Clipping through a keyhole minicraniotomy is a modern option for treating cerebral aneurysms and is less invasive than standard craniotomy. We report the findings of 240 consecutive keyhole clipping surgeries performed in 231 patients aged 34-79 years (mean 63 ± 9 years), resulting in the treatment of 251 unruptured anterior circulating aneurysms. The aneurysms were relatively small (<10 mm). Anterior communicating artery aneurysms (57 cases) and internal carotid artery aneurysms (44 cases) were treated through the supraorbital keyhole (mean size, 29 ± 3 mm) approach (Perneczky method). Middle cerebral artery aneurysms (139 cases) were treated through the pterional keyhole (mean size, 25 ± 2 mm) approach. Each surgery was individualized by using detailed preoperative simulation based on three-dimensional computed tomography angiography. Neck clipping was performed for 244 aneurysms (97%); wrapping was done for 3 aneurysms due to blister or motor-evoked potential abnormality; and neck remnant was identified in 4 aneurysms. Complete stroke occurred in 1 patient and mild dementia in 1 patient. Lacunar infarction developed in 6 patients (2.5%; 2 symptomatic, 4 asymptomatic); however, there were no hemorrhagic complications. Frontalis muscle palsy persisted in 5 patients (2.1%), and chronic subdural hematoma was treated surgically in 13 patients (5.4%). The outcomes at 3 months were score 0 (99.2%), score 1 (0.4%), and score 3 (0.4%) on the modified Rankin scale, and 212 patients (92%) were discharged within 3 days after surgery. The keyhole approach is an effective and minimally invasive treatment option for relatively small unruptured aneurysms.
Standardization of a surgical procedure is important for improving the safety of surgery itself. We have attempted to standardize all of the procedures involved in the anterior temporal approach for the treatment of cerebral aneurysm, taking into account anatomical aspects. We emphasize the importance of standardization because it leads both to increased safety of the procedure and to more efficient training for younger operators.
Introduction: Surgical clipping of a paraclinoid aneurysm can be very difficult because strong adhesion may hinder the dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience of performing retrograde suction decompression during the clipping of paraclinoid internal carotid artery (ICA) aneurysms, and discuss the advantages and pitfalls of the technique. Materials and methods: In this retrospective study, we enrolled 22 consecutive patients, 20 females and 2 males aged 37-78 years (mean, 64 years), including 13 patients with large and 4 patients with giant intracranial aneurysms treated with clipping surgery through suction decompression assistance between March 2004 and August 2013. Direct puncture of the common carotid artery was performed using a 20-gauge needle. The aneurysm was trapped by clamping the common carotid and external carotid arteries followed by temporary clipping of the intracranial ICA distal to the aneurysm neck. Blood was then gently aspirated through a catheter introduced into the cervical ICA, resulting in the collapse of the aneurysm. The aneurysm dome was detached from the perforators and surrounding structures during blood flow interruption, which could be maintained for up to 5 min. This procedure was repeated until the dissection and clipping of the aneurysm were completed. Control angiography was usually performed to confirm complete clipping of the aneurysm and the restoration of blood flow in the intracranial ICA. Results: The admitted patients included 6 patients with a ruptured aneurysm resulting in subarachnoid hemorrhage, 11 with an asymptomatic unruptured aneurysm, and 5 with a symptomatic unruptured aneurysm. The aneurysms were located in the paraclinoid ICA in 14 patients, the posterior communicating artery bifurcation in 6, the ICA bifurcation in 1, and the anterior wall of the ICA in 1. No patient had any complication related to the puncture of the common carotid artery. The surgical outcomes were as follows: good recovery in 12 patients, moderate disability in 4, severe disability in 4, and vegetative state in 1. One patient died of re-rupture of the aneurysm resulting from incomplete dome clipping. Two patients developed cerebral infarction—in 1 patient, this was due to an anterior choroidal artery infarction. Conclusion: Retrograde suction decompression through direct puncture of the common carotid artery is a useful adjunct technique for the clipping of ICA aneurysms.
