Neurosurgery 68[ONS Suppl 2]:ons300–ons309, 2011 DOI: 10.1227/NEU.0b013e3182124810
Neurovascular surgeons have been trying to find a solution to the problem of surgical invasiveness by applying minimally invasive keyhole approaches.
OBJECTIVE: To evaluate the feasibility and surgical outcomes of a superciliary keyhole approach for unruptured intracranial aneurysms (UIAs) as an alternative to a pterional approach.
METHODS: The authors report on a consecutive series of patients who underwent a superciliary approach for clipping UIAs smaller than 15 mm arising at the supraclinoid internal carotid artery (ICA), A1 segment, anterior communicating artery (ACoA), and M1 segment including the middle cerebral artery (MCA) bifurcation. The data were compared with a historical control group (n = 90) who underwent a pterional approach for UIAs.
RESULTS: A total of 120 aneurysms were successfully clipped in 102 patients with a mean age of 58 years. There was no direct mortality related to the surgery, and only 1 (1.0%) patient developed significant morbidity adversely affecting the Glasgow Outcome Scale score. The superciliary approach demonstrated statistically significant advantages over the pterional approach, including a shorter operative duration (mean, 120 min), no intraoperative blood transfusion, and extremely rare postoperative epidural hemorrhages. In addition, temporalis atrophy was rare and palsy of the frontalis persisting more than 6 months only occurred in 6 patients (5.9%) and was resolved within 2 years. The overall cosmetic outcome was excellent.
CONCLUSION: A superciliary approach can be a reasonable alternative to a pterional approach for small (,15 mm) UIAs arising at the supraclinoid ICA, A1, ACoA, and M1 segment including the MCA bifurcation.
J Neurosurg 113:774–780, 2010. DOI: 10.3171/2010.2.JNS09376
The purpose of this study was to identify predictors of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH).
Methods. The authors evaluated the incidence of shunt-dependent hydrocephalus in a consecutive cohort of 580 patients with SAH who were admitted to the Neurological Intensive Care Unit of Columbia University Medical Center between July 1996 and September 2002. Patient demographics, 24-hour admission variables, initial CT scan characteristics, daily transcranial Doppler variables, and development of in-hospital complications were analyzed. Odds ratios and 95% CIs for candidate predictors were calculated using multivariate nominal logistic regression.
Results. Admission glucose of at least 126 mg/dl (adjusted OR 1.6; 95% CI 1.0–2.6), admission brain CT scan with a bicaudate index of at least 0.20 (adjusted OR 1.43; 95% CI 1.0–2.0), Fisher Grade 4 (adjusted OR 2.71; 95% CI 1.2–5.7), fourth ventricle hemorrhage (adjusted OR 1.78; 95% CI 1.1–2.7), and development of nosocomial meningitis (adjusted OR 2.2; 95% CI 1.4–3.7) were independently associated with shunt dependency.
Conclusions. These data suggest that permanent CSF diversion after aneurysmal SAH may be independently predicted by hyperglycemia at admission, findings on the admission CT scan (Fisher Grade 4, fourth ventricle intraventricular hemorrhage, and bicaudate index ≥ 0.20), and development of nosocomial meningitis. Future research is needed to assess if tight glycemic control, reduction of fourth ventricle clot burden, and prevention of nosocomial meningitis may reduce the need for permanent CSF diversion after aneurysmal SAH.
Neurosurgery 67:844-854, 2010 DOI: 10.1227/01.NEU.0000374684.10920.A2
Multidetector computerized tomography angiography (MDCTA) is now a widely accepted technique for the management of intracranial aneurysms.
OBJECTIVE: To evaluate its accuracy for the postoperative assessment of clipped intracranial aneurysms.
METHODS:We analyzed a consecutive series of 31 patients that underwent direct surgical clipping procedures of 38 aneurysms. A 64 slice MDCT scanner (Aquilion 64, Toshiba) was used and results were compared with digital subtraction angiographies (DSA). Two independent neuroradiologists analyzed the following data: examination quality, artifacts, aneurysm remnant, and patency of collateral branches. Interobserver agreement, sensitivity, and specificity were calculated.
