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Findlay MC, Bounajem MT, Kim RB, Henson JC, Azab MA, Cutler CB, Khan M, Brandon C, Budohoski KP, Rennert RC, Couldwell WT. Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use? Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01154. [PMID: 38690880 DOI: 10.1227/ons.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/07/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era. METHODS This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis. RESULTS Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction. CONCLUSION These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.
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Affiliation(s)
| | - Michael T Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert B Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - J Curran Henson
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mohammed A Azab
- Biomedical Sciences, Boise State University, Boise, Idaho, USA
| | - Christopher B Cutler
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Majid Khan
- School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Cameron Brandon
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Pettersson SD, Khorasanizadeh M, Maglinger B, Garcia A, Wang SJ, Taussky P, Ogilvy CS. Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020. World Neurosurg 2023; 178:233-240.e13. [PMID: 37562685 DOI: 10.1016/j.wneu.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time. METHODS A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests. RESULTS A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987. CONCLUSIONS The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.
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Affiliation(s)
- Samuel D Pettersson
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - MirHojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton Maglinger
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfonso Garcia
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - S Jennifer Wang
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Philipp Taussky
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Muhammad S, Rezai Jahromi B, Kaukovalta H, Schwartz C, Hijazy F, Goehre F, Kozyrev DA, Kivisaari R, Hänggi D, Niemelä M. Anatomic Risk Factors for S1 Segment Superior Cerebellar Artery Aneurysm Rupture: A Radiologic Study on 81 Consecutive Patients. World Neurosurg 2021; 158:e344-e351. [PMID: 34740829 DOI: 10.1016/j.wneu.2021.10.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Due to treatment associated risks, it is still debatable which unruptured aneurysm should be treated. Anatomic and morphologic characteristics may aid to predict the rupture risk of superior cerebellar artery (SCA) aneurysm and possibly support in decision- making during treatment. OBJECTIVES To identify morphologic characteristics that could predict the rupture of SCA aneurysms. METHODS A retrospective analysis of computed tomography angiography images of 81 consecutive patients harboring SCA aneurysm who were treated between 1980 to 2014 at Helsinki University Hospital was performed. RESULTS Of the 81 analyzed SCA aneurysms, 30 (37%) were unruptured and remaining 51 (63%) presented with subarachnoid hemorrhage. The mean ± SD size of unruptured SCA aneurysms was 6.2 ± 6.3 mm; mean size of ruptured SCA aneurysms was 5.9 ± 5.4 mm. The mean ± SD aspect ratio was 0.9 ± 0.3 in unruptured and 1.14 ± 0.44 in ruptured SCA aneurysms. The mean ± SD degree angle between basilar artery and aneurysm was 74.7 ± 24.4 in unruptured and 65.9 ± 23 ruptured SCA aneurysms. Patients with ruptured SCA aneurysm showed significantly higher aspect ratio (Mann-Whitney U, P = 0.01) and smaller aneurysm to basilar artery angle (Mann-Whitney U, P = 0.039). Aspect ratio >1.1 had 2.3 times higher risk of rupture (odds ration [OR] 2.3, 95% confidence interval [CI] 0.84-6.34). An aneurysm to basilar angle <70 degrees had 2.8 times higher risk of rupture (OR 2.75, 95% CI 1.086-6.96). CONCLUSIONS Ruptured SCA aneurysms are usually small in size. Higher aspect ratio and smaller angle between SCA aneurysm and basilar artery had significantly higher risk of SCA (S1 segment) aneurysm rupture.
