Neuroendoscopy in microsurgical clipping for ruptured posterior communicating artery aneurysms via keyhole approaches / 中华显微外科杂志

Objective:To explore the value of application and manipulation technique of neuroendoscope in microsurgical clipping of ruptured posterior communicating artery(PCoA)aneurysms via keyhole approaches.Methods:From January 2018 to December 2020, the clinical data of 52 patients who received microsurgical clipping for ruptured via keyhole approach were retrospectively analysed. Forty-one patients had the intraoperative endoscopic monitoring. The supraorbital keyhole approach or pterional keyhole approach was applied based on the characteristics of the aneurysms. According to the in-surgery requirement, a 30° rigid neuroendoscope was used before and/or after clipping. All patients entered postoperative follow-up in outpatient clinic and were evaluated with the modified Rankin Scale(mRS).Results:All 52 patients had 52 ruptured PCoA aneurysms. Eighteen of the patients were treated via supraorbital keyhole approach and 34 via pterion keyhole approach. Pre-and post-clipping endoscopic observation were carried out in 12 cases and 29 only with post-clipping endoscopic observation. Residual aneurysmal neck was detected in 3 patients. Missed clipping of perforators was found in 2 patients and followed by proper adjustment of clips. All patients received follow-up angiographic examinations. Total obliteration of the aneurysm and an intact of internal carotid artery and PCoA were found in 41 patients by the intraoperative endoscopic observation. Two residual aneurysmal neck were detected in 11 patients without intraoperative endoscopic observation. After 11 to 45 months of follow-up, all patients had good recovery(mRS 0-1).Conclusion:It is a safe and effective method with endoscopic observation during microsurgical clipping procedure for ruptured PCoA aneurysms via keyhole approaches. It can effectively make up for the insufficient visual angle of microscope, realise the anatomical relationship between the aneurysm and adjacent structures, and avoid residual aneurysmal neck and an iatrogenic injury to the parent artery and perforators.

Retrograde Stent-assisted Coil Embolization of Wide-neck or Branch-incorporated Posterior Communicating Artery Aneurysm

Endovascular coil embolization using a balloon- or stent-assisted technique for the treatment of wide-necked posterior communicating artery (PcomA) aneurysms is well established. However, complete aneurysm occlusion with preservation of the PcomA can be difficult in case of wide-neck aneurysms with a PcomA incorporation. We present two cases of stent-assisted coil embolization using a retrograde approach through the posterior circulation for wide-neck or branch-incorporated PcomA aneurysms. Retrograde stenting was successful without periprocedural complications. These aneurysms were completely occluded. The patency of the PcomA was maintained in all cases.

Analysis of the therapeutic effect of interventional embolization and surgical clipping for the treatment of posterior communicating artery aneurysms / 介入放射学杂志

Objective To analyze the complications and clinical effects of interventional embolization and surgical clipping for the treatment of posterior communicating artery aneurysms, and to compare the results between the two methods.Methods A total of 90 patients with confirmed posterior communicating artery aneurysm, who were admitted to the Second Affiliated Hospital of Zhengzhou University during the period from August 2013 to March 2015, were enrolled in this study. Of the 90 patients, 49 received interventional embolization therapy (interventional embolization group) and 41 underwent surgical clipping treatment (surgical clipping group). Before the treatment the patient's condition was evaluated according to Hunt-Hess classification, after the treatment the therapeutic effect was assessed with Glasgow prognosis scale (GOS). The postoperative GOS scores and complications in patients with different Hunt-Hess classification were compared between the two groups. Results In patients of Hunt-Hess 0-Ⅲ grade, no statistically significant differences in postoperative GOS scores existed between the interventional embolization group and the surgical clipping group (t=0.842,P>0.05), while the postoperative GOS scores in patients of Hunt-HessⅣgrade of the interventional embolization group was remarkably higher than that in patients of Hunt-HessⅣgrade of the surgical clipping group, the difference was statistically significant (t=1.713,P<0.05). The incidence of complications in the interventional embolization group was significantly lower than that in the surgical clipping group (x2=1.036,P<0.05). Conclusion For the treatment of Hunt-Hess 0-Ⅲgrade posterior communicating artery aneurysms, the interventional embolization and the surgical clipping show no difference in their therapeutic effects; while for the treatment of Hunt-Hess Ⅳ grade posterior communicating artery aneurysms, the interventional embolization in superior to the surgical clipping, as the interventional embolization carries lower operation risk and complication incidence, and it also has reliable effect.

