颈内动脉眼动脉段动脉瘤的手术治疗

目的 对28例颈内动脉眼动脉段动脉瘤进行回顾分析,总结该部位动脉瘤手术方式和结果以进一步改善疗效.方法 2004年5月至2009年8月手术治疗28例(30个)颈内动脉眼动脉段动脉瘤,其中微小动脉瘤4个,小型动脉瘤2个,中型动脉瘤4个,大型、巨大动脉瘤20个.结果 共手术处理28例患者的28个眼动脉段动脉瘤.19例行动脉瘤夹闭或动脉瘤切除+颈内动脉重建,9例行高流量颅内外动脉搭桥+动脉瘤切除+颈内动脉重建或颈部颈内动脉结扎动脉瘤孤立.17例术后行数字减影血管造影、CT血管成像或磁共振血管成像复查,5例搭桥血管通畅,2例搭桥血管闭塞.1例动脉瘤少量残留,余动脉瘤不显影.GOS 4～5分占78%(22/28),死亡1例.结论 颈内动脉眼动脉段动脉瘤尤其是大型巨大型动脉瘤处理困难.辅助高流量颅内外搭桥手术、选择合适的动脉瘤夹,才能取得良好的手术效果.     

Evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery

The primary aim of this study is to assess the value of intraoperative near-infrared indocyanine green videoangiography (ICGA) during intracranial aneurysm surgery. Altogether, 129 patients harboring 152 intracranial aneurysms were recruited in this study between March 2007 and December 2008 and the clinical data were retrospectively analyzed. Intraoperative ICGA was performed to examine the completeness of the aneurysm clipping and the patency of the parent arteries in all cases. The intraoperative findings were compared with that of postoperative digital subtraction angiography (DSA). On all of the patients, 276 successful ICGA investigations were performed intraoperatively. The image quality and resolution were excellent, allowing real-time assessment of the cerebral circulation. Indocyanine green (ICG) angiographic results could be divided into arterial, capillary, and venous phases, comparable to those observed with postoperative DSA. In all cases, the postoperative angiographic results corresponded to the intraoperative ICGA findings. In three cases, the information provided by intraoperative ICG angiography significantly changed the surgical procedure. Intraoperative ICG videoangiography may be a useful tool in real-time evaluation of the aneurysm clipping. Its simplicity and easy reproducibility all suggest it to be carried out as a routine procedure during aneurysm surgery.     

Intraoperative control of extracranial-intracranial bypass patency by near-infrared indocyanine green videoangiography

OBJECT: Recently, intraoperative fluorescence angiography in which indocyanine green (ICG) is used as a tracer has been introduced as a novel technique to confirm successful aneurysm clipping. The aim of the present study was to assess whether ICG videoangiography is also suitable for intraoperative confirmation of extracranial-intracranial bypass patency. METHODS: Forty patients undergoing cerebral revascularization for hemodynamic cerebral ischemia (11 patients), moya-moya disease (18 patients), or complex intracranial aneurysms (11 patients) were included. Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery was performed 35 times in 30 patients (five patients with moyamoya underwent bilateral procedures), STA-posterior cerebral artery bypass surgery in two patients, and saphenous vein (SV) high-flow bypass surgery in eight patients. In each patient, following the completion of the anastomosis, ICG (0.3 mg/kg body weight) was given systemically via an intravenous bolus injection. A near-infrared light emitted by laser diodes was used to illuminate the operating field and the intravascular fluorescence was recorded using an optical filter-equipped video camera. The findings of ICG videoangiography were compared with those of postoperative digital subtraction (DS) or computerized tomography (CT) angiography. In all cases excellent visualization of cerebral arteries, the bypass graft, and brain perfusion was noted. Indocyanine green videoangiography was used to identify four nonfunctioning STA-MCA bypasses, which could be revised successfully in all cases. In two cases of SV high-flow bypasses, ICG videoangiography revealed stenosis at the proximal anastomotic site, which was also revised successfully. In all cases the final findings of ICG videoangiography could be positively validated during the postoperative course by performing DS or CT angiography. CONCLUSIONS: Indocyanine green videoangiography provides a reliable and rapid intraoperative assessment of bypass patency. Thus, ICG videoangiography may help reduce the incidence of early bypass graft failure.     