To reduce the incidence of thromboembolic events during the perioperative period of carotid artery stenting (CAS), filter devices, distal balloons, and proximal guiding balloons have been developed as embolic protection devices. We report the treatment outcomes of 22 patients who underwent 24 CAS procedures with a distal filter and proximal balloon deployed for double protection as a flow arrest system with intermittent antegrade blood flow. Seventeen patients with symptomatic carotid stenosis and 7 patients with asymptomatic carotid stenosis were treated using CAS with the double protection technique. New ischemic lesions were detected on diffusion-weighted magnetic resonance imaging after 7 procedures. One patient experienced a minor stroke and 1 experienced pulmonary infarction postoperatively. Both patients recovered completely within 30 days after the procedures. Our double protection technique appears safe and useful; however, it is complex and expensive to use, and the volume of aspirated blood is high. This technique is suitable for patients with large or soft carotid plaques and clamping intolerance.
Background: Restenosis is an important complication after carotid endarterectomy (CEA), occurring in up to 30% of patients undergoing CEA. Sporadic cases of restenosis have been reported. This study aimed to reveal the natural course of restenosis after CEA and its regression after treatment. Methods: Between January 2004 and August 2013, CEA was performed in 176 patients (190 vessels) at our hospital. Only those patients with a follow-up period of ≥6 months were included in this study. The mean postoperative follow-up period was 39.1 months (range, 6-117 months). A shunt was used in all cases, along with a patch and tacking suture in some cases (5% and 70%, respectively). All patients received antiplatelet drug therapy until the day of surgery. Restenosis was defined as >50% stenosis measured by three-dimensional computed tomography angiography or magnetic resonance angiography according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Duplex ultrasound was used to record peak systolic velocity (PSV) in the surgically treated carotid artery. A PSV of >150 cm/s was considered to indicate a stenosis of >50%, according to the NASCET criteria. Findings: Restenosis developed in 14 out of 190 vessels (8%) and occlusion in 2 (1.1%). Age was the only risk factor significantly associated with restenosis. Restenosis occurred with a significantly higher incidence in younger patients (p = 0.035). Restenosis occurred within 12 months (mean 5.3 months) in all cases. Stenosis progressed 24 months after CEA in some cases, but progression of stenosis >24 months was noted in any case. Of the 14 cases of restenosis, carotid stenting was performed in 4 cases (29%), and medications were prescribed in the remaining 10 cases (71%). In 5 cases (36%), regression was noted after a postoperative period of 30 months. The factors for regression are uncertain; however, the rate of regression increased with time.
Hemorrhagic complication is a major concern in performing endoscopic surgery for cerebral hemorrhage. Here, we summarize the recent improvements and review the procedural details and risks of endoscopic operation. At our institution, there were 12 cases (10.5%) with surgical complications among all cases of endoscopic surgery (N = 111). All complications were categorized into the following three groups: (1) difficulty in achieving robust hemostasis during surgery (n = 3), (2) rebleeding after surgery (n = 8), and (3) cerebral infarction after surgery at the ipsilateral side of the hemisphere (n = 1). After dividing the review period into an early period of 3 years (n = 48) and a late period of 3 years (n = 66), half of the complications were found to be related to problems in hemostasis in the early period, with the following suspected causes: undiscovered dural arteriovenous fistula, oral medication with an anticoagulant before the surgery, and rough handling of the apparatus including the transparent sheath and the metal suction during the operation. Therefore, we incorporated the following improvements in operational procedures preceding the remaining half of the periods: (1) adjusting the intensity of aspiration carefully so as not to injure the blood vessels; (2) avoiding removing a hardened hematoma that often has contact with the ruptured artery unless the hematoma cavity becomes near bloodless; (3) ensuring complete hemostasis before moving deeper into the hematoma cavity; (4) enlarging the tract leading to the hematoma by using a Nelaton catheter before inserting a sheath; (5) stuffing the hematoma cavity with oxidized cellulose just before removing the sheath; (6) mandatory infusion of fresh frozen plasma before surgery in patients taking an anticoagulant; and (7) mandatory application of general anesthesia to stabilize blood pressure and prevent accidental body movements. In the latter period, no more difficulties in hemostasis were encountered during the operation, whereas rebleeding after surgery became the only surgical complication. We compared the statistical importance of risk factors between cases with complication and those without complication, where only vascular anomaly, but not other factors, including anticoagulant medication, cerebral amyloid angiopathy (CAA), or lower platelet counts had a statistically significant role in the development of hemorrhagic complications. In the latter period, a higher incidence of CAA and anticoagulant medication were involved, which also suggests that the above-mentioned improvements might have had a major impact. Endoscopic surgery may become an established method in the treatment of cerebral hemorrhage by virtue of its inherent simplicity, low invasiveness, and effectiveness, for which minimizing surgical complications is important. In this light, we hope this review will prove valuable in the improvement of this surgery.
