Surgical Management of Ruptured Posterior Circulation Aneurysms ­ A Single Center Experience

Objective The treatment of ruptured aneurysms of the posterior circulation is a controversy in neurosurgery. The aim of this work is to describe the experience and results of the early surgical treatment of this pathology at Centro Hospitalar do Porto. Method We retrospectively analyzed the medical records of all patients aged over 18 who, in the period between 1999­2013, were admitted to our center with the diagnosis of ruptured saccular posterior circulation aneurysm. The patients were clinically staged at admission using the Hunt & Hess (H&H) scale. The modified Glasgow Outcome Scale (mGOS) was used to assess the outcome at discharge and after 6 months. Results Between 1999­2013, 59 patients underwent surgery for ruptured posterior circulation aneurysms. Eighty percent of the patients were female, and their average age was 58.7 years. Posterior-inferior cerebellar artery aneurysms accounted for 49.2% of surgeries, while basilar aneurysms accounted for 28.8%. Upon admission, 86.4% of patients were classified as H&H1­3, and 13.6% as H&H4­5. The outcomes at discharge and at 6 months were as follows: at discharge, mGOS1 in 5.1%, mGOS2­3 in 18.6%, and mGOS4­5 in 76.3%; at 6 months, mGOS1 in 10.2%, mGOS2­3 in 10.2%, and mGOS4­5 in 79.6%. There was a statistically significant correlation between basilar aneurysms and worse outcomes (p » 0.011). No correlation was found between the values of the H&H scale upon admission and outcome. Conclusions The functional outcome of our group of patients is mainly in line with what is described in other series from the literature. However, there is a trend toward lower mortality but higher morbidity rates.

Objetivo O tratamento dos aneurismas rotos da circulação posterior é uma controvérsia neurocirúrgica. Pretende-se com este trabalho relatar a experiência e os resultados do tratamento cirúrgico precoce desta patologia no Centro Hospitalar do Porto. Métodos Foram analisados retrospectivamente os processos clínicos dos pacientes com idade > 18 anos que, no período entre 1999­2013, foram admitidos no nosso centro com o diagnóstico de aneurisma sacular roto da circulação posterior. Utilizou-se a escala de Hunt & Hess (H&H) para aferir a gravidade clínica dos pacientes, e a Escala de Outcome de Glagow modificada (mGOS) para aferir o outcome dos pacientes à data da alta e aos 6 meses. Resultados Entre 1999­2013, foram operados 59 pacientes com aneurismas rotos da circulação posterior. Oitenta por centro dos pacientes eram do sexo feminino, com uma média de idade média de 58.7 anos. Aneurismas da artéria cerebelosa posteroinferior foram responsáveis por 49,2% das cirurgias, ao passo que os da artéria basilar, por 28,8%. À admissão, 86,4% dos pacientes eram H&H1­3, e 13,6%, H&H4­5. O outcome à data da alta e aos 6 meses foi o seguinte: à data de alta, mGOS1 em 5,1%, mGOS2­3 em 18,6%, e mGOS4­5 em 76,3%; aos 6 meses, mGOS1 em 10,2%, mGOS2­ 3 em 10,2%, e mGOS4­5 em 79,6%. Verificou-se uma correlação estatisticamente significativa entre aneurismas da basilar e um pior outcome (p » 0,011). Não se verificou qualquer correlação entre os valores da escala de H&H à admissão e o outcome. Conclusões O outcome funcional do nosso grupo de pacientes está em linha com o descrito noutras séries da literatura. Contudo, destaca-se uma tendência para uma mortalidade mais baixa, mas uma morbilidade mais alta no nosso grupo de pacientes.

Microsurgical treatment of aneurysms of posterior circulation / 军事医学

Objective To summarize surgical strategies and skills against aneurysms of posterior circulation .Methods Twenty-one cases of posterior circulation aneurysms who had undergone microsurgery between March 2008 and March 2013 were analyzed retrospectively .Two of these cases had their basilar artery aneurysms clipped via the pterion approach and five through the subtemporal approach .Five posterior cerebral artery aneurysms were clipped via the subtemporal approach , two anterior inferior cerebellar artery aneurysms were clipped via the retrosigmoid approach , three posterior inferior cerebel-lar artery aneurysms were clipped through the far lateral approach , and two vertebral artery aneurysms were clipped similar-ly approach.Results All the aneurysms were clipped successfully .According to Glasgow Outcome Scale (GOS), the cura-tive effect was poor in 3 cases(GOS 2-3 points), good in 16 cases(GOS 4-5 points) and 2 patients died(GOS 1 point). Conclusion Aneurysms of posterior circulation can be treated through microsurgery .Proper surgical strategies , operative ap-proach and delicate surgical skills are critical to the success of surgeries and curative effects .

Far Lateral Approaches for Intracranial Aneurysms / 대한뇌혈관학회지

Surgical approaches to the posterior circulation aneurysms are difficult and still remained as a matter of debate. Many skull base approaches has been developed to overcome the inadequate exposure of these aneurysm by conventional surgical approaches. Far lateral approaches are an extension of suboccipital approach to expose neurovascular structures around the lower clivus. Aneurysms locating at the vertebral arteries, vertebrobasilar junction and lower basilar artery could be exposed by these approach. However, it is not still evident which kind of far lateral approach is most appropriate for the aneurysms of various locations at these vascular territory. Among the 3 kinds of far lateral approaches, such as far lateral, far lateral transcondylar and extreme lateral transcondylar approach, far lateral approach is not recently used frequently. Far lateral transcondylar approach is good far the aneurysm at the origin of posterior inferior cerebellar artery and the extreme lateral transcondylar approach is useful to expose aneurysms around vertebrobasilar junction. For an appropriate selection of surgical approaches, useful surgical guidelines are mandatory. The recent use of "intermeatal line" and "K lines" and others are of many help for the lower basilar and vertebral artery aneurysms. Surgical approach itself needs knowledge and experience for an adequate performance. Once exposed appropriately manipulation of aneurysms at these locations are not very complicated. Microsurgical anatomy of each surgical step is essential for the sucessful management of aneurysms locating at the lower clivus.

Clinical Analysis of Posterior Circulation Aneurysms

Aneurysms of the posterior circulation are regarded as difficulty in their surgical management because of their infrequency and confined space in front of the brain stem and cerebellum and perforators around brain stem. From Januarym 1983 to August 1990, we are reporting a review of 21 cases of surgically treated posterior circulation aneurysms among 334 cases of surgically treated all intracranial aneurysms. They represent 6.3% of all intracranial aneurysms, the average age of these patients was 45 years with range of 28 to 63 years. Of the 21 patients, 12 had aneurysms of basilar artery bifurcation, 4 had aneurysms of the PCA, and two had aneurysms of the SCA, and two had aneurysms of the PICA and one had aneurysm of the AICA. Five patients had multiple aneurysms and one patient associated with moya-moya disease. There were postoperative complications including nine transient or permanent cranial nerve deficit, three disturbance of consciousness, two aseptic meningitis and one osteomyelitis. Two motor weakness, one intraparenchymal hemorrhage, one epidural hemorrhage, one thalamic infartion. The aneurysms varied on size and included 17 small( or =25 mm). Overall surgical outcome was evaluated "excellent" in 7 cases, "good" in 9 cases, "fair" in 2 cases, "poor" in 2 cases, and one patient expired.