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Affiliation(s)
- Sajjad Muhammad
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Kaukovalta
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Christoph Schwartz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ferzat Hijazy
- Department of Neurosurgery, Stroke Center, Bergmannstrost Hospital Halle, Halle, Germany
| | - Felix Goehre
- Department of Neurosurgery, Stroke Center, Bergmannstrost Hospital Halle, Halle, Germany
| | - Danil A Kozyrev
- Department of Paediatric Neurology and Neurosurgery, Northwestern State Medical University, St. Petersburg, Russia
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Sriamornrattanakul K, Wongsuriyanan S. Anterior Temporal Approach for Clipping Posterior-Projecting Supraclinoid Carotid Artery Aneurysms: A More Lateral Corridor to Better Visualize the Aneurysm Neck and Related Branches. World Neurosurg 2021; 149:e549-e562. [PMID: 33556599 DOI: 10.1016/j.wneu.2021.01.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Direct visualization of the aneurysm neck and its related branches during microsurgical clipping of supraclinoid internal carotid artery (SICA) aneurysms using a standard pterional approach may be difficult, especially when aneurysms are posteriorly projected. We evaluated the efficacy and safety of an anterior temporal approach for clipping posterior-projecting SICA aneurysms. METHODS Between December 2017 and March 2020, 26 patients with posterior-projecting SICA aneurysms who received microsurgical clipping via an anterior temporal approach were retrospectively reviewed. The percentage of complete aneurysm obliteration, intraoperative visualization, and preservation of related branches were evaluated. RESULTS Aneurysm locations were the posterior communicating artery (PCoA) (internal carotid artery [ICA]-PCoA) in 22 patients (84.6%), the anterior choroidal artery (AChA) (ICA-AChA) in 3 patients (11.5%), and both locations in 1 patient (3.9%). Complete aneurysm obliteration was achieved in all patients. For ICA-PCoA aneurysms in which the PCoA was preoperatively identified, the artery was intraoperatively identified in all cases and preserved 100% after surgery. For ICA-AChA aneurysms, AChAs were intraoperatively identified and preserved in all cases after surgery. Procedural-related infarction was 8.7% for ICA-PCoA aneurysms and 7.7% for all SICA aneurysms. Transient oculomotor nerve palsy was found in 2 patients (7.7%). No postoperative temporal contusion was detected. A good outcome at 3 months after surgery was achieved in 90% of patients for good clinical-grade subarachnoid hemorrhage and unruptured cases. CONCLUSIONS The anterior temporal approach is safe and effective for clipping SICA aneurysms with posterior projection, with a high preservation rate of the related branches.
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Affiliation(s)
- Kitiporn Sriamornrattanakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
| | - Somkiat Wongsuriyanan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Wongsuriyanan S, Sriamornrattanakul K. Anterior temporal approach for clipping of ruptured basilar tip aneurysms: Surgical techniques and treatment outcomes. Surg Neurol Int 2020; 11:146. [PMID: 32637199 PMCID: PMC7332467 DOI: 10.25259/sni_565_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/01/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Basilar tip (BT) aneurysms are challenging to treat with microsurgical clipping, especially in subarachnoid hemorrhage cases. The anterior temporal approach is one of the surgical approaches for the treatment of aneurysms in this area. The majority of the previous reports on this approach have described unruptured cases. For the ruptured cases assessed in our study, the authors describe the surgical technique, patient characteristics, and surgical outcomes following the use of this technique. METHODS Fourteen patients with ruptured BT aneurysms who received aneurysm clipping with an anterior temporal approach between December 2015 and August 2019 were retrospectively evaluated. The surgical techniques are described, an illustrative case is shown. RESULTS The average patient age was 62.2 years (range: 46-78) for ten women and four men. Nine patients (64.3%) were classified as having a poor grade (World Federation of Neurosurgical Societies Grades 4 and 5) at the first presentation. All of the cases demonstrated complete aneurysm obliteration. Good outcomes (mRS 0 to 2) at 6 months were achieved in 58.3% of the patients and in 77.8% of the patients who had a good Glasgow Coma Score after resuscitation before surgery. Postoperative transient oculomotor nerve palsy and thalamic infarctions were detected in six patients (42.9%) and two patients (14.3%), respectively. CONCLUSION With appropriate case selection, the anterior temporal approach was effective and safe for the clipping of ruptured BT aneurysms.
