Preoperative evaluation of the venous system for potential interference in the clipping of cerebral aneurysm

BACKGROUND: Variations of the venous system affecting the surgical treatment of cerebral aneurysm were evaluated using three-dimensional computed tomography angiography (3D-CTA) to evaluate the essential aspects of preoperative diagnosis. METHODS: This study included 50 patients who underwent clipping of cerebral aneurysm through the pterional and trans-sylvan approaches. The 3D-CTA and operative findings were compared to assess the characteristics of cases in which the veins restrict brain retraction, hinder operative manipulations or require sacrifice because of the position in the operative field. RESULTS: Superficial sylvian veins that restricted brain retraction were identified in 8 cases. The veins entered the cavernous sinus in a relatively high position just below either the sphenoid ridge (superior lateral type) or the anterior clinoid process (superior medial type), and the veins entering at a more medial position were closer to the spatula and tended to be compressed or directly excluded (superior medial type). The inferior medial type did not tend to become tense and so did not restrict brain retraction. The inferior lateral type hardly affected the operative manipulation. The first segment of the basal vein of Rosenthal, the uncal vein entering the cavernous sinus, or the sphenoparietal sinus were located in the operative field in six cases, and affected the manipulation of dissecting arteries, and exposure and clipping of the aneurysm. CONCLUSIONS: 3D-CTA provides essential information for operative planning to protect the venous system during the pterional and trans-sylvian approaches.     

A case of retroperitoneal venous aneurysm]

A case of retroperitoneal venous aneurysm is reported. A 73-year-old woman was referred to us with the chief complaint of left abdominal mass. A giant abdominal mass was palpable and diagnostic imaging examination including ultrasound tomography, excretory pyelography, computed tomography, magnetic resonance imaging and angiography revealed a giant cystic mass encircled by calcification in the left retroperitoneal space. Operation for this cystic mass was performed under the preoperative diagnosis of a giant left renal cyst. During operation the mass was located between the left kidney and the left adrenal gland. Because it was difficult to separate the mass from the left kidney the mass was removed with the left kidney. The extirpated tumor measured 15.5 x 15.0 x 9.5 cm and contained old blood clots and red-yellow colored fluid. A histological examination revealed that the tumor wall was composed of smooth muscle and elastic fibers. Therefore, pathological diagnosis was retroperitoneal venous aneurysm. Retroperitoneal venous aneurysm is very rare. To our knowledge, this is the 8th case of retroperitoneal venous aneurysm reported in Japan.     

Diagnosis and treatment of nontraumatic dissecting aneurysm in the middle cerebral artery]

Two cases of nontraumatic dissecting aneurysm of the middle cerebral artery (MCA) are reported. A 59-year-old woman presented with subarachnoid hemorrhage, mainly in the right sylvian fissure. On admission, the right carotid angiogram revealed a dissecting aneurysm with a double lumen extending from segment M1 to M2 of the right MCA, and an unruptured saccular aneurysm in the right internal carotid artery. Emergency surgery revealed a discolored protrusion of the arterial wall in the right MCA, which was thought to be the cause of her subarachnoid hemorrhage. The protrusion of the arterial wall was clipped and coated with Bemsheet soaked in Biobond. However, disturbance of consciousness persisted and she died of paralytic ileus two months after the operation. The other patient was a hypertensive 33-year-old woman with right hemiparesis and motor dysphasia. CT scans obtained on the day of admission showed no abnormalities. She was treated conservatively with clinical improvement, but CT scans obtained 3 days after the ictus revealed an infarction deep in the left frontal lobe. A left carotid angiogram was made 4 days after ictus and demonstrated severe stenosis of the proximal segment of the left MCA with poor filling of its superior trunk. Despite improvement of her hemiparesis, CT scans obtained 3 weeks after the ictus showed hemorrhagic infarction in the left frontal lobe. Repeat left carotid angiogram revealed a double lumen in the C1 and M1 portions with improvement of the previous severe stenosis of the M1. The 23 reported cases of DA in the MCA with our cases are reviewed and their neuroradiological and clinical features are discussed.     

Diagnosis of cerebral aneurysm using 3-dimensional digital subtraction angiography]

Recent rapid advancement in the technology of magnetic resonance angiography and 3-dimensional computed tomography angiography has opened the door to a less-invasive diagnostic routine for the treatment of cerebral aneurysms. However, from the viewpoint of decision making concerning which treatment to use; conservative therapy; surgical intervention; or endovascular treatment, much more precise information is necessary. Recent progress of rotation digital subtraction angiography has introduced 3-dimensional digital subtraction angiography. In the past year, 28 cases involving 39 aneurysms have been studied using 3-dimensional angiography. This study was carried out, using a rotating C-arm, which rotates 220 degrees in 5.8 seconds. All raw data gathered was transferred to the workstation for image reconstruction. The purpose of this study was to evaluate the clinical potential of 3-dimensional digital subtraction angiography for the diagnosis of the cerebral aneurysms.     

