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

Traumatic pericallosal artery aneurysm

Pericallosal artery aneurysms comprise about 1.5 to 9% of all intracranial aneurysms. Some of them are caused by head injury. We report a 66-year-old male patient with ruptured left pericallosal artery aneurysm, 2.6 x 3.2 mm in size. The patient fell 2 months ago. Operation was done under right interhemispheric approach. The parent artery was avulsed while the clip was adjusted. The avulsed part was sutured and postoperative CAG revealed totally obliteration of the aneurysm while the repaired artery was patent. The patient recovered well after operation

Haemorrhage in the cavum veli interpositi as the primary haemorrhagic source of intraventricular haemorrhage: a case report with reference to radiographic features

The cavum veli interpositi is not a rare ventricular anomaly, however it is usually asymptomatic. A case of primary haemorrhage in the cavum veli interpositi as the bleeding source of intraventricular haemorrhage, without vascular lesion or tumour, was diagnosed and treated by neuroendoscopic surgery. A 17-year-old woman with history of transient visual field loss 2 years ago had sudden onset of headache followed by vomiting. A head CT scan showed intraventricular haemorrhage with predominant haematoma in the cavum veli interpositi. A diagnostic angiography demonstrated no apparent vascular lesion, however remarkably delayed appearance of deep venous system and the straight sinus, with prominent collateral drainage toward the vein of Labbe was noted. An external ventricular drainage was placed immediately, followed by endoscopic removal of intraventricular haemorrhage excluding the haematoma in the cavum veli interpositi on day 3. The left internal cerebral vein was engorged and seemed to be congestive during surgery. The postoperative course showed good recovery without neurological deficit. An angiography was repeated 23 days after the onset and it demonstrated improved venous circulation. This is the first report on a primary haemorrhage in the cavum veli interpositi. The cause of bleeding was unknown however, possible abnormal vascular anatomy in this anomalous space might be associated. The vein of Galen is shifted downward by the cavum veli interpositi and this might cause venous hypertension in the deep venous system. Improvement of the venous circulation on the angiography suggested compression of the veins by haematoma can cause impairment of blood circulation and this fact supports theoretical benefit of haematoma removal. Effectiveness of endoscopic treatment for intraventricular haemorrhage is discussed

Surgical and endovascular combined modality of treatment for aneurysms

Most of the aneurysms can be treated successfully with either surgery or endovascular modality alone. But, some complex aneurysms can be better managed with surgical and endovascular combined modality of treatment. This study was done to review combination options, their indications and outcome. Articles in English literature on surgical and endovascular combined modality of treatment for cerebral aneurysms were reviewed and analyzed based on Pubmed search. Followed combination options were used: Surgery followed endovascular therapy: 1. Extracranial to intracranial bypass surgery followed by endovascular parent vessel occlusion. 2. Aneurysm clipping assisted by temporary balloon occlusion with/without suction decompression. 3. Intentional partial clipping for neck reconstruction followed by endovascular aneurysm packing. 4. Clipping as the first treatment. Regrown or partially clipped aneurysm obliterated by endovascular packing. Endovascular therapy followed by surgery: 1. Partial coiling to prevent rebleed followed by delayed definitive clipping. 2. Permanent parent vessel occlusion followed by surgery for decompression in giant aneurysm. 3. Coiling as the first treatment, reanalyzed aneurysm treated with clipping. 4. Coiling and clipping of multiple remote aneurysms. In various published series; combined modality of treatment has shown better results in complex aneurysms as compared to either of the modality alone with less morbidity. Surgical and endovascular combined modality is very useful addition to the armamentarium for the management of complex aneurysms and can be applied in various combinations. When used rationally, this approach offers the best outcome with reduction of treatment morbidity