RESULTS: Seventy-nine percent of the aneurysms were located in the anterior circulation. Significant artifacts were found with multiple and cobalt-alloy clips. According to DSA, remnants >2 mm were found in 21% of the cases, and 2 patients had one collateral branch occluded. Sensitivity and specificity of 64-MDCTA for the detection of aneurysm remnants were 50% and 100%, respectively. Sensitivity and specificity of 64-MDCTA for the detection of a significant remnant (>2 mm) and the detection of the occlusion of a collateral branch were, respectively, 67% and 100% and 50% and 100%. No relationship was found with the location, type, shape, size, or number of clips, but missed remnants tended to be larger with cobalt-alloy clips.
CONCLUSIONS: 64-MDCTA is a valuable technique to assess the presence of a significant postoperative remnant in single titanium clip application cases and might be useful for longterm follow-up. DSA remains the most accurate postoperative radiological examination.
Neurosurgery 00:000-000, 2010 DOI: 10.1227/01.NEU.0000374684.10920.A2
Multidetector computerized tomography angiography (MDCTA) is now a widely accepted technique for the management of intracranial aneurysms.
OBJECTIVE: To evaluate its accuracy for the postoperative assessment of clipped intracranial aneurysms.
METHODS:We analyzed a consecutive series of 31 patients that underwent direct surgical clipping procedures of 38 aneurysms. A 64 slice MDCT scanner (Aquilion 64, Toshiba) was used and results were compared with digital subtraction angiographies (DSA). Two independent neuroradiologists analyzed the following data: examination quality, artifacts, aneurysm remnant, and patency of collateral branches. Interobserver agreement, sensitivity, and specificity were calculated.
RESULTS: Seventy-nine percent of the aneurysms were located in the anterior circulation. Significant artifacts were found with multiple and cobalt-alloy clips. According to DSA, remnants >2 mm were found in 21% of the cases, and 2 patients had one collateral branch occluded. Sensitivity and specificity of 64-MDCTA for the detection of aneurysm remnants were 50% and 100%, respectively. Sensitivity and specificity of 64-MDCTA for the detection of a significant remnant (>2 mm) and the detection of the occlusion of a collateral branch were, respectively, 67% and 100% and 50% and 100%. No relationship was found with the location, type, shape, size, or number of clips, but missed remnants tended to be larger with cobalt-alloy clips.
CONCLUSIONS: 64-MDCTA is a valuable technique to assess the presence of a significant postoperative remnant in single titanium clip application cases and might be useful for longterm follow-up. DSA remains the most accurate postoperative radiological examination.
J Neurosurg 112:1200–1207, 2010. DOI: 10.3171/2009.10.JNS08754
The aim of the study was to assess postprocedural neurological deterioration and outcome in patients older than 70 years of age in whom treatment was managed in an interdisciplinary context.
Methods. This prospective longitudinal study included all patients 70 years of age or older treated for ruptured cerebral aneurysm over 10 years (June 1997–June 2007). The population was composed of 64 patients. The neurovascular interdisciplinary team jointly discussed the early obliteration procedure for each aneurysm. Neurological deterioration during the postprocedural 2 months and outcome at 6 months were assessed during consultation according to the modified Rankin Scale (mRS) as follows: favorable (mRS score ≤ 2) and unfavorable (mRS score > 2).
Results. Aneurysm sac obliteration was performed by microvascular clipping in 34 patients (53.1%) and by endovascular coiling in 30 (46.9%). Postprocedural neurological deterioration occurred in 30 patients (46.9%), related to ischemia in 19 (29.7%), rebleeding in 1 (1.6%), and hydrocephalus in 10 (15.6%). At 6 months, the outcome was favorable in 39 patients (60.9%). By multivariate regression logistic analysis, the independent factors associated with unfavorable outcome were age exceeding 75 years (p = 0.005), poor initial grade (p < 0.0001), and the occurrence of ischemia (p < 0.0001).
Conclusions. The baseline characteristics of SAH in the elderly were only slightly different from those in younger patients. In the elderly, the interdisciplinary approach may be considered useful to decrease the ischemic consequences.
Acta Neurochir (2010) 152:793–802 DOI 10.1007/s00701-009-0465-4
The aim of our study was to evaluate the diagnostic efficacy of multislice computed tomographic angiography (MSCTA) regarding exclusion quality after aneurysm clipping.