The cerebral venous system

The authors discuss the gross and microscopic anatomy and the physiology of the cerebral venous system. Cerebral veins under pathological circumstances (hypercapnia, arterial hypertension, and increased intracranial pressure), pharmacological observations, the venous blood-brain barrier, and traumatic involvement are reviewed. Neoplastic involvement and radiological aspects are included. Surgical reconstruction of venous sinuses (including the Donaghy technique), tumor removal, sinus thrombectomy, and extraanatomical bypass of the transverse sinus are discussed.     

Significance of the cerebral venous system in the development of DIND in subarachnoid hemorrhage]

The significance of superficial venous system in the development of delayed ischemic neurological deficit (DIND) was studied retrospectively in 18 patients with ruptured aneurysm of the middle cerebral artery (MCA). Neck clipping of the aneurysms was performed via the pterional approach within 72 hours after onset of subarachnoid hemorrhage. All patients were in grade I or II of the Hunt and Hess Grading, and in group 2 or 3 on Fisher's CT classification. The age ranged from 32 to 71 with 48.1% being the mean age. The aneurysm was located on the left side in 5 patients, and on the right side in 13 patients. Arterial and venous phase were evaluated on the pre-and post operative angiograms in these patients. Arterial narrowing was divided into localized and diffuse types according to the degree, and its distribution in the arterial tree. In the venogram, opacification of the superficial sylvian veins (SSV) was the main thing evaluated. Arterial narrowing was observed in 16 cases (9; localized, 7; diffuse). In some cases, visualization of the SSV was poor or fair, and in others it was normal. DIND, including motor deficit or disturbance of consciousness, developed in 10 cases (transient; 6, permanent; 4). The patients with normal visualization of SSV on the postoperative angiogram had good outcome, even if they had diffuse arterial narrowing. On the other hand, the outcome was only fair or poor in those patients who had poor visualization of the SSV, irrespective of arterial narrowing.(ABSTRACT TRUNCATED AT 250 WORDS)     

Endovascular treatment of P3 segment of posterior cerebral artery aneurysm with stent and coils

Posterior cerebral artery (PCA) aneurysms are rare and usually arise from proximal portion of the artery. The distal location is even less frequent, and aneurysms in this location tend to be larger and dissecting. Although they can be treated by direct surgery, recently endovascular procedures have been preferred in some centers. We report a case of large aneurysm of the posterior cerebral artery in a 45-year-old female presenting with headache. An uneventful endovascular treatment was performed with stent and platinum coils achieving total occlusion of the aneurysm, and the patient had good recovery. The findings are compared to earlier reports and literature regarding the issue is discussed.     

Intracranial hemorrhage associated with injury of the critical diploic venous system in clipping for unruptured cerebral aneurysm: a case report

A case of intracranial hemorrhage associated with injury of a critical diploic venous system in clipping for an unruptured cerebral aneurysm was reported. A 67-year-old female presented with a sense of floating. Magnetic resonance angiography (MRA) showed a C1-2 portion aneurysm of the left internal carotid artery 13 mm in size projecting supero-laterally. Three-dimensional CT angiography (3DCTA) volume rendering revealed a developed left fronto-anterior temporal diploic venous system draining the frontal cortical venous return. Because of the large and wide-necked aneurysm, we planned clipping surgery for the purpose of a complete cure. The operation was performed with left fronto-temporal craniotomy at the expense of the diploic venous system. Using techniques such as bipolar coagulation and suction decompression, neck clipping was accomplished via the distal trans-sylvian approach. After the operation, the patient was noticed to be delirious, and post-operative CT demonstrated intracranial hemorrhage in the left frontal lobe with severe brain edema. Motor aphasia was remarkable, but it was gradually relieved, and she left our hospital with no motor weakness. 3 months after the operation, her aphasia was faintly perceptible but she could live independently. We concluded that the injury of a diploic venous system could cause intracranial hemorrhage with intractable brain edema by critically interrupting the frontal venous return.     