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García-Pérez D, Panero I, Eiriz C, Moreno LM, Munarriz PM, Paredes I, Lagares A, Alén JF. Delayed extensive brain edema caused by the growth of a giant basilar apex aneurysm treated with basilar artery obliteration: a case report. BMC Neurol 2020; 20:232. [PMID: 32505180 PMCID: PMC7275367 DOI: 10.1186/s12883-020-01819-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Partially thrombosed giant aneurysms at the basilar apex (BA) artery are challenging lesions with a poor prognosis if left untreated. Here we describe a rare case of extensive brain edema after growth of a surgically treated and thrombosed giant basilar apex aneurysm. Case presentation We performed a proximal surgical basilar artery occlusion on a 64-year-old female with a partially thrombosed giant BA aneurysm. MRI showed no ischemic lesions but showed marked edema adjacent to the aneurysm. She had a good recovery, but 3 months after surgical occlusion, her gait deteriorated together with urinary incontinence and worsening right hemiparesis. MRI showed that the aneurysm had grown and developed intramural hemorrhage, which caused extensive brain edema and obstructive hydrocephalus. She was treated by a ventriculoperitoneal shunt placement. Follow-up MRI showed progressive brain edema resolution, complete thrombosis of the lumen and shrinkage of the aneurysm. At 5 years follow-up the patient had an excellent functional outcome. Conclusions Delayed growth of a surgically treated and thrombosed giant aneurysm from wall dissection demonstrates that discontinuity with the initial parent artery does not always prevent progressive enlargement. The development of transmural vascular connections between the intraluminal thrombus and adventitial neovascularization by the vasa vasorum on the apex of the BA seems to be a key event in delayed aneurysm growth. Extensive brain edema might translate an inflammatory edematous reaction to an abrupt enlargement of the aneurysm.
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Affiliation(s)
- Daniel García-Pérez
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain.
| | - Irene Panero
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Carla Eiriz
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Luis Miguel Moreno
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - José F Alén
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
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Matano F, Murai Y, Sato S, Koketsu K, Shirokane K, Ishisaka E, Tsukiyama A, Morita A. Risk factors for ischemic complications in vascular reconstructive surgeries. Clin Neurol Neurosurg 2020; 193:105768. [DOI: 10.1016/j.clineuro.2020.105768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 10/24/2022]
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Pirayesh A, Ota N, Noda K, Petrakakis I, Kamiyama H, Tokuda S, Tanikawa R. Microsurgery of residual or recurrent complex intracranial aneurysms after coil embolization - a quest for the ultimate therapy. Neurosurg Rev 2020; 44:1031-1051. [PMID: 32212048 DOI: 10.1007/s10143-020-01290-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 11/24/2022]
Abstract
The long-term stability of coil embolization (CE) of complex intracranial aneurysms (CIAs) is fraught with high rates of recanalization. Surgery of precoiled CIAs, however, deviates from a common straightforward procedure, demanding sophisticated strategies. To shed light on the scope and limitations of microsurgical re-treatment, we present our experiences with precoiled CIAs. We retrospectively analysed a consecutive series of 12 patients with precoiled CIAs treated microsurgically over a 5-year period, and provide a critical juxtaposition with the literature. Five aneurysms were located in the posterior circulation, 8 were large-giant sized, 5 were calcified/thrombosed. One presented as a dissecting-fusiform aneurysm, 9 ranked among wide neck aneurysms. Eight lesions were excluded by neck clipping (5 necessitating coil extraction); 1 requiring adjunct CE. The dissecting-fusiform aneurysm was resected with reconstruction of the parent artery using a radial artery graft. Three lesions were treated with flow alteration (parent artery occlusion under bypass protection). Mean interval coiling-surgery was 4.6 years (range 0.5-12 years). Overall, 10 aneurysms were successfully excluded; 2 lesions treated with flow alteration displayed partial thrombosis, progressing over time. Outcome was good in 8 and poor in 4 patients (2 experiencing delayed neurological morbidity), and mean follow-up was 24.3 months. No mortality was encountered. Microsurgery as a last resort for precoiled CIAs can provide-in a majority of cases-a definitive therapy with good outcome. Since repeat coiling increases the complexity of later surgical treatment, we recommend for this subgroup of aneurysms a critical evaluation of CE as an option for re-treatment.
