Detection of intracranial aneurysms with two-dimensional and three-dimensional multislice helical computed tomographic angiography

OBJECTIVE: Computed tomographic angiography (CTA) has become a diagnostic method for the detection of intracranial aneurysms in cases of subarachnoid bleeding. We sought to evaluate the detection of aneurysms with CTA with a novel multislice helical computed tomographic scanner. METHODS: Prospectively, 179 patients underwent multislice CTA, followed by digital subtraction angiography (DSA) of both carotid arteries with or without the posterior circulation, DSA of one carotid artery with or without the posterior circulation, or DSA of the posterior circulation alone. The total number of carotid arteries studied was 298, and the number of vertebrobasilar arteries studied was 124. RESULTS: Of 178 aneurysms verified with DSA or intraoperatively, CTA failed to detect 7 aneurysms of 1 to 2 mm and 1 partially thrombosed, 4-mm aneurysm. The sensitivity and specificity of CTA for aneurysm detection were 0.96 and 0.97, respectively. CONCLUSION: The first generation of multislice computed tomographic technology does not improve CTA to surpass DSA for the detection of small aneurysms of 1 to 2 mm. In practice, however, CTA is superior as a fast noninvasive method without complications.     

多技术联合应用于颅内巨大动脉瘤的显微外科治疗

目的 探讨神经电生理监测、术中超声、术中荧光造影、神经内镜多技术联合应用于颅内巨大动脉瘤的显微外科手术治疗的临床效果。方法 回顾性分析显微手术治疗颅内巨大动脉瘤17例的临床资料。术前采用3D-CTA、MRI和DSA,充分评估动脉瘤的位置、大小和形状。术中应用神经电生理监测评价动脉瘤夹闭前、后的神经功能保留和损害程度;通过微血管多普勒超声的定性和定量分析联合术中荧光造影评定动脉瘤和周围邻近血管的血液流速及通畅度;神经内镜观察动脉瘤区的局部解剖,辨认重要的穿支血管、瘤颈结构和动脉瘤夹情况。手术在手术显微镜下操作,采用载瘤动脉控制性技术、瘤颈成形技术、动脉瘤内减压和切除技术、多瘤夹夹闭技术和血管痉挛保护技术等进行联合治疗。 结果 在多技术联合监测下,显微外科手术成功夹闭巨大动脉瘤17个,术后恢复良好15例,出现轻偏瘫1例,重度偏瘫l例,无死亡病例。DSA复查示瘤颈夹闭完全,载瘤动脉通畅。远期随访仍在进行中。 结论 多技术联合显微手术技术,能有效提高颅内巨大动脉瘤的手术疗效。     

颅内外动脉狭窄合并颅内动脉瘤同期血管内治疗的效果分析

目的探讨同期治疗颅内外动脉狭窄合并颅内动脉瘤的策略及临床效果。方法回顾性分析2013年4月至2018年9月于北京大学第一医院神经外科行同期血管内治疗的15例颅内外动脉狭窄合并颅内动脉瘤患者的临床资料。男性6例,女性9例,年龄(63.9±9.1)岁(范围:43~79岁);动脉狭窄部位共15处,狭窄程度为75%~95%,其中前循环8处,后循环7处;动脉瘤共17个,最大径(5.3±1.2)mm(范围:3~7 mm),其中前循环动脉瘤11个、后循环动脉瘤6个。患者均行同期动脉狭窄支架成形及动脉瘤栓塞术治疗。记录患者围手术期及术后临床症状、影像学资料及并发症情况。结果15处动脉狭窄均成功置入支架(残余狭窄<30%);17个动脉瘤中,10个行单纯弹簧圈栓塞,7个行支架辅助弹簧圈栓塞,均完全栓塞。围手术期1例患者出现轻微脑梗死症状,其余未发生手术相关并发症。术后随访(43.8±8.2)个月(范围:24~85个月),患者术后6~12个月均复查数字减影血管造影,其中2例出现无症状性支架内再狭窄,所有动脉瘤未见复发。截至末次随访时,患者均未出现颅内出血、缺血性卒中等相关症状。结论颅内外动脉狭窄合并颅内动脉瘤应根据血管狭窄的部位、程度及动脉瘤的大小、形态、位置、数量及两者的位置关系等因素综合分析,制定个体化的治疗策略,给予同期血管内治疗可能是一种安全、有效的治疗方法。     

