We analyzed the outcome of surgical treatment for ruptured cerebral aneurysm in 15 aged patients over 80 years old. The neurological grades on admission, according to the Hunt and Kosnik classification, were Grade II in 5 cases, Grade III in 5 cases, Grade IV in 3 cases, and Grade V in 2 cases, and were worse than those of younger patients. Ruptured aneurysm was treated by direct surgery in 8 cases and embolization in 2 cases. The Glasgow outcome scale at discharge was good recovery in 1, moderately disabled in 2, severely disabled in 7, vegetative state in 1, and dead in 4 cases. In cases treated by direct surgery or embolization, unfavorable outcome was caused by primary brain damage, disuse syndrome, and delayed vasospasm. We conclude that radical treatment of ruptured aneurysm in the acute stage and rehabilitation are vitally important in aged patients.
We evaluate the effect of introduction of endovascular treatment with Guglielmi detachable coils (GDC) on the outcome of aged patients (>=70 years old) with subarachnoid hemorrhage (SAH). Between 1990 and 2003, 92 aged patients with SAH underwent angiography as candidates for early aggressive treatment in our hospital. In 1990-96 (Group 1), treatment options were early craniotomy surgery, intensively delayed craniotomy surgery and conservative management (n=38), while GDC embolization at an acute stage was added to those 3 treatment options in 1997-2003 (Group 2, n=54). We compared clinical courses and outcomes assessed by Glasgow Outcome Scale (GOS) at discharge between the 2 groups. The percentage of the patients in whom the aneurysm was occluded at an acute stage (early-treated cases) significantly increased from 47% in Group 1 to 76% in Group 2. In the early-treated cases in Group 2, GDC embolization was chosen as the treatment option in 69% of all cases (Grade I-V) and 78% of poor-graded cases (Grade IV-V). The percentage of favorable outcomes (good recovery and moderately disabled in GOS at discharge) significantly increased from 34% in Group 1 to 63% in Group 2 for all cases, and from 53% to 78% for early-treated cases. None of the poor-graded patients had a favorable outcome in Group 1, while 24% did in Group 2. In the early-treated cases in Group 2, the percentage of favorable outcomes did not differ significantly between the aged (>=70 y) and younger patients (<70 y). The incidence of symptomatic vasospasm significantly decreased from 43% in Group 1 to 13% in Group 2. The outcome of the patients with aneurysms in the internal carotid artery and basilar artery bifurcation improved significantly by the introduction of GDC embolization. The introduction of GDC embolization expanded the indication of early treatment for aged patients with poor grade and, as a consequence, improved the outcome of those patients.
It has been believed that clinical outcomes of the elderly subarachnoid hemorrhage (SAH) patients in poor grades are quite unsatisfactory. Recently, endovascular coil embolization is available for such patients as a less invasive treatment. In this study, we retrospectively analyzed clinical outcome of SAH patients in poor grades who were treated with endovascular coil embolization. Among 54 patients (≧75 years) presenting aneurysmal SAH who underwent early endovascular coil embolization, 24 patients in WFNS Grade IV or V were analyzed. Nineteen patients were in Grade IV, and 5 patients in Grade V. In all the patients, the dome of the aneurysm was successfully embolized with detachable coils. The degree of occlusion of the treated aneurysm was complete occlusion in 21%, neck remnant in 33%, dome filling in 25%, and partial in 21%. The rate of procedural complication was 8.3%. Outcome after 6 months was favorable in 37% of Grade IV and 40% in Grade V, respectively. Endovascular coil embolization was successfully performed in elderly SAH patients in poor neurological grades with a high level of technical success and acceptable clinical outcomes.
To evaluate complications and their prevention in endovascular treatment of dural arteriovenous fistulas (AVFs), we analyze the medical records of 105 patients (47 men 58 women, mean age of 64.2 years) treated with endovascular procedures from 1990 to 2003 in our clinic. Dural AVF was located at the cavernous sinus in 43 patients, transverse-sigmoid sinus in 43, and other regions in 19. There were 201 procedures, including 97 transarterial embolizations (TAE), 84 transvenous embolizations (TVE), 17 surgical TVEs, and 3 sinoplasties. Twelve complications were recorded in 10 patients (3 cavernous sinus, 5 transverse-sigmoid sinus, and 2 craniocervical junction lesions). The complications were divided into 4 categories: wrong strategy (1 case), venous thrombosis (2 cases), procedural error (7 cases), and general condition (1 case; pulmonary embolism). One of the superficial middle cerebral veins was obliterated after coiling of the cavernous sinus in 1 patient, resulting in a mild transient hemiparesis (wrong strategy). The syndrome of paradoxical worsening occurred in 1 patient with cavernous sinus dural AVF after TAE (venous thrombosis of the central retinal vein). One patient with sigmoid sinus dural AVF suffered long-lasting dizziness after TVE. Ipsilateral endolymphatic hydrops were observed and speculated to be a causative factor of the patient's dizziness (venous thrombosis of the inner ear). The procedural error included trigeminal nerve palsy due to excess coil packing (1 case in TVE), ischemic cranial neuropathy (3 cases in TAE), and migration of the embolic materials via the feeding arterial collateral network (3 cases in TAE). Morbidity and mortality were 4.8% and 1.0%, respectively. We discuss causes and preventive measures.
