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Simultaneous Craniotomies for Multiple Intracranial Aneurysm Clippings-One-Stage Surgery with Multiple Craniotomies. World Neurosurg 2021; 158:e689-e696. [PMID: 34800734 DOI: 10.1016/j.wneu.2021.11.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The treatment of multiple intracranial aneurysms (MIAs) involves various modalities and sometimes requires staged operations. This study aimed to prove the efficacy and safety of one-stage multiple craniotomies (OSMC) for multiple cerebral aneurysms. METHODS We retrospectively reviewed the medical records of the patients who underwent treatment for intracranial aneurysms between May 2003 and April 2020. The surgical results, complications, and lengths of hospital stay were compared between the patients who underwent OSMC and those who underwent multistage multiple craniotomies. RESULTS The demographic characteristics of the OSMC and multistage multiple craniotomies groups (n = 82 and 43, respectively) were similar. There were no statistically significant differences between the 2 groups when the amount of blood transfused, complications, and surgical results were compared (P = n.s. for all); however, the operation time and hospitalization period (353.9 minutes vs. 490.3 minutes and 12.3 days vs. 21.8 days, respectively; P = 0.001 for both) were shorter in the OSMC group. The treatment cost (17,000 USD vs. 22,000 USD, P = 0.001) was lower in the OSMC group. CONCLUSIONS OSMC for aneurysm clipping in patients with MIAs is a relatively safe and economical method. Furthermore, it has good clinical outcomes. This new surgical method is worthwhile in that it can be applied to patients who are afraid to undergo multiple surgeries, and we suggest that it is an efficient, low-cost option for the treatment of MIAs.
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Sweid A, Rahm SP, Das S, Baldassari MP, Jabbour P, Alexander TD, Velagapudi L, Chalouhi N, Gooch MR, Herial N, Rosenwasser RH, Tjoumakaris S. Safety and Efficacy of Bilateral Flow Diversion for Treatment of Anterior Circulation Cerebral Aneurysms. World Neurosurg 2019; 130:e1116-e1121. [PMID: 31330338 DOI: 10.1016/j.wneu.2019.07.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/12/2019] [Accepted: 07/13/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Nearly 20% of individuals with an aneurysm will have multiple aneurysms-these individuals are at increased risk of subarachnoid hemorrhage. Treatment of bilateral aneurysms with flow diverters (FDs), or Pipeline embolization device, has not yet been established as an effective therapy. We evaluated the safety and efficacy of a 2-stage treatment of bilateral aneurysms with Pipeline embolization devices placed 6 months apart. METHODS We performed a retrospective review to analyze the clinical and angiographic outcomes of 16 individuals with bilateral aneurysms treated with 2-stage flow diversion at a tertiary referral center from January 2010 to July 2018. RESULTS Of the 16 patients with 33 aneurysms treated with bilateral flow diversion, 1 had 2 aneurysms treated with a single FD on the contralateral side. The aneurysms treated were ophthalmic, superior hypophyseal, posterior communicating, or cavernous segment aneurysms, with an average size of 6.5 mm. No major complications, such as in-stent stenosis, thromboembolic events, distal intraparenchymal hemorrhage, rerupture, stent migration, or neurological death, were recorded. All the patients had good functional outcomes. At the 24-month follow-up examination, 81% of aneurysms showed complete occlusion. No aneurysm required repeat treatment. CONCLUSIONS The results from the present study have demonstrated that 2-stage treatment of bilateral aneurysms with FDs is both safe and efficacious. The timing of contralateral FD stent placement is critical. We found that 6 months allows for adequate neurological recovery and stent endothelialization.
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Affiliation(s)
- Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Sage P Rahm
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Somnath Das
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Tyler D Alexander
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Lohit Velagapudi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nabeel Herial
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
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Fully Endoscope-Controlled Clipping Bilateral Middle Cerebral Artery Aneurysm Via Unilateral Supraorbital Keyhole Approach. J Craniofac Surg 2018; 27:2151-2153. [PMID: 28005775 PMCID: PMC5110332 DOI: 10.1097/scs.0000000000003081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Clipping bilateral middle cerebral artery (bMCA) aneurysms via unilateral approach in a single-stage operation is considered as a challenge procedure. To our knowledge, there is no study in surgical management of patients with bMCA aneurysms by fully endoscope-controlled techniques. The author reported a patient with bMCA aneurysms who underwent aneurysms clipping via a unilateral supraorbital keyhole approach by endoscope-controlled microneurosurgery, and the patient had an uneventful postoperative course without neurologic impairment and complication. Furthermore, the author discussed the advantages and adaptation of endoscope-controlled clipping bMCA aneurysms via unilateral supraorbital keyhole approach.