Early endovascular embolization treatment for the ruptured posterior communicating artery aneurysm:analysis of the mid-term and long-term effects / 介入放射学杂志

Objective To evaluate the mid-term and long-term effects of early endovascular emboli-zation in treating ruptured posterior communicating artery aneurysm. Methods Early endovascular embolization therapy was carried out in 36 patients with ruptured posterior communicating artery aneurysm (36 aneurysms in total), and the effects of embolization therapy were evaluated by using Raymond grading method. The unified imaging review program was formulated, and the mid-term and long-term effects were evaluated at half, 1, 2, 3 and 5 years after the treatment. Results The technical success rate was 100% in 36 patients (36 aneurysms in total). Raymond grading evaluation showed that gradeⅠwas seen in 32 patients, gradeⅡ in 2 patients, and grade Ⅲ in 2 patients. Recurrence of aneurysm was found in 5 patients (13.89%) at half (n=1), 2 (n=1), 3 (n=1) and 5 years (n=2) after the treatment. Re-rupture of the recurrent aneurysm was seen in one patient (2.78%). No death occurred during the following-up period. Conclusion Early endovascular embolization for ruptured posterior communicating artery aneurysm can effectively improve the prognosis of subarachnoid hemorrhage, and regular imaging examination can promptly detect the recurrence of aneurysm. Effective interventions are helpful for preventing deterioration and rupture of aneurysm.

Selection and application of aneurysm clip in posterior communicating artery aneurysm clipping / 中国脑血管病杂志

Objective: To investigate the selection and application of aneurysm clips for microsurgical clipping of posterior communicating artery aneurysms (PCoAA). Methods: The clinical data of 46 patients with PCoAA whom underwent microsurgical clipping in Peking University First Hospital from January 2007 to June 2011 were analyzed retrospectively. The aneurysms were classified according to the relationship between the aneurysm neck and its parent artery. The locations of aneurysm necks, the types of aneurysm clip and the placement of aneurysm clips were analyzed. The patients were followed up by outpatient department examination, telephone inquiry and DSA for 4 months to 4 years. Results: Circled digit oneThe 46 patients with PCoAA were divided into 3 types according to the site of aneurysmal necks in parent artery; internal carotid artery (n = 19), PCoAA (n = 5) proper, and bifurcation (n = 22). Circled digit twoThe bent clip, straight clip, angled fenestrated clip, and bayonet-shaped clip were used in 37, 6, 2, and 1 patients, respectively. The clip length was 6-7 mm in 54.3% patients, and was 5-7 mm in 21.7% patients. In the PCoAA type and bifurcation type aneurysms, the clips were parallel to the direction of the vessels, while in the internal carotid type aneurysms were placed vertically the clips to the internal carotid artery in 13 patient, and parallel to the direction of the vessels in 6 patients. Circled digit threeThe postoperative follow-up showed that the patients did not have the clinical manifestations of aneurysm recurrence and rupture. Twelve patients were followed up with DSA, and it revealed that their aneurysm necks were occluded completely and no residual aneurysms seen. Conclusion: In the PCoAA clipping, confirming the location of aneurysm necks and identifying the relationship between the aneurysm and its surrounding vessels are critical for selecting and placing aneurysm clips. The first choice of bent aneurysm clip may improve the success rate for complete occlusion of PCoAA.

Isolated, Contralateral Trochlear Nerve Palsy Associated with a Ruptured Right Posterior Communicating Artery Aneurysm

Trochlear nerve palsy associated with spontaneous subarachnoid hemorrhage (SAH) is known to be a rare malady. We report here on a patient who suffered with left trochlear nerve palsy following rupture of a right posterior communicating artery aneurysm. A 56-year-woman visited our emergency department with stuporous mental change. Her Hunt-and-Hess grade was 3 and the Fisher grade was 4. Cerebral angiography revealed a ruptured aneurysm of the right posterior communicating artery. The aneurysm was clipped via a right pterional approach on the day of admission. The patient complained of diplopia when she gazed to the left side, and the ophthalmologist found limited left inferolateral side gazing due to left superior oblique muscle palsy on day 3. Elevated intracranial pressure, intraventricular hemorrhage or a dense clot in the basal cisterns might have caused this trochlear nerve palsy.

