Management of intracranial aneurysms by surgical and endovascular treatment--modalities and results from a series of 395 cases.
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The selective occlusion of saccular intracranial aneurysms may be achieved by two techniques: microsurgical clipping and endovascular coiling. Each of them have particular indications which need to be defined. From September 1992 to June 1996, 395 consecutive patients with small or large aneurysms were treated either by surgery (n = 102) or by endovascular coiling (n = 293). Coiling was chosen each time the shape of the aneurysm seemed to be appropriate for this treatment: narrow neck and ratio neck diameter by sac diameter less than one third. Satisfying results with complete or subtotal obliteration and no recanalization on the following controls at 1, 6, 12, and 36 months were obtained in 92% before retreatment and in 98.8% after retreatment. Unsatisfying results were observed after surgery in seven cases and in 25 cases after embolization. After retreatment, it remains three post-surgical and two post-endovascular cases. Good and excellent clinical outcome was noted in 90% for small aneurysms and in 86.5% for large ones. Mortality is of 4.8% in the overall series. In a series in which were applied both types of treatment, surgery in 25% and endovascular techniques in 75%, good results in terms of efficiency and clinical results were achieved. These results are as good as the best series in which surgery was the only choice. Therefore with appropriate selection, endovascular treatment is a good alternative for treatment of the majority of saccular aneurysms. (+info)
Titanium aneurysm clips: mechanical characteristics and clinical trial.
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Titanium clip is well documented to reduce the artifact observed in computed tomography (CT) or magnetic resonance (MR) imaging and improve the quality of these images. There are, however, some demerits based on metallic characteristics including large spring portions, lack of long and fenestration clips, and difficulties to produce. We examined the mechanical characteristics of Sugita titanium aneurysm clips (product of 6 aluminium-4 vanadium-titanium) and investigate the safety in clinical use and the imaging quality compared with those of cobalt (Co) alloy clips. On mechanical test, Sugita titanium clips showed no significant difference in closing force compared with the conventional Co alloy clips. The closing force reduced about 10% after 100 times repeated opening in titanium clips in contrast with no remarkable changes in Co alloy clips. Sixty-four patients with ruptured or unruptured cerebral aneurysms (total number of 71 aneurysms) were treated with Sugita titanium clips through the microsurgical technique. None of the unfavorable outcome occurred in related to the titanium clips. Neither clip dislocation nor deformation was experienced in this series during the follow-up period. The clip artifacts seen in CT and MR image were markedly reduced, however, MR angiography had less quality to resolve anatomical structures due to an existence of vessel gap. These results indicate that in spite of some disadvantages, Sugita titanium clips allow safe and beneficial use routinely in aneurysm surgery insofar as the complete clipping is obtained. (+info)
Treatment and results of partially thrombosed giant aneurysms.
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Partially thrombosed giant aneurysms are one of the most difficult diseases in the neurosurgical field. We have had 18 of these cases namely, three in vertebral artery, four in basilar artery, four in internal carotid artery, five in middle cerebral artery, and two in anterior communicating artery. Nine aneurysms were clipped, two aneurysms were removed with anastomosis, two cases were treated interventionally, and five cases were treated conservatively because of serpentine and fusiform types of aneurysms in internal carotid artery bifurcation. These conservatively treated patients died due to infarction. When surgery is selected in the thrombosed giant aneurysms, the approach is the most important to secure the neck. Three-dimensional computed tomography angiography was useful to plan the strategy for surgery. If the neck is big enough for placement of a clip, arterial reconstruction is the choice. The reconstruction must be done including an adequate size of the artery because of the thick wall. If the aneurysm neck is too small to reconstruct, aneurysmectomy with anastomosis is one of the choices. (+info)
Technical points to improve surgical results in cases with basilar tip aneurysms.
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Surgical results in 82 cases with aneurysm (61 ruptured and 21 unruptured) of the bifurcation of the basilar artery were analyzed and the causes of unfavorable outcome and its measures were discussed. Operation was performed in grade I, II, III, or IV of the Hunt and Kosnik's classification for the patients with ruptured aneurysm. Both in ruptured and unruptured cases, patient's age was not considered. As it turned out, 10 elderly (70 years old or older) cases (8 ruptured and 2 unruptured) were included in this study. Unilateral pterional approach was adopted for all but one case, and temporary clip and/or division of the hypoplastic posterior communicating artery was actively used. Surgery was completed with clipping of the aneurysm in all but six cases and overall surgical result consists of 70% of favorable outcomes. The main causes of unfavorable outcome were surgical procedures and primary brain damage due to subarachnoid hemorrhage. And the factors influenced to increase surgical technical damage to the brain were the patient's age, size of the aneurysm, and/or height of the neck from biclinoids line. The outcome of the higher grade (grade III or IV) in elderly cases was miserable, whereas it was not different from anterior circulation aneurysms in younger cases. From the result we concluded that the surgical indication for elderly cases should be limited in cases with lower grade (grade I or II) without large and/or high-positioned aneurysm. To obtain further improvement of the surgical result in younger cases, additional surgical techniques have to be considered to avoid the injury of perforating arteries from P1 and to reduce the pressure of the brain retraction which are the most important hazards for aneurysm surgery in this area. (+info)
Factors influencing surgical outcome of the basilar bifurcation aneurysms.
