Meningeal Layers Around Anterior Clinoid Process as a Delicate Area in Extradural Anterior Clinoidectomy : Anatomical and Clinical Study

Objective

Removal of the anterior clinoid process (ACP) is an essential process in the surgery of giant or complex aneurysms located near the proximal internal carotid artery or the distal basilar artery. An extradural clinoidectomy must be performed within the limits of the meningeal layers surrounding the ACP to prevent morbid complications. To identify the safest method of extradural exposure of the ACP, anatomical studies were done on cadaver heads.

Methods

Anatomical dissections for extradural exposure of the ACP were performed on both sides of seven cadavers. Before dividing the frontotemporal dural fold (FTDF), we measured its length from the superomedial apex attached to the periorbita to the posterolateral apex which connects to the anterosuperior end of the cavernous sinus.

Results

The average length of the FTDF on cadaver dissections was 7 mm on the right side and 7.14 mm on the left side. Cranial nerves were usually exposed when cutting FTDF more than 7 mm of the FTDF.

Conclusion

The most delicate area in an extradural anterior clinoidectomy is the junction of the FTDF and the anterior triangular apex of the cavernous sinus. The FTDF must be cut from the anterior side of the triangle at the periorbital side rather than from the dural side. The length of the FTDF incision must not exceed 7 mm to avoid cranial nerve injury.     

显微手术治疗前循环动脉瘤

目的：探讨颅内前循环动脉瘤的手术时机和技术。方法：本组74例颅内前循环动脉瘤患者（其中急性出血66例）共82枚动脉瘤。使用Hunt ＆ Hess分级法进行术前临床评价，采用翼点、半球间和眶上锁孔入路进行动脉瘤夹闭。早期（急性出血3d内）夹闭动脉瘤41例，其他行延迟手术。结果：良好60例，轻残2例，重残2例，死亡10例。结论：除术前Ⅳ和Ⅴ级病例主张延期手术外，颅内动脉瘤破裂后应积极争取早期手术夹闭。正确的手术方案和熟练的显微操作技术是颅内动脉瘤手术成功的关键。     

Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

Objective

Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications.

Methods

Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography.

Results

Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely.

Conclusion

The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.     

Distinction between Intradural and Extradural Aneurysms Involving the Paraclinoid Internal Carotid Artery with T2-Weighted Three-Dimensional Fast Spin-Echo Magnetic Resonance Imaging

Objective

The precise intra- vs. extradural localization of aneurysms involving the paraclinoid internal carotid artery is critical for the evaluation of patients being considered for aneurysm surgery. The purpose of this study was to investigate the clinical usefulness of T2-weighted three-dimensional (3-D) fast spin-echo (FSE) magnetic resonance (MR) imaging in the evaluation of unruptured paraclinoid aneurysms.

Methods

Twenty-eight patients with unruptured cerebral aneurysms in their paraclinoid regions were prospectively evaluated using a T2-weighted 3-D FSE MR imaging technique with oblique coronal sections. The MR images were assessed for the location of the cerebral aneurysm in relation to the dural ring and other surrounding anatomic compartments, and were also compared with the surgical or angiographic findings.

Results

All 28 aneurysms were identified by T2-weighted 3D FSE MR imaging, which showed the precise anatomic relationships in regards to the subarachnoid space and the surrounding anatomic structures. Consequently, 13 aneurysms were determined to be intradural and the other 15 were deemed extradural as they were confined to the cavernous sinus. Of the 13 aneurysms with intradural locations, three superior hypophyseal artery aneurysms were found to be situated intradurally upon operation.

Conclusion

High-resolution T2-weighted 3-D FSE MR imaging is capable of confirming whether a cerebral aneurysm at the paraclinoid region is intradural or extradural, because of the MR imaging''s high spatial resolution. The images may help in identifying patients with intradural aneurysms who require treatment, and they also can provide valuable information in the treatment plan for paraclinoid aneurysms.     

