In four difficult aneurysms cases, preoperative views of surgical approach were obtained by three-dimensional and multiplanar reconstruction imaging methods using helical CT scanner. Simulation of various surgical approach views are also possible and an appropriate surgical approach is selected by comparing various surgical views. With this imaging technique, elimination of skull base bone, namely, simulation of bone drilling including the site and extent of bone resection is freely available. The diameter of the orifice of aneurysms and calcified portion of the wall are also visualized. One of the limitations is that small vessels less than 1 mm in diameter are not visualized.
The results, complications, and causes for morbidity of surgical treatment for unruptured intracranial aneurysms were analysed retrospectively in 80 cases. Twenty-three cases (28.8%) developed neurological worsening postoperatively, and in 10 cases (12.5%), these deficits disappeared within 1 month. However, in 13 cases (16.3%), deficits remained permanently. At 3 months after surgery, good outcome was achieved in 73 cases (91.3%), but 6 cases (7.5%) needed some help, and there was one operative death (mortality 1.3%). Age was one of the most important surgical risk factors. The rate of the patients over 65 years old who developed postoperative neurological deficits was statistically higher than that of younger patients (p<0.05). Especially in aged patients over 70 years old, 57.1% of cases developed permanent neurological deficits. Surgical indication for aged patients should be carefully considered. Transient neurological worsening was thought to be due mainly to fragility of the brain. On the other hand, permanent neurological deficits were due mainly to the surgical procedure, such as perforating artery injury, parent artery occlusion, and brain retraction, especially in the cases with large or giant aneurysms. Careful surgical manipulation and consideration of strategy for surgical treatment is essential.
Between September 1992 and December 1994, 166 patients with intracranial aneurysms were admitted to our hospital and underwent microsurgical operations. Of the 166 patients, 8 had the midline vertebral artery aneurysms. Of these 8 cases, 4 were VA-PICA aneurysms, 3 VA-dissecting aneurysms and 1 a VA-BA junction aneurysm. On the A-P view of the vertebral angiograms, the VA-PICA aneurysms were located between 2.5mm and 8mm from the midline. On the lateral view, the aneurysm necks were located 9-14 mm from the internal auditory meatus. We applied the lateral suboccipital transcondylar approach to these midline vertebral aneurysms. Surgical procedures are as follows: (1) the patient is placed in the lateral position with the head kept in the maximal flexion; (2) the following structures are exposed and removed; the ipsilateral suboccipital bone, the condylar fossa, the posterior one-third of the occipital condyle, the dorsolateral rim of the foramen magnum and the ipsilateral posterior arch of the atlas. The jugular tubercle is also removed epidurally if the aneurysm is closer to the internal auditory meatus; (3) after dural incision and gentle minimal upward and medial retraction of the tonsil, the aneurysms are well exposed without retraction of the medulla; (4) utilizing these procedures, direct clipping of the aneurysm is easy. This approach is also successfully utilized for proximal VA clip occlusion with wrapping around the dissecting aneurysm. Postoperative vertebral angiograms revealed that all 8 aneurysms were completely obliterated. There were two complications: one was transient hoarseness; the other was temporary swallowing disturbance. All 8 patients returned to their preoperative occupations without any neurological deficit. This approach took a little longer and more effort was needed to reach the stage of dural opening but, once the dura was opened, the aneurysm was usually seen and reached with minimal retraction of the tonsil. For more midline VA-PICA and vertebrobasilar junction aneurysms, this approach has been very satisfactory and is recommended.
We report on two cases of the stenotic kinking of the internal carotid artery (ICA). One case is a 63-year-old female who experienced a transient ischemic attack of the right hemiparesis. Magnetic resonance imaging (MRI) showed lacunar infarction at the left basal ganglia and angiography showed a stenotic kinking of the left ICA. Since there was a localized atheromatous plaque in the ICA as an operative finding, and considering that it was the cause of kinking, we performed carotid endarterectomy and primary closure. After the operation, the stenotic kinking was improved. Another case is a 65-year-old man who had progressive mild weakness of the right upper extremity. MRI showed a spotty infarction at the parietal lobe and angiography showed a severe stenotic kinking of the left ICA. Although atherosclerotic change was slight, the kinking caused by elongation and the narrowing of the ICA were severe as operative findings. Angioplasty using synthetic patch improved the stenotic kinking. Pathophysiological findings of the kinking of the ICA are various and may cause hemodynamic or thromboembolic events. Meanwhile, there are several surgical methods of treating kinking. The status of the kinking of each case must be considered and the most adequate surgical method selected.
