study was to investigate the risk factors associated with the formation of sporadic intracranial aneurysms in Chinese Han ethnic patients.</p><p><b>METHODS</b>A total of 251 patients with intracranial aneurysm and 338 patients with other cerebral diseases (control group) were enrolled in this study. Single factor and logistic regression model were used to analyze the association of intracranial aneurysms with age; sex; cigarette smoking; alcohol or cocaine consumption; history of hypertension, coronary artery disease, diabetes mellitus and inherited connective tissue disease; and the levels of fasting blood glucose and blood fat. The data expressed as mean +/- standard deviation were processed with the statistical software SPSS13. Quantitative and qualitative data were analyzed by the independent-sample t test, and the chi-square test respectively. Logistic regression method was used to analyze the multiple factors.</p><p><b>RESULTS</b>In the 251 patients, 163 (64.94%) were at age of 40 to 60 years. Sex (OR, 1.41; 95% CI, 1.01 - 1.96), cigarette smoking (OR, 1.81; 95% CI, 1.06 - 3.10), hypertension (OR, 2.32; 95% CI, 1.30 - 4.16) and fasting blood glucose were significantly associated with intracranial aneurysm (P < 0.05). Intracranial aneurysm was correlated with alcohol consumption, coronary artery disease, and the level of blood lipids (P > 0.05). Using logistic regression analysis, we identified female sex and advanced age as significant risk factors for sporadic intracranial aneurysms.</p><p><b>CONCLUSIONS</b>Sporadic intracranial aneurysms mostly occur in people aged 40 to 60 years. Feminine, cigarette smoking, and hypertension are independent risk factors for the disease, and the gender is the most significant factor. Advanced age can increase the effect of these risk factors.</p>

A novel liquid embolic agent Onyx in the treatment of intracranial aneurysms: Preliminary experience / 中国脑血管病杂志

Objective: To explore the therapeutic effect of Onyx (an embolic agent) in the embolization of intracranial aneurysms. Methods: 16 patients with intracranial aneurysms were treated endovascularly, 5 patients with small aneurysms (2 with a narrow-neck, 3 with a wide-neck), and 11 patients with large or giant intracranial aneurysms (all with wide-neck). One patient with large aneurysm recanalized after coiling, and was retreated with Onyx, and the remaining 15 patients were treated with Onyx only. The follow-up time was 6 months to 2 years by letters or digital subtraction angiography (DSA) after the procedures. Results: All the 5 small aneurysms were 100% occluded; of 11 large or giant aneurysms, 7 aneurysms were 100% occluded and 4 aneurysms were 95% occluded. All their parent arteries remained patent. Three patients had procedure-related complications: 1 patient had ipsilateral intracerebral hematoma immediately after the procedure; and 1 patient with the internal carotid-cavernous sinus aneurysm whose oculomotor paralysis worsened after the procedure; another with internal carotid-posterior communicating artery aneurysm had contralateral hemiparesis. The procedure-related morbidity and mortality were 12% and 6%, respectively. Six patients were followed up by DSA, 2 small aneurysms and 1 large aneurysm did not recur, 3 giant aneurysms recurred. The 9 remaining patients were followed-up by letters. Eight patients no new symptom occurred and one died of unknown cause. Conclusion: Both short- and long-term efficacy of Onyx for small wide-necked aneurysms is good, and the short-term efficacy for large and giant wide-necked aneurysms is satisfactory.

