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Orakdogen M, Mammadkhanli O, Simsek O. Optimizing surgical approaches for anterior communicating artery aneurysms: Development and internal validation of a novel surgical scoring system. Neurosurg Rev 2024; 47:121. [PMID: 38499891 PMCID: PMC10948514 DOI: 10.1007/s10143-024-02344-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/16/2024] [Accepted: 03/03/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND The objective was to provide comprehensive preoperative information on both the aneurysm orientation and the side and method of surgical approach for optimal preoperative information and safe clipping using 3D imaging modalities. This was achieved by making an objective risk assessment on the surgical side/method and evaluating its effectiveness with internal validation. MATERIALS AND METHODS Radiologic data of 61 ACoA aneurysm patients between 2012 and 2020 were retrospectively analyzed. A scoring system based on five criteria; ACoA aneurysm dome orientation, A1 symmetry/control, perforating artery control, A2 trace orientation, and A2 fork symmetry was developed. The system is designed to align with the most common surgical approaches in ACoA aneurysm surgery. The patients were categorized into three groups based on the scoring results to determine the most appropriate surgical method. Group I was recommended, Group II was less recommended, and Group III was least recommended. Internal validation was performed to assess the system's effectiveness. Outcomes and complication rates were statistically evaluated. RESULTS When the scoring system was utilized, the mean score difference between the first group and the other groups was 2.71 and 4.62, respectively. There was a homogeneous distribution among the groups in terms of age, sex, WFNS, and Fisher scores. Complication occurred in three patients in Group I and nine patients each in Group II and Group III. The further the deviation from the first option, the higher the complication rate (p = 0.016), and a significant cause-effect relationship was identified (p = 0.021). The ROC curve established a cut-off value of 12.5 points for complications and outcomes. CONCLUSION Our study introduces a new scoring system for ACoA aneurysms, enhancing the use of 3D CTA in daily practice and providing internal validation for the proposed approach. By evaluating objective criteria, this scoring system helps predict surgical risks, prevent complications, and supports personalized evaluation and selection of the surgical approach based on objective criteria.
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Affiliation(s)
- Metin Orakdogen
- Department of Neurosurgery, Trakya University School of Medicine, Trakya University Hospital Trakya University Hospital, 22030 Balkan Campus, Edirne, Turkey
| | - Orkhan Mammadkhanli
- Department of Neurosurgery, Trakya University School of Medicine, Trakya University Hospital Trakya University Hospital, 22030 Balkan Campus, Edirne, Turkey.
| | - Osman Simsek
- Department of Neurosurgery, Trakya University School of Medicine, Trakya University Hospital Trakya University Hospital, 22030 Balkan Campus, Edirne, Turkey
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Orakdogen M, Mammadkhanli O, Chousein B, Simsek O. Development of a comprehensive and clinically applicable novel projection classification system for anterior communicating artery aneurysms. Neurosurg Rev 2024; 47:39. [PMID: 38200376 PMCID: PMC10781864 DOI: 10.1007/s10143-023-02275-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/14/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024]
Abstract
Various surgical and anatomical classifications have been proposed to date related to ACoA aneurysm projection. Nonetheless, a universally accepted classification system is yet to be established. This study is aimed at establishing a standardized classification system for ACoA aneurysms with utilization 3D technology and defining reference lines for their projections. The goal is to create a simple, understandable, surgically beneficial, and reliable classification system based on neurovascular structures in the region, including safe and hazardous zones. The radiologic data of 96 patients with ACoA aneurysm who were treated in our university hospital between 2012 and 2020 were retrospectively analyzed, and a planned classification scale was developed with the data obtained. The classification aimed to create 9 main projection groups in the sagittal plane: superior, inferior, anterior, and posterior in linear orientation, and anterosuperior, posterosuperior, anteroinferior, posteroinferior, and complex in quadrant orientation. The coronal and axial planes included medial, lateral, and midline classifications, resulting in a 3-dimensional classification system with 25 projections. Among the 96 patients, 32 had linear and 64 had quadrant projections. In the sagittal plane, the linear projection breakdown was as follows: superior (28%), inferior (6.25%), anterior (53%), and posterior (12.5%). For the quadrant projection, the distribution was as follows: anterosuperior (53%), posterosuperior (12.5%), anteroinferior (21.87%), posteroinferior (3.12%), and complex (9.37%). Overall, 35.4% aneurysms were anterosuperior, 17.7% anterior, 14.58% anteroinferior, 9.37% superior, 8.3% posterosuperior, 6.25% complex, 4.16% posterior, 2.08% posteroinferior, and 2.08% inferior projection. Our study proposes a projection classification that utilizes 3D technology for safe surgery based on neurovascular structures in the region and thus better reveals safe and hazardous zones, including three plans, three dimensions, and two orientations. The use of this classification system offers valuable guidance for daily practice in the treatment of ACoA aneurysms.