A 61-year-old man was admitted to our hospital, complaining of an enlarging pulsatile hard mass on the left side of the neck. Clinical examination revealed a pulsatile mass in the left laterocervical region and vascular bruit was audible over the mass. Neurological examination was normal apart from bilateral hearing disturbance due to otitis media. CT scan demonstrated a round mass in the left neck, which was homogeneously enhanced by contrast medium. A left carotid angiogram revealed a giant fusiform aneurysm of the extracranial internal carotid artery. Internal trapping of this aneurysm using detachable balloon was performed under EEG monitoring and observation of neurological symptom with successful result. The postoperative course has been uneventful. In this paper, we discuss the advantages of this procedure.
We studied the clinical records of 21 patients from 35 to 80 years old (average 57.8) who were radically operated for subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysms and followed at least 3 months. In all cases, blood clots were removed as widely as possible, and fibrin glue coating therapy was carried out to prevent cerebral vasospasm by protecting the main arteries (C1 portion of the internal carotid artery, M1-M2 portion of the middle cerebral artery, and A1-A2 portion of the anterior cerebral artery) from blood clots. Aneurysm locations were as follows: middle cerebral artery (MCA): 10 cases, anterior communicating artery (Acom A): 6 cases, and internal carotid artery (ICA): 5 cases. All cases were beyond grade 2 in Hunt and Kosnik classification of SAH and belong to group 3 or 4 in Fisher's grading system. As a result, four cases (19%) presented symptomatic chronic hydrocephalus, and needed ventriculo-peritoneal shunt. Three cases had the location in Acom A (3/6, 50%), and one in ICA (1/5, 20%), respectively. All belonged to grade 3 in Hunt and Kosnik classification and represented diffuse symmetrical high density area in all cisterns in computed tomography. Our result did not represent the high frequency of chronic hydrocephalus compared with the former reports. In conclusion, fibrin glue coating therapy did not raise the frequency of chronic hydrocephalus in SAH patients. This seems to suggest that intrathecal injection of fibrin glue can be used for various purposes in the field of clinical neurosurgery.
Middle cerebral artery (MCA) occlusion can be treated successfully with local intraarterial infusion of tissue-type plasminogen activator (t-PA). If the M1 segment of MCA is occluded, the ischemia of lenticulostriate territory occurs. The lenticulostriate arteries are end-arteries, whereas the cortical branches of MCA have leptomeningeal anastomoses. The pathophysiological effect on the lentriculostriate arterial territory after quick reperfusion of the M1 by fibrinolytic therapy is, however, not yet well understood. We investigated changes in neuroradiological findings for the lenticulostriate arterial territory following fibrinolytic therapy for embolic M1 occlusion. The clinical and neuroradiological findings in nine patients treated with intra-arterial infusion of t-PA were reviewed. All patients had had computerized tomographic (CT) scans before and after fibrinolysis. Six (66.7%) had areas of increased attenuation on immediate postperfusion CT scans in the lenticulostriate arterial territory. Three patterns were categorized according to the changes in neuroradiological findings in the lenticulostriate arterial territory following sequential CT scans. In three cases (Group 1), the high density lesions as seen in the immediate postperfusion CT scans disappeared within 24 hours; they subsequently became low density areas. In three cases (Group 2), the high density lesions as seen in the immediate postperfusion CT scans persisted for several days. Only one of them was symptomatic. Three cases (Group 3) had normal findings on immediate postperfusion CT scans; all showed low density areas on the next day. All patients were observed to show hemorrhagic transformation within seven days. In Group 1, the rapid clearance of the high attenuation represented contrast that had entered into the disrupted blood-brain barrier (BBB). In Group 2, hemorrhagic extravasation had occurred in the lenticulostriate arterial territory since the vessel walls were damaged so badly that they no longer could resist the pressure of reperfusion. In Group 3, recirculation caused oligemia due to the no-reflow phenomenon.