Clinical and Radiogical Outcomes of Endovascular Detachable Coil Embolization in Paraclinoid Aneurysms : A 10-Year Experience

Objective

Direct surgical clipping of paraclinoid aneurysms poses technical challenges to even very experienced neurosurgeons, making endovascular treatment an alternative treatment modality in many centers. We have therefore retrospectively evaluated the safety and efficacy of endovascular detachable coil embolization of paraclinoid aneurysms.

Methods

From June 1997 to June 2007, 65 patients underwent endovascular detachable coiling for 67 paraclinoid aneurysms (of which 9 were ruptured and 58 were unruptured) in our institute. Their medical records, radiological images and readings, and operation records were reviewed retrospectively.

Results

After the initial embolization procedure, complete occlusion was achieved in 29 (43.3%) of the aneurysms treated by endovascular detachable coiling. Six aneurysms required retreatment, with two each requiring one, two, or three additional endovascular procedures. Fifty-five (82.1%) aneurysms were measured by three-dimensional time of flight (TOF) magnetic resonance images (MRI) or transfemoral cerebral angiography (TFCA) at a mean follow-up of 29.7 months (range from 4 to 94 months), with 39 aneurysms (70.9%) showing complete occlusion. Thromboembolic events (3.8%) were the most frequent complication. Rupture did not occur during or after any of the procedures. According to the Glasgow Outcome Scale (GOS), 98.4% of the patients treated by coil embolization had a score of 4 or 5.

Conclusion

Our results indicate that endovascular detachable coiling is a safe and effective treatment modality in paraclinoid aneurysms.     

血管内栓塞治疗颅内动脉瘤围手术期并发症

目的总结血管内栓塞治疗颅内动脉瘤围手术期并发症,并讨论其防治方法。方法对184例血管内治疗的颅内动脉瘤患者的临床资料进行回顾性分析。结果36例患者在围手术期出现并发症,包括动脉瘤破裂出血6例,血管内栓塞6例,脑积水21例,其它并发症3例。其中死亡5例,肢体功能障碍2例。结论血管内栓塞、动脉瘤破裂出血和脑积水是颅内动脉瘤血管内治疗围手术期常见并发症,要积极防治,熟悉动脉瘤和载瘤动脉的解剖特点,掌握栓塞技巧和手术操作要求,早期引流蛛网膜下腔积血,有助于减少并发症的发生,提高患者治愈率。     

277例颅内动脉瘤的显微外科手术治疗

目的探讨颅内动脉瘤的手术策略、术中脑保护以及疗效等。方法采用夹闭、切除、孤立、包裹等方法手术处理277例共312个动脉瘤。其中在低温停循环条件下手术夹闭5例,行动脉瘤孤立3例,行动脉瘤包裹2例。结果277例中,127例术后行DSA检查,绝大多数动脉瘤夹闭满意。按GOS标准,良好243例(87.7%),差13例,死亡21例。189例得以随访,恢复良好180例(95.2%),中残或重残7例,死亡2例。结论手术夹闭是治疗动脉瘤的确实有效的方法。对复杂性颅内动脉瘤,需采用充分的显露,血管临时阻断,有效的脑保护,动脉瘤切开减压,缩窄瘤颈瘤体成型或载瘤动脉的塑型等措施,方能达到满意的手术效果。     

血管内治疗床突旁未破裂颅内动脉瘤的疗效分析

目的 评估血管内治疗床突旁未破裂颅内动脉瘤(unruptured intracranial aneurysm,UIA)的安全性和有效性.方法 回顾性纳入2017年1月-2019年12月于空军军医大学唐都医院神经外科连续收治的床突旁UIA患者.收集患者的基线资料和影像学资料,统计动脉瘤栓塞结果、围手术期并发症发生情况及预...     