Endoscopic indocyanine green video angiography in aneurysm surgery: an innovative method for intraoperative assessment of blood flow in vasculature hidden from microscopic view

Recently, intraoperative fluorescence video angiography using indocyanine green (ICG) has been widely used in aneurysm surgery. This is a simple and useful method to confirm complete occlusion of the aneurysm lumen and preservation of blood flow in the arteries around the aneurysm. However, the observation field of ICG video angiography is limited under a microscope, making it difficult to confirm the flow in the arteries behind the parent arteries or aneurysm. The authors developed a new technique of intraoperative endoscopic ICG video angiography to assess the blood flow in perforating arteries hidden by the parent arteries or aneurysm. The endoscope emits excitation light with a wavelength of approximately 800 nm, and video images were obtained through a cut filter. The authors used this ICG fluorescence endoscope in treating 3 patients with unruptured cerebral aneurysms. During clip placement, the endoscope was inserted to confirm aneurysm occlusion. Then, ICG was intravenously administered, and the fluorescence in the vessels was observed via the endoscope as well as under the microscope. The blood flow in the perforating arteries was clearly identified, and no procedural complication occurred. The authors conclude that the technique is very useful and facilitates intraoperative real-time assessment of the patency of perforating arteries behind parent arteries or aneurysms.     

Comparison of computerized tomography angiography and digital subtraction angiography in ruptured cerebral aneurysm surgery

Objective: The aim of the present study was to review the efficacy of 16‐row multislice computerized tomography angiography (CTA) in ruptured cerebral aneurysm surgery by comparison with conventional digital subtraction angiography (DSA). Methods: A systemic review of patients suffering from ruptured cerebral aneurysm was performed. We report the results obtained during the 19‐month period from April 2003 to October 2004. In total, 32 patients had undergone aneurysm surgeries, in which 11 patients had both DSA and CTA performed. Results: Among the 11 patients with both DSA and CTA performed, two aneurysms were missed in DSA in two patients. The sensitivity and specificity of CTA were 100%. The correlation of CTA with DSA in operative findings was 100%. Our CTA could detect the aneurysm size down to 2 mm in diameter. Conclusion: The diagnostic accuracy of 16‐row multislice CTA is promising and it compares well with DSA for detection and evaluation of ruptured cerebral aneurysms. It is safe and effective to establish treatment decision on the basis of CTA alone in the majority of cases.     

Identification of the optimal cortical target point for extracranial-intracranial bypass surgery in patients with hemodynamic cerebrovascular insufficiency

OBJECT: The objective of this report is to describe a new approach to identify the optimal cortical target point for extracranial-intracranial (EC-IC) bypass surgery, to reliably find suitable recipient vessels for the anastomosis. METHODS: Thirty consecutive patients (17 men and 13 women; mean age 54.6 +/- 11.79 years [+/- standard deviation]) with hemodynamic cerebrovascular insufficiency due to stenoocclusive arterial disease underwent EC-IC bypass surgery. The end of the Sylvian fissure was identified preoperatively using a specially designed template and external landmarks. At surgery, a 3-cm trephination was made, centered over the target point as determined by the template. The number, diameter, and length of the exposed cortical arteries were assessed using photographs and indocyanine green (ICG) angiograms. RESULTS: At least 1 recipient artery appropriate for anastomosis (>or= 1 mm) was found in every craniectomy. The mean number of suitable recipient arteries per craniotomy was 2.09 +/- 0.87, the mean diameter was 1.28 +/- 0.24 mm, and the mean length 10.83 +/- 4.87 mm. Bypass patency was confirmed by intraoperative ICG angiography, postoperative computed tomography angiography, and digital subtraction angiography, and reached 100%. CONCLUSIONS: Performing a 3-cm craniectomy over the described target point, reliably allows access to suitable recipient arteries for EC-IC bypass surgery.     