Medullary venous malformation with azygos anterior cerebral artery aneurysm: a case report

A case of medullary venous malformation with azygos anterior cerebral artery aneurysm is reported, which was associated with the leptomenigeal angiomatosis on the cortex of the right frontal lobe. A 62-year-old female was admitted to the Kurume University Hospital on June 21, 1985, because of a convulsive seizure. On admission, neurological and general examinations, except for slightly liver function disorder, was no abnormality. Plain CT scan showed the cortical atrophy and two small high-density areas in the right frontal lobe. Enhanced CT scan showed a high-density area in the genu of the corpus callosum. MRI (magnetic resonance imaging), on T2 weighted image, showed a high signal intensity area in the right paraventricular deep white matter and the right frontal region. A right internal carotid angiogram in the venous phase showed numerous enlarged medullary veins in the deep frontal region, converging into a single large draining vein that empties into the basal vein of Rosenthal. An azygos anterior cerebral artery was visualized on the right and left carotid angiograms. The aneurysm was situated at the distal end of the azygos artery. Twenty eight days after admission, a right frontal cranioplastic craniotomy was performed. During operation, the surface of the right frontal lobe was covered by fine, vascular networks, which was reddish brown. A right frontal lobectomy, including venous malformation and vascular networks, was performed. The aneurysm was clipped via an interhemispheric approach. Histologically, the malformation vessels had spread into the subarachnoid space.(ABSTRACT TRUNCATED AT 250 WORDS)     

Infective endocarditis with cerebral mycotic aneurysm: treatment dilemma

Cerebral mycotic aneurysms are uncommon but severe complications of infective endocarditis. Management of these patients remains controversial. We present a case of a 23-year-old man who had infective endocarditis complicated by an intracranial mycotic aneurysm. Because antimicrobial therapy was not effective in reducing the size of the mycotic aneurysm, a decision was made to perform craniotomy before cardiac surgery. The patient underwent an open heart operation 20 days after aneurysm clipping. His postoperative course was uneventful, and the patient continues to be healthy without neurological complications.     

Endovascular treatment of primitive persistent trigeminal artery aneurysm associated with middle cerebral artery aneurysm

We report the case of a primitive trigeminal artery aneurysm associated with an ipsilateral middle cerebral artery aneurysm. A 64-year-old Caucasian woman suffered from a severe acute headache. A head CT scan displayed subarachnoid hemorrhage and subsequent cerebral angiography showed right, wide-necked persistent trigeminal artery and ipsilateral middle cerebral artery aneurysms. The patient underwent embolization of both aneurysms with Guglielmi detachable coils. The association of a PPTA aneurysm and an ipsilateral MCA aneurysm has not been reported in the English literature.     

Time-related changes in the cerebral blood flow in subarachnoid hemorrhage due to ruptured cerebral aneurysm]

Cerebral blood flow (CBF) was determined by the 123I-IMP SPECT reference sample method in 39 patients with subarachnoid hemorrhage (SAH) due to ruptured cerebral aneurysm. They were examined according to the time lapse after onset, severity, CT findings, and prognosis. These 39 patients were admitted to our medical center within 36 hours after the onset, and SAH and ruptured aneurysm were diagnosed by CT scan and angiography, respectively. Patients with intraventricular hemorrhage, intracerebral hematoma, and other severe complications were excluded. The stage of SAH was divided into three, by designating the day of onset as day 0: day 0-4 as the acute stage, day 5-20 as the subacute stage, and day 21 and after that as the chronic stage. Acute stage surgery was conducted within 48 hours after the onset on principle. Hyperdynamic therapy and cisternal drainage were conducted in severe case of SAH. The prognosis was evaluated with Glasgow outcome scale (GOS). The average CBF was 33.39, 29.44, and 33.15 in the acute, subacute, and chronic stages, respectively. These are values lower than the reference sample value, 43.39 (ml/100 g/min). Only a small number of cases, however, revealed vasospasm by angiography conducted in the acute stage. There was a correlation between the CT severity in the acute stage and the decrease in CBF. In the group with low density area (LDA) on CT due to delayed cerebral ischemia in the subacute stage, the average CBF was 28.28 and 23.95 in the acute and subacute stages, respectively. These values were significantly lower than 35.97 and 32.45, respectively, in the group without LDA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical treatment of aged patients with ruptured cerebral aneurysm; evaluation of the operations performed without using retractors]

Sixteen patients over 70 years of age with ruptured cerebral aneurysms in the anterior circulation were surgically treated via the pterional approach. Self-retaining brain retractors (SRBRs) were used in seven patients (Group A), but not in nine other patients (Group B). On admission there were no significant differences between the groups in terms of the neurological grading of Hunt & Kosnik or the CT grading of Fisher. The timing of the operation was decided on the basis of the neurological grading of Hunt & Kosnik and the systemic complications present in each case. Early operation (within 2 days) was performed in 10 cases (5 cases in each group), whereas delayed operation (after 15 days) was carried out in 6 cases (Group A: 2 cases; Group B: 4 cases). Symptomatic vasospasm occurred in 43% of Group A and in 33% of Group B. Postoperative CT scans showed new or aggravated brain edema in the fronto-temporal region (the site of craniotomy) in 3 Group A cases, but not in any Group B cases. By means of technetium-99m-labeled hexamethyl-propyleneamine oxime single photon emission computed tomography (SPECT) the regional cerebral blood flow (CBF) in the fronto-temporal region of the operated side was studied in 6 patients (3 cases in each group) one day after and three months after the operation. One day after the operation, the regional CBF in the fronto-temporal region had decreased in the three Group A cases, but no changes were observed in the three Group B cases. Three months after the operation the regional CBF impairment had improved in 2 of the Group A cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