Microvascular decompression in trigeminal neuralgia

Trigeminal neuralgia, like other rhizopathies, has defied categorization, clarification in pathology and effective treatment, despite several efforts, in several disciplines. The different rhizopathies like trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, tinnitus, spasmodic torticollis, etc., all share a common pathology i.e., a vascular compression of the cranial nerve at the root entry zone. A comprehensive description of the features of trigeminal neuralgia and the surgical management with microvascular decompression is detailed in this article. Microvascular decompression is a relatively safe surgery and complications are very unlikely in dexterous hands

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

Postoperative mental functions in patients with frontal meningiomas

The meninges [dura mater, arachnoid, pia mater] are the site of numerous pathological lesions including inflammation and neoplasm Meningiomas are the most frequently observed lesions and the most common of primary meningeal tumours. Over the years, meningiomas has been histologically classified and some entities have been added to the cadre of meningioma variants, while others have been designated as other types of tumours. The 200 revision of the World Health Organisation [WHO] grading system provided diagnostic guidelines. Most meningiomas are biologically benign and correspond to the WHO grade. However, certain meningiomas have an increased tendency to recur or follow an aggressive clinical behavior and are assigned an WHO grade and have a substantially increased incidence of recurrence. Rhabdoid meningioma, papillary meningioma and anaplastic meningioma corresponding to WHO grade have an even higher incidence of recurrence and may be associate with systemic metastasis or brain invasion. There is some information regarding the nature of mental deficits caused by intracranial meningiomas. In this study the authors examined the mental functioning of patients with frontal meningiomas. Twenty-one patients with frontal meningiomas were examined for various neurological symptoms after surgery. Observed neurological symptoms were memory deficits [verbal and fungal], attention and executive functions. The time period between onset of the effect on mental functions of meningioma and postoperative observations ranged from 2-3 months. Postoperative findings revealed a few or no differences in memory or executive functions, although, a postoperative improvement in attentional function was observed. The results of the study indicate that the surgical removal of frontal meningiomas does not impair patients' mental functioning

Application of rigid endoscope to the microsurgery of anterior circulation cerebral aneurysms

To evaluate the usefulness of endoscope during anterior circulation cerebral aneurysm surgery. From June 2004 to June 2005, endoscope was applied in 83 aneurysms of anterior circulation cerebral aneurysm surgeries. There was no mortality in our series and no new neurological deficits occurred after surgery. One aneurysm ruptured during the microsurgical dissection, which was not related to endoscope manipulation. Endoscope provided new information in 28 aneurysms. The clips were re-adjusted in 10 cases after endoscopic examination. Endoscope is useful during anterior circulation cerebral aneurysm surgery. It can provide valuable information which is not available from microscope, it is useful both before and after clipping. Most importantly, it provides information regarding the completeness of neck obliteration and the preservation of important perforators

Distal anterior cerebral artery aneurysms, traumatic and non-traumatic

Distal anterior cerebral artery [ACA] aneurysms are rare and compose less than 5% of all intracranial aneurysms. Most of the aneurysms in this location are congenital, saccular ones, but it is also a well-known location for traumatic aneurysm. The mechanism of aneurysm development, clinical scenario and/or surgical difficulty are different between these two groups. Between March 2005 to February 2006, 6 cases of distal ACA aneurysms were treated at the Department of Neurosurgery, Fujita Health University, Aichi Prefecture, Japan. The clinical presentations, neurological findings, and treatment were analyzed. Of 6 patients, 2 were male and 4 were female, aged from 66-79 years. Of 6 cases, one was traumatic aneurysm, which occurred 2 months after a fall injury. Of the 5 congenital aneurysms, one was unruptured, the other 4 were all ruptured. One patient had multiple aneurysms. We believe that there are differences between the congenital and traumatic aneurysms in respect to the mechanism of development, aneurysm location, and treatment difficulties

Extracranial internal carotid fibromuscular dysplasia associated with successfully treated hyperacute cerebral infarction

