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Garling RJ, Mallari RJ, Kanesen D, Hontiveros B, Sivakumar W, Kelly DF, Barkhoudarian G. Avoidance of Major Vascular Injury in Transcranial Brain Tumor Surgery Using Real-Time Doppler Navigation: Technical Note and Case Series. Oper Neurosurg (Hagerstown) 2025:01787389-990000000-01509. [PMID: 40094389 DOI: 10.1227/ons.0000000000001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Accepted: 11/20/2024] [Indexed: 03/19/2025] Open
Abstract
BACKGROUND AND OBJECTIVES In endoscopic endonasal surgery, the Doppler probe has proven useful for localizing the paraclival and cavernous internal carotid arteries (ICA) and avoiding ICA injury. Similarly, during transcranial brain tumor removal, the Doppler probe may help avoid major vascular injury, particularly for tumors encasing or adherent to Circle of Willis branches. In this study, we describe the technique, outcomes, and potential neurovascular benefits of real-time navigation using the Doppler probe during craniotomy for brain tumor removal. METHODS Patients from 2015 to 2022 who underwent craniotomy for brain tumor resection and the Doppler probe was used were retrospectively analyzed. Data collection included demographics, tumor pathology, incidence of major/minor vascular injury, MRI-confirmed stroke/infarction, and extent of tumor resection. RESULTS In total, 695 patients underwent 840 craniotomies for brain tumor resection; in 501 craniotomies (59.6%), the Doppler was used. One major vascular injury (0.2%) of a supraclinoid ICA was directly attributed to non-Doppler probe use immediately before vessel injury, leading to stroke and severe neurological decline. There were 7 strokes (1.4%) leading to permanent neurological deficit attributable to vasospasm or small vessel injury and 26 asymptomatic infarctions/strokes (5.2%) attributable to unrecognized vascular injury or spasm at the time of surgery. CONCLUSION In this series of 501 craniotomies for brain tumor removal where the Doppler probe was used, the rate of direct large vessel injury was under 1%. Although our data show that smaller vessel injuries can still occur and may lead to permanent neurological deficits, routine Doppler probe use may help guide tumor dissection and aggressiveness of removal, avoiding inadvertent major arterial injury. Our experience suggests that it is most useful as tumor dissection progresses as the resulting brain shift makes stereotactic neuronavigation less reliable. We recommend routine Doppler probe use during transcranial brain tumor removal, particularly for tumors encasing or adherent to major arteries.
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Affiliation(s)
- R Justin Garling
- Pacific Neuroscience Institute, Santa Monica, California, USA
- John Peter Smith Hospital, Fort Worth, Texas, USA
| | | | - Davendran Kanesen
- Department of Neurosurgery, Hospital Umum Sarawak, Ministry of Health, Kuching, Sarawak, Malaysia
| | - Byron Hontiveros
- Section of Neurosurgery, Department of Neurosciences, Makati Medical Center, Makati City, Metro Manila, Philippines
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, Santa Monica, California, USA
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Santa Monica, California, USA
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Santa Monica, California, USA
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
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Ahmetspahic A, Burazerovic E, Rizvanovic H, Selimovic E, Kujaca E, Pojskic M, Feletti A, Arnautovic K. QEVO ®-Assisted Anatomical Inspection of Adjacent Perforators in Microsurgical Clipping-Technical Note. Brain Sci 2025; 15:300. [PMID: 40149822 PMCID: PMC11940354 DOI: 10.3390/brainsci15030300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2025] [Revised: 03/04/2025] [Accepted: 03/06/2025] [Indexed: 03/29/2025] Open
Abstract
INTRODUCTION Aneurysms of brain vessels are life-threatening conditions with various adverse outcomes, some stemming from microsurgical intervention, particularly when major vessel perforators are inadequately protected. The use of endoscopes enhances the approach to aneurysms by providing closer visualization (180-360 degrees) of the local anatomy, potentially reducing accidental damage. To improve visualization and efficiency, a microscope-integrated 45-degree angled microinspection endoscopic tool (QEVO®, Carl Zeiss, OberkochenTM) has been developed and employed in various neurosurgical procedures. METHODS Between 2021 and 2025, 27 brain aneurysms were treated with QEVO® assistance at the Department of Neurosurgery, Clinical Center of the University of Sarajevo. The choice of the videos corresponds to the best image quality in videos and on the microscopic determination of adjacent vessel perforators, which were not adequately seen purely by the surgical microscope in specific cases. Exclusion criteria included cases without a need for QEVO® assistance in perforator visualization, severe brain edema, intraoperative aneurysm rupture, posterior circulation, or low video quality. RESULTS Case 1 demonstrates an anterior choroidal artery (AchA) aneurysm; Case 2 presents an anterior communicating artery (AcommA) aneurysm; and Case 3 features contralateral middle cerebral artery (MCA) microsurgical clipping with QEVO® assistance. CONCLUSIONS The QEVO® tool significantly improves the visualization of aneurysm-perforator relationships, increasing the likelihood of preserving perforators during standard microsurgical clipping. This innovative approach may reduce surgical complications and enhance patient outcomes, highlighting the tool's potential as an adjunct in aneurysm microsurgery.
