The initial treatment for ruptured intracranial aneurysm in the acute stage may be unsuccessful or incomplete. The strategy and outcome of additional treatment have become unclear since the introduction of Guglielmi detachable coils. Between January 1996 and July 2005, 730 patients underwent clipping (636 cases) or coiling (94 cases) for ruptured intracranial aneurysms in the acute stage at our institution, and 26 patients (3.6%) required subsequent surgery or other intervention. These 26 patients were classified into 4 groups: initial clipping followed by additional coiling (Group A), clipping followed by clipping or wrapping (Group B), coiling followed by clipping or wrapping (Group C), and coiling followed by coiling (Group D). The outcomes at discharge were evaluated with the GOS. In Group A (8 patients), 4 patients had good outcomes and 4 had poor outcomes, whereas in Group B (3 patients), all had good outcomes. After initial clipping, 11 of 636 patients (1.73%) required additional treatment, 5 of these 11 (45.5%) suffered re-rupture, and 4 (36.4%) had poor outcomes. In Group C (9 patients) and Group D (6 patients), all patients had good recovery. After initial coiling, 15 of 94 patients (16.0%) required additional treatment. None of these 15 (0%) suffered re-rupture, and all (100%) had good outcomes. Present experience with intravascular treatment cannot determine the superiority of any method of additional treatment, so the choice should be decided case-by-case. We emphasize the need for better results at the initial treatment and close neuroimaging follow-up.
Endovascular treatment has become a major treatment modality for cerebral aneurysms. However, some aneurysms are difficult to treat using a single modality. We analyzed combined endovascular and surgical treatments of aneurysms. From May 1997 to December 2005, there were 185 cases (198 aneurysms) of treated endovascular aneurysms, 86 of which were ruptured and 99 of which were unruptured. Supplemental combinations of both treatments were performed in 25 of the ruptured and 26 of unruptured cases. Supplemental treatments were classified into a combination of endovascular and clipping for multiple aneurysms (19 cases), surgical clipping for failed endovascular attempt (12 cases), embolizations for recurrence after clipping (10 cases), surgery for recurrent aneurysms after embolization (5 cases), bypass surgery before parent artery occlusion for giant aneurysm (4 cases), embolization for failed surgical attempt (1 case), and hematoma evacuation after coil embolization (1 case). The patients with multiple aneurysms tended to refuse multiple surgeries and select endovascular treatments. Failed endovascular attempt required emergency surgical clipping to reduce the risk of rebleeding. For recurrent aneurysm after clipping, endovascular treatment was less invasive and safer than surgery. In the ruptured cases, 55 (66.3%) showed mRs 0 to 2. In the unruptured cases, we experienced morbidity associated with procedure by thromboembolism (3 cases) and coil penetration (1 case). A supplemental combination of endovascular and surgical treatments should be considered to realize a positive outcome for cerebral aneurysms while considering the risks and benefits of each treatment.
Most patients with intracavernous large and giant aneurysms show cranial nerve signs, and a variety of surgical treatments have been developed. From the viewpoint of multimodality therapy, a combination of bypass and IC ligation or a combination of intravascular therapy and surgery has been performed. We studied 29 consecutive patients with intracavernous large and giant aneurysms during the past 15 years. All the patients presented with cranial nerve signs. Therapeutic modalities for each patient were selected depending on anatomical features of the aneurysm on radiological examinations and neurological/hemodynamic conditions during balloon test occlusion (BTO). ICAs were occluded surgically or endovascularly in 6 patients without bypass surgery. ICA ligation was simultaneously combined with high-flow bypass in 4 patients or with STA-MCA anastomosis in 14 patients, in which 2 patients developed delayed ischemic neurological symptoms due to emboli from the thrombosed aneurysms. STA-MCA anastomosis followed by internal coil trapping of the aneurysm under antiplatelet and anticoagulant therapy was successfully performed in 2 recent patients. Pre-operative neurological symptoms ameliorated when treatment was initiated within 3 months after the onset of symptoms. Favorable clinical outcomes can be expected for patients with an intracavernous large or giant ICA aneurysm treated surgically or endovascularly based on adequate pre-operative radiological, neurological and hemodynamic evaluations. The treatment algorithm for the management of intracavernous large or giant aneurysms of ICA should be reviewed and revised according to the development of new devices and techniques.
We consider the role of radiosurgery in the management of high-grade arteriovenous malformations (AVMs) based on our experiences and a review of the literature. In general, the larger the AVM volume is, the higher the risk of complication after radiosurgery, while radiosurgery can be applied to slender-shaped AVMs with a volume of less than 10 cc even if the largest diameter is larger than 3 cm. Staged radiosurgery might be one treatment option for otherwise untreatable AVMs larger than 10 cc with repeated hemorrhage or progressing symptoms, although the indication must be judiciously determined, considering the hemodynamic changes that can occur after radiosurgery. In the treatment of AVMs adjacent to the critical white matter fiber tracts, including the corticospinal tract and the optic radiation, the risk of complication can be reduced by integrating tractography based on diffusion-tensor magnetic resonance imaging.