经翼点入路显微手术治疗Willis环前部动脉瘤（附50例报道）

通过对５０例Ｗｉｌｌｉｓ环前部动脉瘤（Ｈｕｎｔ－Ｈｅｓｓ分级Ⅰ～Ⅴ级）的显微手术治疗,以探讨手术时机、手术技巧对术后疗效的影响。方法 对来我科首诊的自发性蛛钢古腔出血（ＳＡＨ）的病人作头颅ＣＴ,对高度怀疑为颅内动脉瘤患行全脑血管造影（ＤＳＡ）检查,若确诊为颅内动脉瘤,争取１２小时、最迟７２小时内（但由外院转诊已错过急性期均在两周后）经Ｙａｓａｒｇｉｌ‘ｓ翼点入路开颅行显微手术夹闭动脉瘤。结果     

开颅夹闭和血管内栓塞治疗颅内动脉瘤的效果及并发症分析

目的 探讨开颅夹闭和血管内栓塞治疗颅内动脉瘤效果及其并发症。方法 近五年来我院收治颅内动脉瘤患者46例，其中开颅夹闭25例（Hunt—Hess分级：Ⅰ-Ⅱ级20例，Ⅲ级3例，Ⅳ级2例），共28个动脉瘤；血管内栓塞21例（Hunt—Hess分级：Ⅰ-Ⅱ级15例，Ⅲ级4例，Ⅳ级2例），共24个动脉瘤。临床结果按GOS进行评价。结果两组的良好率、并发症发生率及死亡率无显著差异（P〉0．05）。全组病情Ⅰ-Ⅱ级动脉瘤患者治疗的良好率为100％（35／35），并发症发生率为5．7％（2／35），Ⅲ-Ⅳ级者分别为36．4％（4／11），81．8％（9／11），两者相差显著（P〈0．05）。结论开颅夹闭和血管内栓塞治疗颅内动脉瘤，两者临床结果相仿，且各有其优缺点：动脉瘤患者病情级别越高．治疗效果越差．     

Complications of Neuroform Stent in Endovascular Treatment of Intracranial Aneurysms

Background  The Neuroform stent can help in the treatment of difficult, wide-necked intracranial aneurysms. The objective of our study is to report some of the challenges associated with the Neuroform stent in the treatment of intracranial aneurysms. Methods  From January 2003 to August 2006, consecutive patients treated with Neuroform stent for intracranial aneurysms were prospectively enrolled. Information on patient demographics, cerebrovascular risk factors, aneurysm size and location were collected. Technical and clinical complications as well as clinical outcomes were measured. Data were analyzed retrospectively using SPSS software version 11.5. Results  Successful deployment of the stent, in the target artery, was achieved in 65/67 (97%) patients. Stent deployment failed in two cases and the migration of stent developed in one during coiling. Postoperative thromboembolic events developed in three patients. These three patients possessed hyperactive platelets, and were treated with intravenous eptifibatide. Intraoperative rupture of aneurysm developed in one patient, which was secured by subsequent coiling. Majority of the patients had good outcomes GOS (Glasgow Outcome Score) 1 or NIHSS (National Institute of Health Stroke Scale) 0 in 63/67 (94%), GOS 2 or NIHSS 2 in one patient and GOS 3 or NIHSS 4 was observed in three cases. Conclusion  Despite a low rate of intraoperative complications, post-procedural thromboembolic events were common in Neuroform stent-treated patients, which might be associated with hyperactive platelets. Further studies are warranted to identify any potential relationship between post-stent hyperactive platelets and thromboembolism.     