颅内动脉瘤破裂出血后假性动脉瘤的血管内治疗时机与并发症防治

目的探讨颅内动脉瘤破裂出血后在其破口周围所形成的假性动脉瘤与真性动脉瘤（TAN-FAN）复合体的血管内栓塞时机及并发症防治方法。方法采用电解可脱性弹簧圈对58例TAN—FAN复合体进行血管内栓塞。结果58例TAN—FAN复合体中24例（41．4％）为出血后7天内进行栓塞，20例（34．5％）为出血后7天～2周内进行栓塞，14例（24．1％）为出血后2周～1个月内进行栓塞。58个动脉瘤均被成功栓塞，其中真性动脉瘤腔100％闭塞者46个，95％闭塞者9个，90％闭塞者3个；13例A型与31例B型假性动脉瘤腔均未行弹簧圈填塞，14例C型中11例仅用弹簧圈疏松填塞假性动脉瘤腔，另3例用3D-GDC仅栓塞真性动脉瘤腔部分。术中并发动脉瘤破裂1例；并发脑血管痉挛2例；并发脑梗死3例。1例复发者经二次补充GDC栓塞而治愈。其治疗结果根据Glasgow预后评分：Ⅰ级43例，Ⅱ级11例，Ⅲ级3例，全组死亡1例，死亡率1．7％。术后随访3～60个月均无再出血。结论对动脉瘤破裂后形成的TAN—FAN复合体应早期进行血管内栓塞；只有根据TAN—FAN复合体不同的类型采用不同的栓塞方法进行个体化治疗，并具有丰富的动脉瘤栓塞经验，才能最大限度的降低并发症。     

颅内前循环动脉瘤的显微外科手术治疗

目的 探讨颅内前循环动脉瘤显微外科手术治疗方法,总结前循环动脉瘤治疗的相关经验.方法 回顾性分析近2年来显微外科治疗Ⅰ～Ⅳ级颅内前循环动脉瘤171例(共174个动脉瘤)的临床资料,以及不同部位动脉瘤的手术技巧及治疗经验.结果 Ⅰ～Ⅳ级颅内前循环动脉瘤171例,其中后交通动脉瘤67例,前交通动脉瘤56例,大脑中动脉瘤32例,颈内动脉分叉部动脉瘤10例,眼动脉瘤6例,多发动脉瘤3例.均成功进行了手术夹闭,术后GOS评分预后分级Ⅰ级3例,Ⅲ级6例,Ⅳ级14例,Ⅴ级148例.结论 良好的显露及显微外科技术是成功夹闭动脉瘤的关键;术中预判、动脉瘤夹合理的选择、载瘤动脉的正确阻断是值得重视的影响手术成败的因素.     

A prospective single-center analysis of the safety and efficacy of the hydrocoil embolization system for the treatment of intracranial aneurysms