We present a series of 100 patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysms of the vertebrobasilar circulation, which were treated at University Hospital of Kumamoto and its 17 affiliated hospitals during a recent 5-year period. Ninety-five patients were admitted to the hospitals within Day 3 (day of SAH=Day 0). Seventy-six patients had surgery; 28 within the first week after SAH (early surgery group) and 48 after Day 8 (late surgery group). Management outcome at 6 months after SAH was significantly correlated with clinical grade (Hunt and Hess) on admission (p<0.0001). The overall mortality rate was 28%. Sixty-one patients were functioning independently (good), and 11 patients patients were significantly disabled (poor). Twenty-one (64%) of 33 elderly patients above 65 years old had unfavorable (poor or dead) outcome. Nineteen (79%) of 24 patients without surgery for aneurysm (no surgery group) had unfavorable outcome. Of 46 patients with basilar aneurysms, 6 patients (50%) in the early surgery group had favorable outcome, compared to 17 patients (85%) in the late surgery group and only 2 patients (14%) in the no surgery group. All three elderly patients and 3 of 4 poor grade (Grade 3 or 4) patients who underwent early sugery for basilar aneurysm had unfavorable outcome. Of 26 patients with vertebral saccular aneurysms at the origin of posterior inferior cerebellar artery, 8 patients (80%) in the early surgery group and 8 patients (67%) in the late surgery group had favorable outcome, whereas all 4 patients in the no surgery group died due to rebleeding or angiospasm. We recommend early surgery for patients with vertebral saccular aneurysm. However, early surgery for patients with basilar aneurysm should be performed only in cases with good preoperative grade (Grade for 2) and non-elderly patients.
To determine the most proper timing of surgery for ruptured aneurysms, the outcome of patients between those who received emergency surgery and those who received early planned surgery was compared. Between 1990 and 1994, 211 patients were admitted to Saiseikai Kumamoto Hospital within three days after the onset of subarachnoid hemorrhage and operated within two days. They were classified into 3 groups. Group 0 (42 patients, 19,9%) are those who underwent emergency surgery on admission, group 1 (114 patients, 54.0%) are those who received surgery on the following day of admission and group 2 (55 patients, 26.1%) are those operated on thereafter. Good outcome ratio (good recovery or moderately disabled in Glasgow Outcome Scale) of group 0, 1 and 2 was 71.4%, 87.7% and 74.5%, respectively. The outcome of group 1 was significantly superior to that of group 0 after stratification of preoperative neurological gradings in each group. On the other hand, five of 183 patients (2.7%) in the planned surgery group had aneurysm rerupture while waiting for surgery and 2 patients died of hemorrhage. The overall outcome was better in group 1 than group 0. This study suggested that emergency surgery on admission for ruptured aneurysm was not necessarily indispensable and planned surgery on the following day achieved better results than emergency surgery. It is also stressed that the timing of surgery should be determined on the basis of manpower or accommodation capacity in each institution.
We report the results of a nationwide survey of brain docks that was conducted in May 1995. As of May 1995, 412 institutions in Japan were equipped with a brain dock system, and doctors in 241 (58.5%) of these institutions belong to the Japanese Society for Detection of Asymptomatic Brain Disease. The highest concentration of institutions equipped with a brain dock system was Tokyo Metropolis, which has 48 institutions (11.7%), and 35.7% of the institutions were located in the Kanto area. Saga was the only prefecture that had no institution with a brain dock system. As for the administrative foundations, hospitals operated by medical corporations comprised the largest percentage at 40.9%, and there were also 7 university hospitals. Regarding the examination protocols of the brain dock program, the execution rate of MRI and MRA were 98.0% and 95.4%, respectively, and intellectual tests were performed in 36.8% of the institutions. The MR equipment used in the brain dock included 1.5 tesla (37.2%), 1.0 T (20.6%), and 0.5 T (38.6%). The detection rate of asymptomatic cerebral infarctions varied greatly from 1.1% to 56% according to the institution, with an average of 18.6%. The detection rate of unruptured cerebral aneurysms was 1-3% in 44.8% of the institutions, 3-5% in 18.8%, and more than 5% in 20.8%. Of the institutions with a brain dock system 77.3% apply neck clipping to the treatment of detected aneurysms. Of all the respondents, 82.7% emphasized the need to increase the number of institutions equipped with brain dock systems.