Wrap-clipping with a Dacron mesh silastic sheet. Technical note

Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results

Background

We have been performing the clipping on crossed wrapping (COCW) method using 2 strips of cotton on patients with an internal carotid artery blood blister-like aneurysm (IC-BLA). This method is reliable in preventing the clips from slipping off and the aneurysm walls from being damaged during clipping, and it enables more appropriate and safer clipping. Here we report the technical details of this method and the long-term outcomes of patients receiving this procedure.

Methods

Fifteen of 1275 (1.5%) patients with a ruptured cerebral aneurysm who received treatment at the Saiseikai Kumamoto Hospital during the period from January 1, 1999, to December 31, 2016, had an IC-BLA. All 15 patients were treated with COCW, except for the first patient, who was treated using a single strip of cotton. The long-term outcome of the treatment was analyzed.

Results

The mean follow-up period was 74 months. The first patient experienced rerupture of an aneurysm 10 days after the operation. No complications or regrowth of an aneurysm were observed in the remaining 14 patients during the follow-up period, except for 1 patient who received a reoperation for the regrowth of an aneurysm. As the final outcome, the numbers of patients with a Modified Rankin Score of 0, 3, and 6 were 13, 1, and 1, respectively.

Conclusions

It is suggested that COCW is a treatment that enables safe and long-term management of lesions in IC-BLAs.

Wrap-clipping as a rescue surgical technique for vessel perforation due to stent strut: a technical note

BACKGROUND

Arterial injury related to stent strut is rare during stent-assisted coil embolization.

METHOD

The patient underwent stent-assisted coil embolization for a right middle cerebral artery aneurysm. At this time, the parent arterial injury at M1 portion of the middle cerebral artery resulted in subarachnoid hemorrhage. The arterial penetration caused by the stent strut was repaired with wrap-clipping.

RESULTS

Postoperative angiograms demonstrated the complete obliteration of the arterial injury. The patient was discharged without neurological deficits. Neither recurrence nor stenosis was observed after surgery.

CONCLUSIONS

Wrap-clipping is a useful procedure to repair the arterial injury due to the stent strut.

Partial wrap-clipping of the entrance of the pseudolumen of a fusiform aneurysm in the posterior inferior cerebellar artery: a technical note

Background

Fusiform aneurysms in the posterior inferior cerebellar artery (PICA) are rare and challenging to treat. Surgical treatment options for a fusiform aneurysm in the PICA include trapping with/without bypass and wrap-clipping, when elimination of the pathological wall from the systemic circulation and prevention of perforator injury are important. In addition, lower cranial nerve impairment due to surgical manipulation should also be avoided.

Method

A fusiform-shaped aneurysm was found in a proximal part of the PICA by magnetic resonance angiography undertaken for evaluation of repeated vertigo in a 36-year-old man. The patient underwent direct surgery via a lateral suboccipital transcondylar fossa approach. The entrance of the pseudolumen was the only part to be wrapped and obstructed by clip application, through the corridor between the acoustic and glossopharyngeal nerves to avoid lower cranial nerve injury.

Results

Indocyanine green (ICG) videoangiography demonstrated obliteration of pseudolumen and patency of peripheral PICA and perforator contributing to the medulla oblongata. The postoperative course was uneventful without periprocedural complications, including dysphagia and hoarseness.

Conclusions

Partial wrap-clipping technique for obstruction of the entrance into a pseudolumen is one of alternatives for dissecting fusiform-shaped aneurysm in the PICA. ICG videoangiography was helpful to confirm the obliteration of the pseudolumen and patency of parent vessel and perforators.

Surgical Flow Alteration for the Treatment of Intracranial Aneurysms That Are Unclippable, Untrappable, and Uncoilable

OBJECTIVE

The treatment of complex intracranial aneurysms remains challenging. One approach is the application of surgical flow alteration to treat aneurysms that are neither clippable, trappable, or coilable. The efficacy and limitations of surgical flow alteration have not yet been established.

METHODS

Cases of complex aneurysms treated with surgical flow alteration (proximal occlusion with or without bypass, distal occlusion with or without bypass and bypass only) were included in this retrospective study.