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Affiliation(s)
- Ariyan Pirayesh
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan.
| | - Nakao Ota
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Kosumo Noda
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Ioannis Petrakakis
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Sadahisa Tokuda
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
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Szmuda T, Słoniewski P, Ali S, Dzierżanowski J, Kamieniecki A, Siedlecki K. Can sectioning the posterior communicating artery be predicted with computed tomography angiography in the microsurgical clipping of basilar apex aneurysms? Acta Neurochir (Wien) 2020; 162:567-579. [PMID: 31748903 DOI: 10.1007/s00701-019-04138-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Microsurgical clipping is a viable option for managing high-riding basilar apex aneurysms (BAXs) using a transsylvian approach. Cutting the posterior communicating artery (PCoA) at the perforator-free zone provides sufficient exposure of BAX, although it is not always safe. The aim was to qualitatively predict sectioning of the interfering PCoA by using preoperative computed tomographic angiography (CTA). METHODS A virtual trajectory from the lesser sphenoid wing to the neck of the aneurysm was simulated on CTA in 19 consecutive patients operated on BAX aneurysms from 2013 to 2018. The angles on CTA resembled the typical view through the extended pterional craniotomy. Next, the ipsilateral PCoA was tracked from the internal carotid to its end at the posterior cerebral artery in the trajectory. RESULTS The opticocarotid and carotid-oculomotor window served as the corridors for entering the interpeduncular fossa in 16 patients (84.2%) and in 3 patients (15.8%), respectively. The PCoA was intentionally cut during nine surgeries and preserved in 10 of them. The PCoA was cut more often when positioned toward the cranial base and more medially in the corridor; both the Kernel density analysis and the data points representing the position of the PCoA supported this finding (p < 0.01). The CTA-based position of either ends of the PCoA in the trajectory did not differ between cut and not-cut groups (p = 0.19-0.96). Aneurysm projection, rupture, size, PCoA diameter, length, and other distances on CTA were not related to the sectioning of PCoA (p > 0.05). CONCLUSIONS The probability of PCoA sectioning is higher when the PCoA is positioned medially and closer to the cranial base. If the anatomical course of the PCoA is recognized beforehand, it can contraindicate surgery. Preoperative CTA-based planning facilitates the surgery of BAX aneurysms. Therefore, CTA can make microsurgical clipping planning more predictable for the neurosurgeon and safer for the patient.
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Darsaut T, Roy D, Weill A, Bojanowski M, Chaalala C, Bilocq A, Findlay J, Rempel J, Chow M, O’Kelly C, Ashforth R, Kotowski M, Magro E, Lemus M, Fahed R, Arikan F, Arrese I, Sarabia R, Altschul D, Chagnon M, Guilbert F, Shankar J, Proust F, Nolet S, Gevry G, Raymond J. A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: Interim results from ISAT2. Neurochirurgie 2019; 65:370-376. [DOI: 10.1016/j.neuchi.2019.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/09/2019] [Accepted: 05/30/2019] [Indexed: 01/08/2023]
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Anterior Temporal Approach for Clipping of Upper Basilar Artery Aneurysms: Surgical Techniques and Treatment Outcomes. World Neurosurg 2019; 131:e530-e542. [DOI: 10.1016/j.wneu.2019.07.211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/28/2019] [Accepted: 07/29/2019] [Indexed: 11/18/2022]
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12
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Janjua MB, Reddy S, Welch WC, Ozturk AK, Price AV, Weprin B, Swift DM, Krisht AF. Concomitant ruptured anterior circulation and unruptured posterior circulation aneurysms: Treatment strategy and review of literature. J Clin Neurosci 2019; 66:252-258. [PMID: 31113699 DOI: 10.1016/j.jocn.2019.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 03/22/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
Basilar artery apex or bifurcation is the most common location for aneurysms arising from posterior cerebral circulation. Reports of unruptured aneurysms of the basilar bifurcation associated with ruptured anterior circulation aneurysms are rare. The presence of multiple intracranial aneurysms poses a significantly high risk to management than a single aneurysm due several factors involved. Surgical management is considered the best treatment modality for most aneurysmal types and location with quite a few limitations when applicable. Authors have conducted a literature review of anterior and posterior circulation concomitant aneurysms and report their own experience with a case of anterior communicating artery blister type aneurysmal rupture presented with the symptoms and signs of subarachnoid hemorrhage concomitant with an unruptured basilar artery bifurcation aneurysm. Moreover, the anomalous origin of thalamoperforators at the basilar apex instead of the posterior cerebral artery makes it reasonably challenging for the microsurgical clipping. Discussed is the clinical presentation, radiological studies obtained, surgical approach utilized with an adequate exposure of the entire circle of Willis as well as the critical decision making when managing these challenging cases.