接受围手术期标准加速康复管理的颅内动脉瘤患者营养状态与显微外科夹闭术后并发症关系研究

目的 调查接受围手术期标准加速康复管理的颅内前循环动脉瘤患者营养状态、营养支持与显微外科夹闭术后并发症的关系。方法 前瞻性连续入组2018年1月-2019年3月接受显微外科夹闭手术治疗的颅内前循环动脉瘤患者,围手术期采用标准加速康复管理。收集患者的人口学资料,动脉瘤特点（部位、直径、是否破裂）,既往病史（高血压和糖尿病）,手术前后营养相关指标（营养风险、人体测量、实验室检查、营养支持方式等）,术后并发症包括肺部感染、颅内感染、下肢深静脉血栓、卒中（缺血性卒中和颅内出血）等。根据术后至出院是否出现上述1项及以上并发症,分为并发症组和无并发症组,比较2组患者临床指标的差异,并通过多元logistic回归分析营养相关指标对颅内动脉瘤术后并发症的影响。结果 共纳入颅内前循环动脉瘤患者97例,其中33例（34.02%）发生术后并发症,64例（65.98%）无并发症。并发症组术前动脉瘤破裂（12.1% vs. 0,P=0.009）,高血压（72.7% vs. 50.0%,P=0.005）和糖尿病比例（9.0% vs. 3.1%,P=0.032）高于无并发症组;营养相关指标中术前BMI（26.37±6.58 kg/m2 vs. 24.61±3.32 kg/m2,P=0.015）、三头肌皮褶厚度（24.92±8.57 mm vs. 18.61±8.09 mm,P=0.001）、小腿围（37.60±3.067 cm vs. 36.06±3.44 cm,P=0.039）高于无并发症组,血红蛋白水平（136.06±13.93 g/L vs. 143.27±12.08 g/L,P=0.010）低于无并发症组;术后营养干预的比例（84.8% vs. 40.6%,P=0.030）以及口服营养补充（33.3% vs. 26.5%,P＜0.001）、肠内营养（12.1% vs. 0,P＜0.001）、肠外营养（39.3% vs. 14.0%,P＜0.001）支持的比例均高于无并发症组,肠外营养持续时间长于无并发症组[5.0（3.0～11.5）d vs. 1.0（1.0～3.5）d,P=0.009]。多元logistic分析显示术前高TSF（OR 1.230,95%CI 1.056～1.363,P=0.008）是动脉瘤患者术后并发症的危险因素,术后1 d白蛋白水平高（OR 0.734,95%CI 0.561～0.961,P=0.025）是术后并发症的保护因素。结论 皮下脂肪增多可能会增加颅内动脉瘤患者显微外科夹闭术后至出院期间并发症的风险,而术后1 d时的白蛋白水平高可能减少术后并发症风险。     

Endovascular Treatment of Aneurysms Arising from the Proximal Segment of the Anterior Cerebral Artery

Objective

Aneurysms arising from the proximal segment of the anterior cerebral artery (A1) are rare and challenging to treat. The aim of this study was to report our experience with endovascular treatment of A1 Aneurysms.

Methods

From August 2007 through May 2012, eleven A1 aneurysms in eleven patients were treated endovascularly. Six aneurysms were unruptured and 5 were ruptured. One patient with an unruptured A1 aneurysm presented with subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. Procedural data, clinical and angiographic results were reviewed retrospectively.

Results

All of the aneurysms were successfully treated with coil embolization. Six were treated with a simple technique while the remaining 5 required adjunctive technique : double catheters (n=2), balloon-assisted (n=2), and stent-assisted (n=1). The immediate angiographic control showed a complete occlusion in all cases. Procedure-related complication occurred in only one patient : parent artery occlusion, which was not clinically significant. All patients had excellent clinical outcomes but one patient was discharged with a slight disability. No neurologic deterioration or bleeding was seen during the follow-up period in this cohort of patients. Follow-up angiography (mean, 20 months) was available in ten patients and revealed stable occlusion in all cases.

Conclusion

Endovascular treatment is a feasible and effective therapeutic modality for A1 aneurysms. Tailored microcatheter shaping and/or adjunctive techniques are necessary for successful aneurysm embolization because of the projection and location of A1 aneurysms.     

