Direct Microsurgical intracranial approach is a standard technic for the treatment of ruptured intracranial aneurysms. Nevertheless aneurysms of the anterior communicating artery present particular difficulties because of their critical location, their various projections, the serious circulatory disturbances that may follow their rupture or vasospasm, the prevalence of local vascular anomalies, and their tendency for fatal recurrent hemorrhage. The authors analyzed 102 cases of anterior communicating artery aneurysms, surgically treated at Yonsei University Hospital in the Department of Neurosurgery from 1971 through August 1981. The operative mortality of the microsurgical pterional approach was 4.8% and the morbidity was 5.9% as compared to a mortality of 16.7% and a morbidity of 44.4% seen before the advent of microsurgery.
Adult ; Aged ; Female ; Human ; Intracranial Aneurysm/diagnosis ; Intracranial Aneurysm/surgery* ; Male ; Microsurgery/methods ; Middle Age ; Postoperative Complications ; Tomography, X-Ray Computed

OBJECTIVETo study the clinical characteristics, surgical principles and treatment options of blood-blister-like cerebral aneurysms in supra-clinoid segment of internal carotid artery.

METHODSTwelve blood-blister-like aneurysms were retrospectively studied including 4 open-surgery cases and 8 endovascular-treated cases from November 2008 to December 2012. Patients comprised 8 female and 4 male patients, whose mean age was 46.6 (range 38-56) years. Eleven patients presented with severe headache as the primary symptom, and 1 patient was found with aneurysm incidentally. Preoperative Hunt-Hess graded 0 in 1 patient, graded I in 5 patients, graded II in 4 patients, and graded III in 2 patients. By DSA examinations, 4 blood-blister-like aneurysms located in anterior wall and 8 in medial-anterior wall of supra-clinoid segment of internal carotid artery. Open surgical treatment included direct clipping, trapping, or wrapping and interventional treatment included stent-assisted coiling or simple stent placement. Intra-operative electroencephalogram and somatosensory evoked potentials monitoring was regularly used. Microvascular Doppler ultrasonography and indocyanine green videoangiography were used to assess blood flow in parent and branch vessels. The patients were followed up at 6 months by CT angiography (CTA) examination in outpatient clinic.

RESULTSFor 4 open surgeries, 2 aneurysms were directly clipped, 1 was trapped and 1 was wrapped. The patient underwent trapping paralyzed postoperatively. For endovascular treatment, 6 patients were coiled assisted with stents and 2 patients were treated with simple stent placement. All the patients were followed with a mean follow-up time of 16 months (range, 6-61 months). At 6 months follow-up, 3 out of 4 surgical treated patients had good outcome and 1 was moderately severe disabled by modified Rankin scale; 1 patient underwent wrapping recurred and was transferred to endovascular treatment. Of the 6 patients treated with stent-assisted coiling, 4 patients were recurrent and coil replacements were performed. Two patients with simple stent placement had no recurrences.

CONCLUSIONSBlood-blister-like aneurysm is a special type of complex cerebral aneurysm. Comprehensive understanding of blood-blister-like aneurysm is the key to successful treatment.Open surgery is difficult procedure with high risk and complications while stent-assisted coiling has a high recurrent rate. To date, neither is the safe and effective treatment option.

Adult ; Carotid Artery, Internal ; pathology ; surgery ; Female ; Humans ; Intracranial Aneurysm ; diagnosis ; surgery ; Male ; Middle Aged ; Retrospective Studies ; Treatment Outcome

We report an exceptional case of a de novo giant fusiform aneurysm of the basilar trunk, which developed shortly after the therapeutic occlusion of the right internal carotid artery for a fusiform carotid aneurysm. It would appear to be appropriate to call this entity a sequential giant fusiform aneurysm. The patient was successfully treated with endovascular occlusion of the giant basilar trunk aneurysm following bypass surgery.
Adult ; Carotid Artery Diseases/therapy ; Carotid Artery, Internal ; Cerebral Angiography ; Female ; Humans ; Intracranial Aneurysm/diagnosis/*surgery ; Magnetic Resonance Imaging

OBJECTIVETo evaluate the effectiveness of cerebral revascularization in the treatment of intractable aneurysms and to discuss the indications, surgical techniques, and the outcome of the revascularization.