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Affiliation(s)
- Metin Orakdogen
- Department of Neurosurgery, Trakya University School of Medicine, Trakya University Hospital, 22030 Balkan Campus, Edirne, Turkey
| | - Orkhan Mammadkhanli
- Department of Neurosurgery, Trakya University School of Medicine, Trakya University Hospital, 22030 Balkan Campus, Edirne, Turkey.
| | - Baris Chousein
- Department of Neurosurgery, Private Kesan Hospital, Büyük Cami Neighborhood, 22800, Keşan, Edirne, Turkey
| | - Osman Simsek
- Department of Neurosurgery, Trakya University School of Medicine, Trakya University Hospital, 22030 Balkan Campus, Edirne, Turkey
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Cheng CM, Dogan A. Quantitative measurement of the surgical freedom for anterior communicating artery complex-a comparative study between the frontotemporal pterional and supraorbital craniotomy; a laboratory study. Acta Neurochir (Wien) 2019; 161:2513-2519. [PMID: 31650332 DOI: 10.1007/s00701-019-04097-8] [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: 07/19/2019] [Accepted: 10/07/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To quantitatively measure surgical degree of freedom (SDF) to the anterior communicating artery (AComA) complex via removal of the orbital rim. Comparisons of SDF quadrants were made between a supraorbital and standard frontotemporal pterional craniotomy according to the surgeons' geometric microscope compass-based views. METHODS Eleven latex-injected formalin-fixed cadaveric heads; 14 sides (eight unilateral and three bilateral) were dissected. Standard frontotemporal pterional and subsequent supraorbital craniotomy approaches were conducted in each specimen. Point "0" was allocated as a point 1 cm distal to the ipsilateral A1 and A2 junction of AComA. The tip of a 10-cm long pointer was used to locate point 0. The base of the pointer stick was maneuvered outside the craniotomy in eight compass directions, with the most peripheral points expressed as target points 1-8. The center of this octagon was attributed point C. A pyramid was established by connecting the points 0, C, and 2 neighboring target points. A frameless stereotaxic instrument was used as a three-dimensional digitizer to measure pyramid volume. Each neighboring two pyramids form a hexagonal cone and was expressed as a surgical freedom quadrant (cm3). The quadrants are depicted counterclockwise (surgeons view) as orbital-nasal, vertex-nasal, vertex-temporal, and orbital-temporal. RESULTS Total SDF obtained via supraorbital and pterional approaches were 122.8 ± 109.66 and 159.94 ± 93.65, respectively (mean ± SD cm3; supraorbital < pterional by 30.2%). Supraorbital to pterional, in the orbital-nasal quadrant was 21.9 ± 35.5 and 13.04 ± 8.7, vertex-nasal 31.3 ± 28.5 and 16.7 ± 13.7, vertex-temporal 39.5 ± 42.14 and 60.4 ± 4.7, and orbital-temporal 30.14 ± 42.14 and 70.01 ± 42.14, respectively (mean ± SD cm3). In the vertex-nasal quadrant, the supraorbital approach provides a 47.3% increase in SDF compared to the standard frontotemporal pterional craniotomy approach. CONCLUSION Given that the AComA complex is located more nasally and the surgeon's view is more vertex, we propose that a supraorbital craniotomy allows a more contralateral portion of the AComA complex to be visualized during dissection.
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Soares FP, Velho MC, Antunes ACM. Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil. Surg Neurol Int 2019; 10:193. [PMID: 31637094 PMCID: PMC6800289 DOI: 10.25259/sni_41_2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/09/2019] [Indexed: 11/25/2022] Open
Abstract
Background: The aim of the study was to characterize the clinical profile of patients with anterior communicating artery (ACoA) aneurysms and examine potential correlations between clinical findings, aneurysm morphology, and outcome. Methods: A review of medical records and diagnostic neuroimaging reports of patients treated at a neurosurgical service in Porto Alegre, Brazil, between August 2008 and January 2015 was performed. Results: During the period, 100 patients underwent surgery for ACoA aneurysms. Fifteen had unruptured aneurysms and 85 had ruptured aneurysms. Ruptured aneurysms had a higher aspect ratio than unruptured ones (2.37 ± 0.71 vs. 1.93 ± 0.51, P = 0.02). Intraoperative rupture occurred in 3%, and temporary clipping was performed in 15%. Clinical vasospasm occurred in 43 patients with ruptured aneurysms (50.6%). Overall, mortality was 26%; 25 patients in the ruptured group (29.4%) and one in the unruptured group (6%). The Glasgow Outcome Scale (GOS) was favorable (GOS 4 or 5) in 54% of patients, significantly more so in those with unruptured aneurysms (P = 0.01). In patients with ruptured aneurysms, mortality was associated with preoperative Hunt and Hess (HH) score (P < 0.001), hydrocephalus (P < 0.001), and clinical complications (P < 0.001). Unfavorable outcomes were associated with HH score (P < 0.001), Fisher grade (P = 0.015), clinical vasospasm (P = 0.012), external ventricular drain (P = 0.015), hydrocephalus (P < 0.001), and presence of clinical complications (P = 0.001). In patients with unruptured aneurysms, presence of clinical complications was the only factor associated with mortality (P < 0.001). Conclusion: Despite advances in the management of subarachnoid hemorrhage and surgical treatment of aneurysms, mortality is still high, especially due to clinical complications.