The 3rd Cranial Nerve Palsy due to Posterior Communicating Artery Aneurism Mimicking Acute Vestibulopathy (Vestbular Neuritis) / 대한이비인후과학회지

We present a 66-year old woman complaining of dizziness and vomiting for the previous three days. Her symptoms were quite similar to vestibular neuritis except for mild headache. Spontaneous nystagmus recording, head shake test, and slow harmonic acceleration results were also similar to vestibular neuritis. But the caloric test was not consistent with the chair test results. During the neurologic examination, ptosis, mydriasis, and the diplopia in the left eye were detected, which was indicative of central organic pathology. Bilateral posterior communicating artery aneurysm that was compressing the left oculomotor nerve was detected by CT angiography. A careful and precise neurologic examination should never be neglected when examining a dizzy patient. It was also noticeable that, acute third nerve palsy may present as intermittent saccades which mimic spontaneous nystagmus in vestibular neuritis.

An Analysis of Prognostic Factors forRecovery from Oculomotor Nerve Palsy in Patients withPosterior CommunicatingArtery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: The aim of this study was to identify the prognostic factors for recovery from oculomotor nerve palsy in patients with a posterior communicating artery aneurysm after surgical intervention. METHODS: We retrospectively reviewed 16 patients with a ruptured or unruptured posterior communicating artery aneurysm that was associated with oculomotor nerve palsy and these patients were treated in our hospital between 2002 and 2006. Fifteen of the 16 patients were women, and the patients' ages ranged between 38 and 75 years (mean age: 52.6 years), and the follow up period was from 0.5 to 36 months (mean: 8.75 months). RESULTS: The total number of aneurysmal cases treated over the 5-year study period was 1135, and there were 223 patients (19.6%) with posterior communicating artery aneurysms. Among these 223 patients, 16 (7.2%) presented with third cranial nerve palsy (4 ruptured, 12 unruptured). Ptosis was presented in all cases (100.0%). Extraocular muscle palsy was presented to some degree by 10 cases (62.5%). The affected pupils were dilated and fixed in all patients (100.0%). The ptosis improved completely in 13 patients (81.3%), and incompletely in 3 patients (18.7%) within 6 months. The dilated and fixed pupils were improved in 10 of the 16 patients (62.5%). The extraocular muscle palsies recovered completely in 15 cases within 6 months. The mean interval between palsy onset and the time of surgery was 6.2 days for the complete recovery cases, and 22 days for the incomplete recovery cases. However, recovery of papillary function was unpredictable. CONCLUSIONS: The duration of symptoms and the degree of preoperative deficits are considered as prognostic factors for the postoperative recovery from third nerve palsy in patients with a posterior communicating artery aneurysm.

Endovascular treatment of oculomotor nerve palsy caused by unruptured aneurysm of posterior communicating artery:an analysis of therapeutic effects / 介入放射学杂志

Objective To investigate the therapeutic effects of endovascular management for oculomotor nerve palsy caused by unruptured aneurysm of posterior communicating artery.Methods Endovascular treatment was carried out in 11 patients with oculomotor nerve palsy due to unruptured aneurysm of posterior communicating artery.The choice of the therapeutic opportune moment and the treatment way were retrospectively evaluated.The relationship between the therapeutic results and the treatment time and way was analyzed.Results Of the 11 patients,complete recovery of oculomotor nerve palsy was obtained in 10(90.91%) and partial recovery in one(9.09%).Conclusion Oculomotor nerve palsy cause by unruptured aneurysm of posterior communicating artery can be effectively treated by endovascular management,and the recovery of oculomotor nerve function depends on the time to take treatment and the degree of nerve palsy.