OBJECT: The HydroCoil embolization system is a helical platinum coil coated with a polymeric hydrogel that expands when it contacts aqueous solutions to increase filling volumes, improve mesh stability, and possibly elicit a healing response within the aneurysm. In this paper, the authors report the 1-year recurrence and complication rates of 67 aneurysms embolized with the HydroCoil system. METHODS: Sixty-four consecutive patients (67 total aneurysms) with small (< or =7 mm), large (8-15 mm), very large (16-24 mm), and giant (> or =25 mm) aneurysms in the anterior and posterior intracranial circulations were treated with HydroCoils between March 2003 and September 2004. All aneurysms were embolized by the senior author (A.S.B) with HydroCoils alone or in combination with bare platinum coils, until either there was no further angiographic contrast filling of the aneurysm or the microcatheter was pushed out of the dome by the coil mass. Balloon assistance was used in three cases and combined Neuroform stent-coil embolization in eight other cases. To evaluate the safety and 1-year efficacy of the HydroCoil system, periprocedural complications were recorded, and angiographic recurrences were categorized using the Raymond-Roy Occlusion Classification (RROC) system. The 1-year aneurysm recurrence rate independent of size was 15% in patients treated with HydroCoils. Seventy percent of the patients had stable occlusions. The recurrence rate for small aneurysms was 3.7%, and the combined recurrence rate for small and large aneurysms was 6%. Fifteen percent of the aneurysms initially categorized as RROC Type 2 or 3 with stasis of contrast material at the time of initial embolization improved in RROC type, allowing the authors to develop the aneurysm embolization grade to predict recurrence. The neurological complication rate was 14.9%, of which 4.5% represented permanent neurological deficits. CONCLUSIONS: The HydroCoil embolization system is safe and provides excellent 1-year occlusion of small and large aneurysms with initial RROC Type 1, as well as those with RROC Types 2 and 3 with stasis of contrast material at the time of embolization. Very large and giant aneurysms were not as successfully occluded with this system. Treatment of large and giant internal carotid artery aneurysms was more likely to result in cranial nerve palsies and postembolization headaches than treatment in other locations. The aneurysm embolization grade the authors developed using the results of this study accurately predicted 1-year recurrence rates based on the immediate postembolization angiographic characteristics of the treated aneurysm.     

Endovascular treatment of posterior circulation aneurysms

The objective of this paper was to analyse the technical and clinical outcome in patients receiving endovascular treatment for posterior circulation intracranial aneurysms at Royal Perth Hospital. The case notes and angiograms of 35 patients with ruptured and unruptured posterior circulation aneurysms treated by endovascular coil occlusion between 1992 and 1998 were included in the study. The degree of angiographic occlusion achieved, and periprocedural, short and long-term clinical outcome were retrospectively analysed. Total aneurysm occlusion was achieved at initial treatment in 46% of cases, with 90% or greater occlusion achieved in 97% of cases. For aneurysms 12 mm or less in diameter, 100% of patients treated electively, and 100% of patients with grade I or II subarachnoid haemorrhage treated in the acute postictal phase had a good clinical outcome (Rankin Disability Score 1 and 2), with no serious morbidity or associated mortality. Excluding patients with grade V subarachnoid haemorrhage, the treatment-related serious morbidity rate was 3.4% and procedure-related mortality rate was 0%. We conclude that endovascular management provides an effective means of treatment for selected cases of posterior circulation aneurysms.     

Screening for unruptured asymptomatic intracranial aneurysms in patients undergoing coronary angiography

In screening for unruptured asymptomatic intracranial aneurysms, an intracranial intra-arterial digital subtraction angiography (IA-DSA), posteroanterior view, was obtained in 72 consecutive patients who underwent coronary angiography for workup of angina pectoris. In cases where an aneurysm was suspected from IA-DSA, conventional intracranial angiography was obtained. Five asymptomatic unruptured aneurysms were detected in four of these cases. The aneurysms ranged from 4 to 16 mm in diameter. There were no complications associated with the coronary angiography nor with the additional intracranial IA-DSA, which required less than 5 minutes to perform in all cases. The value of performing intracranial IA-DSA in patients undergoing coronary angiography to screen for unruptured asymptomatic aneurysm is discussed, as is the possible racial differences in the frequency of aneurysms.     