脑动脉瘤术中吲哚菁绿相关问题及麻醉管理

背景 整合显微镜的吲哚菁绿(indocyanine green,ICG)荧光造影技术应运而生,因其价廉、操作简单、可重复等优点,现已广泛应用于评价颅内动脉瘤夹闭手术的夹闭效果,但临床上也会有过敏、一过性SpO2下降、渗漏等相关问题,给麻醉医师围手术期工作带来新的挑战.目的 为ICG在动脉瘤术中应用的麻醉管理提供参考.内容 综述ICG血管造影在动脉瘤术中的研究进展以及可能出现的副作用及其防止策略.趋向 ICG血管造影能够安全、有效地评估动脉瘤夹闭效果,将广泛应用于颅内动脉瘤夹闭手术.     

The role of 3D-computed tomography angiography (3D-CTA) in investigation of spontaneous subarachnoid haemorrhage: comparison with digital subtraction angiography (DSA) and surgical findings

Spontaneous subarachnoid haemorrhage is a clinical condition that may be attributed to various underlying causes, such as rupture of intracranial aneurysms and arteriovenous malformations (AVMs). Suspected cerebrovascular abnormalities can be detected either with digital subtraction angiography (DSA) or with computed tomography angiography (CTA) combined with postprocessing tools, namely multiplanar reformation, maximum intensity projection, shaded surface display, virtual endoscopy and direct volume rendering. We prospectively studied a group of 205 patients with spontaneous subarachnoid haemorrhage. One-hundred-ninety-eight patients underwent both DSA and CTA, and formed our study group. Patients with intracranial aneurysms underwent surgical or endovascualar treatment. DSA was negative for 35 patients, detected 178/179 aneurysms and 15 AVMs. CTA correctly detected 176/179 aneurysms and all 15 cases of AVMs, whereas it was negative in 35 cases. After 3D reconstruction the size, location and the relationship to the parent vessel of the aneurysms, the extent of the AVMs with the main feeding vessel(s), nidus and draining veins were reliably shown by CTA, although DSA provided more anatomic details related to the anatomy of the adjacent vessels. The accuracy, sensitivity, positive predictive accuracy and negative predictive accuracy for CTA was 98, 97.9, 100 and 94.3% and for DSA was 99, 99.3, 100 and 98%, respectively. It is suggested that CTA is a reliable alternative to DSA in detecting intracranial aneurysms. The role of CTA in demonstrating AVMs can be considered complementary to that of DSA.     

Rupture of a giant carotid aneurysm after extracranial-to-intracranial bypass surgery

We report a case of a fatal rupture of a previously unruptured giant aneurysm of the bifurcation of the internal carotid artery (ICA), which occurred after an extracranial-intracranial (EC-IC) bypass and the partial occlusion of the ICA. Interim angiography showed retrograde filling of the proximal middle cerebral artery to the aneurysm. There have been four previously reported cases of giant aneurysms rupturing after treatment with an EC-IC bypass and carotid ligation, and it appears likely that a change in pressure/flow dynamics produced by the bypass may have been the cause. The technique of carotid ligation with an EC-IC bypass is used frequently to treat unclippable intracranial aneurysms, and the resulting hemodynamic changes need to be considered carefully to prevent this type of complication. To minimize hemodynamic stress on the aneurysm, we suggest that 1) the bypass caliber should be as small as possible consistent with sufficient cerebral blood flow after ICA occlusion, and 2) complete ICA occlusion should be performed as soon as possible after the bypass.     