Fibromuscular dysplasia [FMD] is a segmental non-atheromatous and non-inflammatory stenosing angiopathy of unknown cause and the cervico-cephalic [cc] FMD is relatively uncommon. The big majority of the ccFMD patients are Caucasians and there have been several reports in Japan up to the present, the greatest number of which were associated with intracranial aneurysms or discovered post-mortem. The association with cerebral infarction has been rarely described in Japanese patients. We report a case of hyperacute cerebral ischemia caused by embolism, originating in the internal carotid artery. We performed super-selective thrombolysis of a middle cerebral artery embolic ooclusion by a microcatheter with excellent result. Although ccFMD can be associated with a range of vascular pathology and cerebral ischemia is only one of the possibilities, it should be considered as a cause in these young patients where there is no evidence of other embolic sources. Early intervention in these cases can prevent ischemic brain damage

Experience with anterior petrosal approach for aneurysms of mid-basilar artery

Anterior petrosal approach [Kawase's approach] is an established technique for the management of basilar artery aneurysms arising near the origin of anterior inferior cerebellar artery [Ba-AICA], however the extent of petrosectomy may vary from patient to patient. Authors report their experience with Kawase's approach for the management of these aneurysms in 5 patients. During the last 10 years, anterior petrosal approach was used to clip aneurysms of Ba-AICA junction in five patients, who were not suitable for endovascular therapy. Both ruptured and unruptured aneurysms were included in this series. Successful clipping could be achieved in all but one patient. In this patient with a large aneurysm and complex morphology, residual filling was noted in the postoperative angiogram. Postoperatively one patient developed hemiparesis and transient sixth nerve palsy. There was no operative mortality in this series. For patients with small Ba-AICA shoulder aneurysms, where clipping is preferred method of treatment, sufficient exposure is achieved through Kawase approach, however minor variation may be required while resecting the petrous bone

Anterior internal carotid artery aneurysm

Anterior internal carotid artery aneurysm is a rare kind of aneurysm caused by atherosclerosis. This paper summarises the authors' experience with this kind of rare aneurysm. From January 2001 to December 2004, 6 cases of anterior internal carotid artery aneurysms were treated at Fujita Health University Hospital. The patients' clinical presentation, image data, treatment and outcome are described. Through the authors' limited number of cases, we concluded that all the aneurysms were located at the supraclinoid portion of the internal carotid artery. Two of our cases did not have arteriosclerosis. We used clipping and wrapping techniques to manage these easily ruptured aneurysms

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

Treatment of severe subarachnoid haemorrhage -440 cases clipping versus coiling

We reviewed the ruptured cerebral aneurysm treatment in Fujita Health University Hospital with multimodalities of treatment. Form 1996 to 2002, cerebral aneurysms were treated by two methods: direct microsurgical clipping and endovascular coiling. Both were selected based on definite guidelines of clinico-radiological criteria as follows: endovascular therapy comprised of GDC embolisation and CSF washout with UK or TPA performed in cases with Hunt and Kosnik grade 4 [GCS 7,8], and grade 5 [without hydrocephalus or intracranial haemorrhage], age > 70 years, subacute stage [4-14 days of vasospasm], basilar aneurysm and peripheral MCA/PCA aneurysms. Microsurgical clipping with drainage procedure was performed in cases with Hunt and Kosnik grade 0-3, grade 4 [GCS 9-12], age less than 70 years, grade 5 with hydrocephalus or intracerebral haematoma and acute stage [0-3 days after bleed]. The patient's outcome was measured using Glasgow Outcome Score [GOS] at the time of discharge. In our series of severe [poor grade] SAH cases, 120 cases underwent clipping and 59 cases underwent coiling. Though they accounted for 37.8% and 48% of total SAH cases respectively, the outcome was satisfactory. In each treatment modality, a favourable outcome [good recovery/moderate disability] was found in 75.4% of clipping cases and 55.2% of coiling cases clipping had a better outcome than coiling in cases of acute severe SAH in our series and is in contrast to ISAT results