We compare outcomes of ruptured aneurysmal subarachnoid hemorrhage mainly treated by surgical clipping between 2000 and 2004 (early term) with outcomes of patients mainly treated by surgical clipping between 2005 and 2007 (late term) with first selection of endovascular coiling to poor-grade, posterior circulation, or elderly patients. Between January 2000 and September 2007, 287 patients were treated and 147 and 140 patients belonged to early and late terms, respectively. Poor grade patients (Hunt and Kosnik Grade IV, V) comprised 24.5% and 34.5% (NS), posterior circulation patients comprised 14.3% and 10.7% (NS), and, elderly patients (over 70 year-old) comprised 23.1% and 35.0% in early and late terms, respectively. The rate of elderly was significantly higher in late term than in early (p＜0.05). Endovascular coiling was performed on 10.9% and 29.8% of patients in early and late terms, respectively, and the rate was significantly higher in late term than in early (p＜0.01). Good outcomes were assessed with modified Rankin Scale of 0－2 at 6 months. Good outcomes were 61.2% and 62.1% in early and late terms, respectively (NS). In poor-grade patients, good outcomes were 13.9% and 27.7% (NS), in posterior circulation, 47.6% and 53.3% (NS), and in elderly, 26.5% and 53.5% in early and late terms, respectively, and the rate of good outcomes in elderly was significantly higher in late term than in early (p＜0.05). Outcomes of ruptured aneurysmal patients were significantly improved in elderly patients, but not in poor grade, nor in posterior circulation, due to first selection of endovascular coiling. Despite the significant increase of elderly patients, total outcomes of ruptured subarachnoid hemorrhage in late term were not inferior to those of early term.
Although endovascular coil embolizations have increased in number, open surgery is still predominant for the treatment of ruptured cerebral aneurysms in Japan, partly because there are not enough follow-up results of endovascular coil embolization to discuss long-term outcomes of the procedure. We retrospectively analyzed radiological and clinical results in patients with ruptured cerebral aneurysms treated with coil embolization. From 1997 to 2006, 100 patients with ruptured intracranial aneurysms were treated with endovascular coil embolization. Clinical records and radiological findings of all these patients were retrospectively checked till the end of 2007. Thirty-one patients were 70 years or over in age, and 39 patients were in WFNS grade IV or V on admission. Although this cohort was older and higher in WFNS grade than in other reports, initial and follow-up results were the same. Mean follow-up periods were 42.1 months. Fifteen patients died during follow-up, and 76 patients showed complete obliterations of the aneurysm by the initial procedure. We experienced 10 major recurrences that needed retreatment, and 1 patient suffered from rebleeding while a retreatment was scheduled. Seven recurrent aneurysms were 10 mm or more in diameter at the initial treatment. The second treatment was successfully performed in 5 patients without complications or recurrences during 38 months of mean follow-up after the second procedure. One patient with a large basilar tip aneurysm suffered from a late regrowth of the aneurysm at 2.5 years after an initial tight packing, for which 4 additional treatments were performed. Endovascular treatment of ruptured cerebral aneurysms with coils seems to have good clinical and radiological results. However, the risk of regrowth, which results in bleeding, may continue until late follow-up periods, particularly in aneurysms more than 10 mm. Retreatment should be considered as soon as possible when major recurrence, which permits additional coils, occurs.
The only way to prevent venous brain injury is to meticulously preserve the veins. In every surgical approach, there are various bridging veins blocking access to the subarachnoid space. It is necessary to understand venous anatomy, such as frontal bridging veins for the interhemispheric approach, sylvian veins for the pterional approach, and temporal bridging veins for the subtemporal approach. High-quality cerebral angiography is necessary for adequate pre-operative evaluation of venous anatomy. With the advent of new-generation CT scanning, 3D-CT angiograms using 64 slice scanners offer an alternative means of preoperative evaluation of the venous system. Indeed, CT venogram might be superior to conventional cerebral angiography in obtaining 3D anatomical information before surgery. Meticulous microsurgical technique is essential to preserve the venous structure during surgery, as are the appropriate use of high magnification and good illumination, moist operative field, careful dissection and minimized retraction. Vein preservation must be a critical part of surgical strategy, and perhaps the most important point in vein preservation is to keep the importance of those veins in mind at all times. To learn several techniques of vein preservation aids in the surgical strategy, and keeps the skills of the surgeon polished.
