We performed a follow-up study of the visual field in 10 patients with temporo-occipital subcortical cerebral hematoma. The hematoma location was: temporal (3 patients), occipital (4 patients) and temporo-occipital (3 patients). In 7 patients in whom hematoma was 30mm or larger in diameter, surgical treatment was applied, whereas conservative treatment was performed in the other 3 in whom hematoma was under 30mm in diameter and whose visual field defect was slight. In all of 7 patients who underwent surgical treatment, severe visual field defect was recognized. However, visual field was almost fully recovered except for 3 patients who were left with only quadrant hemianopsia. In conclusion, the prognosis of impaired visual field was unexpectedly good with appropriate treatment. When we discuss surgical indication for a subcortical hematoma, not only mortality but functional prognosis should be considered. We considered that a patient with subcortical hematoma that is larger than 30mm in diameter should be treated surgically even if his/her consciousness is not disturbed and only visual field defect is present.
Among 875 patients with intracranial aneurysm operated on during the past 14 years, the authors encountered eleven who had experienced recurrent hemorrhage caused by the rupture of aneurysms which had not been noticed at the time of the initial operation. The age at the time of initial hemorrhage was relatively young (average 43.7 years), and the interval between initial and recurrent hemorrhage varied between 4 and 16 years. Multiple aneurysms occurred in four cases and hypertension in four others. Clinical grades at the time of the second admission were relatively poor, and in eight patients there were complications with intracerebral hematomas, intraventricular hemorrhages or acute subdural hematoma. Retrospective evaluation of the first angiograms disclosed tiny aneurysms in five cases, and these grew and ruptured at recurrent hemorrhage. In eight patients, the outcome was good; one remained moderately disabled, and two died. We conclude that the possibility of recurrent hemorrhage after the clipping of a ruptured aneurysm should be considered in all aneurysmal patients, especially in those who are young or have multiple aneurysms or hypertension. Their angiograms should be investigated detailly to determine whether or not suspicious tiny aneurysms are present. In addition, late postoperative follow-up angiography to determine the growth or development of another aneurysm might also be needed.
Proximal anterior cerebral artery aneurysms (A1 An) are rare and occupy 0.88-4% of all cerebral aneurysms. They are characterized by both vascular anomalies and high incidences of multiplicity. We had 288 patients, including some with multiple surgeries, resulting in a total of 339 operations in our hospital from November 1991 through November 1996. Of the 339 operations, 6 cases (1.8%) were of the A1 An type. We outline the characteristics of A1 An, the diagnoses and operations. Patients were 60 years old on average. Two cases suffered from subarachnoid hemorrhage and the remaining 4 had unruptured aneurysms. All A1 An were saccular and occurred at the origin of perforators. The sizes of 6 cases were 3.0mm on average. In 5 of 6 cases, the location of the A1 An was within one-third of the length of Al on the proximal side. Vascular anomaly existed in none of our cases, but in 1 case multiple aneurysms existed. All cases were approached via ipsilateral frontotemporosphenoidal craniotomy. To avoid excess compression of the frontal base, we set up the patient's head in the vertex down position, taking care to avoid kinking of perforators of Al at the clipping. The size of ruptured A1 An in our cases were 3.4mm and 3.5mm, which is smaller than the average 8.2mm size of aneurysms in other regions. Therefore, it can be said that one of the characteristics of A1 An is the high risk of the rupture in spite of its small size. When we diagnose A1 An, it is important to understand its characteristics. We should not miss the vascular anomaly and the other anuerysms. It is also important to avoid compression of the frontal base and kinking of perforators of Al at the operation. Finally we suggest that operation of A1 An should be positively considered unless it is of belowaverage size as there is a high risk of rupture in such cases.
We have often experienced cases of recurrence of subarachnoid hemorrhage (SAH) due to the rupture of aneurysms that were not recognized at the previous postoperative angiograms. For this reason, we investigated the natural history of 54 aneurysm patients who had been operated more than 7 years before. Follow-up angiograms revealed aneurysms in 11 patients (20.4%, 14 aneurysms) and all were female. Among 14 aneurysms, 9 were new aneurysms and 5 were recurrent ones. New aneurysms had a tendency to be revealed at a contralateral artery to an original artery. In 5 cases of recurrent aneurysms, 2 had a recurrence of SAH and eventually died.
Although the pterional approach (PA) is the most commonly employed for the intracranial aneurysms in the anterior circulation and of the upper portion of the basilar artery (BA), there are some difficult cases among them in clipping surgery with PA. In the past 8 years, we used skull base approaches to access and treat 41 aneurysms involving the anterior communicating artery complex, middle cerebral artery, proximal internal carotid artery (ICA) or BA. The approaches included orbital osteotomy and orbitozygomatic osteotomy. Removal of the rim and roof of the orbit and additional decompression of the optic nerve and anterior clinoid resection, namely, the orbitocranial approach (OCA) allowed shorter and multi-directional accesses to the highly-located aneurysms with a minimal brain retraction. OCA was very useful for clipping surgeries of a high BA aneurysm and of a ruptured aneurysm in the anterior circulation with a swollen brain in the acute stage. Orbitozygomatic temporopolar approach, which consists of the frontotemporal and orbitozygomatic osteotomy, allowed more upward visual axis through the temporopolar route and multidirectional working space for a high BA tip aneurysm associated with a short intracranial ICA. Skull base surgeries, used selectively, can provide improved access to highly-located aneurysms and large or giant aneurysms, while minimizing brain retraction.