Size and location of ruptured and unruptured intracranial aneurysms measured by 3-dimensional rotational angiography

OBJECTIVE: The aim of the study was to report about accurate size and location of a consecutive series of ruptured and unruptured aneurysms taking the complex 3-dimensional (3D) anatomy and parent vessel morphology into consideration by using the newly developed 3D rotational angiography (3D-RA). METHODS: One hundred eighteen consecutive patients with 155 saccular intracranial aneurysms were included in the study and received 3D-RA reconstructions for measurement of maximal height and width of the aneurysmal sac. Statistical evaluation compared values for ruptured (n = 83) and unruptured (n = 72) aneurysms. RESULTS: Mean height and width of unruptured aneurysms were 5.7 and 5.7 mm; of ruptured aneurysms, 6.7 and 6.1 mm (not significant, P = .7 for height and P = .9 for width). The majority of ruptured aneurysms, 81.9% and 59%, were smaller than 10 and 7 mm; likewise, 81.9% and 68.1% of unruptured aneurysms were smaller than 10 and 7 mm. The difference in frequency of small (<10/<7 mm) aneurysms between unruptured and ruptured aneurysms was not significant (P = 1.0 and .32, respectively). The majority (69.4%) of small ruptured aneurysms (<7 mm) were located in the anterior circulation. Most ruptured aneurysms were in the size group 4 to 6 mm in height and 2 to 4 mm in width, and a critical threshold size for aneurysm rupture could not be identified. CONCLUSIONS: An automated calibration procedure applied to all images and excellent visualization of aneurysm and parent vessel morphology using 3D-RA allow accurate size measurement of intracranial aneurysms which may be smaller than previously thought. Small aneurysm (<7 mm), also in the anterior circulation, should be carefully evaluated for treatment.     

Study of multiple cerebral aneurysms comprised of both ruptured and unruptured aneurysm--an analysis of incidence rate with respect to site and size

The purpose of this investigation was to study the incidence rate of rupture with respect to the site and size of multiple cerebral aneurysms that include both ruptured and unruptured aneurysms. Site and size were investigated in 58 cases of this type of multiple cerebral aneurysm. All cerebral aneurysms were examined with MR angiography, 3D-CT angiography and digital subtraction angiography, as well as seeing measured using 3D-CT or digital subtraction angiography. As regards the site of the 58 ruptured cerebral aneurysms under study, 18 were internal carotid aneurysms (C2 or C3: 4 cases, IC-PC: 12 cases, IC-ancho.: 1 case, IC terminal: 1 case), 25 were anterior communicating aneurysms, 10 were middle cerebral aneurysms, 4 were anterior cerebral aneurysms and 1 case was a VA-PICA aneurysm. The ruptured internal carotid aneurysms were 4.0-21.0 mm in size, the anterior communicating aneurysms were 1.8-13 mm, the middle cerebral aneurysms were 2.0-21.3 mm, the anterior cerebral aneurysms were 3.2-9.1 mm, and the VA-PICA aneurysm was 4.4 mm. The sites of the 89 unruptured cerebral aneurysms break down as follows: 29 were internal carotid aneurysms (C2 or C3: 4 cases, IC-PC: 10 cases, IC-ancho.: 10 cases, IC terminal: 5 cases), 18 were anterior communicating aneurysms, 34 were middle cerebral aneurysms, and there were 5 cases of posterior circulation aneurysm. In size, the unruptured internal carotid aneurysms were 1.0-18.3 mm, the anterior communicating aneurysms were 1.0-6.5 mm, the middle cerebral aneurysms were 1.0-10.3 mm, the anterior cerebral aneurysms were 1.0-3.3 mm, and the posterior circulation aneurysms were 2.2-17.3 mm. Out of 58 ruptured cerebral aneurysms, 44 were of the largest size category, and 53 (91.4%) were in the largest size category and/or anterior communicating aneurysms. The accumulated incidence rate of rupture of anterior communicating aneurysms rose suddenly upon reaching 2 mm in size, and after reaching 3 mm, these aneurysms accounted for a nearly uniform 55%-60% of the incidence rate of rupture. The accumulated incidence rate of rupture of IC-PC aneurysms rose drastically at 4 mm in size with the data describing a parabolic slope when graphed. IC-PC aneurysms represented a uniform 55% of the incidence rate of rupture after reaching 8 mm in size. The accumulated incidence rate of rupture of middle cerebral aneurysms rose in a gently sloping parabola beginning at 4 mm, and stabilized at 20% upon reaching 10 mm. These results suggest that each site is associated with a characteristic size and rate of aneurismal rupture. Special attention should thus be paid to large and anterior communicating aneurysms when operating on multiple cerebral aneurysms.     

