Contralateral approach to anterior circulation aneurysms

Objective Multiple intracranial aneurysms are frequent, with an incidence of 15-40% among intracranial aneurysms carriers. Of these carriers, 20-40% have bilateral intracranial aneurysms. The rupture risk is higher for patients with multiple intracranial aneurysms. For those patients, several treatment options are available (microsurgery comprising a unilateral-contralateral approach, bilateral craniotomies in one-stage or two stages surgery, and endovascular methods) varying from institution s resources and surgeon s experience. The present study focuses and analyses the angiographic characteristics, specific parameters, and surgical results of the unilateral-contralateral approach for ICA-opht segment and MCA aneurysms. In addition, it describes and analyses the proximal vascular control by transient cardiac arrest induced by adenosine during the contralateral clipping of ICA-opht segment aneurysms. Patients and Methods We retrospectively reviewed 68 patients with ICA-opht segment and bMCA aneurysms treated through a contralateral approach at the department of neurosurgery of the University of Helsinki, between January 1998 and December 2013. A detailed analyses of the aneurysms characteristics and constrains of the contralateral surgical corridor was performed. A further subgroup analysis of 8 patients harboring ICA-opht segment aneurysms approached through a contralateral craniotomy and requiring intravenous adenosine administration to induce transient cardiac arrest during microsurgical clipping was performed as well. Results ICA-opht segment aneurysms: All the 30 ICA-opth aneurysms were small (less than 7 mm), unruptured, saccular, and had no wall irregularities, calcifications or secondary pouches. Microsurgical clipping of these aneurysms was possible when the prechiasmatic distance had a median of 5.7 mm (range 3.4-8.7 mm) and the interoptic distance a median of 10.5 mm (range, 7.6-15.9). The most frequent aneurysm dome projection was superomedial (77%). Of the patients with ICA-opht segment aneurysms approached through a contralateral craniotomy, 93% had good postoperative outcome at 3-month follow-up. bMCA aneurysms: The contralateral approach for bMCA aneurysms was possible in 38 patients. All the 38 contralaterally approached MCA aneurysms were unruptured and had saccular shape (expect one with bilobular shape). The majority (97%) of contralateral aneurysms were small to medium in size. The median length of the contralateral A1 was 13.2 mm (range: 6-19.8 mm), and the median length of the contralateral M1 was 14.2 mm (range: 4.6-21 mm). Of the patients with unruptured bMCA aneurysms treated through a contralateral approach, 24 (86%) patients had good outcome and 4 (14%) had poor outcome at 3-month follow-up, 1 patient was lost to follow-up. There were 9 patients harboring bMCA aneurysm presented with SAH due to a ruptured ipsilateral aneurysm. Of these patients, 7 (78%) had good outcomes, and 2 (22%) had poor outcomes at 3 months. Olfactory disturbances were present in 21% of cases treated through a contralateral approach. Transient cardiac arrest induced by adenosine during contralateral clipping of ICA-opht aneurysms: 8 patients received intravenous bolus of adenosine to induce transient cardiac arrest during clipping. Of the total patients, 5 received single bolus of adenosine, and 3 patients received multiple doses. The median single dose of adenosine was 22.5 mg (range, 5-50 mg). The asystole time range between 20-40 seconds after adenosine administration. All the 8 patients showed good surgical outcomes at 3-month and 1-year follow-up, and showed no procedure-related complications. Conclusion: The contralateral approach remains as a feasible option for microsurgical treatment of ICA-opht segment aneurysms, and bMCA aneurysms. Its feasibility depends on general parameters related to the aneurysm itself (shape, morphology, size, status and projection), and specific parameters that varies according to the vascular segment to be treated (prechiasmatic and interoptic distances, length of A1 and M1). Transient cardiac arrest induced adenosine represents a useful tool to obtain proximal vascular control while performing a contralateral approach for ICA-opth segment aneurysms in selected patients.Johdanto Multippelien kallonsisäisten aneurysmien esiintyvyys on 15-40% kaikista aneurysma-potilaista. 20-40% aneurysmat ovat molemminpuoliset. Aneurysman puhkeamisen riski on niillä potilailla, joilla multippelit aneurysmat. Multippeli aneurysmat voidaan hoitaa mikrokirurgisesti klipsamalla unilateraalisen tai bilateraalisen kraniotomian kautta tai endovaskulaarisesti täyttämällä aneurysmat. Meidän tutkimuksessa on analysoitu multippeleita ICA-oftalmika (ICA-oft) ja MCA aneurysmien kuvantamisominaisuuksia ja mikrokirurgisen hoidon tuloksia riippuen lähestymistavasta. Lisäksi tutkimuksessa analysoitiin adenosiinilla väliaikaisen sydämen- ja verenkiertopysähdyksen käyttöä ICA-oftalmica aneurysmien leikkauksissa. Aineisto Olemme retrospektiivisesti analysoineet 68 potilaan ICA-oft ja bilateraali MCA (bMCA) aneurysmat, jotka hoidettiin HYKS Neurokirurgian klinikassa vv. 1998-2013. Aneurysmien ominaisuudet ja kirurgisen lähestymistavan nyansseja on myös analysoitu. Erikseen olemme katsoneet läpi ryhmä ne ICA-oft aneurysmapotilaita (n=8), jolla aneurysman klipsaus oli tehty vastakkaiselta puolelta käyttäen intraoperatiivista sydämen-ja verenkiertopysähdystä adenosiinilla. Tulokset ICA-oft aneurysmat: Kaikki aneurysmat olivat pienkokoisia (halkaisija alle 7 mm), vuotamattomia, sakkularisia, ilman seinämän epätasaisuuksia tai kalkkeumia. Aneurysman mikrokirurginen klipsaus oli mahdollinen jos prekiasmaattinen etäisyys oli 5,7 mm (3,4-8,7) ja interoptinen etäisyys oli 10,5 mm (7,6-15,9). Useimmiten anurysma suuntautui superomediaalisesti (77%). Kolmen kuukauden kontrollissa ICA-oft aneurysman kontralateraaliklipsauksen tulokset oli hyviä 93%:lla potilaista bMCA-aneurysmat: Tässä ryhmässä kontralateraaliklipsaus oli sopiva 38 potilailla. Kaikissa tapauksissa aneurysma oli vuotamaton ja sakkularinen. Suurin osa (97%) näistä aneurysmista oli pieniä tai keskikokoisia. Kontralateraali A1 segmentin mediaani pituus oli 13,2 mm (6-19) ja kontralateraali M1 segmentin mediaani pituus oli 14,2 mm (4,6-21). bMCA-aneurysmien ryhmässä kontralateraaliklipsauksen tulokset 3 kk kontrollissa oli hyviä 24 (86%) potilaalla ja huonoja 4 (14%) potilaalla. Hajuaistin ongelmat ovat tulleet esille 21%:lla potilaista. Väliaikainen sydämen pysähdys adenosiinilla ICA-oft aneurysman leikkauksessa: Tämä menetelmä on käytetty kahdeksalla potilaalla. Viisi heistä saivat yhden boluksen adenosiinia ja kolmelle annettiin tätä lääkettä toistetusti. Adenosiinin mediaani annos oli 22,5 mg (5-50mg). Sydämen pysähdys kesti 20-40 sek. Kolmen kuukauden kontrollissa kaikilla potilaalla tässä ryhmässä oli hyvät tulokset eikä todettu adenosiiniin liittyviä komplikaatiota. Johtopäätökset: Kontralateraali lähestyminen soveltuu osaan ICA-oft ja bMCA aneurysmien hoitoon. Soveltuminen kontralateraaliseen lähestymiseen riippuu aneuryman morfologisista ominaisuuksista ja verisuonen etäisyydestä kriittisiin alueisiin ja kallonpohjan anatomiasta (prekiasmaattinen, interoptinen etäisyys, A1 ja M1 pituus). Väliaikainen sydämen pysähdys adenosiinilla sallii proksimaalisen kontrollin ICA-oft aneurysmaleikkauksessa kontralateraaliavauksen aikana