To reduce surgical invasiveness, the supraorbital keyhole approach was applied to the treatment of cerebral aneurysms in the anterior circulation. Twenty-four aneurysms in 22 patients were treated with the keyhole craniotomy placed in the supraorbital area. Preoperative CT angiography was evaluated to determine the optimal side of the craniotomy and feasibility of the surgery according to the predicted direction of clip insertion. The clipping was accomplished in all cases without major complications. The postoperative mRS grade was 0 in 18 patients (82%), 1 in 2 patients (9%) and 5 in 2 patients (9%). Though careful case selection is an essential prerequisite, clipping of the anterior circulation aneurysm is feasible with the supraorbital keyhole approach with reduced surgical invasiveness.
We report 5 patients (2 females and 3 males) with endovascular coil embolizations for ruptured dissecting aneurysms of the vertebral artery (VA). The age of the patients varies between 44 and 66 (mean 54.8) years. All patients had a Hunt and Kosnik Grade of V at admission. One patient had a dissecting aneurysm of the VA distal to the PICA. One patient had a dissecting aneurysm of the VA without the PICA. Three patients had a dissecting aneurysm of the VA involving the PICA. One patient with a dissecting aneurysm of the VA involving the PICA underwent proximal occlusion, and the other 4 patients underwent internal trapping. All patients underwent endovascular coil embolizations on the day or the next day of the onset. Subsequent rupture occurred in 4 patients before embolization. The Glasgow Outcome Scale at 3 months after the embolization was good recovery in 3 patients. We had no ruptured aneurysm and no coil compaction at 0 to 40 months (mean 26.2 months) after embolization. Our experience showed that the internal trapping for ruptured dissecting aneurysms of the vertebral artery should be performed as soon as possible, even if the patients have a Hunt and Kosnik Grade of V.
The treatment of cerebral AVMs aims to prevent hemorrhage, control seizures and ameliorate neurological deficits. Of these, prevention of hemorrhage is the most important. There is no established treatment strategy for the lesion. The treatment strategy based on Spetzler-Martin grading is that Grades I, II, and III are a therapeutic target but Grades IV and V should be treated conservatively. According to an AHA Scientific Statement, surgical extirpation should be conceded for Spetzler-Martin Grades I and II, and surgical extirpation with preoperative feeder embolization is often effective for Spetzler-Martin Grade III, but single surgical extirpation is not recommended for Spetzler-Martin Grades IV and V. However, it is difficult to decide the treatment based only on Spetzler-Martin grading system, and applied treatments should be individualized even for patients with cerebral AVMs of the same size and location because each patient has a unique clinical condition and medical background. In this paper, we analyze clinical date of patients with cerebral AVMs to estimate annual bleeding rate and re-bleeding rate, morbidity and mortality rates of surgical extirpation, and also discuss decision making of any treatment for patients without a history of hemorrhage.
We describe 2 surgical cases with de novo cerebellar cavernous angioma (CA). The first was a 56-year-old woman who presented with symptoms of increased intracranial pressure and cerebellar signs. Neuro-imaging findings demonstrated a heterogeneous hemorrhagic mass lesion in the right cerebellum, which was totally resected. Retrospectively, no lesions were detected in T2-weighted (WI) magnetic resonance (MR) images obtained 3 years 4 months prior to the operation. The second case was a 40-year-old woman with symptoms of increased intracranial pressure and cerebellar signs. She had undergone surgical treatment for cerebellar hemorrhaging in the vermis due to CA with asymptomatic coexistent venous angioma 7 years prior. Retrospectively, a small de novo lesion was seen in the left cerebellum on T2-WI MR images obtained 3 years before our examination. The lesion grew to a large heterogeneous hemorrhagic mass in the left cerebellum, which was resected surgically. Both cases were compatible with CA histologically, and neither had a family history of CA or radiation therapy. We concluded that the de novo appearance, growth along with bleeding, indicated the etiology in these 2 symptomatic cases of cerebellar CA.