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Affiliation(s)
- M Burhan Janjua
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, United States; Department of Neurological Surgery, CHI St. Vincent Arkansas Neuroscience Institute, Little Rock, AR, United States.
| | - Sumanth Reddy
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, United States
| | - William C Welch
- Department of Neurological Surgery, University of Pennsylvania Hospital, United States
| | - Ali K Ozturk
- Department of Neurological Surgery, University of Pennsylvania Hospital, United States
| | - Angela V Price
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, United States
| | - Bradley Weprin
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, United States
| | - Dale M Swift
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, United States
| | - Ali F Krisht
- Department of Neurological Surgery, CHI St. Vincent Arkansas Neuroscience Institute, Little Rock, AR, United States
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Postoperative Antiplatelet Therapy in the Treatment of Complex Basilar Apex Aneurysms Implementing Hunterian Ligation and Extracranial-to-Intracranial Bypass: Review of the Literature with an Illustrative Case Report. World Neurosurg 2018; 123:113-122. [PMID: 30537547 DOI: 10.1016/j.wneu.2018.11.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 11/22/2022]
Abstract
Large broad-based basilar artery (BA) apex aneurysms involving multiple arterial origins are complex lesions commonly not amenable to direct clipping or endovascular management. BA proximal (Hunterian) occlusion with extracranial-to-intracranial bypass is a supported strategy if 1 or both posterior communicating arteries are small. Hunterian ligation risks sudden aneurysm thrombosis and thromboembolism in the perforator-rich BA apex. There currently exist no guidelines for antiplatelet and anticoagulant therapy after Hunterian ligation for complex BA apex aneurysm treatment. We present a literature review and an illustrative case of an 18-year-old man who presented with progressive headaches and was found to have a large unruptured BA apex aneurysm involving the origins of the bilateral superior cerebellar and posterior cerebral arteries. Given the small posterior communicating arteries and complexity of the aneurysm, proximal BA occlusion with unilateral superficial temporal artery-to-superior cerebellar artery bypass was recommended. Despite antiplatelet treatment with acetylsalicylic acid before and after operation, the patient experienced acute ischemia of the brainstem and cerebellum and an embolic left temporal lobe infarct. The patient received dual antiplatelet therapy starting on postoperative day 6, after which he experienced no new infarcts and made a significant neurologic recovery. The current evidence suggests that proximal BA occlusion in complex BA apex aneurysm cases is thrombogenic and can be especially dangerous if thrombosis occurs suddenly in aneurysms without pre-existing intraluminal thrombus. Dual antiplatelet therapy during the first postoperative week presents a possible strategy for reducing the risk of ischemia due to sudden aneurysm thrombosis.
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Matsukawa H, Kamiyama H, Noda K, Ota N, Takahashi O, Shonai T, Tokuda S, Tanikawa R. Embryological basilar apex disposition as a risk factor of basilar apex aneurysm. J Clin Neurosci 2018; 58:79-82. [PMID: 30327221 DOI: 10.1016/j.jocn.2018.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 09/10/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022]
Abstract
The pathogenesis of basilar apex aneurysm (BAA) are still poorly understood. Embryologically, basilar apex anatomical disposition is formed by the fusion of both caudal internal carotid divisions on the midline. To compare basilar apex morphology by embryological classification among patients with BAAs, anterior circulation aneurysms (ACAs), and controls. Prospectively collected data of 47 consecutive patients with unruptured BAAs (42 females and five males), age- and gender-matched 47 patients with unruptured ACAs, and 47 controls without any aneurysms were analyzed. Based on embryology, basilar apex morphology was classified into symmetric cranial fusion (SCrF), symmetric caudal fusion, and asymmetric fusion type. Posterior communicating artery (Pcom) was classified into hypoplastic, adult, or fetal type. The asymmetrical Pcom was defined as bilaterally different type Pcom. The ACAs located at the anterior communicating artery (n = 18), paraclinoid portion (n = 12), middle cerebral artery (n = 8), anterior cerebral artery (n = 5), the top of internal carotid artery (n = 2), and anterior choroidal artery (n = 2). Compared with the ACA group and controls, smoking, asymmetrical Pcom (fetal and adult type), and SCrF type were more prevalent in patients with BAAs by residual analysis. The multinomial logistic regression comparative analysis demonstrated that SCrF type was associated with BAAs (vs. ACA group; odds ratio, 13; 95% confidence interval, 3.8-41 and vs. controls; odds ratio, 25; 95% confidence interval, 5.4-121). The assessment of basilar apex morphology may aid in the understanding of the pathogenesis of BAA and the prediction of BAA formation.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Kosumo Noda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Osamu Takahashi
- Center for Clinical Epidemiology, Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Takaharu Shonai
- Department of Radiology, Teishinkai Hospital, Sapporo, Japan
| | - Sadahisa Tokuda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan.