Cerebral revascularization in treatment of intractable aneurysms / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the effectiveness of cerebral revascularization in the treatment of intractable aneurysms and to discuss the indications, surgical techniques, and the outcome of the revascularization.</p><p><b>METHODS</b>During the recent 4-year period, 9 radical artery grafts were performed in patients with intractable or giant internal carotid artery (ICA) aneurysms. The indications for cerebral revascularization included parent vessel occlusion during the treatment of the intractable aneurysms with poor collateral circulation or the young patients. Modified techniques were taken to use the main trunk of superficial temporal artery (STA) as donor, while M3 branches near the bifurcation of the M2 segment of the middle cerebral artery (MCA) were chosen as the recipient arteries. STA-Radial artery (RA)-MCA bypass was followed by parent vessel occlusion via chronic cervical ICA ligation or balloon occlusion.</p><p><b>RESULTS</b>Postoperative angiography demonstrated the patency of the grafts in eight cases. The procedure of the parent vessels occlusion was uneventful in these patients. Follow-up showed the patients were in excellent conditions after successful treatment of aneurysms. Significantly delayed filling of the graft was revealed in one patient, who could not tolerate balloon occlusion test and occlusion of parent artery failed.</p><p><b>CONCLUSIONS</b>Extracranial-to-intracranial bypass followed by parent vessel occlusion is a safe and effective method to treat intractable ICA aneurysms. Radical artery as graft can offer high-flow revascularization with less complications. Combined surgical and endovascular treatment might be the future direction for the treatment of the difficult aneurysms.</p>

Diagnosis and treatment of tentorial dural arteriovenous fistulae / 中华外科杂志

<p><b>OBJECTIVE</b>Tentorial dural arteriovenous fistulae are uncommon but life-threatened lesions. We present our experience of 5 cases with tentorial dural arteriovenous fistulae, review the relevant literature and present the rationale of our current management strategy.</p><p><b>METHODS</b>The data of five patients with tentorial DAVF treated in Huashan Hospital between June 2002 and May 2003 were reviewed retrospectively, including their ill history, neuroimagings, operation records and follow-up data.</p><p><b>RESULTS</b>There were 3 females and 2 males with age from 25 to 52 years (average, 42.6 years). Clinical manifestations were acute subarachnoid hemorrhage in 2 cases, progressing neurological deficits in 3 cases. MRI and DSA were major diagnostic and follow-up modalities. Borden classification type II was in 1 case, type III in 4 cases. According to DAVF location, tentorial marginal type were in 3 cases, tentorial lateral type 1 case, tentorial medial type 1 case. Two patients had transarterial embolization preoperatively. All patients underwent craniotomy with the coagulation of the nidus and tentorium, disconnection of leptomeningeal venous drainage. The surgical approaches were via trans-anterior-petrous approach in 3 cases, transpterional subdural approach 1 case, transoccipital and transtentorial approach 1 case. All patients had clinical improvement, there was no surgical mortality and morbidity. Postoperative DSA confirmed obliteration of DAVF in 3 cases, MRI demonstrated the thrombosis of venous aneurysm and the disappearance of previous brainstem edema, partial thrombosis of venous aneurysm in 1 case. Follow-up study ranging from 1 to 2 year showed no recurrence and all patients resume their full activities.</p><p><b>CONCLUSIONS</b>Tentorial DAVF is an aggressive vascular lesion, causing subarachnoid hemorrhage and progressive neurological deficits. Prompt diagnosis and definite treatment for tentorial DAVF are mandatory. Obliteration of the nidus and/or leptomeningeal venous drainage should be the goal of treatment. Microsurgical procedures with/without endovascular intervention are the best choice of treatment.</p>

Embolization of intracranial aneurysms with new mechanically detachable coils / 中国医学科学院学报

<p><b>OBJECTIVE</b>To primarily embolize intracranial aneurysms with new-developed mechanically detachable coils, which is called Detachable Coil System (DCS).</p><p><b>METHODS</b>Five intracranial aneurysms were embolized with DCS, in which 2 were giant aneurysms. DCS with J coils were initially used to make baskets in giant aneurysms, and then other kinds of coils were utilized to pact the aneurysmal cavity. Whereas, spiral coils were mostly used in smaller aneurysms. Coils of DCS were detached by rotating the delivering wire after the coils were satisfactorily positioned in aneurysms.</p><p><b>RESULTS</b>Two of the 5 cases were totally occluded with DCS. Two was sub-totally embolized. Pushing, withdrawal, and adjusting of DCS were safe and efficient. Detachment of DCS was fast. In one case of wide-necked giant aneurysm, coils could not stay inside the aneurysm, which was treated by occlusion of the parent artery.</p><p><b>CONCLUSIONS</b>DCS is a new addition to the interventional radiologist's armamentarium. Detachment is faster. J coils are suitable for giant aneurysms for its unique way of coiling. But more evaluation depends on accumulation of the clinical usage.</p>