Spontaneous disappearance of aneurysm after total removal of accompanying intracranial arteriovenous malformation. Case report]

A 55-year-old male was hospitalized with severe headache. On admission, neurological examination revealed no abnormal findings. Plain computed tomography (CT) showed a slightly high-density area in the medial surface of the right parietal lobe. A marked enhancement in the same region was noted in enhanced CT. Cerebral angiography showed an arteriovenous malformation (AVM) in the medial surface of the right parietal lobe and two aneurysms on the right pericallosal artery which fed the AVM. In addition, a saccular aneurysm was noted at the anterior communicating artery. It was not possible to treat the AVM, two aneurysms nearby the AVM, and the unruptured anterior communicating artery aneurysm simultaneously with a single craniotomy. It was therefore decided to perform surgery for the AVM and two aneurysms nearby the AVM prior to clipping of the anterior communicating artery aneurysm. Total excision of the AVM and two aneurysms nearby the AVM was performed. Cerebral angiography performed 18 days after surgery revealed no AVM and also reduction in size was noted of the anterior communicating artery aneurysm. Three months later, repeated cerebral angiography showed disappearance of the aneurysm. This was further confirmed 15 months after surgery by angiography. From the literature, 117 cases of coexistence of AVM and aneurysms of the brain were collected and classified into three types according to their anatomical and hemodynamic correlation. It is suggested that hemodynamic stress, due to increased blood flow caused by the AVM, played a major role in the development of the aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Value of Intraoperative Angiography for Surgical Treatment of Cerebral Arteriovenous Malformations in Eloquent Brain Areas

Summary  Intraoperative digital subtraction angiography (DSA) allows intraoperative assessment of outcome of cerebral arteriovenous malformations (AVM). This study reports on 21 patients with AVMs in eloquent areas of the brain extirpated between July 1995 to March 1998. Extirpation was always followed by intraoperative DSA. Intraoperative angiography disclosed an occult residual nidus in 4 cases (19%). Complete extirpation of the AVM was achieved in all cases. Following surgery the neurological condition improved in 15 cases (71%), remained unchanged in 5 (24%), and worsened in 1. There were no secondary postoperative haemorrhages, nor complications related to the angiography. These results indicate that intraoperative DSA should be considered in the course of surgical treatment of cerebral AVMs in eloquent areas of the brain.     

吲哚菁绿荧光造影在穿支皮瓣微循环检测中的应用

目的评价吲哚菁绿荧光造影在皮瓣微循环检测中的准确性和安全性。方法回顾2014年7月至2018年5月的15例皮瓣手术,术中对皮瓣进行吲哚菁绿荧光造影,将术中造影结果与术中传统主观评估结果进行比较;术后2周记录皮瓣成活情况,将之与术中造影结果进行比较,并记录并发症情况。结果 15例皮瓣造影发现7例皮瓣存在微循环问题,传统主观观察法仅发现2例存在微循环障碍。其中,3例皮瓣在处理后再次造影仍提示有局部循环障碍,术后这3例皮瓣均发生局部坏死,坏死区域与术中造影"暗区"基本相符。所有术中造影患者术后均未出现相关并发症。结论吲哚菁绿荧光造影检测皮瓣灌注情况的准确性高,对皮瓣微循环障碍的敏感性高,可有效降低皮瓣术后局部坏死发生率,在临床应用中具有一定的实用价值。     

Distal anterior choroidal artery aneurysm associated with an arteriovenous malformation. Intraoperative localization and treatment

BACKGROUND

Distal anterior choroidal artery aneurysms are rare. The outcome of patients with distal anterior choroidal artery aneurysms has been poor, and the treatment of such aneurysms is surgically challenging.

CASE DESCRIPTION

The authors describe the case of an 8-year-old girl with a ruptured distal anterior choroidal artery aneurysm associated with an arteriovenous malformation (AVM). The patient experienced sudden onset of headache and vomiting. Computed tomography revealed an intraventricular haemorrhage, and cerebral angiography demonstrated an aneurysm arising from the distal portion of the right anterior choroidal artery. The patient also had an AVM in the ipsilateral temporal lobe fed by the branches of the middle cerebral artery. A right frontotemporal craniotomy was performed with the aid of intraoperative angiography to eliminate both the AVM and the aneurysm. Intraoperative angiography was helpful in confirming the complete removal of the AVM and in accurate localization of the small and deeply placed distal anterior choroidal artery aneurysm. Both the AVM and the aneurysm were successfully treated and the patient was discharged without any neurological deficits.