RESULTS

Among a total of 16 cases, there were 7 giant aneurysms (≥25 mm diameter) and 9 large aneurysms (>10 mm diameter); 15 of 16 aneurysms were unruptured. There were 8 aneurysms located in the anterior circulation, while the other 8 were in the posterior circulation. Aneurysms were treated with proximal occlusion in 10 cases and distal occlusion in 5 cases; in 1 case, the aneurysm occluded spontaneously after bypass without parent artery occlusion. All but 2 cases underwent prior or concurrent bypass surgery. Complete obliteration of the aneurysm at the latest imaging follow-up was shown in 12 of 16 cases (75.0%). Bypass patency was confirmed in 13 of 15 cases (86.7%). Surgery-related morbidity developed in 3 cases (18.8%, Glasgow outcome scale of 4) and all were perforator infarctions. There were no mortalities.

CONCLUSION

Surgical flow alteration resulted in a high rate of aneurysmal obliteration with acceptable morbidity. Although several limitations remained, it could represent an alternative method for treating complex aneurysms.

Evaluation of a clip-reinforced wrapping technique with collagen-impregnated Dacron for intracranial aneurysms inaccessible to other treatment

OBJECTIVE

To describe our clip-reinforced wrapping technique (CRW) with collagen-impregnated Dacron and report our experience in intracranial aneurysms (IA) untreatable by coil embolization (CE) or surgical clipping (SC).

METHODS

Between July 2003 and November 2010, CRW was performed on 20 IAs in 18 patients using a collagen-impregnated Dacron fabric (Hemashield(®), USA) fixed with a clip around the parent vessel and the IA.

RESULTS

Two patients (11%) died of complications from their subarachnoid hemorrhage and preexisting conditions. In the remaining 16 patients, after an average follow-up of 45 months (min: 27, max: 77), 16 (89%) out of the 18 treated aneurysms were no longer visible and two were reduced and stable.

CONCLUSION

Our preliminary results suggest that CRW with Hemashield could be an accurate and safe alternative technique for some IA without any other treatment option.

IMPLICATIONS

Description of an alternative surgical technique for otherwise untreatable intracranial aneurysms.

Changing Treatment Strategy From Clipping to Radial Artery Graft Bypass and Parent Artery Sacrifice in Patients With Ruptured Blister-Like Internal Carotid Artery Aneurysms

BACKGROUND:

Blood blister-like aneurysms (BBAs) are aneurysms with ill-defined fragile necks arising from an internal carotid artery (ICA) and associated with high mortality.

OBJECTIVE:

To describe strategies and outcomes in patients in whom radial artery (RA) graft bypass with ICA sacrifice was considered as the primary treatment during the acute phase of subarachnoid hemorrhage.

METHODS:

The authors analyzed the clinical records of 20 patients who were treated between 2004 and 2011 at their hospital and affiliate institutions.

RESULTS:

A majority of the patients were treated during the acute phase (<24 hours, n = 15). A favorable outcome was achieved in 18 (90%) patients. The treatment strategies used were as follows: (1) ICA trapping/external carotid artery (ECA)-RA-middle cerebral artery (MCA) bypass (n = 13), (2) ICA trapping/superficial temporal artery-MCA bypass (n = 2), (3) aneurysm clipping with RA-MCA temporary bypass (n = 3), (3) aneurysm clipping with proximal ICA ligation and ECA-RA-MCA bypass (n = 1), and (4) direct clipping (n = 1). Postoperative infarction was observed in 6 patients and was ascribed to vasospasm (n = 1), retrograde thrombosis associated with trapping (n = 2), and reasons unrelated to the surgical procedures (n = 3).

CONCLUSION:

Trapping with RA graft bypass demonstrated favorable results in patients with internal carotid BBAs. Although trapping/RA graft bypass is a definitive treatment for BBAs located proximal to the origin of the posterior communicating artery, some distal BBAs preclude ICA trapping to spare the perforating arteries.

A study of vertebrobasilar artery dissection with subarachnoid hemorrhage

We retrospectively studied clinical characteristics of 368 patients with cerebral artery dissections who were diagnosed in 172 Japanese hospitals. Of these patients, 130 (35%) presented with subarachnoid hemorrhage, 217 (59%) with cerebral infarctions, and 21 (6%) with transient ischemic attacks. We analyzed 109 (84%) subarachnoid hemorrhage cases caused by vertebrobasilar artery dissection to evaluate conservative and surgical treatment from the viewpoint of postoperative rerupture and infarction.Subsequent ruptures were observed in 14% of the 21 cases with nonsurgical treatment. For the preventive purpose of rerupture, 88 patients received surgical interventions: 68 trappings, 13 proximal occlusions, 6 aneurysmal sac occlusions and 1 stenting. Rerupture was experienced in 33% of the aneurysmal sac occlusion patients while not occurring in the other three surgical interventions. In the group without vascular anastomosis, postoperative cerebral infarction was observed in 25% of the trapping, none of the proximal occlusion and 33% of the aneurysmal sac occlusion cases.In this study, aneurysmal sac occlusion treatments were more frequently complicated by rerupture or cerebral infarction postoperatively than the other treatment methods. It was difficult to determine which surgical treatment can achieve better surgical outcome among the proximal occlusion and trapping with or without vascular anastomosis.