Treatments for cerebral arteriovenous malformations (AVMs) remain controversial due to frequent unfavorable results at long-term follow-up after stereotactic radiodurgery and the improved results of microsurgical resection, especially in high-graded AVMs by the Spetzler-Martin grading. We investigated previously treated AVM cases and discuss the efficacy and safety of microsurgical resection utilizing preoperative embolization and intraoperative monitoring. We evaluated the efficacy of the multimodality treatment based on 137 previously treated AVM cases in Shinshu University Hospital during the last 27 years. Of a total of 137 cases, 82 were treated before the introduction of embolization, while 55 were treated after the introduction of embolization. Of the 82 cases treated before embolization was introduced, 63 (77%) lesions were removed totally and 11 (13%) removed partially, with 8 (10%) untreated. Of the 74 surgically removed cases before embolization was introduced, 12 cases (16%) showed severe intra/post-operative bleeding. Of the 55 cases treated after embolization was introduced, 40 (73%) lesions were removed totally, 3 (5%) were partially removed, 7 (13%) were treated with radiosurgery and 5 (9%) were untreated. In the 43 surgically removed cases after embolizaton was introduced, 1 (2%) case encountered severe intra/post-operative bleeding during surgical removal and 2 (5%) suffered embolization-related complications. The introduction of multimodality treatment for AVM has enabled safer surgical resection and improved the results even in cases of high-graded AVMs using Spetzler-Martin grading.
The population of our local area is about 300,000, and 12 hospitals have emergency rooms, but all neurosurgical cases are transferred to our hospital. Subarachnoid hemorrhage (SAH) cases that do not have a mass lesion do not need immediate surgery. So we carefully regulate the transfer of patients according to their condition and our clinical circumstances and patient care priorities at the time of consultation. We retrospectively evaluated the relationship between the time required for transfer and outcome of SAH in our community. From January 1, 2002, to June 30, 2005, our hospital admitted 97 SAH cases with ruptured cerebral aneurysm. We analyzed the relationships between time required for admission and clinical outcome at 30 days after major SAH in the patients who were operated within 72 hours after the onset of SAH (n=82). We postponed 22 admissions (26.8%) for about 12 hours due to poor Hunt-Kosnik grade (7 cases) or late-night consultation (15 cases). The relationship between Hunt-Kosnik grade and time required for admission was not significant. The relationship between outcome and time required for admission was also not significant. However, the time required for admission tended to be shorter in proportion to the severity of SAH or poor outcome. Misdiagnosis of SAH (21.6%) and the patients' ability to endure the pain prolonged the preadmission periods. Our control of admission does not influence the outcome of SAH. Neurosurgeons need to enlighten citizens about this potentially fatal disease and educate physicians about the importance of sudden onset of severe headache as an indication of SAH and the need for emergency transfer to a neurosurgical treatment facility.
We describe a cavernous malformation of the optic nerve with enlargement of the optic canal. This 17-year-old high school girl presented with sudden onset of the temporal and orbital pain, and blurred vision on the right. She visited an eye clinic and was treated with eye drops and a steroid under the diagnosis of optic neuritis. Three months later, she again experienced the same symptoms and received MRI that revealed a lesion in the right optic nerve. She was referred to us for further evaluation and treatment. On admission, her neurological exam showed deterioration of visual acuity: rt. 0.02 (0.04) lt. 0.06 (1.5), central scotoma of the right visual field by Goldmann perimetry and optic atrophy. A Rhese-Goalwins view of X-ray demonstrated an enlargement of the right optic canal. MRI revealed diffuse swelling of the intracranial portion of the right optic nerve without any enhanced lesion by gadolinium DTPA. Because of deterioration of the right vision and suspicion of a mass lesion, an exploratory craniotomy was performed. The right optic nerve was enlarged with yellowish and brownish discoloration in part, suggesting intra-axial vascular malformation associated with hemorrhage. We performed a neurotomy of the right optic nerve and the mass was removed en bloc. Histological examination of the specimen disclosed cavernous malformation. Only 22 cases of cavernous malformation originating from the optic nerve and chiasm have been reported as far as we have learned from the literature. We review these cases and discuss the clinical characteristics and treatment modality of the cavernous malformation of the optic nerve.