CONCLUSION

This case is the youngest reported patient with a distal anterior choroidal artery aneurysm. This report is also the first to describe an association of such an aneurysm with an AVM. The etiology of the aneurysm formation in this case and surgical strategy for deeply placed vascular lesions are discussed.     

Assessment of incomplete clipping of aneurysms intraoperatively by a near-infrared indocyanine green-video angiography (Niicg-Va) integrated microscope

OBJECTIVE: The objective of this article was to assess the clinical use and the completeness of clipping with total occlusion of the aneurysmal lumen, real-time assessment of vascular patency in the parent, branching and perforating vessels, intraoperative assessment of blood flow, image quality, spatial resolution and clinical value in difficult aneurysms using near infrared indocyanine green video angiography integrated on to an operative Pentero neurosurgical microscope (Carl Zeiss, Oberkochen Germany). MATERIALS AND METHODS: Thirteen patients with aneurysms were operated upon. An infrared camera with near infrared technology was adapted on to the OPMI Pentero microscope with a special filter and infrared excitation light to illuminate the operating field which was designed to allow passage of the near infrared light required for excitation of indocyanine green (ICG) which was used as the intravascular marker. The intravascular fluorescence was imaged with a video camera attached to the microscope. ICG fluorescence (700-850 nm) from a modified microscope light source on to the surgical field and passage of ICG fluorescence (780-950 nm) from the surgical field, back into the optical path of the microscope was used to detect the completeness of aneurysmal clipping RESULTS: Incomplete clipping in three patients (1 female and 2 males) with unruptured complicated aneurysms was detected using indocyanine green video angiography. There were no adverse effects after injection of indocyanine green. The completeness of clipping was inadequately detected by Doppler ultrasound miniprobe and rigid endoscopy and was thus complemented by indocyanine green video angiography. CONCLUSION: The operative microscope-integrated ICG video angiography as a new intraoperative method for detecting vascular flow, was found to be quick, reliable, cost-effective and possibly a substitute or adjunct for Doppler ultrasonography or intraoperative DSA, which is presently the gold standard. The simplicity of the method, the speed with which the investigation can be performed, the quality of the images, and the outcome of surgical procedures have all reduced the need for angiography. This technique may be useful during routine aneurysm surgery as an independent form of angiography and/or as an adjunct to intraoperative or postoperative DSA.     

Tailored flow alteration treatment for intracranial internal carotid artery aneurysms: strategy beyond parent artery occlusion with bypass. Case report

A 58-year-old woman with multiple right internal carotid artery (ICA) aneurysms detected incidentally was referred to us. Three-dimensional computed tomography (CT) angiography revealed a broad-necked paraclinoid aneurysm and an aneurysm on the C(1) segment. Aneurysm clipping with preservation of the anterior choroidal artery and posterior communicating artery was not possible because these vessels could not be adequately identified. Intraoperative digital subtraction angiography during obliteration of the cervical portion of the ICA confirmed retrograde flow from the extracranial-intracranial (EC-IC) bypass to the right ophthalmic artery and stagnation of flow in the aneurysms. The cervical portion of the ICA was ligated. Postoperative three-dimensional CT angiography confirmed complete occlusion of both aneurysms and absence of ischemic lesions involving branches of the ICA. Reversal of the blood flow in the ICA via the EC-IC bypass primarily into the ophthalmic artery as the flow outlet by obliterating the cervical portion of the ICA was successful. To prevent ischemia in the territory fed by the perforating arteries of the ICA, tailored flow alteration treatment may be superior to simple parent artery occlusion of the ICA with/without bypass. The pattern of flow alteration should be deliberately based on individual anatomic variations, especially the preservation of flow outlets.     