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Tayebi Meybodi A, Benet A, Rodriguez Rubio R, Yousef S, Mokhtari P, Preul MC, Lawton MT. Comparative Analysis of Orbitozygomatic and Subtemporal Approaches to the Basilar Apex: A Cadaveric Study. World Neurosurg 2018; 119:e607-e616. [PMID: 30077027 DOI: 10.1016/j.wneu.2018.07.217] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The subtemporal and orbitozygomatic approaches are the most commonly used surgical approaches for the treatment of basilar artery apex (BAX) aneurysms. Relative advantages and disadvantages are generally reported based on surgeons' experience. This study was performed to provide a detailed comparison between the subtemporal and orbitozygomatic approaches based on cadaveric dissection analysis for the treatment of BAX aneurysms. METHODS Subtemporal and orbitozygomatic approaches were performed on 5 cadaveric heads (10 sides), and the following variables were assessed and compared between the 2 approaches: 1) number of exposed perforators on P1-posterior cerebral arteries (PCA); 2) lengths of exposure and clipping for bilateral PCA, superior cerebellar arteries (SCA), and basilar trunk; 3) surgical area of exposure; and 4) surgical freedom at the BAX. RESULTS Number of perforators exposed on P1-PCA was not different between the subtemporal and orbitozygomatic approaches. Exposure and clipping of ipsilateral SCA and PCA were superior using the subtemporal approach, and better for contralateral SCA and PCA using the orbitozygomatic approach, all reaching statistical significance. The orbitozygomatic approach provided greater exposure and clipping length for the proximal basilar trunk. Although the surgical area of exposure was similar between the 2 approaches, the overall surgical freedom was greater in the orbitozygomatic approach. CONCLUSIONS The orbitozygomatic approach provides a greater number of surgical corridors to the BAX and is superior regarding multiple surgically relevant anatomic parameters. Importantly, control over the basilar trunk and over the contralateral SCA and PCA (blind spots) is superior with the orbitozygomatic approach.
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Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Arnau Benet
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Sonia Yousef
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, USA
| | - Pooneh Mokhtari
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
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Burkhardt JK, Riina HA, Tanweer O, Shirani P, Raz E, Shapiro M, Nelson PK. Flow diversion and microvascular plug occlusion for the treatment of a complex unruptured basilar/superior cerebellar artery aneurysm: case report. J Neurosurg 2018; 130:1978-1983. [PMID: 29957112 DOI: 10.3171/2018.1.jns172465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/16/2018] [Indexed: 11/06/2022]
Abstract
The authors present the unusual case of a complex unruptured basilar artery terminus (BAT) aneurysm in a 42-year-old symptomatic female patient presenting with symptoms of mass effect. Due to the fusiform incorporation of both the BAT and left superior cerebellar artery (SCA) origin, simple surgical or endovascular treatment options were not feasible in this case. A 2-staged (combined deconstructive/reconstructive) procedure was successfully performed: first occluding the left SCA with a Pipeline embolization device (PED) coupled to a microvascular plug (MVP) in the absence of antiplatelet coverage, followed by reconstruction of the BAT by deploying a second PED from the right SCA into the basilar trunk. Six-month follow-up angiography confirmed uneventful aneurysm occlusion. The patient recovered well from her neurological symptoms. This case report illustrates the successful use of a combined staged deconstructive/reconstructive endovascular approach utilizing 2 endoluminal tools, PED and MVP, to reconstruct the BAT and occlude a complex aneurysm.