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Affiliation(s)
- Adi Ahmetspahic
- Department of Neurosurgery, Clinical Center of University of Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina; (A.A.); (E.B.)
- Department of Medicine, University Sarajevo School of Science and Technology, 71000 Sarajevo, Bosnia and Herzegovina; (H.R.); (E.S.); (E.K.)
| | - Eldin Burazerovic
- Department of Neurosurgery, Clinical Center of University of Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina; (A.A.); (E.B.)
| | - Hana Rizvanovic
- Department of Medicine, University Sarajevo School of Science and Technology, 71000 Sarajevo, Bosnia and Herzegovina; (H.R.); (E.S.); (E.K.)
| | - Ema Selimovic
- Department of Medicine, University Sarajevo School of Science and Technology, 71000 Sarajevo, Bosnia and Herzegovina; (H.R.); (E.S.); (E.K.)
| | - Eleonora Kujaca
- Department of Medicine, University Sarajevo School of Science and Technology, 71000 Sarajevo, Bosnia and Herzegovina; (H.R.); (E.S.); (E.K.)
| | - Mirza Pojskic
- Department of Neurosurgery, Philipps University of Marburg, 35043 Marburg, Germany
| | - Alberto Feletti
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, 37126 Verona, Italy;
| | - Kenan Arnautovic
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, TN 38138, USA;
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Ali H, Majeed K, Bibi S, Syed H. Letter to the editor: "Giant unruptured middle cerebral artery aneurysm revealed by intracranial hypertension: is a systematic decompressive hemicraniotomy mandatory?". Neurosurg Rev 2024; 47:573. [PMID: 39242427 DOI: 10.1007/s10143-024-02825-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2024] [Revised: 08/25/2024] [Accepted: 09/02/2024] [Indexed: 09/09/2024]
Affiliation(s)
- Hassam Ali
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan.
| | - Kanwal Majeed
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Shahida Bibi
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Hina Syed
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
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Chlorogiannis DD, Aloizou AM, Chlorogiannis A, Kosta N, Sänger JA, Chatziioannou A, Papanagiotou P. Exploring the latest findings on endovascular treatments for giant aneurysms: a review. Rev Neurosci 2024; 35:451-461. [PMID: 38158880 DOI: 10.1515/revneuro-2023-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
Giant intracranial aneurysms represent a very challenging aspect of aneurysmal pathophysiology with very high mortality and morbidity if left untreated. Their variety in clinical presentation (subarachnoid hemorrhage, cranial nerve palsy, etc.) and pathological and imaging properties (location, anatomy, presence of collateral circulation) pose serious questions regarding the best treatment option. Admirable advances have been achieved in surgical techniques, while endovascular modalities with flow diversion techniques have become widely used. However, there is still lack of data regarding whether a single endovascular technique can be the universal treatment for such cases. In this review, we aim to summarize the current funds of knowledge concerning giant intracranial aneurysms and the role of endovascular management in their treatment.