Prospective evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery

OBJECT: The authors prospectively compared a new technique of surgical microscope-based indocyanine green (ICG) videoangiography with intraoperative or postoperative digital subtraction (DS) angiography. METHOD: The technique was performed during 187 surgical procedures in which 124 aneurysms in 114 patients were clipped. Using a newly developed setup, the ICG technique has been integrated into an operating microscope (Carl Zeiss Co., Oberkochen, Germany). A microscope-integrated light source containing infrared excitation light illuminates the operating field. The dye is injected intravenously into the patient, and intravascular fluorescence from within the blood vessels is imaged using a video camera attached to the microscope. The patency of parent, branching, and perforating arteries and documentation of clip occlusion of the aneurysm as shown by ICG videoangiography were compared with intraoperative or postoperative findings on DS angiography. The results of ICG videoangiography corresponded with intra- or postoperative DS angiography in 90% of cases. The ICG technique missed mild but hemodynamically irrelevant stenosis that was evident on DS angiography in 7.3% of cases. The ICG technique missed angiographically relevant findings in three cases (one hemodynamically relevant stenosis and two residual aneurysm necks [2.7% of cases]). In two cases the missed findings were clinically and surgically inconsequential; in the third case, a 4-mm residual neck may require a second procedure. Indocyanine green videoangiography provided significant information for the surgeon in 9% of cases, most of which led to clip correction. CONCLUSIONS: Microscope-based ICG videoangiography is simple and provides real-time information about the patency of vessels of all sizes and about the aneurysm sac. This technique may be useful during routine aneurysm surgery as an independent form of angiography or as an adjunct to intra- or postoperative DS angiography.     

Evaluation of a distal pericallosal aneurysm visualized with 3-dimensional digital subtraction angiography: case report and treatment implications

BACKGROUND: Digital subtraction angiography (DSA) is considered the gold standard in the evaluation of cerebrovascular structures. Recently, 3-dimensional DSA (3D-DSA) has been increasingly used to obtain detailed information about the morphology and dimensions of intracranial aneurysms. We report the case of a patient who presented with a distal pericallosal artery aneurysm, which appeared by 2D imaging to be a fusiform, possible mycotic aneurysm. This was then revealed to be a saccular bifurcation aneurysm by 3D-DSA. This additional information changed the treatment plan for this patient from medical management to a surgical approach. CASE DESCRIPTION: The patient is a 56-year-old man with a history of hypertension and alcohol abuse with withdrawal seizures, who presented with a large intracranial hemorrhage on initial computed tomography scan. After stabilization with intracranial pressure management, the patient underwent magnetic resonance angiography and 4-vessel DSA. These initial studies showed a distal, fusiform pericallosal aneurysm consistent with a mycotic aneurysm. Rotational DSA was then used to generate 3D images of the structure that revealed a saccular bifurcation aneurysm. This enabled the decision to offer operative treatment rather than conservative medical management. DISCUSSION: This report highlights the value of 3D-DSA in establishing the appropriate treatment plan for patients with unique cerebral aneurysms. The higher resolution images used in this case provided information that was crucial in shifting the treatment focus from medical management, for what appeared to be a mycotic aneurysm by traditional DSA, to surgical intervention, for a clear hemodynamic aneurysm at a vessel bifurcation seen with 3D-DSA. Accurate pre-interventional evaluation and differential diagnosis are critical to designing the most effective lowest risk treatment plan. The standard method in the diagnosis of cerebral aneurysms has been DSA. Yet, higher resolution images of unclear or high-risk aneurysms are often required to guide clinical decision making. The emergence of new, less invasive endovascular techniques for securing intracranial aneurysms has placed greater emphasis on precisely defining the shape and dimensions of an aneurysm. Three-dimensional DSA is currently the highest resolution imaging modality available for the evaluation of intracranial aneurysms. CONCLUSION: 3D-DSA was used to evaluate a small, distal pericallosal artery aneurysm and revealed a saccular bifurcation aneurysm not visualized with magnetic resonance angiography and conventional DSA. This additional resolution permitted the team to consider a surgical approach for a patient who would otherwise have been treated medically. This high-resolution technique is particularly useful in guiding clinical decision making in the context of aneurysms that carry a relatively broad differential diagnosis, potentially high interventional risk, and unclear morphology.     