The pterional approach including subfrontal approach and transsylvian approach that Yasargil advocated in 1984 is most well known and popular approach for neurosurgeons. The distal transsylvian approach, which we usually perform for the aneurysm of internal carotid, middle cerebral and basilar bifurcation, is a modified approach of Yasargil's transsylvian approach. The key points of distal transsylvian approach are preserving all veins, and beginning dissection from the most distal area of the sylvian fissure where the frontal, temporal, and parietal lobes face each other. To preserve all vessels including pial capillary vessels, a precise and meticulous sharp dissection technique is required under a highly magnified microscopic operative field. It should be noted that indirect injury of the pia mater or pial vessels can be caused by an inappropriate tension to the brain or direct injury can be caused by cutting of arachnoid trabeculae because of poor visability. We describe several microsurgical technical points for the less invasive distal sylvian approach and considerations about the mechanism of damaging pial vessels and pia mater.
We investigated the usefulness of motor evoked potential (MEP) for detecting the cerebral blood flow insufficiency (BFI) during aneurysm surgery. The study population consisted of 269 patients with intracranial aneurysms who underwent surgery via a standard frontotemporal craniotomy. After the dura mater had been opened, a grid electrode strip with 16 small electrodes was inserted subdurally into the hand motor cortex from the edge of the craniotomy. The hand motor cortex was stimulated by short train stimuli. The MEPs were recorded from the contralateral thenar muscles in all but 3 patients who had severe preoperative motor paresis. We evaluated intraoperative MEP findings, causes of MEP changes and motor outcomes in the 266 patients in whom MEPs could be recorded. Out of 232 patients whose MEP remained unchanged, one developed mild and transient hemiparesis, and the other 231 had no postoperative motor paresis. Thirty-two of the other 34 patients manifested transient MEP changes. The transient MEP changes were thought to be attributable to BFI of the cortical branches in 4 patients, of the perforating artery in 15, and of either the cortical branches or the perforating artery in 13 patients. Of these 32 patients, 24 did not show any postoperative motor paresis; transient motor paresis was recognized in the other 8. In 2 patients, MEP disappeared and did not recover. These patients developed severe hemiparesis, and a postoperative CT scan revealed a new low-density area in the corona radiata, putamen and internal capsule. The findings of this study suggest that the monitoring method introduced here is safe and reliable for detecting intraoperative BFI in both the perforating artery and cortical branches. MEP monitoring is useful in preventing postoperative motor paresis in aneurysm surgery.
We report here 3 cases of major artery injury during surgery for cerebral aneurysms. Case 1 was 63-year-old female with unruptured aneurysms on the right distal anterior cerebral artery (D-ACA) and right middle cerebral artery. Upon release of the temporary clip on the proximal anterior cerebral artery after clipping of the D-ACA aneurysmal neck, the aneurysm was avulsed together with the clip on the aneurysmal neck by the clip applier. The arterial defect was closed with 2 stitches and clipped to maintain the vessel structure. Case 2 was 49-year-old female with ruptured left anterior wall aneurysm of the internal carotid artery (ICA). When a clip was placed at the aneurysm covered with blood clots, the aneurysm ruptured at its base and a large hole appeared in the wall of the artery. The defect in the wall was closed with 3 stitches and reinforced with 2 clips parallel to the ICA axis. Case 3 was 52-year-old male with left paraclinoid unruptured aneurysm. For the purpose of proximal control, the cervical ICA was exposed and prepared for temporary ligation by silicon rubber tape. During the clipping procedure for the aneurysm, the ICA was temporarily ligated many times, resulting in wall dissection at the ligated portion. After the blood flow was stopped, the ICA was incised and the clots in the wall were removed. The dissected intima was cut off and 3 tacking sutures were placed on each side of the proximal and distal ends of the dissection. Injury to a major arterial trunk rarely occurs during surgery for cerebral aneurysms. Even so, microsurgical instruments for stitching in a deep field should be prepared for these sudden events for successful surgery.