Selective intraoperative angiography in intracranial aneurysm surgery: intraoperative factors associated with aneurysmal remnants and vessel occlusions

BACKGROUND: The objective of this study was to assess the role of selective intraoperative angiography and to analyze the factors associated with faulty clip application. METHODS: Two hundred thirty-eight patients undergoing surgery for intracranial aneurysms were studied consecutively for intraoperative angiography (IOA)-related events. The procedure was performed in 155 operations. Demographic details, clinical grade of the patient, location and size of the aneurysm, intraoperative rupture, application of the temporary clip, IOA findings, and final outcome were analyzed. RESULTS: In the 155 patients in the series, there were 125 anterior circulation aneurysms and 30 on the vertebrobasilar system. Aneurysms were smaller than 10 mm in 63% of the patients, and 19 were giant aneurysms. Thirty-eight percent were unruptured, 36% were Hunt and Hess Grades I and II, 21% were Grade III, and 5% were Grades IV and V. An intraoperative rupture occurred in 18 operations. Intraoperative angiography was normal in 88%; in 11 cases (7%) there was a residual neck, and in 8 (5%), occlusion of the artery was observed. An incomplete clipping was significantly related to intraoperative rupture of the aneurysm (p < 0.008) and anterior location of the aneurysm (p = 0.05), whereas vessel occlusion had a significant association with posterior location of the aneurysm (p < 0.0005). An eventful IOA had significant association with poor outcome (p < 0.003). CONCLUSION: Intraoperative rupture and a posterior location of the aneurysm had a significant correlation with residual aneurysm and vessel occlusion, respectively. The use of IOA is justified in aneurysms associated with these factors.     

前循环动脉瘤的诊治(附56例报告)

目的探讨前循环动脉瘤的诊断方法,治疗时机的选择,术中注意事项及术后处理的相关问题。方法回顾性分析确诊为颅内前循环动脉瘤的56例患者的临床资料,包括检查手段、手术时机、手术方法、术后处理及预后。结果在56例患者61个动脉瘤中,直接手术夹闭57个,行载瘤动脉孤立术2例(均为眼动脉瘤),行动脉瘤包裹术2例(眼动脉瘤1例,前交通动脉瘤1例)。本组治愈40例(71.4%),轻残6例,重残4例,植物生存2例,死亡4例(7.1%)。结论三维DSA使动脉瘤的诊断更加准确;动脉瘤确诊后应尽早手术,翼点入路是治疗前循环动脉瘤行之有效的方法;手术后脑水肿和脑血管痉挛是致残和死亡的主要原因。     

Review of endovascular stent‐assisted embolization for management of intracranial aneurysms

Objective: This was a retrospective review of the results using stent‐assisted coil embolization for management of intracranial aneurysms. Methods: The records of seven patients treated with stent‐assisted Gugliemi detachable coil (GDC) embolization were retrieved from the authors’ prospectively maintained database. The clinical presentation, site and type of aneurysms, treatment procedure and complications, and outcome of these identified cases were reviewed. Results: Between January 2002 and May 2004, seven patients with intracranial aneurysms, four of which were ruptured, were treated by stent‐assisted GDC embolization. Four aneurysms were located at the anterior circulation and three were at the posterior circulation. The indications for stent use were: giant aneurysm (>2.5 cm), dissecting pseudo‐aneurysm, broad‐necked aneurysm and the need for preservation of important parent arteries or branches. Concerning the technical aspect, all except one had successful stent deployment. One stent dislodged after apparent successful deployment. GDC embolization was continued and the aneurysm was partially occluded. More than 90% occlusion of aneurysm sac was achieved in six aneurysms. Intraoperative complications included over‐coagulation, failure in stent deployment, displacement of stent, coil entrapment and thromboembolism. One patient had added focal neurological deficit after the procedure, and one became vegetative due to an unrelated cause. The patient in whom the stent was dislodged suffered another subarachnoid haemorrhage 4 months later and died. Conclusion: Percutaneous intracranial stent is a new and useful device to assist embolization of cerebral aneurysms that were previously not amenable to endovascular therapy. These preliminary results suggest that this procedure could achieve satisfactory outcomes without significant complications.     