Direct and indirect revascularization surgeries are standard surgical therapeutic options in patients with moyamoya disease. We report on the case of a 35-year-old man with moyamoya disease who suffered from transient and permanent neurological deficits after undergoing a left revascularization surgery. Postoperative computed tomography (CT) revealed new infarctions in the left frontal and occipital lobes. Perfusion CT revealed findings suggestive of transient increase in cerebral blood flow (CBF) in the frontal lobe on the contralateral side of the surgery and a xenon-CT (Xe-CT) obtained on the 26th postoperative day showed improved bilateral CBFs. If patients with moyamoya disease have collateral flows by ipsilateral anterior cerebral artery (ACA) to contralateral ACA and stenosis or occlusion of the ipsilateral A1-A2 junction (ACA steal phenomenon), bilateral CBFs may improve after revascularization surgery.
We report a case of angiographically occult micro arteriovenous malformations (AVMs) presenting a clinical picture as chronic intracerebral hematoma in the case of a 31-year-old woman. She suffered from gradually worsening headache and nausea for a week. Brain magnetic resonance imaging (MRI) performed at the out-patient department (O.P.D.) revealed the presence of a cystic mass lesion (diameter, 6 cm) with niveau at the left caudate head. After the patient was admitted to our hospital, the cystic mass gradually increased in size and her conscious level and right hemiparesis deteriorated. MRI with gadolinium enhancement showed no abnormal enhancement of the lesion, and repeated digital subtraction angiography did not reveal any abnormal vascular structure. After the third surgical intervention, she was discharged from our hospital without any major neurological deficit. Intraoperative findings revealed the cystic mass had a blackish-brown liquid collection similar to cases of chronic subdural hematoma. Histological examination indicated the presence of micro AVM.
It is clearly important to avoid damage to the major arterial trunk during surgery. However, it is also useful to consider how to address problems associated with an unexpected arterial injury. We report a case in which a left proximal A2 occlusion and urgent A3A3 anastomosis were performed for arterial injury during surgery for an unruptured anterior communicating artery aneurysm. When an arterial injury occurs, closing of the arterial defect should first be attempted by stitching or clipping. If this is impossible, it might be necessary to occlude the artery and perform vascular reconstruction. However, there are 2 major problems in a case requiring urgent vascular reconstruction such as A3A3 anastomosis: the difficulty of suturing vessels in a deep and narrow field, and the requirement for further preparation of vascular components to make them adequate for vascular reconstruction. Good judgment and prompt performance of the procedure is required to avoid ischemic complications.
It is sometimes difficult to preserve the proximal patent arteries when surgically treating a complex aneurysm located at the P2P3 segment of the PCA. In such cases, revascularization of the distal posterior cerebral artery (PCA) may prevent the development of postoperative ischemic complications with visual field defects. We report the revascularization of the distal PCA territories of a patient with a partially thrombosed aneurysm located at the P2P3 segment of the PCA, and the postoperative course. A 42-year-old man with a large partially thrombosed aneurysm located at the P2P3 segment of the right PCA presented with left hemiparesis. Due to the aneurysm is localization in the cerebral peduncle, primary clipping or endovascular occlusion was considered to be too hazardous. After the occipital artery (OA) to the PCA were anastomosed with a lateral semiprone position, postoperative cerebral angiography demonstrated perfusion of the right PCA from the right OA via the anastomosis, and the aneurysm was successfully treated with simultaneous occlusion of the aneurysm and parent PCA with coils in one anesthesia. The patient had an uneventful postoperative course through day 4, but on day 5, severe cerebral infarction was revealed on the right occipital lobe. OA-PCA anastomosis is a useful method of treatment choice of complex PCA aneurysm, but perioperative antiplatelet therapy is also important to improve the outcome.