Direct clipping of giant thrombosed basilar artery (BA) aneurysms continues to pose a formidable challenge in spite of the widespread use of skull base surgery technique. Recently, we employed deep hypothermic circulatory arrest for 2 cases of such complex BA aneurysms with the aid of cardiac surgeons and neuroanesthesiologists. Canulation for cardiopulmonary bypass was performed centrally through the atrium in Case 1 (open chest technique) and peripherally through the femoral vein in Case 2 (closed chest technique). In both cases, giant thrombosed BA aneurysms were directly clipped without any new neurological deficits. The open chest method has several advantages such as rapid response to cardiac over-distension and ventricular fibrillation, and reduction of cooling and rewarming times. However, increased blood loss and post-operative pericardial and pleural effusion resulting from central canulation may occur. In this context, the simple closed chest technique is preferable unless the patient has severe aortic valve disease and significant organic dysfunction. Heparin-coated equipment can be utilized to prevent serious hemorrhagic complications due to clotting defect. During circulatory arrest, the blood is not drained from the patient through the cardiopulmonary bypass because of the risk of air embolism and migration of intraluminal thrombus.Low-flow bypass is also preferred as an alternative to complete circulatory arrest for protection of the brain and other organs, and for identification of perforators around the aneurysm. Deep hypothermia with the option of circulatory arrest can be indispensable to the safe management of complex basilar artery aneurysms.
Aneurysms of the dorsal (anterior) wall of the internal carotid artery (IC d-ANs) are rare. Although their clinical features are well described, their mechanism of pathogenesis is unknown. We present 6 cases, including an autopsy case, of IC d-AN and the pathogenesis of IC d-ANs on the basis of clinical records, anatomic findings and history. Most IC d-ANs have fragile walls and necks and can be described as “blister like.” In our series, 3 aneurysms were of the blister type and 3 were of the saccular type. Although the operative findings and clinical course differ a little between blister-type and saccular-type IC d-ANs, we could not conclude that these 2 types of aneurysm have different pathogenesis. Moreover, the possibility still remains that some blister-type aneurysms may grow to saccular aneurysms. Some authors report that the blister-type, or fragile wall, aneurysm may be a type of dissecting aneurysm. Intraoperative and pathologic findings suggest that these aneurysms may be pseudoaneurysms caused by a partial- or full-thickness tear through the wall of the artery,but they cannot be defined as dissecting aneurysms because there is no dissecting lumen. Moreover, if there are findings of dissecting aneurysm intraoperatively we should treat it as dissecting aneurysm. IC d-ANs should be defined more clearly on the basis of findings of the aneurysm and the parent artery because IC d-ANs are classified on the basis of intraoperative features, not pathologic findings.
Some Takayasu's arteritis (TA) patients suffer from occlusion and/or stenosis of major extracranial cerebral arteries. Various carotid reconstructions have been employed for these patients to relieve brain ischemic insult. Although the occlusive lesions could be treated with bypass grafts, indications and guidelines for operative management have not been well established. We present a new reconstructive procedure using internal thoracic artery (ITA, living graft) as the donor for bypass surgery to supplement the cerebral blood flow. The case is a 38-year-old woman who presented with three episodes of syncope attack. The patient was admitted to our hospital and diagnosed as TA. Before the operation, the patient was scheduled to undergo aortocarotid bypass using saphenous veins. However, a dilated ascending aorta with an extremely thin wall made it impossible. Finally, we decided to use the ITA as the donor for bypass surgery. This patient is now free of cerebral ischemic insult 15 months after operation. Although the procedure is still at a preliminary stage, we describe one successful case.
We report a case of subarachnoid hemorrhage associated with systemic lupus erythematosus. The 53-year-old female patient had suffered from Raynaud Syndrome butterfly rash, skin erosion, stomatitis, arthritis, pyrexia, pneumonia, pericarditis and lupus nephritis for 10 years. Antinuclear, DNA, SS-A, CL-β2GP1 and SCL-70 antibodies were positive. Subarachnoid hemorrhage happened just after pulse treatment with steroid hormone and angiography showed dissecting aneurysm of the right vertebral artery. Neck clipping was performed for the saccular portion of this fusiform aneurysm. However, rebleeding occurred two days after operation and trapping of the right vertebral artery was done. The arterial dissection was found to deteriorate and fusiform-like dilatation with intramural hemorrhage was seen on the operation. After operation, the patient suffered from athelectasis, pneumonia, nephrosis, pleural effusion and pulmonary edema due to the hypoalbuminemia and overhydration. The consciousness level recovered well in the chronic stage but she now has a tracheostomy, requires tube feeding and is confined to a wheel chair. Systemic lupus erythematosus is often associated with the fusiform aneurysm of the major cerebral artery as shown in this case. The trapping operation is recommended for this fusiform aneurysm. Furthermore, intensive care is necessary to prevent infection, renal and cardiac failure and bleeding tendency.