Results and Current Trends of Multimodality Treatment for Infectious Intracranial Aneurysms

The authors retrospectively reviewed their cases of infectious intracranial aneurysms and discuss results and trends of current treatment modalities including medical, neurosurgical, and endovascular. Twenty patients (10 males and 10 females; mean age 46 years) with 23 infectious aneurysms were treated by various treatment modalities during a 15-year period. Fifteen cases (75.0%) were caused by infective endocarditis. Eleven aneurysms (47.8%) were ruptured. Two aneurysms (8.7%) presented a mass effect and 7 (30.4%) were unruptured and asymptomatic. The average aneurysm size was 6.5 ± 4.8 mm (range 1–22 mm). The aneurysms were located in proximal cerebral circulation in 7 (30.4%) and distal in 16 (69.6%). Six (26.1%) aneurysms were treated surgically (5: trapping, 1: neck clipping), 10 (43.5%) endovascularly (7: trapping, 2: proximal occlusion, 1: saccular coiling), and the remaining 7 (30.4%) medically. Endovascular treatment was gradually increased with time. Medical and surgical treatments were continuously performed during the study period. Surgery was preferred for the patient with intraparenchymal hematoma or treated by bypass surgery. Three periprocedural minor complications occurred in endovascular treatment. There was one postoperative infarction with permanent deficit developed from surgical treatment. During the follow-up period (mean 28.8 months), none of the aneurysms presented a recurrence or rebleeding. Thirteen patients (65.0%) had favorable clinical outcomes (modified Rankin Scale: 0–2), although four (20.0%) had poor outcomes (modified Rankin Score: 5–6). A multimodal approach for the management of infectious aneurysms achieved satisfactory results. Endovascular intervention is a feasible and efficacious treatment option and surgical intervention is still an indispensable procedure.     

Virtual endoscope-assisted intracranial aneurysm surgery: evaluation of fifty-eight surgical cases.

OBJECTIVE: Better visualization of the intracranial aneurysm may improve surgical outcomes. To this aim, we evaluated the effectiveness of using virtual endoscopy (VE) during intracranial aneurysm surgery. METHODS: Fifty-eight patients with 63 intracranial aneurysms were enrolled in this study. Every patient was examined by digital subtraction angiography (DSA) and a randomly selected twenty-six cases were also examined by computed tomography (CT). CT angiography data were linked via imaging software for reconstruction of VE images. All patients were operated on using standard microsurgical procedures. Among these cases, randomly selected cohorts of twenty-six patients with 28 intracranial aneurysms were operated on also using VE-assisted surgical procedures. The surgical results of both groups were compared to determine the efficacy of the VE-assisted surgical procedure. RESULTS: Aneurysm locations, surgical timing and Hunt-Hess grade distribution were not statistically significant between both groups (p=0.948). However, significantly reduced complication rates and increased post-operative Glasgow outcome scores were observed in the VE group (p<0.05) compared to control. CONCLUSION: Aneurysms and surrounding anatomic structures were well depicted by VE in three dimensions with interactive fly-through views. This method improved our surgical results by improving visualization of the aneurysm and increasing surgical orientation. We report that this method can be very helpful to surgeons during intracranial aneurysm surgery and may reduce post-surgical complications.     