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To contribute to a better understanding of the clipping operation of the basilar bifurcation aneurysm, factors influencing the surgical outcome were analyzed in 80 patients. The age range of the patients was 34-74 years, with a mean age of 58.4 years, and there were 61 females and 19 males. Fifty-eight patients had been admitted because of subarachnoid hemorrhage and a basilar bifurcation aneurysm ruptured in 49 patients. The size of the aneurysms ranged between 2 and 19 mm with a mean of 7.9 +/- 3.9 mm. The height of the aneurysm neck was between -10 and 17 mm measured above a biclinoid line with a mean of 4.8 +/- 5.2 mm. Pterional approach was utilized in 72 patients and subtemporal in eight. Optic unroofing or removal of anterior clinoid process were performed in five patients, zygomatic osteotomy in 10, posterior clinoid removal in seven, and anterior petrosectomy in one. A bridging vein of the temporal lobe was divided in 16 patients. A short and/or hypoplastic posterior communicating artery was divided in 11 patients. Temporary occlusion of the basilar trunk was performed in 39 patients. Surgical outcome (Glasgow Outcome Scale) at 3 months after the operation was good recovery in 42 (53%), moderately disabled in 23 (29%), severely disabled in five (6%), vegetative survival in two (3%), and dead in eight (10%). The aneurysm size proved to be a single preoperative factor which significantly correlated with the surgical outcome (Spearman's rank correlation test, p < 0.0001). Division of the posterior communicating artery significantly contributed to the surgical outcome as an intraoperative factor (Mann-Whitney's U test, p = 0.01). The larger the aneurysm size was, the more often the posterior communicating artery was sectioned. Extreme care should be taken to obliterate a large aneurysm with a clip graft especially when division of the posterior communicating artery is required. (+info)
Management of aneurysms of the vertebral artery-posterior inferior cerebellar artery complex.
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Aneurysms of the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) account for only about 3% of all diagnosed intracranial aneurysms. The surgical therapy of these aneurysms is complex and difficult due to the close topographical relationship between the neurovascular structures. Here, we report upon 27 patients with 29 such aneurysms. Of these, 22 patients (81%) were hospitalized because of a subarachnoid hemorrhage. Sixteen of these patients (72%) had an additional intraventricular hemorrhage. Twenty-one patients (78%) were surgically treated for their aneurysms, three of them also for an associated arteriovenous malformation. Aneurysms of the VA and the proximal PICA were exposed via a transcondylar (n = 11) or lateral suboccipital (n = 3) approach, those originating from the distal PICA via a paramedian suboccipital (n = 7) route. Endovascular therapy was used in three patients. A patient with a fusiform aneurysm of the vertebrobasilar junction was treated with a ventriculoperitoneal shunt only. Three aneurysms with a complex morphology were not treated. Of the patients operated upon, two died postoperatively due to vasospasm. Two other patients developed an incomplete dorsolateral medullary syndrome. One individual was lost for follow-up. The median follow-up period was 4.6 years (range 3-86 months). Both, the overall mortality (2/27) and morbidity (2/27) were 7.5%, respectively. Our results show that even complex vascular lesions of the posterior fossa can be treated with a satisfactory long-term outcome in the majority of our patients (85%). The multimodal management and an individually tailored microsurgical approach are key issues for the treatment of such aneurysms. (+info)
Experimental and clinical evaluation of the harmonic scalpel in thoracic surgery.
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The Harmonic Scalpel is an ultrasonic instrument for cutting and coagulating tissue. We are reporting our evaluation of the Harmonic Scalpel safety and efficacy in both experimental and clinical thoracic surgery. First, we confirmed the safety in thoracic surgery by following two preliminary studies using the Harmonic Scalpel. 1: Pulmonary parenchyma was incised using "Coagulating Shears" to evaluate hemostasis and air leakage. 2: Pulmonary hilar vessels were contacted directly with "Dissecting Hook" blade at optimum cutting power mode to evaluate potential vascular wall injury by the Harmonic Scalpel. Subsequently, the Harmonic Scalpel was used for a partial lung resection due to metastatic lung cancer. Particular application was for a chest wall incision, interlobar separation of the lung, and dissection of a pulmonary artery, in lung cancer operations. We concluded that cutting and hemostasis of pulmonary parenchyma could be achieved with minimal tissue damage using the Harmonic Scalpel. Compared to electric coagulation, the Harmonic Scalpel minimizes tissue charring and dissection, and eliminates thermal injury in thoracic surgery. (+info)
High-pressure trocar insertion technique.
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BACKGROUND: The majority of laparoscopic complications occur at the time of Veress needle and trocar insertion. Although not very frequent, they increase the morbidity and mortality of both diagnostic and operative laparoscopic procedures. Alternative techniques of trocar insertion have been described but have not completely eliminated the risk of injury. TECHNIQUE: After Veress needle insertion and establishment of pneumoperitoneum to 25 to 30 mm Hg, insertion of a short trocar is performed in the deepest part of the umbilicus without elevation of the anterior abdominal wall. The result is a parietal peritoneal puncture directly beneath the umbilicus. The high-pressure setting used during initial insertion of the trocar is lowered as soon as safe abdominal entry is documented. EXPERIENCE: The trocar insertion technique described above was performed in 3041 procedures. No vascular injury occurred. There were two bowel perforations. No complications related to the increased intra-abdominal pressure were observed. CONCLUSION: The high-pressure abdominal entry technique has the advantage of reducing intra-abdominal trocar-related injuries without requiring additional instrumentation or additional training. (+info)