Wrap-clipping with polytetrafluoroethylene for ruptured blisterlike aneurysms of the internal carotid artery. Technical note

A technique combining wrapping and clip occlusion of aneurysms by using polytetrafluoroethylene (PTFE) for treatment of ruptured blisterlike aneurysms of the supraclinoid internal carotid artery (ICA) is described. The diameter of the abnormal arterial lesion along the long axis of the ICA and the distance between the origin of the ophthalmic artery and the origin of the posterior communicating artery (PCoA), or the origin of the PCoA and the origin of the anterior choroidal artery are measured intraoperatively; a strip of PTFE membrane is then trimmed with scissors to match this diameter and distance. After temporarily occluding the cervical ICA, the intracranial ICA that includes the lesion is wrapped with the strip of PTFE, and one or more aneurysm clips are applied parallel to the ICA. This procedure was successfully accomplished in six patients, all of whom had an uneventful postoperative course with no recurrent subarachnoid hemorrhage during the follow-up period. "Wrap-clipping" using PTFE is a useful procedure for management of ruptured blisterlike aneurysms of the ICA.

A combination of wrapping and clipping using a collagen-impregnated dacron fabric (Hemashield)

BACKGROUND

We describe techniques combining wrapping and clipping using a collagen-impregnated Dacron knitted fabric (Hemashield) for accidental arterial perforations and broad-based aneurysms. The results of these techniques in seven patients are presented.

METHODS

Clip-reinforced wrapping was performed to obtain hemostasis in two patients with arterial perforations and in a patient with a ruptured broad-based aneurysm in the internal carotid artery. Clipping of the broad neck of the aneurysm and wrapping with Hemashield (wrap-clipping) was performed in four patients with unruptured aneurysms (one internal carotid artery, two middle cerebral artery, one basilar artery).

RESULTS

In the three patients treated with clip-reinforced wrapping, complete hemostasis was obtained just after clip application. In the patient with a ruptured broad-based aneurysm, postoperative angiography demonstrated that the dome of the aneurysm was well compressed. In the four patients treated with wrap-clipping, postoperative angiography revealed successful clipping of the broad neck of the aneurysm.

CONCLUSION

In this early experience, there were no problems in the use of Hemashield for clip-reinforced wrapping or wrap-clipping.

Subarachnoid hemorrhage associated with angiographic "stenotic" or "occlusive" lesions in the carotid circulation

BACKGROUND

It has been assumed that dissecting aneurysms presenting with subarachnoid hemorrhage (SAH) are extremely rare in the carotid circulation. This may be partially attributed to the difficulty in their diagnosis. The documented angiographic findings include arterial narrowing or occlusion. The purpose of the present study is to investigate the origin of SAH associated with "stenotic" or "occlusive" lesions, which might have been categorized into "SAH of unknown origin."

METHODS

Between April 1984 and June 1994, 580 patients underwent thorough angiographic investigation to determine the origin of their nontraumatic SAH. Of these patients, five patients had as the only lesion suspected as the source of SAH a single stenosis or occlusion in the carotid circulation that was revealed at the first angiography performed within 48 hours following the onset. We detail these five patients and discuss the current strategy for the treatment of SAH associated with stenotic or occlusive lesions in the carotid circulation.

RESULTS

Arterial narrowing or occlusion were located in the internal carotid artery (ICA) in two patients, in the middle cerebral artery (MCA) in two patients, and in the posterior communicating artery in one patient. Three patients underwent operation (circumferential wrapping with cotton gauze), and dissecting aneurysms were confirmed in all of them. They all attained good recovery without rebleeding over a long-term period. Two patients died of fatal rebleeding on day 8 and on day 9 while awaiting the second angiography. In one of the patients with ICA stenosis, autopsy revealed a lacerated ICA without a definite saccular aneurysm. In the last patient with M2 occlusion, dissecting aneurysm was strongly suspected from the clinical course.

CONCLUSION

To prevent early fatal rebleeding, exploratory craniotomy for angiographic stenotic and occlusive lesions associated with SAH may be justified if all underlying conditions are met, because they may likely include dissecting aneurysms: (1) single stenotic or occlusive, (2) surgically accessible, and (3) consistent with the localization of SAH from CT scan.