Editorial : Pathophysiology and treatment of fusiform intracranial aneurysms

Non peer reviewe

In Reply : Superficial Temporal Artery: Distal Posterior Cerebral Artery Bypass Through the Subtemporal Approach: Technical Note and Pilot Surgical Cases

Non peer reviewe

Brainstem Cavernous Malformations Management : Microsurgery vs. Radiosurgery, a Meta-Analysis

Given the rareness of available data, we performed a systematic review and meta-analysis on therapeutic strategy microsurgical resection and stereotactic radiosurgery (SRS) for brainstem cavernous malformations (BSCMs) and assessed mortality, permanent neurological deficits (PNDs), rebleeding rate, and patients who require reintervention to elucidate the benefits of each treatment modality. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used for protocol development and manuscript preparation. After applying all inclusion and exclusion criteria, six remaining articles were included in the final manuscript pool. In total, this meta-analysis included 396 patients, among them 168 patients underwent microsurgical treatment and 228 underwent SRS. Findings of the present meta-analysis suggest that regarding the total group of patients, in terms of mortality, late rebleeding rate, and PNDs, there was no superiority of the one method over the other. Applying the leave-one-out method to our study suggests that with low robust of the results for the bleeding rate and patients who require reintervention outcome factor, there was no statistical difference among the surgical and SRS treatment. Microsurgical treatment of BSCMs immediately eliminates the risk of rehemorrhage; however, it requires complete excision of the lesion and it is associated with a similar rate of PNDs compared with SRS management. Apparently, SRS of BSCMs causes a marked reduction in the risk of rebleeding 2 years after treatment, but when compared with the surgical treatment, there was not any remarkable difference.Peer reviewe

The Extended Lateral Supraorbital Approach and Extradural Anterior Clinoidectomy Through a Frontopterio-Orbital Window : Technical Note and Pilot Surgical Series