儿童颅内动脉瘤的诊断和治疗

目的探讨儿童颅内动脉瘤的临床特点和治疗策略。方法回顾性分析了7例儿童颅内动脉瘤的临床资料。7例儿童动脉瘤中,4例位于后循环,3例位于前循环;1例伴有AVM。仅1例是女童。开颅手术治疗1例,血管内治疗4例,2例未治。结果治疗的5例中,3例经血管内栓塞治愈。1例经开颅手术治愈,1例基底动脉主干梭形动脉瘤经血管内栓塞部分瘤体,症状好转。无死亡。结论儿童颅内动脉瘤罕见,其临床状态常较好,经过积极治疗后大多数可以获得良好的预后。     

Surgical Experience of the Ruptured Distal Anterior Cerebral Artery Aneurysms

Objective

Distal anterior cerebral artery (DACA) aneurysms are fragile and known to have high risks for intraoperative premature rupture and a relatively high associated morbidity. To improve surgical outcomes of DACA aneurysms, we reviewed our surgical strategy and its results postoperatively.

Methods

A total of 845 patients with ruptured cerebral aneurysms were operated in our hospital from January 1991 to December 2005. Twenty-three of 845 patients had ruptured DACA aneurysms which were operated on according to our surgical strategy. Our surgical strategy was as follows; early surgery, appropriate releasing of CSF, appropriate surgical approach, using neuronavigating system, securing the bridging veins, using temporary clipping and/or tentative clipping, meticulous manipulation of aneurysm, and using micro-Doppler flow probe. Twenty of 23 patients who had complete medical records were studied retrospectively. We observed the postoperative radiographic findings and checked Glasgow Outcome Scale score sixth months after the operation.

Results

Nineteen DACA aneurysms were clipped through a unilateral interhemispheric approach and one DACA aneurysm was clipped through a pterional approach. Postoperative radiographic findings revealed complete clipping of aneurysmal neck without stenosis or occlusion of parent arteries. In two patients, a residual neck of aneurysm was visualized. Seventeen patients showed good recovery, one patient resulted in moderate disability, while 2 patients died.

Conclusion

With our surgical strategy it was possible to achieve acceptable surgical morbidity and mortality rates in patients with DACA aneurysms. Appropriate use of tentative clipping, temporary clipping and neuro-navigating systems can give great help for safe approach and clipping of DACA aneurysm.     

A Dural Arteriovenous Fistula of the Anterior Cranial Fossa Angiographically Mimicking an Anterior Ethmoidal Artery Aneurysm

Venous aneurysm or varix at the venous side of the fistula commonly exist in dural arteriovenous fistula (DAVF) of the anterior cranial fossa, which may be initially mistaken with aneurysm on computed tomography and magnetic resonance imaging, but always identified by angiography. We report a very unusual case of anterior cranial fossa DAVF angiographically mimicking an anterior ethmoidal artery aneurysm, which was ultimately corrected by surgery. A 41‐year‐old male presented with right frontal intraparenchymal hematoma with intraventricular extension. Angiography revealed a vascular lesion adjacent to the anterior fossa mimicking an anterior ethmoidal artery aneurysm, which was surgically proven to be a partially thrombosed venous varix of drainaging vein originated from the cribriform plate. A diagnosis of anterior cranial fossa DAVF was made, and venous varix was excised. Follow‐up angiography after the operation revealed complete disappearance of the lesion. Our case illustrates a unique occasion that a proximal venous varix without obvious outflow angiographically in DAVF might be mistaken with an aneurysm.     

Saccular Aneurysm of the Azygos Anterior Cerebral Artery: Three Case Reports

The azygos anterior cerebral artery, a rare anomaly in the circle of Willis in which only a single vessel supplies the medial aspects of both anterior cerebral hemispheres, is closely associated with saccular aneurysms. We present three cases of azygos anterior cerebral artery aneurysms among the 781 cerebral aneurysms surgically treated at our institution in an 11-year period. These three cases all involved elderly women who presented with subarachnoid hemorrhage. Conventional cerebral angiography and CT angiography revealed small saccular aneurysms at the distal ends of the azygos anterior cerebral arteries. These aneurysms were clipped successfully using a bifrontal interhemispheric approach. Hence, the pathogenesis of these particular aneurysms relating to hemodynamic change, associated anomalies, and surgical pitfalls is discussed with review of literature.