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Bocanegra-Becerra JE, Koester SW, Batista S, Perret CM, Bertani R. Clipping of Bilateral Ophthalmic Artery Aneurysms Through a Single Craniotomy. Cureus 2023; 15:e47291. [PMID: 38021998 PMCID: PMC10659564 DOI: 10.7759/cureus.47291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Bilateral ophthalmic aneurysms are rare and involve two aneurysms in the ophthalmic arteries, one on each, leading to potential symptoms such as vision loss and headaches. The treatment options for aneurysms, ranging from surgery and endovascular embolization to observation, depend on various factors, including aneurysm size and the patient's health. Microsurgery, while presenting complexities due to the intricate anatomy of the anterior clinoid region, offers potential advantages such as enhanced decompression rates and reduced aneurysm recurrence. The presented surgical video illustrates the treatment of bilateral ophthalmic artery aneurysms via a single craniotomy. This method reduces surgical duration and trauma, facilitating quicker patient recovery. However, this method bears potential risks, especially to both optic nerves. As underscored in the video, the utmost anatomical understanding in the anterior clinoid area is pivotal for successful outcomes and reduced complications.
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Affiliation(s)
| | - Stefan W Koester
- Medical School, Vanderbilt University School of Medicine, Nashville, USA
| | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, BRA
| | - Caio M Perret
- Neurological Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, BRA
- Neuroscience, Federal University of Rio de Janeiro, Rio de Janeiro, BRA
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Rajagopal N, Balaji A, Yamada Y, Kawase T, Kato Y. Etiopathogenesis, clinical presentation and management options of mirror aneurysms: A comparative analysis with non-mirror multiple aneurysms. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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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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Yu LH, Shang-Guan HC, Chen GR, Zheng SF, Lin YX, Lin ZY, Yao PS, Kang DZ. Monolateral Pterional Keyhole Approaches to Bilateral Cerebral Aneurysms: Anatomy and Clinical Application. World Neurosurg 2017; 108:572-580. [PMID: 28927909 DOI: 10.1016/j.wneu.2017.09.048] [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: 06/13/2017] [Revised: 09/07/2017] [Accepted: 09/09/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To study the anatomy and clinical application of monolateral pterional keyhole approaches for treating bilateral cerebral aneurysms. METHODS Twelve formalin-fixed cadaveric heads underwent right pterional keyhole approaches for management of simulative contralateral aneurysms. The length of the contralateral middle cerebral artery (MCA), distal internal carotid artery (DICA), anterior cerebral artery, and ophthalmic segment of the internal carotid artery (OICA) was recorded. The operability of contralateral aneurysms was assessed using a modified numeric grading system. A total of 16 patients (12 patients with ruptured aneurysms) with bilateral cerebral aneurysms undergoing contralateral pterional keyhole approaches were included. RESULTS The contralateral A1 segment of the anterior cerebral artery, proximal A2 segment, M1 segment of the MCA, DICA, and OICA was exposed via pterional keyhole approaches. An additional 2 mm of the OICA was exposed after incision of the falciform dural fold was completed. Contralateral aneurysms of the M1 segment (posterior), M2 segment, MCA bifurcation (inferior), A2 segment (lateral), DICA (posterior and lateral), and OICA (superior, inferior, and lateral) could not be fully exposed to perform simulated surgical clipping (operability rate <75%). A total of 36 aneurysms underwent adequate surgical clipping via unilateral pterional keyhole approaches, whereas 1 aneurysm of the A3 segment did not. CONCLUSIONS Contralateral aneurysms of the M1 segment (anterior, superior, and inferior), MCA bifurcation (superior and lateral), A1 segment, A2 segment (anterior, posterior, and medial), internal carotid artery bifurcation, DICA (anterior and medial), and OICA (medial) were fully exposed from different angles and surgical maneuvers were performed via pterional keyhole approaches, including in patients presenting with subarachnoid hemorrhage.
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Affiliation(s)
- Liang-Hong Yu
- Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Huang-Cheng Shang-Guan
- Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guo-Rong Chen
- Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shu-Fa Zheng
- Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhang-Ya Lin
- Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Pei-Sen Yao
- Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
| | - De-Zhi Kang
- Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
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Orning JL, Shakur SF, Alaraj A, Behbahani M, Charbel FT, Aletich VA, Amin-Hanjani S. Accuracy in Identifying the Source of Subarachnoid Hemorrhage in the Setting of Multiple Intracranial Aneurysms. Neurosurgery 2017; 83:62-68. [DOI: 10.1093/neuros/nyx339] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 05/16/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Subarachnoid hemorrhage cases with multiple cerebral aneurysms frequently demonstrate a hemorrhage pattern that does not definitively delineate the source aneurysm. In these cases, rupture site is ascertained from angiographic features of the aneurysm such as size, morphology, and location.
OBJECTIVE
To examine the frequency with which such features lead to misidentification of the ruptured aneurysm.
METHODS : Records of patients who underwent surgical clipping of a ruptured aneurysm at our institution between 2004 and 2014 and had multiple aneurysms were retrospectively reviewed. A blinded neuroendovascular surgeon provided the rupture source based on the initial head computed tomography scans and digital subtraction angiography images. Operative reports were then assessed to confirm or refute the imaging-based determination of the rupture source.