Mid-term results of an endovascular stent-graft by means of median sternotomy for distal aortic arch aneurysm

Migration and perigraft leakage are major problems after endovascular stent graft (EVG) by means of median sternotomy for distal aortic arch aneurysm. Anchoring sutures have been applied to prevent these problems. We evaluate the mid-term results and the efficacy of anchoring sutures. The operation was performed on 19 men and 2 women with a mean age of 70 years (range, 59-81). The aneurysms were 19 true (12 fusiform, 7 saccular), 1 chronic dissection, and 1 penetrating aortic ulcer. EGVs were implanted by way of the aortic arch under retrograde cerebral perfusion in 13 patients and selective cerebral perfusion in 8. Total arch replacement was performed in 2 patients, and aortocoronary bypass grafting in 4. Anchoring sutures to fix the EVG were applied in 9 patients. The average follow-up period was 28 months (range, 2-56). There were no operative mortalities, but 1 paraplegia, 1 stroke, and 2 cases of temporary spinal cord dysfunction occurred. All aneurysms were thrombosed completely after surgery and reduced in diameter (66.9 +/- 17.4 mm to 57.3 +/- 15.7 mm, p < 0.0001). EVG-related complications arose in 4 patients. A chronic Type B dissection revealed impending rupture because of false lumen infection 1 year after operation, and redo surgery was performed. Migration occurred in 3 patients, all with fusiform aneurysms. One of these had a graft kink 1 year later. Another showed aneurysm enlargement with serous pleural effusion 3 years after operation. The third required redo surgery because of perigraft leakage at 3 years after surgery. There were 2 late deaths caused by stroke. There were no EVG-related complications in the 9 cases in which anchoring sutures were applied and in the 7 cases with saccular aneurysms. No spinal cord dysfunction occurred in 8 cases with low-flow antegrade perfusion by way of both axillary arteries while the aorta was opened. Logistic regression analysis showed significant relevance to complications of large aneurysms, greater than 80 mm in diameter. A large aneurysm tends to give rise to complications involving EVG migration. Anchoring sutures of EVG may prevent EVG-related complications.     

Surgery for giant intracranial aneurysms using advanced technology

PURPOSE: Outcome of surgery for giant intracranial aneurysms is still unsatisfactory. The reason for complications is occlusion of perforators or parent arteries by the aneurysmal clipping itself or temporary occlusion of the main arteries. We report the surgical outcome of treatment of giant aneurysms using several advanced techniques which we devised to prevent these complications. MATERIALS AND METHODS: The subjects were eight patients with giant intracranial aneurysms who underwent surgery during the recent five years. Six patients had ruptured and two had unruptured aneurysms. Aneurysms were located at the ICA in five and the MCA in three patients. Aneurysmal sizes ranged from 25 to 50 mm. Preoperative 3DCTA was performed to investigate the aneurysm and the surrounding vessels in all cases. Patients with unruptured aneurysms at the ICA underwent balloon occlusion tests to check the potential for safe temporary occlusion of the parent artery, with SEP monitoring and Xe-SPECT. Intraoperative angiography and neuroendoscopes were used to prevent problems and complications which might be caused by aneurysmal clipping. RESULTS: In seven of eight cases, the aneurysmal neck was completely obliterated with clips and in one case the aneurysm was trapped with STA-MCA anastomosis. Glasgow Outcome Scale of the patients showed good recovery in six, moderately disabled (MD) in one and dead in one. The patient demonstrating MD developed hemiparesis due to vasospasm. One patient died from rebleeding of the aneurysm caused by slippage of the aneurysmal clip despite the confirmation of complete obliteration by intraoperative angiography. CONCLUSIONS: A better surgical outcome of treatment for giant aneurysms was obtained by temporary clips whose placement was based on the results of balloon occlusion test, as well as the use of intraoperative angiography and neuroendoscopes.     

