A newly designed puncture needle for suction decompression of giant aneurysms. Technical note

Suction Decompression Assisted Clipping of a Large Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

This operative video demonstrates the important considerations and details to perform a suction decompression technique to assist in clipping of a large middle cerebral artery (MCA) aneurysm (Video 1). We present the case of a 58-year-old man with a 5-day history of dizziness. A computed tomography angiography revealed a 15-mm-diameter aneurysm in the left middle cerebral artery and a 6-mm-diameter aneurysm in the anterior communicating artery. Characterization of both lesions was obtained with a cerebral angiogram. Given the wide nature of the base of the MCA lesion, a surgical obliteration was considered best. A left frontotemporal craniotomy with the patient under total intravenous anesthesia and continuous neurophysiological monitoring was performed to approach both intracranial aneurysms. Access through the Sylvian fissure corridor was obtained, and the dome of the MCA lesion was quickly identified. The large aneurysm neck challenged visualization of the takeoff vessels of the MCA divisions, and after careful dissection, visualization remained poor; therefore, a suction decompression technique was considered appropriate to gain anatomical control.1, 2 For doing so, we used a 21-gauge needle wired to a 3-mm retractor on the Greenberg System, connected distally to suction. After cornering the lesion with temporary aneurysm clips, needle insertion was performed, enabling aneurysmal collapse and perfect visualization of the take-off vessels, which allowed proper clip deployment across the lesion. Next, we approached the anterior communicating artery aneurysm through the subfrontal region with successful clip deployment. Careful suction decompression could help the surgeon in obtaining better visualization. Patient approval and consent was obtained for submission of this video to this journal.

The significance of intraoperative monitoring of muscle motor evoked potentials during unruptured large and giant cerebral aneurysm surgery

The goal of this study was to characterize the utility of muscle motor evoked potentials (MMEPs) elicited by direct cortical stimulation as a means of monitoring during unruptured large and giant cerebral aneurysm surgery. This analysis focused on intraoperative changes in MMEPs and their relationship to postoperative motor function. The study population consisted of 50 patients who underwent surgery for large (n = 31) or giant (n = 19) cerebral aneurysms. Intraoperative MMEPs were continuously and successfully obtained in muscles belonging to the vascular territory of interest. There was no postoperative motor paresis in 31 (62%) patients in whom intraoperative MMEPs remained unchanged. Transient MMEP change occurred in 15 (30%) of the 50 patients, but 9 of those patients had no postoperative motor deficits, 5 had transient motor deficits, and 1 suffered permanent motor deficits resulting from postoperative delayed blood flow insufficiency due to arteriosclerosis of the parent artery. Permanent MMEP loss occurred in 4 (8%) of 50 patients, all of whom developed severe and permanent postoperative motor deficits. MMEP is a useful monitoring modality in patients undergoing surgery for large or giant cerebral aneurysms. This strategy can help predict functional prognosis or guide the neurosurgeon intraoperatively in an effort to promote better outcomes.

[Giant supratentorial intracranial aneurysms. Analysis of 22 cases]

INTRODUCTION

Giant intracranial aneurysms represent 2 to 5% of all aneurysms. They are well characterized from the anatomical and clinical point of view. Their natural history shows its potential lethality. Surgical treatment of giant aneurysms is a challenge for neurosurgeons.

MATERIAL AND METHODS

Twenty-two patients were operated on through pterional craniotomy, specialized neuroanesthesia and microneurosurgical technics. Auxiliary methods like transitory clipping and retrograde decompression-suction technique were applied. Patients were followed at intensive care units and they were evaluated three months after the operation. Nineteen patients were in the fourth and sixth decade of life. Seventeen were females. Aneurysms were located at middle cerebral artery bifurcation; paraclinoidal carotid artery; proximal anterior cerebral artery and carotid bifurcation. Ninety one percent of aneurysms were clipped. Retrograde decompression-suction technique was performed in thirteen cases.

RESULTS

Seventeen patients had good outcome and one patient died (4.5%). There were 6 postoperative complications and in four disappeared three months later.

CONCLUSIONS

Giant aneurysms were operated on following main neurosurgical rules helped by auxiliar procedures to reduce aneurysms size and wall, aneurysms tension. New knowledge about giants aneurysms and the development of new techniques will permit better results.

Open surgery of giant paraclinoid aneurysms improved by intraoperative angiography and endovascular retrograde suction decompression

In three consecutive cases of giant left sided paraclinoid aneurysms we employed an endovascular retrograde suction decompression technique in combination with intra-operative angiography. A double-lumen balloon catheter was placed in the left internal carotid artery by the transfemoral route. After balloon inflation and placement of a temporary clip distal to the aneurysm blood was aspirated and the aneurysm collapsed. Thus further dissection of the aneurysm could easily be achieved and clips could be placed. Afterwards real-time digital subtraction angiography was performed. Intra-operative angiography led to clip repositioning in all cases either due to a clip induced stenosis of the parent vessel, or because of incomplete aneurysm obliteration. Afterwards successful clipping could be confirmed in all cases. Outcome was excellent in one case, good in the other. The third case, extremely complicated by an accompanying craniopharyngioma, showed a satisfactory outcome, but presented new neurological deficits.

Multiple clipping technique for large and giant internal carotid artery aneurysms and complications: angiographic analysis

Experience with surgical clipping of 16 large and nine giant aneurysms of the intradural internal carotid artery (ICA) is described. Reconstruction of the parent artery with part of the aneurysmal wall was necessary in the majority of cases. Multiple clips were required for satisfactory clipping in 20 cases. Complications related to the clipping procedure comprised occlusion and stenosis of the parent carotid artery in isolated cases. Straightening of the parent carotid artery with consequent kinking of the middle cerebral artery was seen in three cases of an aneurysm with a dome directed ventrally in the proximal segment of the ICA. The factors that caused straightening of the ICA are analyzed. It was observed that an excessive change in the direction of the ICA can cause cerebral infarction.