RESULTS
One hundred fifty-one patients had multiple aneurysms. Seventy-one patients had definitive hemorrhage patterns on initial computed tomography scans and 80 patients had nondefinitive hemorrhage patterns. Thirteen (16.2%) of the cases with nondefinitive hemorrhage patterns had discordance between the imaging-based determination of the rupture source and intraoperative findings of the true ruptured aneurysm, yielding an imperfect positive predictive value of 83.8%. Of all multiple aneurysm cases with subarachnoid hemorrhage treated by surgical or endovascular means at our institution, 4.3% (13 of 303) were misidentified.
CONCLUSION
Morphological features cannot reliably be used to determine rupture site in cases with nondefinitive subarachnoid hemorrhage patterns. Microsurgical clipping, confirming obliteration of the ruptured lesion, may be preferentially indicated in these patients unless, alternatively, all lesions can be contemporaneously and safely treated with endovascular embolization.
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Affiliation(s)
- Jennifer L Orning
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Sophia F Shakur
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Mandana Behbahani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Victor A Aletich
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
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Wang WX, Xue Z, Li L, Wu C, Zhang YY, Lou X, Ma L, Sun ZH. Treatment Strategies for Intracranial Mirror Aneurysms. World Neurosurg 2017; 100:450-458. [PMID: 28131928 DOI: 10.1016/j.wneu.2017.01.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
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Transient Cardiac Arrest Induced by Adenosine: A Tool for Contralateral Clipping of Internal Carotid Artery-Ophthalmic Segment Aneurysms. World Neurosurg 2015; 84:1933-40. [PMID: 26341426 DOI: 10.1016/j.wneu.2015.08.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND The disadvantages of a contralateral approach (CA) include deep and narrow surgical corridors and inconsistent ability to achieve proximal control of the supraclinoid internal carotid artery (ICA). However, a CA remains as a microsurgical option for selected ICA-ophthalmic (opht) segment aneurysms. OBJECTIVE To describe transient cardiac arrest induced by adenosine as an alternative tool to obtain proximal vascular control and soften the aneurysm sac in selected patients while performing a CA. METHODS From January 1998 to December 2013, we retrospectively identified 30 patients with ICA-opht segment aneurysms treated through a CA. Of those, 8 patients received an intravenous bolus of adenosine to induce transient cardiac arrest for softening of the aneurysm sac. We reviewed preoperative clinical status, characteristics of the contralateral aneurysm, adenosine doses, asystole time, recovery of normal circulation, outcome, and complications. RESULTS No preoperative cardiac or pulmonary pathologies were found in the study population. All contralateral ICA-opht segment aneurysms were unruptured, small, and saccular in shape. Transient cardiac arrest was induced because it was impossible to apply a temporary clip on the parent contralateral supraclinoid ICA. The median dose of adenosine was 22.5 mg (range, 5-50 mg) and the asystole time ranged from 20 to 40 seconds. All patients (n = 8) had good postoperative outcomes. No brain infarction or cardiac complications appeared postoperatively. CONCLUSIONS In selected patients, transient cardiac arrest induced by adenosine during a contralateral approach allows a brief flow arrest and softening of the aneurysm for safer exposure and clipping.
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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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Andrade-Barazarte H, Kivelev J, Goehre F, Jahromi BR, Hijazy F, Moliz N, Gauthier A, Kivisaari R, Jääskeläinen JE, Lehto H, Hernesniemi JA. Contralateral Approach to Internal Carotid Artery Ophthalmic Segment Aneurysms: Angiographic Analysis and Surgical Results for 30 Patients. Neurosurgery 2015; 77:104-12; discussion 112. [PMID: 25812068 DOI: 10.1227/neu.0000000000000742] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Contralateral aneurysm clipping can be applied to bilateral intracranial aneurysms of the anterior circulation and to selected aneurysms on the medial wall of the internal carotid artery (ICA). OBJECTIVE To identify anatomic and radiological parameters that would favor a contralateral microsurgical approach to ICA-ophthalmic segment (ICA-opht) aneurysms. METHODS For the period January 1957 to December 2012, we retrospectively analyzed 268 patients with ICA-opht aneurysms treated in our institution. Of these patients, 30 underwent a contralateral approach; 15 patients (50%) had multiple intracranial aneurysms, and 15 patients had a single aneurysm on the contralateral side of the craniotomy. RESULTS Thirty saccular aneurysms located on the contralateral ICA were treated. Six aneurysms (20%) were present in patients with a subarachnoid hemorrhage due to associated aneurysms, whereas 24 aneurysms (80%) had no history of bleeding. Contralateral aneurysms were smaller than 14 mm and showed no wall irregularities, calcifications, or secondary pouches. Projections of the aneurysms were superomedial (n = 23, 77%), medial (n = 4, 13%), and superior (n = 3, 10%). The median prechiasmatic distance was 5.7 mm (range, 3.4-8.7 mm), the median interoptic distance was 10.5 mm (range, 7.6-15.9 mm), and the median distance between both ICAs was 14.7 mm (range, 10.4-21.4 mm). CONCLUSION The contralateral approach for ICA-opht aneurysms remains a treatment option for intracranial aneurysms. Its feasibility depends on specific anatomic parameters related to the aneurysm itself and to the prechiasmatic distance, interoptic distance, and relationship of the ICA with the anterior clinoid process.
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Affiliation(s)
- Hugo Andrade-Barazarte
- *Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland; ‡Department of Biosciences, University of Helsinki, Helsinki, Finland; §Department of Neurosurgery, NeuroCenter, Kuopio University Central Hospital, Kuopio Finland
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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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