BACKGROUND: Lateral approaches to treat anterior cranial fossa lesions have evolved since the first frontotemporal approach described by Dandy in 1918. We describe a less invasive approach to perform extradural anterior clinoidectomy through a lateral supraorbital (LSO) approach for anterior circulation aneurysms and anterolateral skull base lesions. METHODS: The extended LSO approach involves performing a standard lateral supraorbital craniotomy followed by drilling of the sphenoid wing and lateral wall of the orbit through the frontal bony opening of the LSO approach, without any temporal extension of the craniotomy. This creates a frontopterio-orbital window exposing the periorbita; superior, medial, and anterior aspect of the temporal dura mater; and superior orbital fissure. After unroofing the superior orbital fissure, the meningo- orbital fold is cut, and the temporal dura mater is peeled from the lateral wall of the cavernous sinus to expose the anterior clinoid process allowing a standard opening of the optic canal and anterior clinoidectomy. RESULTS: The extended LSO approach and extradural anterior clinoidectomy allowed access to 4 sphenoid wing/anterior clinoidal meningiomas, 5 anterior circulation aneurysms, 2 temporomesial lesions, and 1 orbital/cavernous sinus abscess. Postoperatively, 2 patients had transient hemiparesis, 2 patients had transient third nerve palsy, and 1 patient had minimal visual field deterioration. All patients had a modified Rankin Scale score CONCLUSION: The extended LSO approach opens a new route (frontopterio-orbital window) to perform extradural anterior clinoidectomy safely and increases surgical exposure, angles, and operability of a less invasive keyhole craniotomy (LSO approach) to treat anterior cranial fossa lesions.Peer reviewe

The orbitozygomatic stich: A technical modification of the lateral supraorbital approach

Peer reviewe

Posterior Cerebral Artery Aneurysms : Treatment and Outcome Analysis in 121 Patients

Peer reviewe

Long-Term Causes of Death and Excess Mortality After Carotid Artery Ligation

Peer reviewe

Retrograde Suction Decompression for Clip Occlusion of Internal Carotid Artery Communicating Segment Aneurysms

BACKGROUND: Retrograde suction decompression (RSD) can achieve proximal parent vessel control, improve aneurysm neck visualization, and allow parent vessel reconstruction for direct clipping of internal carotid artery (ICA) aneurysms. The aim of the present study was to describe the technique and surgical results of RSD for direct clipping of ICA communicating segment (C1) aneurysms. METHODS: The clinical data and treatment summaries of 20 patients who underwent RSD-assisted clipping of ICA C1 aneurysms were retrospectively reviewed. Pre- and postoperative three-or four-dimensional computed tomography angiograms, postoperative magnetic resonance images, surgical notes, operative complications, and outcomes were assessed. RESULTS: All patients except one harbored unruptured C1 aneurysms. Extracranial-intracranial graft bypass using the radial artery was performed in five patients. Fifteen patients required temporary clipping of the posterior communicating artery for further reduction of blood back-flow into the aneurysm. All aneurysms were successfully clipped and postoperative three-or four-dimensional computed tomography angiography revealed no major branch occlusion or residual aneurysm. At the 6-month follow-up examination, 19 patients had a good outcome and 1 patient had poor outcome associated with anterior choroidal artery ischemia. No death had occurred at 6-month follow-up examination. CONCLUSIONS: The RSD technique is a useful procedure to achieve proximal vascular control, to soften and shrinkage the aneurysm sac, and to provide a wide and clean operative field allowing safe clip placement. The RSD technique requires special attention to the relationship between the perforators and the aneurysm, and close cooperation between the surgeon and the assistant.Peer reviewe

The endoscopic transpterional port approach: anatomy, technique, and initial clinical experience

OBJECTIVEThe evolution of microsurgical and endoscopic techniques has allowed the development of less invasive transcranial approaches. The authors describe a purely endoscopic transpterional port craniotomy to access lesions involving the cavernous sinus and the anterolateral skull base.METHODSThrough single- or dual-port incisions and with direct endoscopic visualization, the authors performed an endoscopic transpterional port approach (ETPA) using a 4-mm straight endoscope in 8 sides of 4 formalin-fixed cadaveric heads injected with colored latex. A main working port incision is made just below the superior temporal line and behind the hairline. An optional 0.5- to 1-cm second skin port incision is made on the lateral supraorbital region, allowing multiangle endoscopic visualization and maneuverability. A 1.5- to 2-cm craniotomy centered over the pterion is done through the main port, which allows an extradural exposure of the cavernous sinus region and extra/intradural exposure of the frontal and temporal cranial fossae. The authors present a pilot surgical series of 17 ETPA procedures and analyze the surgical indications and clinical outcomes retrospectively.RESULTSThe initial stage of this work on cadavers provided familiarity with the technique, standardized its steps, and showed its anatomical limits. The clinical ETPA was applied to gain access into the cavernous sinus, as well as for aneurysm clipping and meningioma resection. Overall, perioperative complications occurred in 1 patient (6%), there was no mortality, and at last follow-up all patients had a modified Rankin Scale score of 0 or 1.CONCLUSIONSThe ETPA provides a less invasive, focused, and direct route to the cavernous sinus, and to the frontal and temporal cranial fossae, and it is feasible in clinical practice for selected indications with good results