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Acik V, Cavus G, Bilgin E, Arslan A, Gezercan Y, Okten Aİ. Surgical Treatment of Mirror Middle Cerebral Artery Aneurysms: Bilateral and Unilateral Approach. World Neurosurg 2017; 108:774-782. [DOI: 10.1016/j.wneu.2017.09.078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
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Comparison of Unilateral and Bilateral Craniotomy for the Treatment of Bilateral Middle Cerebral Artery Aneurysms: Anatomic and Clinical Parameters and Surgical Outcomes. World Neurosurg 2017; 108:627-635. [PMID: 28887278 DOI: 10.1016/j.wneu.2017.08.175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 08/26/2017] [Accepted: 08/28/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare 2 craniotomy approaches (unilateral and bilateral) in terms of anatomic and clinical parameters and surgical outcomes. METHODS Between January 2011 and December 2014, 19 patients with bilateral unruptured middle cerebral artery (MCA) aneurysm were treated with unilateral craniotomy (group 1), and 10 patients were treated with bilateral mini-craniotomy (group 2). We compared demographic data, characteristics of aneurysms, radiologic and clinical parameters, postoperative complications, and surgical outcomes between the 2 groups. RESULTS No statistically significant differences in aneurysm characteristics were found between the 2 groups. Radiologic parameters did not have any influence on surgical outcomes or the incidence of postoperative complications. Group 1 had a higher incidence of olfactory dysfunction (11 of 19; 58%) and residual neck at the contralateral aneurysm (10 of 19; 53%), whereas no patients in group 2 had olfactory dysfunction or residual neck at the contralateral aneurysm. All patients in group 2 had good surgical outcomes (modified Rankin scale score 0). The length of hospital stay was similar in the 2 groups. CONCLUSIONS Bilateral mini-craniotomy for the treatment of bilateral MCA aneurysms was associated with better surgical outcomes and fewer complications. Bilateral mini-craniotomy does not require as much retraction of the frontal lobe to apply a clip completely at the contralateral aneurysm. Therefore, it represents a safe and effective therapeutic option for unruptured bilateral MCA aneurysms.
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Andrade-Barazarte H, Kivelev J, Goehre F, Jahromi BR, Noda K, Ibrahim TF, Kivisaari R, Lehto H, Niemela M, Jääskeläinen JE, Hernesniemi JA. Contralateral Approach to Bilateral Middle Cerebral Artery Aneurysms: Comparative Study, Angiographic Analysis, and Surgical Results. Neurosurgery 2015; 77:916-26; discussion 926. [PMID: 26308631 DOI: 10.1227/neu.0000000000000930] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bilateral aneurysms located between the 2 middle cerebral artery (MCA) bifurcations may be approachable through a single unilateral approach. OBJECTIVE To identify anatomic parameters based on imaging that would favor a contralateral approach. METHODS From January 1998 to December 2013, we retrospectively identified 173 patients with bilateral intracranial aneurysms. Fifty-one patients had bilateral MCA aneurysms. A total of 38 patients underwent a single craniotomy with a contralateral microsurgical approach (group 1 or contralateral group) and 13 patients underwent bilateral craniotomies (group 2 or bilateral group). For both groups, we analyzed aneurysm characteristics, morphology, size, projections, and distance to the contralateral corridor, as well as surgical time, outcome, and postoperative complications. RESULTS All aneurysms approached contralaterally were unruptured and without wall calcifications. Of the contralaterally approached aneurysms, 97% were smaller than 14 mm. 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). The contralateral group had a good postoperative outcome (modified Rankin Scale 0-3) in 80% of ruptured cases and 86% of unruptured cases. The median surgical time was 120 minutes (range: 75-255 minutes), 43% shorter than the bilateral group. CONCLUSION The contralateral approach for bilateral MCA aneurysms in selected patients is feasible in experienced hands, with acceptable morbidity and mortality. The contralateral approach requires a meticulous preoperative analysis of the characteristics of the aneurysms to be clipped and of the anatomic constraints of the microsurgical operative corridor. ABBREVIATIONS A1, anterior cerebral artery proximal segmentbMCA, bilateral middle cerebral arteryCTA, computed tomographic angiographyHH, Hunt-Hess scaleIA, intracranial aneurysmsICA, internal carotid arteryICAbif, internal carotid artery bifurcationMCA, middle cerebral arteryM1, middle cerebral artery proximal segmentmRS, modified Rankin ScaleSAH, subarachnoid hemorrhage.