Improvement of Unilateral Oculomotor Nerve Palsy after Clipping of Internal Carotid-posterior Communicating Artery Aneurysm

OBJECTIVE: The most common cause of sudden unilateral oculomotor nerve palsy is aneurysms of the internal carotid-posterior communicating artery. But their post-operative clinical courses are not well known. The aim of this study is to evaluate clinical courses of oculomotor palsy after aneurysmal neck clipping and importance of early treatment. METHODS: Ten patients who had unilateral oculomotor palsy and angiographically demonstrated internal carotid-posterior communicating artery aneurysm are reviewed. All patients were women and their median age was 55 years. Five patients showed complete oculomotor palsy. All aneurysms were unruptured state and had narrow, long neck and their mean size was 7.8mm(5-10mm). Craniotomy and aneurysm clipping was performed emergently in all patients. Seven patients(group A) were operated within 8 days after the onset of oculomotor palsy and three patients(group B) were operated at 15, 25 and 35 days, respectively. RESULTS: First noticeable change was improvement of ptosis(mean duration: >13.6 weeks) and followed by improvement of horizontal gaze(>19.4 weeks) and vertical gaze(>23.9 weeks). Recovery time for pupillary light reflex varied greatly(>14.2 weeks). Complete palsy usually took more time to recover when compared with incomplete palsy. Among group A patients 4 patients recovered completely(57%). In case of group B, 2 of 3(67%) patients recovered completely but their mean recovery time was longer than group A patients. CONCLUSION: Oculomotor palsy associated with internal carotid-posterior communicating artery aneurysms usually takes a long time to recover completely. Only the early surgical intervention would solve this problem.

Resolution of Third Cranial Nerve Palsy Following Endovascular Treatment of the Posterior Communicating Artery Aneurysm

Third cranial nerve palsy may indicate the presence of an intracranial aneurysm, most commonly in the posterior communicating artery. The effect of endovascular management of posterior communicating artery aneurysms on recovery from third cranial nerve palsy is not well documented. We report two patients with third cranial nerve palsy caused by posterior communicating artery aneurysms. Endovascular treatment resulted in subsiding of ptosis within two weeks. Resolution of extraocular muscle function occurred within one to three months after treatment. Endovascular treatment, which has recently been introduced into neurosurgical practice, is effective in preventing aneurysmal rupture, and in eliminating manifestations due to mass effects.

True Posterior Communicating Artery Aneurysm / 대한뇌혈관외과학회지

A case with a true posterior communicating artery aneurysm is reported, who had been managed by early surgical neck clipping and post-operative intensive cares for numerous complications. The small saccular aneurysm was located at the proximal posterior communicating artery and directed superiorly. A lacunar infarct developed at right anterior thalamus post-operatively, which had resulted probably from the occlusion of a fine posterior communicating arterial perforator. Aneurysms of the posterior communicating artery itself are saccular or fusiform. Great cares should be taken in surgical aneurysmal neck clipping to avoid any injury of the perforators and the oculomotor nerve;trapping of the posterior communicating artery to treat fusiform or wide-necked aneurysms will result in unpredictable outcomes.

Length of the Supraclinoid Internal Carotid Artery in Patients with Posterior Communicating Artery Aneurysm: Preliminary Study / 대한뇌혈관외과학회지

OBJECTIVES: When the supraclinoid portion of internal carotid artery (ICA) is shortened, the anterior clinoid process may have to be partially removed to secure adequate exposure and proximal control of the ICA in posterior communicating artery (P-com) aneurysm. The goal of this study is to investigate, with direct measurement, the relationship between the length of the supraclinoid ICA and aneurysm formation in P-com segment. MATERIAL AND METHODS: The author measured intraoperatively the length of the supraclinoid ICA of patients with P-com aneurysm and compared that of patients with anterior communicating artery (A-com) aneurysm and middle cerebral artery (MCA) bifurcation aneurysm (n=7 each). Additionally, the length of M1 portion of the MCA and A1 portion of the anterior cerebral artery was measured with image analyzer on CT angiogram and also compared that in the same patients. RESULTS: The length of the supraclinoid ICA was 11.6+/-.6 mm and it was similar to that reported at autopsy. The length of the supraclinoid ICA in patients with P-com aneurysm was shorter than that of A-com aneurysm (Student T test, p<0.001) and MCA aneurysm (Student T test, p<0.05). CONCLUSION: It is now generally accepted that aneurysm is acquired lesion, resulting from a complicated interplay of anatomical, hemodynamic, and degenerative factors. These preliminary results suggest when the supraclinoid portion of ICA is shortened, more hemodynamic stress may be produced to anatomically proximally located P-com segment at higher flow rates than other locations of anterior circulation, resulting in aneurysm formation of P-com segment.