颅内动脉瘤的血管内栓塞治疗

目的探讨应用电解可脱性弹簧圈(GDC)栓塞治疗颅内动脉瘤的临床效果。方法2002年6月-2004年6月我们采用GDC栓塞颅内动脉瘤126例(其中4例有2个动脉瘤,共130个)。前交通动脉瘤42个,后交通动脉瘤53个,颈内动脉瘤6个,大脑中动脉瘤10个,大脑后动脉瘤8个,大脑前动脉瘤6个,小脑后下动脉瘤2个;基底动脉瘤3个。按Hunt-Hess分级:Ⅰ级38例,Ⅱ级54例,Ⅲ级23例,Ⅳ级11例。必要时辅以篮筐技术、重塑技术、支架技术、双微导管或连环技术、蚕食技术。结果成功栓塞126例动脉瘤,其中103例为100%栓塞,21例为95%,2例为90%。12例在栓塞后6~18个月进行造影随访,所栓塞动脉瘤均未见复发征象。结论GDC栓塞颅内动脉瘤是安全、有效和微创的治疗手段。联合运用多种栓塞技术有助于减少术后并发症,提高治愈率。     

An infant case of spinal arteriovenous malformation with a large venous aneurysm]

An 18-month-old boy was admitted to our hospital with sudden onset of paraplegia, analgesia of the lower limbs, dysuria and constipation. His gestational and birth histories were unremarkable. Past history revealed he had lymphangioma in his left inguinal region, and had been treated in another hospital. Neurological examination revealed flaccid paraplegia, analgesia below Th12 dermatome and dysuria. MRI revealed an intramedullary high intensity lesion surrounded by round low intensity areas located from TH11 to L2 vertebral levels, suggesting the existence of vascular tumor or spinal AVM. Spinal angiogram revealed arteriovenous fistula with large intramedullary aneurysmal vascular dilatation from T12 to L2 vertebral level. The feeder was the Adamkiewicz artery which branched from the left Th12 intercostal artery. First, artificial embolization with thrombin gelfoam was performed successfully. However, follow-up MRI showed an image of flow void in the aneurysm again, indicating recanalization of the AVF. Therefore, an operation was undertaken on October 24th, 1988. The patient was placed in prone position and osteoplastic laminotomy from Th10-L2 was performed. The thrombus and wall of the aneurysm were mostly removed through the lumbosacral midline myelotomy for decompression. Then, the feeder and drainers were ligated. Postoperative course was uneventful. 2.5 years after the operation, he still had flaccid paralysis at the ankle joints bilaterally, analgesia below L4 dermatome, neurogenic bladder and constipation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of cerebral metabolism]

The brain requires high amounts of energy for cellular homeostasis and neurological functions. This energy is mainly supplied by the oxidation of glucose, although other substrates may be used in critical situations. The capacity of the brain to conserve energy is illustrated by flow metabolism coupling, and by the separation between functional and basal activity. The evaluation of cerebral metabolism is defined as the assessment of energy substrates availability and utilization. This evaluation may be performed in physiological or pathological conditions, at a regional or at the global level, at rest or during activation processes. The main techniques discussed in this review include monitoring of venous blood in the jugular bulb, cerebral microdialysis, near infrared spectroscopy, cerebral oximetry using microprobe electrodes, positron emission tomography, magnetic resonance and the magnetoencephalography.     

Ruptured cerebral aneurysm in childhood--report of two cases]

We report two pediatric patients with rupture of cerebral aneurysm developing subarachnoid hemorrhage. These two patients complained of headache and vomiting. Patient 1 was a 15-year-old girl. Cranial computed tomography (CT) showed a high density area in the left sylvian fissure, suggesting subarachnoid hemorrhage. Left carotid arteriography revealed an aneurysm at the left internal carotid artery bifurcation. Surgical pathology showed a saccular type aneurysm with disappearance of internal elastic membrane. Patient 2 was a 14-year-old girl. Cranial CT exhibited a high density area in the basal cistern and hematoma in the right frontal lobe, penetrating to the right lateral ventricle. Right carotid arteriography showed a right anterior cerebral aneurysm in the right anterior cerebral artery. Both patients underwent craniotomy and trapping successfully, and their subsequent clinical courses were uneventful.