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Affiliation(s)
| | - Athina-Maria Aloizou
- Department of Neurology, St. Josef-Hospital, Ruhr Universität Bochum, 44791Bochum, Germany
| | - Anargyros Chlorogiannis
- Department of Health Economics, Policy and Management, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Nefeli Kosta
- Department of Biology, University of Patras, 265 04 Patras, Greece
| | | | - Achilles Chatziioannou
- First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Areteion Hospital, 115 28 Athens, Greece
| | - Panagiotis Papanagiotou
- First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Areteion Hospital, 115 28 Athens, Greece
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, 28205 Bremen, Germany
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Rahmanian A, Mohammad Hosseini E, Sourani A, Jamali M, Saffarian A, Eghbal K, Taherpour S, Foroughi M. Microsurgical treatment of ophthalmic artery aneurysm, a case series of 55 patients with long-term follow-up. BMC Surg 2024; 24:139. [PMID: 38714953 PMCID: PMC11075342 DOI: 10.1186/s12893-024-02419-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/18/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Ophthalmic artery aneurysm (OAA) can be secured in endovascular or microsurgical approaches. Still there are controversies in technique selection and their long term outcomes. METHODS All the patients with OAA were treated microsurgically and followed. Demographic data, neurological status, physical examination findings, angiographic data, operation details, and intraoperative and postoperative events were recorded and analyzed. P < 0.05 was considered significant. RESULTS Among 55 patients, 38 were females (69.1%). Median preoperative glasgow coma scale (GCS), Fisher Grade, and Hunt and Hess(HH) scores were 15, 1 and 1, respectively. The most common neurologic manifestation was visual problems (n = 15). The most common anatomical projection was medial (43.6%) oriented lesions. 85.5% of them only had 1 ophthalmic aneurysm while multiple aneurysms were reported in 14.6%. In 52 patients temporary clip was used. in 21 patients (38.2%) intraoperative aneurysm rupture occurred. Larger aneurysm size and preoperative hydrocephalus were associated with higher rates of aneurysm rupture (P = 0.003 and 0.031). 28.5% of the patients with visual problems had clinical improvement in the postoperative period. The mean follow-up period was 5 years. Follow-up angiography showed a 100% obliteration rate with a 0.0% recurrence rate. Median values for follow-up glasgow outcome scale and modified Rankin scale were 5 and 0, respectively. favorable neurological outcomes were associated with better primary GCS and HH scores. CONCLUSION OAA microsurgery is an effective and safe procedure with significant improvement in both visual and neurological status. Low recurrence rate and excellent clinical recovery are the most important advantages of microsurgery in OAA treatment.
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Affiliation(s)
| | | | - Arman Sourani
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran.
- Environment Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Mohammad Jamali
- Neurosurgery department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arash Saffarian
- Neurosurgery department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Keyvan Eghbal
- Neurosurgery department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sanaz Taherpour
- Neurosurgery department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mina Foroughi
- Isfahan Students' Research Committee (ISRC), Isfahan University of Medical Sciences, Isfahan, Iran
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Šmigoc T, Kozorog N, Ravnik J. Case series: Intraoperative neuromonitoring and angiography in the surgical treatment of vascular malformations. Front Neurol 2023; 14:1182576. [PMID: 37954642 PMCID: PMC10637549 DOI: 10.3389/fneur.2023.1182576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/27/2023] [Indexed: 11/14/2023] Open
Abstract
In the surgical treatment of cerebral vascular malformations, e.g., aneurysms and arteriovenous malformations, the risk of ischemic complications is 6.7%, and a residual aneurysm is possible in 5.2% of these cases. Ischemic lesions can result in permanent neurological deficits, and a residual aneurysm can lead to the recurrence of the aneurysm in 2% of cases. In this article, we present five cases (two cases of ruptured aneurysms, two cases of non-ruptured aneurysms, and a case of arteriovenous malformation) in which we reduced the aforementioned risks with the use of intraoperative neuromonitoring and angiography. Intraoperative neuromonitoring (IONM) is used to measure motor and sensory-evoked potentials to detect brain hypoperfusion. Intraoperative angiography with the dye indocyanine green (ICG-A), which fluoresces in a vessel under a microscope after intravenous administration, helps to identify residual aneurysm sacs and distal blood flow. With the use of IONM and ICG-A, we identified abnormalities and adjusted our interventions and treatments. IONM and ICG-A can lead to a better outcome after surgical treatment of cerebral vascular abnormalities.
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Affiliation(s)
- Tomaž Šmigoc
- Department of Neurosurgery, Surgical Clinic, UMC Maribor, Maribor, Slovenia
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Sharma V, Garg M, Bhaskar S, Tiwari S, Bhatia PK, Jha DK. Handmade models for aneurysm surgery: A useful tool for training. Surg Neurol Int 2022; 13:571. [PMID: 36600742 PMCID: PMC9805621 DOI: 10.25259/sni_941_2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/26/2022] [Indexed: 12/14/2022] Open
Abstract
Background Aneurysm surgery is considered difficult by young and trainee neurosurgeons. This is due to difficulty in understanding orientation of aneurysm complex (proximal and distal vessels, aneurysm neck, and fundus) in relation to the surrounding structures (skull, brain, vessels, and nerves) after head is rotated, extended, and fixed on the head frame. Virtual three-dimensional (3D) imaging studies and 3D-printed models help young neurosurgeons but are not accessible to most of the centers due to need for resources (human and equipment). Authors used handmade 3D models of aneurysm complex to train young neurosurgeons before and during surgery to make them understand steps to treat it. Methods RadiAnt DICOM viewer software (2022.1.1, 64-bit, Medixant, Poznan, Poland) was used for acquiring 3D Volume Rendering Technique images to make aneurysm models preoperatively. Twisted 20 Gauze galvanized iron wires were used for making proximal and distal branches and Epoxy Putty (M-seal, Pidilite ® industries, Mumbai, India) was used to make smooth surfaces of the vessels, aneurysm necks, and fundi. Models were used in operating room (OR) before and during surgery to help surgeons and trainees get oriented to the aneurysm complexes. Results Handmade models, oriented as per patients' head position, were useful to make surgeons and trainees to understand projection of various components of the aneurysm complex in relation to adjacent structures, especially skull base, during both preoperative planning and in OR even before completion of the dissection. Conclusion Handmade models of aneurysms are inexpensive tool and can help trainee neurosurgeons to plan and execute surgical management of aneurysms.