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Affiliation(s)
| | - Maira Cristina Velho
- Graduate Program in Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Balaji A, Rajagopal N, Yamada Y, Teranishi T, Kawase T, Kato Y. A Retrospective Study in Microsurgical Procedures of Large and Giant Intracranial Aneurysms: An Outcome Analysis. World Neurosurg X 2019; 2:100007. [PMID: 31218282 PMCID: PMC6580892 DOI: 10.1016/j.wnsx.2019.100007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/24/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Intracranial aneurysms are considered large if >10 mm and giant if >25 mm. The risk of aneurysmal rupture compounds with increase in size of the aneurysm, thus, warranting appropriate intervention. In this study, we have analyzed the outcome and effectiveness of microsurgical procedures in large and giant aneurysms. METHODS A retrospective analysis of all the patients who underwent microsurgical procedures for large and giant cerebral aneurysms from 2014-2018 in our institute was conducted. There were a total of 52 patients, in which direct clipping was performed in 42 (80.7%) patients, proximal trapping in 3 (5.7%) patients, trapping with bypass in 3 (5.7%) patients, suction decompression in 3 (5.7%) patients, and 1 (1.9%) patient underwent surgical reconstruction. RESULTS Among the 52 patients, in the postoperative period, 1 (1.9%) patient became comatose, 1 (1.9%) patient developed hemiplegia, 1 (1.9%) patient had a transient hemiparesis, and 1 (1.9%) patient had transient lower cranial nerve palsy. Two (3.8%) patients had chronic subdural hematoma during the 3-month follow-up. There was no mortality in our series. CONCLUSIONS There are several treatment strategies available to manage large and giant cerebral aneurysms. In this study, we had minimal morbidity (3.8%), favorable outcome (96.1%), and no mortality. Therefore, we would like to conclude that appropriate microsurgical procedures, in experienced hands, can be considered as first line in the management for large and giant intracranial aneurysms, especially those with complex anatomy, wide neck, mass effect, partial thrombosis, and the presence of critical perforating vessels from the aneurysm wall.
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Key Words
- 3D, 3-Dimensional
- BTO, Balloon test occlusion
- Bypass
- CFD, Computational fluid dynamics
- CTA, Computed tomography angiogram
- Clipping
- DIVA
- DIVA, Dual image video angiography
- DSA, Digital subtraction angiography
- GOS, Glasgow Outcome Scale
- Giant
- ICA, Internal cerebral artery
- ICG, Indo-cyanine green
- Intracranial aneurysm
- MEP, Motor evoked potential
- MRI, Magnetic resonance imaging
- OA, Occipital artery
- Outcome
- PICA, Posterior inferior cerebellar artery
- RSD, Retrograde suction decompression
- Trapping
- VA, Vertebral artery
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Affiliation(s)
- Arun Balaji
- Department of Neurosurgery, Kovai Medical Centre and Hospital, Coimbatore, India
| | - Niranjana Rajagopal
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Takao Teranishi
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Tsukasa Kawase
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Yoko Kato
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
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Deshaies EM, Villwock MR, Singla A, Toshkezi G, Padalino DJ. Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms. J Vis Exp 2015:e51661. [PMID: 26325337 DOI: 10.3791/51661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.
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Affiliation(s)
- Eric M Deshaies
- Neurovascular and Stroke Center, Crouse Neuroscience Institute; Department of Biology, Syracuse University;
| | - Mark R Villwock
- Neurovascular and Stroke Center, Crouse Neuroscience Institute
| | - Amit Singla
- Department of Neurosurgery, University of Florida
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Prospective factors of temporary arterial occlusion during anterior communicating artery aneurysm repair. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:231-5. [PMID: 25366629 DOI: 10.1007/978-3-319-04981-6_39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
INTRODUCTION This study was undertaken to determine variables that could predict, in the perioperative period of anterior communicating artery (ACom) aneurysms surgeries, the likelihood of postoperative sequelae and complications, after temporary arterial occlusion (TAO). PATIENTS AND METHODS In a universe of 32 patients submitted to ACom aneurysm repair in the last 7 years, 21 needed TAO intraoperatively, and had their data examined retrospectively. RESULTS Aneurysms larger than 7 mm were more likely to be treated with longer TAO time than small aneurysms, (p < 0.0001). There was no statistical correlation between time of occlusion and outcome. Age, Glasgow Coma Scale at initial evaluation, and Fisher scale at first CT scanning were independent factors of unfavorable outcome (p < 0.001). Meanwhile gender, tobacco addiction, obesity, arterial hypertension, dyslipidemia, location of TAO (A1 or A2), intraoperative rupture (IR) and the aneurysm size were not identified as independent prognostic factors.During follow-up period, two thirds of the patients had a favorable outcome, accomplishing normal daily life activities without major complications. Most patients developed clinical vasospasm (66.6 %), with 19 % of the patients harboring a severe disease. Delayed ischemic neurological deficit was observed in 28.5 %, without any statistical correlation to time of TAO or IR. CONCLUSION TAO during ACom aneurysm repair does not seem to add more morbidities to the procedure, and is not an independent prognostic factor.
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