Methods. Sixty patients (74 aneurysms) underwent microsurgical exclusion using titanium clips. The presence of aneurysm remnants on MSCTA was compared by a neuroradiologist to 2D digital subtraction angiography (DSA), which was considered as a reference examination. The contribution of 3D DSA was assessed in a subpopulation of 29 patients (35 aneurysms).
Results. With 2D DSA, six aneurysm remnants (8%) were diagnosed, and only five (7%) by MSCTA. The specificity and sensitivity were 98.5 and 83%, respectively. MSCTA failed to demonstrate one large remnant (>2 mm) because of clip artifacts (six clips). With 3D DSA six supplementary remnants were diagnosed. Two were large remnants blinded by vessel overlaps and clip artifacts. Four were small “dogeared” remnants (≤2 mm). No additional treatment was required for small remnants.
Conclusion. In the postoperative period, MSCTA was considered a useful tool to evaluate the large remnants as well as a non-invasive ulterior examination for suspected bifurcation. Nevertheless, 3D DSA is still required for an accurate evaluation of aneurysms treated by more than three clips.
Neurosurg Rev (2010) 33:205–216. DOI 10.1007/s10143-009-0234-0
Non-saccular aneurysms (NSAs) of the internal carotid artery trunk include blood blister-like aneurysms (BBAs) and dissecting aneurysms (DAs), which are susceptible to disastrous intra- and postoperative bleeding. This study was conducted to clarify the clinical features of NSAs and the results of early bypass and trapping. Nineteen ruptured NSAs were identified in 937 patients with subarachnoid hemorrhage (SAH). The principal treatment was to trap the aneurysm following bypass surgery as soon as possible after SAH onset. Angiography revealed nine BBAs and ten DAs. Eight patients (four BBA and four DA) were treated in the chronic stage because of delayed arrival (n=3) or lack of aneurysm on initial angiography (n=3), or other reasons (n=2). The remaining 11 patients underwent early surgery using trapping after bypass, except for one BBA-type (clipped). During surgery, corresponding intraoperative findings were confirmed for each aneurysm type. There were six preoperative reruptures; five were determinant of patient outcome. In 14 patients without preoperative rerupture influencing outcome, 11 patients were independent at discharge and three patients dependent due to surgical complication. There was one case of minor intraoperative bleeding; no postoperative rerupture occurred. There was no delayed vasospasm-related deficit, although temporary symptomatic spasm occurred in three patients. Early bypass and trapping appeared to be an acceptable treatment strategy for these NSAs eliminating intra- and postoperative bleeding and not increasing a chance of delayed vasospasm.
Neurosurgery 65:719–726, 2009 DOI: 10.1227/01.NEU.0000354350.88899.07
OBJECTIVE: With improvements in endovascular techniques, fewer aneurysms are treated by surgical clipping, and those aneurysms targeted for open surgery are often complex and difficult to treat. We devised a hollow, 3-dimensional (3D) model of individual cerebral aneurysms for preoperative simulation and surgical training. The methods and initial experience with this model system are presented.
METHODS:The 3D hollow aneurysm models of 3 retrospective and 8 prospective cases were made with a prototyping technique according to data from 3D computed tomographic angiograms of each patient. Commercially available titanium clips used in our routine surgery were applied, and the internal lumen was observed with an endoscope to confirm the patency of parent vessels. The actual surgery was performed later.
RESULTS: In the 8 prospective cases, the clips were applied during surgery in the same direction and configuration as in the preoperative simulation. Fine adjustments were necessary in each case, and 2 patients needed additional clips to occlude the atherosclerotic aneurysmal wall. With these 3D models, it was easy for neurosurgical trainees to grasp the vascular configuration and the concept of neck occlusion. Practicing surgery with these models also improved their handling of the instruments used during
aneurysm surgery, such as clips and appliers.
CONCLUSION: Using the hollow 3D models to simulate clipping preoperatively, we could treat the aneurysms confidently during live surgery. These models allow easy and concrete recognition of the 3D configuration of aneurysms and parent vessels.
Neurosurgery 68[ONS Suppl 2]:ons300–ons309, 2011 DOI: 10.1227/NEU.0b013e3182124810