There have been few reports about the pathologic features of an intracranial aneurysm accompanied by oculomotor nerve palsy (OMNP). We report the histopathologic features of an internal carotid artery posterior communicating artery aneurysm (Pcom An) with OMNP. A 77-year-old female patient with an acute-onset OMNP received aneurysm neck clipping and additional decompression of the oculomotor nerve through aneurysm sac resection. The histopathological findings demonstrated a pseudo-aneurysm with acute thrombus, elastic lamina disruption, elimination of vascular smooth muscle, and adventitial thinning. The choice between clipping and coiling as a treatment modality is still debated in cases of Pcom An accompanied by OMNP. Coil embolization for psuedoaneurysms may not be curative. In addition, surgery has the advantages of immediate decompression of the oculomotor nerve and the acquisition of unusual aneurysm specimens for pathophysiological investigation. Therefore, clipping may be a suitable treatment for OMNP caused by Pcom An.
We present a case of distal posterior inferior cerebellar artery (PICA) dissection with subarachnoid hemorrhage that was difficult to diagnose. A 72-year-old woman with a 2-year history of saccular cerebral aneurysm clipping presented with recurrent subarachnoid hemorrhage. Angiograms after the first and second subarachnoid hemorrhage showed irregular stenosis of the distal PICA that was thought to be arteriosclerotic change because of the same finding on previous angiograms. After the third subarachnoid hemorrhage, angiogram revealed aneurysmal dilatation from the irregular stenosis of the distal PICA. Based on the clinical course and interval change in angiographic findings after each episode, this patient was diagnosed with a distal PICA dissecting aneurysm with a hemorrhagic onset and was successfully treated with endovascular surgery. We present this case with a review of the literature.
In the present report, we describe a case of dissecting aneurysm of the vertebral artery (VA) involving the posterior inferior cerebellar artery (PICA). A 64-year-old woman presented with vomiting and disturbed consciousness. Computed tomography (CT) imaging revealed a subarachnoid hemorrhage with intraventricular hemorrhage. Three-dimensional computed tomography angiography revealed a dissecting aneurysm of the left VA involving the PICA, located at the proximal end of its dissection. The aneurysm was successfully treated by trapping and diagonal proximal occlusion, which enabled the preservation of the PICA.
The incidence of pial arteriovenous fistulas (pAVFs) is low, and most cases are treated by interrupting the shunt via endovascular or direct surgery. In the present report, we describe a very rare case of pAVF and discuss the treatment and pathological findings of such cases in the literature. A 63-year-old woman presented with a sudden headache and vomiting. Computed tomography (CT) indicated the presence of a subarachnoid hemorrhage, but she was treated conservatively. The hematoma size gradually decreased and her neurological findings remained unchanged. Angiography indicated the presence of pAVF. The fistula was fed by small branches of the common trunk between the right anterior inferior cerebellar artery and posterior inferior cerebellar artery, and drained into the varix. Feeder occlusion was performed through Histoacryl infusion under local anesthesia. One day after embolization, the patient underwent right suboccipital craniotomy, and the pAVF was extirpated by electrocoagulation. Postoperative angiography indicated that the fistula had disappeared. She was discharged without any new neurological deficits. Thus, pAVF was treated in a more safe and reliable manner with combined therapy as compared to one-staged therapy.
Brainstem cavernous malformations (BCMs) presenting with hemorrhage are known to have a higher risk of rebleeding than cavernous malformations in other locations. We report two cases of BCMs with recurrent bleeding and gradual neurological deterioration over a short period treated with emergency operations. The first case was a 46-year-old-man presenting with sudden vertigo and intra-fourth-ventricular hemorrhage demonstrated by computed tomography (CT). Over two weeks, the patient's consciousness level declined, and associated CT images showed a gradually increased hemorrhage size. Consequently, emergency operation via a midline suboccipital approach was performed on day 15. Intraoperative findings were consistent with a diagnosis of a rare intra-fourth-ventricular cavernous malformation. The second case was a 45-year-old man presenting with a sudden onset of left motor and sensory disturbances. CT showed pontine hemorrhage. Symptoms of neurological decline and radiologically identified rebleeding were observed, and an emergency operation via the midline suboccipital approach was performed on day 16. Surgical management is typically recommended for BCMs presenting with hemorrhage due to the high risk of rebleeding and morbidity, and emergency operation is sometimes necessary, as in these cases.