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Affiliation(s)
- Jan-Karl Burkhardt
- 1The Irene and Bernard Schwartz Neurointerventional Radiology Center, Departments of Neurosurgery and Radiology, New York University School of Medicine, NYU Langone Medical Center, New York, New York; and
| | - Howard A Riina
- 1The Irene and Bernard Schwartz Neurointerventional Radiology Center, Departments of Neurosurgery and Radiology, New York University School of Medicine, NYU Langone Medical Center, New York, New York; and
| | - Omar Tanweer
- 1The Irene and Bernard Schwartz Neurointerventional Radiology Center, Departments of Neurosurgery and Radiology, New York University School of Medicine, NYU Langone Medical Center, New York, New York; and
| | - Peyman Shirani
- 1The Irene and Bernard Schwartz Neurointerventional Radiology Center, Departments of Neurosurgery and Radiology, New York University School of Medicine, NYU Langone Medical Center, New York, New York; and
- 2Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Eytan Raz
- 1The Irene and Bernard Schwartz Neurointerventional Radiology Center, Departments of Neurosurgery and Radiology, New York University School of Medicine, NYU Langone Medical Center, New York, New York; and
| | - Maksim Shapiro
- 1The Irene and Bernard Schwartz Neurointerventional Radiology Center, Departments of Neurosurgery and Radiology, New York University School of Medicine, NYU Langone Medical Center, New York, New York; and
| | - Peter Kim Nelson
- 1The Irene and Bernard Schwartz Neurointerventional Radiology Center, Departments of Neurosurgery and Radiology, New York University School of Medicine, NYU Langone Medical Center, New York, New York; and
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Matsukawa H, Kamiyama H, Tsuboi T, Noda K, Ota N, Miyata S, Miyazaki T, Kinoshita Y, Saito N, Takahashi O, Takeda R, Tokuda S, Tanikawa R. Subarachnoid hemorrhage after surgical treatment of unruptured intracranial aneurysms. J Neurosurg 2017; 129:490-497. [PMID: 29076778 DOI: 10.3171/2017.3.jns162984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Only a few previous studies have investigated subarachnoid hemorrhage (SAH) after surgical treatment in patients with unruptured intracranial aneurysms (UIAs). Given the improvement in long-term outcomes of embolization, more extensive data are needed concerning the true rupture rates after microsurgery in order to provide reliable information for treatment decisions. The purpose of this study was to investigate the incidence of and risk factors for postoperative SAH in patients with surgically treated UIAs. METHODS Data from 702 consecutive patients harboring 852 surgically treated UIAs were evaluated. Surgical treatments included neck clipping (complete or incomplete), coating/wrapping, trapping, proximal occlusion, and bypass surgery. Clippable UIAs were defined as UIAs treated by complete neck clipping. The annual incidence of postoperative SAH and risk factors for SAH were studied using Kaplan-Meier survival analysis and Cox proportional hazards regression models. RESULTS The patients' median age was 64 years (interquartile range [IQR] 56-71 years). Of 852 UIAs, 767 were clippable and 85 were not. The mean duration of follow-up was 731 days (SD 380 days). During 1708 aneurysm years, there were 4 episodes of SAH, giving an overall average annual incidence rate of 0.23% (95% CI 0.12%-0.59%) and an average annual incidence rate of 0.065% (95% CI 0.0017%-0.37%) for clippable UIAs (1 episode of SAH, 1552 aneurysm-years). Basilar artery location (adjusted hazard ratio [HR] 23, 95% CI 2.0-255, p = 0.0012) and unclippable UIA status (adjusted HR 15, 95% CI 1.1-215, p = 0.046) were significantly related to postoperative SAH. An excellent outcome (modified Rankin Scale score of 0 or 1) was achieved in 816 (95.7%) of 852 cases overall and in 748 (98%) of 767 clippable UIAs at 12 months. CONCLUSIONS In this large case series, microsurgical treatment of UIAs was found to be safe and effective. Aneurysm location and unclippable morphologies were related to postoperative SAH in patients with surgically treated UIAs.
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Affiliation(s)
- Hidetoshi Matsukawa
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Hiroyasu Kamiyama
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Toshiyuki Tsuboi
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Kosumo Noda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Nakao Ota
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Shiro Miyata
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Takanori Miyazaki
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Yu Kinoshita
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Norihiro Saito
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Osamu Takahashi
- 2Center for Clinical Epidemiology, Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Rihee Takeda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Sadahisa Tokuda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Rokuya Tanikawa
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
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