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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Regan KS, Venter G. An anatomical investigation of the suboccipital- and inferior suboccipital triangles. Anat Cell Biol 2023; 56:350-359. [PMID: 37105903 PMCID: PMC10520854 DOI: 10.5115/acb.23.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
The suboccipital triangle (ST) is a clinically relevant landmark in the posterior aspect of the neck and is used to locate and mobilize the horizontal segment of the third part of the vertebral artery before it enters the cranium. Unfortunately, this space is not always a viable option for vertebral artery exposition, and consequently a novel triangle, the inferior suboccipital triangle (IST) has been defined. This alternative triangle will allow surgeons to locate the artery more proximally, where its course is more predictable. The purpose of this study was to better define the anatomy of both triangles by measuring their borders and calculating their areas. Ethical clearance was obtained from the University of Pretoria (reference number: 222/2021) and both triangles were subsequently dissected out on both the left and right sides of 33 formalin-fixed human adult cadavers. The borders of each triangle were measured using a digital calliper and the areas were calculated using Herons Formula. The average area of the ST is 969.82±153.15 mm2, while the average area of the IST is 307.48±41.31 mm2. No statistically significant differences in the findings were observed between the sides of the body, ancestry, or sex of the cadavers. Measurement and analysis of these triangles provided important anatomical information and speak to their clinical relevance as surgical landmarks with which to locate the vertebral artery. Of particular importance here is the IST, which allows for mobilisation of this artery more proximally, should the ST be occluded.
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Affiliation(s)
- Kirsten Shannon Regan
- Department of Anatomy, Faculty of Medicine, University of Pretoria, Pretoria, South Africa
| | - Gerda Venter
- Department of Anatomy, Faculty of Medicine, University of Pretoria, Pretoria, South Africa
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Djukić B, Djukić-Macut N, Djulejić V, Boljanović J, Milić I, Marinković S, Blagojević M. Medullary branches of the vertebral artery: microsurgical anatomy and clinical significance. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05613-7. [PMID: 37162608 DOI: 10.1007/s00701-023-05613-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Since the medullary arteries are of a great neurologic and neurosurgical significance, the aim was to perform a detailed microanatomic study of these vessels, as well as of the medullary infarctions in a group of patients. METHODS The arteries of 26 halves of the brain stem were injected with India ink and gelatin, microdissected and measured with an ocular micrometer. Neurologic and magnetic resonance imaging (MRI) examinations were performed in 11 patients. RESULTS The perforating medullary arteries, averaging 6.7 in number and 0.26 mm in diameter, most often originated from the anterior spinal artery (ASA), and rarely from the vertebral (VA) (38.5%) and the basilar artery (BA) (11.6%). They supplied the medial medullary region. The anterolateral arteries, 4.8 in number and 0.2 mm in size, most often arose from the ASA and PerfAs, and nourished the anterolateral region. The lateral arteries, 2.2 in number and 0.31 mm in diameter, usually originated from the VA and the posterior inferior cerebellar artery (PICA). They supplied the lateral medullary region. The dorsal arteries, which mainly arose from the PICA and the posterior spinal artery (PSA), nourished the dorsal region, including the roof of the 4th ventricle. The anastomotic channels, averaging 0.3 mm in size, were noted in 42.3%. Among the medullary infarctions, the lateral ones were most frequently present (72.8%). CONCLUSION The obtained anatomic data, which can explain the medullary infarctions symptomatology, are also important in order to avoid damage to the medullary arteries during neurosurgical and neuroradiologic interventions.
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Affiliation(s)
- Bojana Djukić
- Department of Neuroscience, Institute of Medical Research, University of Belgrade, Belgrade, Serbia
| | - Nataša Djukić-Macut
- Seat in Mitrovica, Faculty of Medicine, University of Prishtina, Mitrovica, Serbia
| | - Vuk Djulejić
- Faculty of Medicine, Institute of Anatomy, University of Belgrade, Dr. Subotić, 4/2, 11000, Belgrade, Serbia
| | - Jelena Boljanović
- Faculty of Medicine, Institute of Anatomy, University of Belgrade, Dr. Subotić, 4/2, 11000, Belgrade, Serbia
| | - Ivan Milić
- Faculty of Medicine, Clinic of Neurosurgery, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Slobodan Marinković
- Faculty of Medicine, Institute of Anatomy, University of Belgrade, Dr. Subotić, 4/2, 11000, Belgrade, Serbia.
| | - Miloš Blagojević
- Faculty of Veterinary Medicine, Institute of Anatomy, University of Belgrade, Belgrade, Serbia
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Rossmann T, Veldeman M, Nurminen V, Lehecka M. How I do it: lateral approach for craniocervical junction tumors. Acta Neurochir (Wien) 2022; 165:1315-1322. [PMID: 36434269 DOI: 10.1007/s00701-022-05426-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/10/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The far lateral approach has been developed to access lesions at the craniocervical junction and upper cervical spinal canal. Associated morbidity triggered the development of less invasive tailored approaches. METHOD In this lateral approach to the craniocervical junction, the occipital condyle is kept intact, vertebral artery manipulation is minimized, and the sigmoid sinus is not skeletonized. A linear incision through skin and muscles and use of an abdominal wall fat graft minimize the risk of cerebrospinal fluid leakage. CONCLUSIONS The exposure provided is sufficient for the majority of tumors in this region and allows for low complication rates.
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Affiliation(s)
- Tobias Rossmann
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland.
- Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria.
| | - Michael Veldeman
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Ville Nurminen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland
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Das KK, Nandan M, Bhaisora KS, Srivastava AK, Jaiswal AK, Behari S. Modified Retromastoid Approach and Clipping of "High-Riding" VA-PICA Junction Aneurysm: An Operative Video. Neurol India 2021; 69:833-836. [PMID: 34507397 DOI: 10.4103/0028-3886.325361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background and Introduction Clipping an aneurysm on an elongated and tented V4 segment near the origin of the posterior inferior cerebellar artery (high-riding VA-PICA junction aneurysm) can be challenging. Objective We demonstrate the microsurgical clipping technique of such an aneurysm using a modified retromastoid approach (MRMA) and glossopharyngeal-cochlear triangle (GCT). Surgical Technique A 50-year-old female with a ruptured high-riding left VA-PICA junction aneurysm underwent an MRMA. Using segmental vessel isolation with proximal and distal temporary clips, this aneurysm was occluded through the GCT by applying a tandem clipping technique while preserving the PICA. Results The procedure was uneventful. Apart from transient ataxia, she recovered completely and maintains a good status at follow-up. Conclusion In high-riding VA-PICA junction aneurysms, a conventional far lateral approach may create awkward viewing and working angles. An MRMA with a horizontal trajectory through the GCT may be a more appropriate strategy.
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Affiliation(s)
- Kuntal K Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Maruti Nandan
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh S Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun K Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh K Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Pilipenko Y, Eliava S, Okishev D, Okisheva E, Spyrou A. Vertebral artery and posterior inferior cerebellar artery aneurysms: Results of microsurgical treatment of eighty patients. Surg Neurol Int 2019; 10:227. [PMID: 31819820 PMCID: PMC6884955 DOI: 10.25259/sni_326_2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/24/2019] [Indexed: 11/04/2022] Open
Abstract
Background The choice of surgical approaches and options for the microsurgical vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms repair remains controversial. Methods A retrospective analysis of the clinical, surgical, and angiographic data of 80 patients with VA and PICA aneurysms treated from 2012 to 2018 was performed. Results The aneurysms were saccular in 50 cases (62.5%) and fusiform in 30 cases (37.5%). The median suboccipital craniotomy was the most common approach (73.8%). Retrosigmoid craniotomy was performed in 25% of patients. There were the following types of microsurgical operations: neck clipping (61.25%), clipping with the artery lumen formation (13.75%), trapping (10%), proximal clipping (5%), and deconstruction with anastomosis (10%). Fifty-seven (71.3%) patients were discharged without worsening of the clinical signs after surgery. The most common postoperative neurological disorder was palsy of IX and X cranial nerve revealed in 14 (17.5%) patients. No fatal outcomes or patients in vegetative state were identified. The complete occlusion of PICA and VA aneurysms according angiography was in 77 (96.3%) cases. Conclusion Microsurgical treatment is an effective method for VA and PICA aneurysms. The majority of VA and PICA aneurysms do not require complex basal approaches. A thorough preoperative planning, reconstructive clipping techniques, and anastomoses creation, as well as patient selection based on the established algorithms and consultations with endovascular surgeons, may reduce the number of complications and increase the rate of complete microsurgical occlusion in VA and PICA aneurysms.
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Affiliation(s)
- Yuri Pilipenko
- 3 Department (vascular pathology), Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation
| | - Shalva Eliava
- 3 Department (vascular pathology), Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation
| | - Dmitry Okishev
- 3 Department (vascular pathology), Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation
| | - Elena Okisheva
- Department of Internal Diseases, Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Andronikos Spyrou
- 3 Department (vascular pathology), Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation
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Eliava SS, Pilipenko YV, Shechtman OD, Kheyreddin AS, Okishev DN, Konovalov AN, Spiru AM, Kisariev SA, Gorozhanin VA, Varyukhina MD. [Microsurgical treatment of aneurysms of vertebral and posterior-lower cerebellar arteries: surgical approaches, exclusion options, treatment results]. Zh Vopr Neirokhir Im N N Burdenko 2019; 83:5-17. [PMID: 31577266 DOI: 10.17116/neiro2019830415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aneurysms of vertebral (VA) and posterior inferior cerebellar arteries (PICA) are relatively rare pathologies and account for 3.4% of the total number of intracranial aneurysms. MATERIAL AND METHODS The experience of microsurgical treatment of 67 patients with VA and PICA aneurysms in N.N. Burdenko National Medical Research Center for Neurosurgery of the RF Ministry of Health from 2012 to 2017 is presented. RESULTS Most patients underwent reconstructive microsurgical interventions: clipping of the aneurysm neck in 42 (62.7%) patients and complex clipping with the formation of arterial opening - in 10 (14.9%). Exclusion of the aneurysm together with the carrier artery (trapping, proximal clipping) was performed on 10 (14.9%) patients. In 5 (7.5%) patients, deconstruction of the carrier artery of the aneurysm was performed after creating local anastomoses. The radical exclusion of aneurysms in the studied group was 95.5%. Postoperative dysfunction of the caudal group of cranial nerves was detected in 11 (16.4%) patients. There were no lethal outcomes, or cases with vegetative status outcomes. CONCLUSION Microsurgical intervention is an effective way to treat VA and PICA aneurysms, subject to the principles of patient selection based on existing treatment algorithms as well as adherence to an interdisciplinary approach.
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Affiliation(s)
| | | | | | | | - D N Okishev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A M Spiru
- Burdenko Neurosurgical Center, Moscow, Russia
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