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Affiliation(s)
- Hugo Andrade-Barazarte
- *Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; ‡Department of Neurosurgery, University Central Hospital Antonio Maria Pineda, Barquisimeto, Venezuela; §Department of Neurosurgery, Stroke Center, Bergmannstrost Hospital, Halle, Germany; ¶Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan; ‖Department of Neurosurgery, Loyola University Medical Center, Maywood, Illinois; #Department of Neurosurgery, Kuopio University Central Hospital, Kuopio, Finland
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Inci S, Akbay A, Ozgen T. Bilateral middle cerebral artery aneurysms: a comparative study of unilateral and bilateral approaches. Neurosurg Rev 2012; 35:505-17; discussion 517-8. [PMID: 22580988 DOI: 10.1007/s10143-012-0392-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 03/07/2012] [Accepted: 03/07/2012] [Indexed: 11/25/2022]
Abstract
The best surgical method for the treatment of patients with bilateral middle cerebral artery (bMCA) aneurysms has not been fully determined yet. The main purpose of this study is to compare the surgical results of unilateral and bilateral approaches to bMCA aneurysms including mean operation time, mean hospital stay, and mean cost, in the experience of the same neurosurgical team. Between January 2001 and June 2010, 22 patients with bMCA aneurysms were surgically treated in our institution. In 12 cases (54.5 %), ipsilateral and contralateral MCA aneurysms were successfully clipped via unilateral approach. In the remaining 10 cases, bilateral approach was necessary because of some technical difficulties. Although the surgical results were almost the same, mean operation time and mean hospital stay were, respectively, 46 and 37 % shorter and mean cost per person was 23 % lower for the patients in the unilateral group. In addition, the severity of brain edema, total length of the contralateral (A1+M1) segment, and the configuration of contralateral aneurysm were found to be the determinant parameters affecting the feasibility of the unilateral approach. To our knowledge, this is the first study in the literature that compares the clinical outcomes of unilateral and bilateral approaches to bMCA aneurysms. The results of surgery for both approaches are almost the same. However, the unilateral approach has certain advantages compared to the bilateral approach. Therefore, the unilateral approach may be a good alternative in surgical management of patients with bMCA aneurysms in selected cases and the abovementioned parameters can help the neurosurgeon in patient selection.
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Affiliation(s)
- Servet Inci
- Department of Neurosurgery, School of Medicine, University of Hacettepe, Ankara, Turkey.
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Arrese I, Sarabia R. Contralateral approach for middle cerebral artery aneurysms with long M1 segment: report of 2 cases. Neurocirugia (Astur) 2012; 23:122-6. [DOI: 10.1016/j.neucir.2012.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 02/27/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Ignacio Arrese
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
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Rodríguez-Hernández A, Gabarrós A, Lawton MT. Contralateral clipping of middle cerebral artery aneurysms: rationale, indications, and surgical technique. Neurosurgery 2012; 71:116-23; discussion 123-4. [PMID: 22307073 DOI: 10.1227/neu.0b013e31824d8f66] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Contralateral clipping of middle cerebral artery (MCA) aneurysms seems dangerous and ill advised but could become an important technique because of the prevalence of MCA aneurysms, the limitations of endovascular therapy, and increasing interest in less invasive techniques. OBJECTIVE To define patient selection, surgical technique, and results with contralateral MCA aneurysm clipping. METHODS Forty-two patients with bilateral MCA aneurysms were treated either in 1 stage with a single craniotomy and contralateral aneurysm clipping (group 1, 11 patients) or in 2 stages with bilateral craniotomy (group 2, 31 patients). Surgical technique consisted of ipsilateral sylvian fissure split, subfrontal dissection, contralateral sylvian fissure split, mobilization of medial orbital gyrus, and contralateral aneurysm clipping. RESULTS Group 1 patients were older than group 2 patients (60.3 vs 55.4 years, respectively). Clinical presentation with subarachnoid hemorrhage was less common in group 1. Nine group 1 patients (82%) had left-sided craniotomies, and the ipsilateral aneurysm was larger than the contralateral aneurysm. All aneurysms were clipped without intraoperative complications (136 aneurysms). Mean neurosurgical charges were decreased by contralateral MCA aneurysm clipping: $39 297 in group 1 vs $57 977 in group 2. CONCLUSION Contralateral MCA aneurysm clipping can be viewed as an extreme microsurgical technique or as a less invasive technique that spares patients a second craniotomy in the management of bilateral aneurysms. This technique is acceptable in selected patients with contralateral aneurysms that are unruptured, have simple necks, project inferiorly or anteriorly, are associated with short M1 segments, and reside in older patients with sylvian fissures widened by brain atrophy.
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Affiliation(s)
- Ana Rodríguez-Hernández
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA
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Rajesh A, Praveen A, Purohit A, Sahu B. Unilateral craniotomy for bilateral cerebral aneurysms. J Clin Neurosci 2010; 17:1294-7. [DOI: 10.1016/j.jocn.2009.10.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 10/01/2009] [Accepted: 10/04/2009] [Indexed: 11/28/2022]
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