Hemodynamic compensation via an excimer laser-assisted, high-flow bypass before and after therapeutic occlusion of the internal carotid artery

OBJECTIVE: High-flow, extracranial-intracranial (EC-IC) bypass operations are performed to prevent strokes among patients with giant aneurysms who cannot tolerate internal carotid artery (ICA) occlusion. However, the volume flow through the bypass, compared with preoperative ICA flow, has not been evaluated for any type of bypass. We describe a prospective case study that tested the ability of the high-flow EC-IC bypass to replace the volume flow of the ipsilateral ICA after deliberate ICA occlusion. METHODS: Seven consecutive patients with giant aneurysms of the ICA who experienced test occlusion failure underwent nonocclusive, excimer laser-assisted, EC-IC bypass surgery before permanent ICA occlusion. Volume flow values in the ICAs, the basilar artery, the EC-IC bypass, and the middle cerebral arteries were measured with magnetic resonance angiography. RESULTS: No significant changes in volume flow to the ipsilateral and contralateral hemispheres were observed after bypass surgery and therapeutic ICA occlusion. Before bypass surgery, the volume flow through the ipsilateral ICA was 243 +/- 74 ml/min, that through the contralateral ICA was 264 +/- 32 ml/min, and that through the basilar artery was 141 +/- 43 ml/min. After bypass surgery and therapeutic occlusion of the ipsilateral ICA, the volume flow through the bypass was 199 +/- 72 ml/min, that through the contralateral ICA was 303 +/- 82 ml/min, and that through the basilar artery was 153 +/- 72 ml/min. No significant preoperative versus postoperative changes in middle cerebral artery flow were observed on either side. CONCLUSION: The flow through the high-flow EC-IC bypass was able to replace the volume flow of the ipsilateral ICA after deliberate ICA occlusion for the treatment of giant aneurysms.     

Treatment of a giant aneurysm of the cavernous internal carotid artery associated with a persistent primitive trigeminal artery: case report

A case of an unruptured giant aneurysm of the cavernous portion of the left internal carotid artery associated with a persistent primitive trigeminal artery (PTA) is presented. The usual surgical approach to giant aneurysms at this site, including ligation of the ipsilateral internal carotid artery (ICA) and an extracranial-intracranial (EC-IC) bypass, was inadequate because of continued blood supply to the aneurysm via the PTA from the vertebrobasilar system. The patient was successfully treated with a combination of EC-IC bypass surgery, ICA ligation, and simultaneous intravascular balloon obliteration of the ICA just distal to the junction of the PTA and immediately proximal to the aneurysmal neck. Follow-up radiological investigations showed thrombosis of the aneurysm.     

Proximal aneurysms in association with arteriovenous malformations: do they resolve following obliteration of the malformation with stereotactic radiosurgery?

One-hundred consecutive patients were identified who had arteriovenous malformations (AVMs) treated by stereotactic radiosurgery (STRS) which were totally obliterated as shown by follow-up angiography. Of these cases, seven had intracerebral aneurysms at initial angiography, two of which were multiple. Five patients had saccular aneurysms at commonly recognized sites on the circle of Willis or main proximal cerebral arteries, while two patients had aneurysms on distal AVM feeder arteries in atypical sites (one saccular, one fusiform). Saccular aneurysms at typical sites were found to be unchanged in size following AVM obliteration. The significance of this finding in the management of patients who present with subarachnoid haemorrhage and who have both aneurysms and AVMs is discussed.