We retrospectively assessed endovascular treatment by selective embolization with detachable platinum coils of ruptured intracranial aneurysms in 42 patients over 70 years of age (ranging from 70 to 91 years old). Preoperative Hunt and Hess grading revealed that 7 patients were in Grade I, 13 in Grade II, 9 in Grade III, 8 in Grade IV and 5 in Grade V. The aneurysms were located in the internal carotid artery in 18 patients, in the anterior communicating artery in 8, in the distal anterior cerebral artery in 5, in the middle cerebral artery in 4 and in the posterior circulation in 5. The approach was transfemoral in 39 patients, transbrachial in 1 and transcarotid in 2. The immediate angiographical outcomes were complete occlusion in 21 patients (50%), neck remnant in 8 (19%) and body filling in 13 (31%). No procedure-related morbidity or mortality was observed. The follow-up period by either conventional angiography or magnetic resonance angiography ranged from 3 to 17 months in 17 patients. Rebleeding was not observed during the follow-up period. Clinical outcomes were evaluated using the Glasgow Outcome Scale (GOS). In the 29 patients with Grade I-III, 25 patients (86%) showed good recovery or moderate disability and 4 showed severe disability or vegetative state. In the 13 patients with Grade IV-V, 4 patients (31%) showed good recovery or moderate disability and 9 (69%) showed severely disability or vegetative state or died. Symptomatic cerebral vasospasm occurred in 6 patients (21%) of Grade I-III patients. The main cause of poor outcome in Grade I-III patients was cerebral vasospasm in 2 and pneumonia in 2. Endovascular surgery is a useful therapeutic option for treatment of ruptured intracranial aneurysm in patients over 70 years of age, especially those in Hunt and Hess Grade I-III. However, treatment indication should be carefully determined in poor-grade patients.
Recently, angioplasty/stenting has been reported as a treatment option for intracranial atherosclerotic stenosis. We describe clinical results of angioplasty/stenting for 21 patients with intracranial vertebrobasilar stenosis (21 lesions). The procedure was performed under local anesthesia via the percutaneous transfemoral route. In 13 cases, we performed angioplasty only, while we used stents in 8 of 21 cases. The mean stenosis in 13 cases of angioplasty decreased from 76.2% to 26.4%, while 82.5% of the stenotic rate remarkably reduced to 11.3% in 8 cases of stenting. The 30-day morbidity and 30-day mortality rate were 4.8% and 0%, respectively. There was only 1 hemorrhagic complication (cerebellar hemorrhage) in case of stenting, and no ischemic events during or after the procedures. Restenosis (more than 50%) occurred in 3 of 21 cases (14.3%) during the mean follow-up period of 12 months. Our procedure-related morbidity and mortality rates were possibly not higher than those reported by other authors. In this study, angioplasty/stenting for intracranial vertebrobasilar artery stenosis was an effective treatment, but strict indications may be required because the procedure-related 30-day morbidity rate was still high compared with that of extracranial atherosclerotic stenosis, in addition to unknown natural history of intracranial vertebrobasilar stenosis.
A recent randomized trial showed that carotid artery stenting (CAS) is comparable to carotid endarterectomy (CEA) in high-risk patients with severe carotid-artery stenosis. However, selection criteria between CEA and CAS are not consistent among institutions. We retrospectively compared perioperative results of these 2 revascularization strategies in our hospital. We reviewed records of 78 cases who underwent CEA or CAS with protection devices in Kurashiki Central Hospital. CAS was indicated for patients with surgically high-risk conditions. When soft plaque was suspected by preoperative carotid imaging, CEA was indicated in principle. CEA was performed for 47 vessels (mean age: 69.2±6.0 years, 75% symptomatic) and CAS for 31 vessels (mean age: 70.5±6.6 years, 65% symptomatic). Soft plaque was detected by preoperative imaging in 57% of CEA patients and in 6% of CAS patients (p<0.01). The 30-day morbidity/mortality rate was 2.1% in CEA (n=1) and 9.7% in CAS (n=3) (p=0.30). Asymptomaitc hyperintensities on diffusion-weighted imaging after revascularization were detected in 23% of CEA patients and 45% of CAS patients (p=0.02). Considering the higher risk conditions in the CAS group, perioperative results were comparable between CAS and CEA. At present, revascularization strategies should be selected based on patients' conditions and plaque characterization.
Complete neck closure of aneurysms having thick-walled necks is difficult. To make clipping safer and surer, we have developed a modified fenestration clip, which has a 1-mm wide slit-like fenestration with 5 mm long closing tip of blades. We used this clip in cases having a thick-wall aneurysm. Complete clipping was achieved in all patients without technical complications. Slit-shaped fenestration was useful for controlling the neck and dome and also for securing of the surgical field. Aneurysm formation and tip closure technique are safely and precisely achieved with the modified clip in a thick-wall aneurysm.