Normal perfusion pressure breakthrough in arteriovenous malformation surgery: the concept revisited with a case report

The pathophysiological mechanisms and the salient features of normal perfusion pressure breakthrough (NPPB) are discussed on the basis of an operated case of arteriovenous malformation.

Surgical clipping of basilar aneurysms: relationship between the different approaches and the surgical corridors

BACKGROUND

Surgical clipping for basilar artery aneurysm (BAA) is a technically demanding procedure due to the depth of the surgical field and the presence of vital perforating arteries in the vicinity. The incorporation of various modifications in the conventional approaches has expanded the surgical armamentarium in dealing with these difficult lesions.

METHODS AND FINDINGS

87 patients of BAA were operated at our center, out of which in 48 patients, a pterional transsylvian approach was used. In 12 patients, this approach had to be extended to incorporate the anterior temporal approach in 6 cases, transzygomatic subtemporal approach in 2 cases and transcavernous approach in 4 cases. The surgical indications for the additional approaches and the relationships between the surgical corridors gained by their inclusion were studied. The use of neuroendoscopy facilitated adequate clipping in one case of high BAA without the incorporation of bone drilling, thus opening new surgical corridors.

INTERPRETATION

The variable situation of the BAA makes it mandatory for the surgeon to be prepared to simultaneously work through multiple surgical corridors. Neuroendoscopic-assisted microneurosurgery occasionally utilizes a narrow surgical corridor to facilitate BAA clipping using the conventional approaches and eliminates the need to gain access using additional surgical corridors.

Treatment of unruptured intracranial aneurysms--a clinicopathological correlation

OBJECT

Brain check-up is very important for detecting the incidence and prevalence of aneurysms in the population and to get the definite strategy for the treatment of intracranial aneurysms.

METHODS

This is a retrospective study of 116 aneurysms detected by brain check-up between 1998-1999 which were treated either by clipping or endovascular coiling. In some cases the aneurysmal wall was resected for histopathological examination and compared with five normal autopsy cases.

CONCLUSIONS

Direct surgery is the primary option for a patient with an aneurysm in the anterior circulation especially in young patients. Intravascular therapy is suitable for aneurysms in the posterior circulation and in intracavernous site.

Endoscope-assisted microsurgery for cerebral aneurysms

We performed endoscope-assisted microsurgery for 64 patients with cerebral aneurysms from June 1998 to January 1999. Two patients were treated under picture-in-picture imaging using a surgical microscope connected with an endoscopic-image display system. The study included 34 patients with incidental discovery: 3 IC oph, aneurysm, 1 from cavernous (C3) portion, 8 at ICPC, 1 from infundibular dilatation, 2 at IC bifurcation, 6 at AcoA, 1 at A1A2, 8 at MCA, 1 at P1, 1 from basilar tip, 1 at AICA, 1 at VA and 1 from PICA. The study also included 30 patients with subarachnoid hemorrhage: 5 ICPC, 2 from anterior choroidal, 1 from IC infundibular dilatation, 10 from AcoA, 2 from A2A3, 7 from MCA, 2 from basilar tip and 1 from PICA. They were classified into gr. 1 for 2, gr. 2 for 8, gr. 3 for 10, gr. 4 for 7, and gr. 5 for 3 cases.

Control of hemorrhage during AVM surgery--with special reference to treatment of dilated capillaries and arteries around the nidus

Control of hemorrhage during AVM surgery is one of the key issues to prevent NPPB. Inadequate procedures for hemostasis of feeders and drainers, so-called dilated capillaries and arteries (moja moja blood vessels) that are located on the side facing the normal brain, and inappropriate surgical strategies for intraoperative hemorrhage from these blood vessels are frequently the main cause of the difficulty in achieving hemostatic control. We conclude that it is important to aggressively reduce the occurrence of intraoperative hemorrhage and prevent or minimize the dilatation of abnormal capillaries and arteries due to inappropriate surgical procedures on the basis of the fundamental surgical strategy, i.e., feeder-->nidus-->drainer. Adequately securing the length and adequate coagulation of hemorrhagic blood vessel, employing a skillful bipolar coagulator technique aimed at controlling intraluminal pressure and blood flow on the central side, are believed to be key factors in hemorrhage treatment.