Surgical treatment of unruptured intracranial aneurysms over the past 22 years

The medical records of 312 patients who underwent surgical intervention for unruptured intracranial aneurysm by the same neurosurgeon between April 1979 and December 2000 were analyzed retrospectively to clarify the complexities of this treatment. Patients were divided into Groups I (earlier) to IV (later) according to the date of surgery. Outcome was evaluated as no change after surgery, transient postoperative deterioration (TD), or permanent deterioration (PD). Operative period, background disease, age, aneurysm location and size, postoperative results, and affecting factors were investigated. The overall rate of PD was 5%, including one death (0.3%), and the overall rate of TD was 11%. Cases of middle cerebral artery aneurysm and small aneurysm with diameters less than 10 mm in all locations showed favorable outcomes. There were no significant differences in operative results and period except the lower incidence of TD in Group IV. Surgical outcome was significantly correlated with aneurysm size. Vertebrobasilar artery aneurysm was associated with worse operative results. Most of the causes of PD were related to operative procedures, mainly perforator injury and general complications. Unruptured aneurysm can be treated safely, especially in cases of middle cerebral artery aneurysm and small aneurysm of less than 10 mm diameter in all locations. Larger aneurysms and vertebrobasilar artery aneurysm should be treated by experienced neurosurgeons.     

Guidelines for the surgical treatment of unruptured intracranial aneurysms: the first annual J. Lawrence pool memorial research symposium--controversies in the management of cerebral aneurysms

The management of unruptured cerebral aneurysms remains one of the most controversial topics in neurosurgery. To this end, we discuss the diagnosis and estimated prevalence of these lesions as well as review the literature regarding the rate of rupture for cerebral aneurysms and risks of operative intervention. Our interpretation of the literature concludes that aneurysms are present in approximately 1% of the adult population, varying between less than 1% in young adults to 4% in the elderly. The yearly risk of subarachnoid hemorrhage for an unruptured intracranial aneurysm is approximately 1% for lesions 7 to 10 mm in diameter. Based on these assumptions, we recommend that 1) with rare exceptions, all symptomatic unruptured aneurysms should be treated; 2) small, incidental aneurysms less than 5 mm in diameter should be managed conservatively in virtually all cases; 3) aneurysms larger than 5 mm in patients younger than 60 years of age should be seriously considered for treatment; 4) large, incidental aneurysms larger than 10 mm should be treated in nearly all patients younger than 70 years of age; and 5) microsurgical clipping rather than endovascular coiling should be the first treatment choice in low-risk cases. Critical to our guidelines is collaboration by a highly experienced cerebrovascular team of microneurosurgeons and endovascular neurosurgeons working at a tertiary medical center with a high case volume and using a decision-making paradigm designed to offer only low-risk treatments. In certain patients for whom both treatment and natural history carry high risks, such as those with giant aneurysms, nonoperative management is typically elected.     

The hemodynamics of intracranial aneurysm by transcranial Doppler arteriography]

The use of an ultrasonic transcranial Doppler arteriography (TCDA) technique for noninvasive diagnosis of cerebral aneurysm is described. Twenty one patients with intracranial aneurysm previously diagnosed by conventional angiography were evaluated with Trans-Scan (EME). Mapping image was used as a guide to identify parent artery and aneurysm. In four patients, we could not record aneurysmal blood flow because of their poor or non existent acoustic window. Good images were recorded in 17 patients. The location of aneurysms were A-com (1 case), Distal ACA (2 cases), IC (7 cases), MCA (3 cases), Basilar (1 case) and IC fusiform (3 cases). Two types of Doppler spectra were obtained from the aneurysmal blood flow. One was characterized by a high density zone along the base line and the other was characterized by a homogeneous high density zone. In both types, Doppler sound was characterized by low frequency sound. The low frequency sound reflects the turbulent flow in the aneurysm. The pattern of Doppler spectra obtained from ordinary arteries was characterized by a high density zone along the descending limb of the envelope. Doppler sound is characterized by high frequency sound. A homogeneous spectral pattern was obtained in both aneurysms and ordinary arteries. But it was possible to differentiate them by Doppler sound. Consequently to be able to hear Doppler sound is very important. We were able to detect fourteen of seventeen aneurysms (A-com 1/1, Distal ACA 1/2, IC 7/7, MCA 2/3, Basilar 1/1, and IC fusiform 2/3). The rate of detection was 82 percent. Aneurysm size ranged from 5mm x 4mm to 16mm x 18mm.(ABSTRACT TRUNCATED AT 250 WORDS)