Ischemic Complication after Surgery for Posterior Communicating Artery Aneurysm

OBJECTIVE: The purpose of this study is to elucidate the causes of the ischemic complication after surgery for posterior communicating artery aneurysm and to represent the ways of preventing or minimizing this specific complication. METHODS: Between January 2000 and December 2001, fifty one patients were treated for the posterior communicating artery aneurysm. The medical records and neuroimaging studies of the patients were reviewed retrospectively. RESULTS: Among the series of 51 surgically treated patients, the authors experienced 6 cases of ischemic complication involving 3 thalamus, 2 posterior cerebral artery territory and 1 periventircular white matter. Four patients were treated by aneurysmal neck clipping and one patient with fusiform aneurysm and one patient with infundibulum at internal carotid-posterior communicating artery junction by parent artery trapping and parent artery occlusion, respectively. In 4 cases with aneurysmal clipping the authors could not confirm the patency of the parent artery or posterior communicating artery during operation by the obstacle such as internal carotid artery and/or aneurysmal dome. The neurological deficits developed postoperatively were improved or subside during hospital courses and all six patients showed good outcome(Glasgow Outcome Scale score V) at discharge. CONCLUSION: In most cases the posterior communicating artery itself can be separated from the neck of the aneurysm and thereby preserved to avoid a significant infarct in the thalamus and occipital lobe.

Clinical Analysis of the Pattern of Anterior-Posterior Circulation in Patients with Posterior Communicating Artery Aneurysm

OBJECTIVE: The purpose of study was to assess the status of posterior communicating artery in patient with aneurysms arising from the internal carotid-posterior communicating artery and the angiographic blood flow pattern of anterior-posterior circulation through the posterior communicating artery especially to the posterior cerebral artery. The clinical outcomes according to the pattern of posterior communicating artery and the blood flow to the posterior cerebral artery were analysed. PATIENTS AND METHODS: The data includes 41 cases of internal carotid-posterior communicating artery aneurysm among 248 cases of aneurysms which were operated from September 1993 to August 1998. The clinical informations were obtained by review of the records and radiologic films retrospectively. The statistical analysis were performed using Chi-square tests. RESULTS: The female was predominant and peak age was fifties. The operative result was in close relation with initial Hunt-Hess grades(p=0.039), Fisher grade(p=0.001) but showed no statistical differences with age(p=0.106). The flow pattern of posterior cerebral artery was mainly from both anterior and posterior circulation(28cases, 68%), and the size of posterior communicating artery was smaller than P1 segment of posterior cerebral artery in 28cases(68%) but each of them showed no statistical differences with outcome. CONCLUSIONS: Even though there were no statistical differences of outcome according to the size of posterior communicating artery and the pattern of blood flow to the posterior cerebral artery, it is mandatory to save the posterior communicating artery for the preservation of otherwise normal blood flow to the perforators and main branches of posterior circulation.

Oculomotor Nerve Palsy in Internal Carotid-Posterior Communicating Artery Aneurysm

Internal carotid-posterior communicating artery aneurysms are frequently related to third nerve palsy which is reversible after the clipping of aneurysm. The authors had analyzed 61 cases in 52 patients who have posterior communicating artery aneurysm and evaluated the factors affecting the development of third nerve palsy and its recovery after clipping of the aneurysm. The results are followings 1) Oculomotor nerve palsy was noticed in 10 patients(16.4%) among 61 cases of posterior communicating artery aneurysm, of which 6 had complete and 4 had partial palsies. 2) Posteriolateral inferior direction of the aneurysm seemed to be closely related to the development of ophthalmoplegia. 3) Development of ophthalmoplegia was not related to the clinical status of the patient on admission, but to the amount of subarachnoid hemorrhage on initial CT scan and size of the aneurysm. 4) Preoperative degree of third nerve palsy and the timing of operation are not definitely related to the recovery of ophthalmoplegia. 5) The recovery of third nerve palsy are normalization of ptosis, normalization of EOM limitation and normalization of papillary change in order.

Rupture of Giant Posterior Communicating Artery Aneurysm During Carotid Angiography: A Case Report

The authors report a case of the ruptured giant posterior communicating artery aneurysm that found during carotid angiography. The contrast agent was extravasated into the lateral ventricle through the temporal horn of it and the vasospasm localized to the vicinity of aneurysm had seen. To see the aneurysm actually bleed during angiography is a rare event.