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Affiliation(s)
- Vikrant Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mayank Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Suryanarayanan Bhaskar
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pradeep Kumar Bhatia
- Department of Anesthesia and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Deepak Kumar Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India,Corresponding author: Deepak Kumar Jha, Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
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Thavara BD, Yamada Y, Joshi G, Tanaka R, Miyatani K, Devareddy G, Nakao K, Kawase T, Kato Y. Analysis of the Surgical Outcome of Unruptured Intracranial Saccular Aneurysms in Octogenarians (80-89 Years). Asian J Neurosurg 2020; 15:640-643. [PMID: 33145219 PMCID: PMC7591182 DOI: 10.4103/ajns.ajns_44_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/07/2020] [Accepted: 04/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background: The prevalence of unruptured intracranial aneurysms is increasing in elderly population in Japan. Octogenarians (80–89 years) are more prone to complications due to increased age, comorbidities, increased risk of vasospasm, and treatment risks. Aim: The aim is to study the surgical outcome of unruptured intracranial saccular aneurysms in elderly patients aged between 80 and 89 years. Patients and Methods: A retrospective study was conducted involving all the cases of unruptured intracranial saccular aneurysms operated surgically in elderly patients aged between 80 and 89 years. All the cases operated between January 2017 and October 2019 were included in the study. The preoperative neurological status was assessed using the Glasgow Coma Scale (GCS). The comorbidities and risk factors involved were assessed. Postoperative neurological status was assessed by (1) postoperative GCS score and by the (2) presence or absence of the motor weakness of limbs. Results: Thirty-three aneurysms were operated in 27 patients. Two patients were operated two times at separate occasions for different aneurysms during the study period and hence making a total of 29 surgeries. The age range was 80–88 years, with a mean of 82.4 years ± 2.64 standard deviation (SD). There were 7 (24.1%) males and 22 (75.86%) females. All the patients had a preoperative GCS score of 15/15 without focal neurological deficit. The mean size (mm) of the aneurysms was 6.57 ± 4.04 SD. There were 31 (93.94%) aneurysms in the anterior circulation and 2 (6.06%) aneurysms in the posterior circulation. The comorbidities and risk factors were analyzed and found to be not influencing the outcome of the patients. Clipping was done in 32 aneurysms. One case of posterior inferior cerebellar artery (PICA) aneurysm underwent occipital artery to PICA bypass surgery. The postoperative complications include chronic subdural hematoma (CSDH) in 7 (24.13%) patients, extradural hematoma in 1 (3.4%), meningitis in 1 (3.4%), and lower cranial nerve palsy in 1 (3.4%) patient. All the patients were discharged with GCS score 15/15 without motor weakness of the limbs. The mean duration of stay was 16.62 days ± 9.98 SD. Conclusion: Surgery for unruptured saccular aneurysms in octogenarians has got a good result in the tertiary care facility. Advanced age alone should not be considered for preferring coiling over clipping. Octogenarians are more prone to developing postoperative CSDH.
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Affiliation(s)
- Binoy Damodar Thavara
- Department of Neurosurgery, Government Medical College, Thrissur, Kerala, India.,Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Girish Joshi
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan.,Department of Neurosurgery, Apollo Speciality Hospital, Bengaluru, Karnataka, India
| | - Riki Tanaka
- Department of Neurosurgery, Government Medical College, Thrissur, Kerala, India
| | - Kyosuke Miyatani
- Department of Neurosurgery, Government Medical College, Thrissur, Kerala, India
| | - Gowtham Devareddy
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan.,Department of Neurosurgery, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Kazutaka Nakao
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
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