Early Treatment of Pseudo-Sac Formation in a Thrombotic Cavity at the Aneurysm Rupture Site

The authors report on an endovascular experience using electrically detachable coils and direct clipping for the treatment of ruptured irregularly shaped aneurysms associated with pseudo-sac formation in a thrombotic cavity at the rupture site. These aneurysms might be fragile and associated with a high possibility of repeated rupture, especially, during an endovascular and direct clipping procedures. Between March 1998 and August 2001, 298 aneurysm patients underwent operations at our hospital. Among these patients, 4 patients showed pseudo-sac formation in a thrombotic cavity at the aneurysm rupture site, and were treated using an early endovascular occlusion technique or direct clipping after diagnostic angiography. These aneurysms showed delayed opacification and delayed washout of contrast medium from the irregularly shaped portion of the aneurysm on digital subtraction angiography. Moreover these aneurysms tend to rerupture during GDC embolization because of the fragile pseudoaneurysmal thrombotic cavity at the rupture point. Ruptured aneurysm with pseudo-sac formation in thrombotic cavity display delayed and irregularly shaped filling and retention of contrast medium at the rupture point. Early treatment of these aneurysms prevents rebleeding from the pseudo-sac in the thrombotic cavity at the ruptured site.

Management of The Poor Grade Aneurysm Patient / 대한뇌혈관학회지

Patients who suffer a severe aneurysmal subarachnoid hemorrhage(SAH) and who have arrived in the emergency room with devastated neurological or medical condition by this event are categorized as poor grade(Grade IV or V) aneurysm patients. As the poor grade patients are more prone to develop rebleeding, acute hydrocephalus, intracerebral and intraventricular hematoma, and delayed ischemic neurological deficits, the management of these patients remains challenging and controversial. However, it is now becoming evident that a significant number of the poor grade patients can be salvaged with an aggressive management from the moment of patient's arrival to the hospital. Initial management for the poor grade patients should be directed to the life threatening conditions such as cardiopulmonary depression, seizure, acute intracranial hypertension and rebleeding. The authors suggest that: 1) the Grade IV patients should be treated aggressively with direct clipping for patients with non-complex aneurysms, acute hydrocephalus, or significant amount of intracerebral hematoma; 2) The Grade V patients who show neurological improvement with supportive care could be the patients for an aggressive management; 3) Intra-aneurysmal treatment with Guglielmi Detachable Coil would be an alternative therapeutic option in the poor grade patients with advanced age, poor general physical condition, or complex aneurysm such as aneurysm of the posterior circulation or paraclinoid segment of the internal carotid artery.

Direct Microsurgical Clipping of Cavernous Carotid Artery Aneurysms

We have recently operated directly on two patients with multiple aneurysms including cavernous carotid artery aneurysms(CCAAS). The pterional extradural transclinoidal and intradural transcavernous approach was used for CCAAS in two patients. Both two CCAAS could be clipped in Dolenc's anteromedial triangle between the optic nerve and the IIIrd nerve. There was no surgical mortality and morbidity was minimal. The combined extradural and intradural transcavernous approach was very useful and safe for direct clipping of CCAAS.

Direct Microsurgical Repair of Traumatic Carotid-Cavernous Fistula

The case of a 55-year-old male developed high flow carotid-cavernous fistula(ccF) after head trauma was successfully treated by a direct microsurgical approach to the cavernous sinus. The cavernous sinus was approached through Dolenc's anteromedial and paramedical triangle by a combined extradural and subdural route. A single tear in the wall of horizontal segment of the cavernous carotid artery was obliterated using Sugita clip while temporary clips were placed on the supraclinoid and the petrous portion of the internal carotid artery.

Subtemporal Approach for Basilar Bifurcation and Basilar-Superior Cerebellar Artery Aneurysms

The pterional(Transsylvian) and subtemporal approaches are main surgical route for direct clipping of basilar bifurcation and basilar-superior cerebellar artery aneurysms. In general , the pterional approach has the advantage for high placed aneurysm and the subtemporal approach has the advantage for low placed and posterior directed aneurysm of basilar bifurcation. The authors has been performed surgery for 5 cases of basilar bifurcation and basilar-superior cerebellar artery aneurysms through subtemporal route during 1.5 years with good results in 3 cases, fair result in 1 case, and death in 1 case. We described about this 5 cases detaily and discussed the subtemporal approach for these lesions.

Oculomotor Nerve Palsies in Intracranial Aneurysms

The authors reviewed twenty four patients with internal carotid-posterior communicating artery aneurysms with oculomotor palsy from 1976 to 1984. The incidence of third nerve palsy in the posterior communicating artery aneurysms was 37.5%(24 out of 64). The occurrence of the third nerve palsy without subarachnoid hemorrhage was 20.8%(5 out of 24). The initial degree of third nerve involvement seems to parallel the degree of recovery. Direct clipping of the aneurysm showed far better results than those of carotid ligation. The average duration of neurological recovery was 4.9 month after treatment. The order of third nerve function recovery was as follows:ptosis, pupil, medial gaze, and upward and downward gaze.