The ruptured blister-like aneurysm originating from the anterior wall of the internal carotid artery (BLA) was known to have several pitfalls in diagnosis and treatment. Because of their unusual size and shape, BLAs are apt to be overlooked in the initial conventional examination. Furthermore, BLAs with fragile walls can rupture easily during microsurgery and cause postoperative fatal rebleeding more frequently than other aneurysms. We retrospectively reviewed 8 patients with BLA seen at our institution during the past 8 years to discuss couterplans for pitfalls in diagnosis and treatment. Seven of 8 patients were women between the age of 28 and 62 years (mean 48.6 years). BLAs were localized in the right side in 6 patients. In 4 patients, multiple angiographies were required to confirm the diagnosis because of lack of awareness of these lesions. We believe the key point to avoid misdiagnosis is to focus on the anterior wall of the internal carotid artery using several 3-dimensional images such as 3D-CTA. We treated all the BLAs with the so-called clipping on wrapping method (CWM). All patients except the first 1, who died of postoperative rebleeding due to incomplete obliteration of the neck, achieved favorable clinical outcomes. We describe the detailed procedure of CWM, which we modified to prevent poor clinical outcomes.
ISAT findings and the improvement of the endovascular devices have led to increased use of endovascular surgery (endosaccular coil embolization) in the treatment of ruptured cerebral aneurysms. Since April 2003, Juntendo University and some affiliated hospitals have adopted an endovascular surgery as the first treatment of choice for ruptured cerebral aneurysms. Furthermore, a few affiliated hospitals adopted endovascular surgery when it was thought to be superior to surgical clipping. As a result, 205 patients (127 females, 78 males) with a mean age of 59.3 years (range 22-91) underwent endovascular surgery for a ruptured cerebral aneurysm within 72 hours from onset between April 2003 and March 2007. We report in this study our experiences of endovascular surgery in the acute stage for subarachnoid hemorrhage due to rupture of a cerebral aneurysm. The frequent locations of the aneurysms were of the anterior communicating artery (36.1%), internal carotid artery (31.2%) and the middle cerebral artery (17.1%). The rate of the aneurysms in the posterior circulation was 12.2%. The mean aneurysmal dimensions were 5.6±2.5 mm for the long axis, 4.0±2.0 mm for the short axis, and 2.9±1.2 mm for the neck width. The aneurysms with 10 mm or larger size comprised 7.8% of all aneurysms. The immediate angiographic results showed complete occlusion at 69.8%, neck remnant at 15.1%, body filling at 12.2% and attempted cases at 2.9%. Clinical outcome excluding attempted cases, according to the Glasgow outcome scale, at discharge or transfer to another hospital shows that the favorable outcome consisted of either good recovery or moderate disability (81.4%), and the unfavorable outcome consisted of either severe disability, persistent vegetative state or death (18.6%). The overall permanent morbidity and mortality rate directly related to the procedure was 1.5%. We had only 1 case of bleeding from the coiled aneurysm leading to death. Symptomatic cerebral vasospasm developed in 17.6% of all patients. Radiological evaluations after 3 months by either cerebral angiography or brain magnetic resonance angiography showed the following anatomical changes of the coiled aneurysms: unchanged, 51.9%; minor recurrence, 25.5%; major recurrence, 16.0% and progressive thrombosis, 6.6%. All aneurysms with major recurrences were retreated endovascularly. Endovascular surgery in the acute stage of ruptured cerebral aneurysms was safe and improved the clinical outcome. The problem of treated aneurysm recurrence, however, still remains to be resolved. Therefore, patients who have undergone endovascular surgery for a ruptured cerebral aneurysm, should be closely followed up with clinical and radiological evaluations.
Forty-eight patients with 52 unruptured aneurysms were treated by 50 keyhole clipping procedures. The 32 middle cerebral artery aneurysms were treated through the pterional keyhole approach using an outer canthal skin incision. The 16 internal carotid artery aneurysms and 4 anterior communicating artery aneurysms were treated through supraorbital keyhole craniotomy via an eyebrow skin incision (Perneczky method). Preoperative three-dimensional computed tomography angiography with the osteotomy technique was used to determine the best location and size for the keyhole in each patient. No scalp hair shaving, drainage placement, or anti-convulsant medication were needed. The mean sizes of the pterional and supraorbital keyholes were 25×23 mm and 29×21 mm, respectively. The outcomes on the modified Rankin Scale were Grade 0 in 46 cases, Grade 1 in 3 cases with frontalis muscle weakness, and Grade 3 in 1 case with lacunar infarction. Most of the patients were discharged on the 2nd or 3rd postoperative day. Keyhole clipping surgery is another treatment option for relatively small unruptured anterior circulation aneurysms and may require only overnight hospitalization.
An opening of the frontal sinus during bifrontal craniotomy is relatively common but may lead to various postoperative complications. The existing surgical repair of the frontal sinus involves total resection of the mucosa, packing of the frontonasal duct, and covering the nasal recess by pericranial flap. We have been using an original surgical technique of frontal sinus repair avoiding mucosal injury, which includes (A) drilling the edge of the frontal sinus without mucosal injury, (B) dissection of the frontal sinus mucosa submucosaly, (C) craniotomy after complete dissection of the mucosa, (D) pushing down the coagulated mucosa to the frontonasal duct, (E) packing by small bone pieces and a collagen sheet with fibrin glue over the nasal recess and (F) covering burr holes with a titanium plate.