METHODSDuring the recent 4-year period, 9 radical artery grafts were performed in patients with intractable or giant internal carotid artery (ICA) aneurysms. The indications for cerebral revascularization included parent vessel occlusion during the treatment of the intractable aneurysms with poor collateral circulation or the young patients. Modified techniques were taken to use the main trunk of superficial temporal artery (STA) as donor, while M3 branches near the bifurcation of the M2 segment of the middle cerebral artery (MCA) were chosen as the recipient arteries. STA-Radial artery (RA)-MCA bypass was followed by parent vessel occlusion via chronic cervical ICA ligation or balloon occlusion.

RESULTSPostoperative angiography demonstrated the patency of the grafts in eight cases. The procedure of the parent vessels occlusion was uneventful in these patients. Follow-up showed the patients were in excellent conditions after successful treatment of aneurysms. Significantly delayed filling of the graft was revealed in one patient, who could not tolerate balloon occlusion test and occlusion of parent artery failed.

CONCLUSIONSExtracranial-to-intracranial bypass followed by parent vessel occlusion is a safe and effective method to treat intractable ICA aneurysms. Radical artery as graft can offer high-flow revascularization with less complications. Combined surgical and endovascular treatment might be the future direction for the treatment of the difficult aneurysms.

Adolescent ; Adult ; Carotid Artery, Internal ; surgery ; Cerebral Arteries ; surgery ; Cerebral Revascularization ; methods ; Female ; Follow-Up Studies ; Humans ; Intracranial Aneurysm ; diagnosis ; surgery ; Ligation ; Male ; Middle Aged

OBJECTIVETo discuss the surgical treatment of the giant aneurysms of middle cerebral artery.

METHODSClinical data, surgical methods and outcomes were analyzed in 17 giant aneurysms of middle cerebral artery treated from January 2001 to March 2008. CT scan, CTA, MRA, DSA and 3D-DSA were performed before operations so that we could comprehend the location, size, and shape of aneurysms and compensatory circulation of collateral branches to design the individualized treatment options. All patients had been surgically treated mostly by modified pterional approach, of which, direct clipping of the aneurysms was accomplished in 4 patients, aneurysms trapping or removal after trapping in 4, aneurysms excision or trapping combined with vessels reconstruction in 7, and aneurysms wrapping in 2 cases.

RESULTSCT and MRI revealed the shape and size of aneurysms clearly, while DSA and 3D-DSA could demonstrate the aneurysm's neck and relationship with the adjacent structure. Postoperative neurological function was evaluated according to Glasgow Outcome Scale when patients were discharged. Twelve patients had excellent neurological outcomes. However 4 patients were moderately disabled and one were severely disabled. No patient was dead postoperatively.

CONCLUSIONSIt is necessary to perform elaborate imaging before operations for individualized surgical planning. The temporary occlusion of the parent artery and elimination of intra-aneurysmal thrombus are helpful to clipping the aneurysmal neck. Vessels reconstruction is a new and effective method of treating the giant aneurysms of middle cerebral artery.

Adolescent ; Adult ; Aged ; Female ; Follow-Up Studies ; Humans ; Intracranial Aneurysm ; diagnosis ; surgery ; Male ; Middle Aged ; Middle Cerebral Artery ; Retrospective Studies ; Treatment Outcome ; Young Adult

Somatosensory evoked potential (SSEP) changes during cerebral aneurysm surgery and their relationship to postoperative neurologic complications have been studied on many occasions. However, it is still a matter of debate whether SSEP monitoring is really helpful in detecting or preventing neurologic complications. We studied 87 patients undergoing aneurysm surgery of the anterior cerebral circulation and SSEPs were monitored in 60 of these patients. All patients were grade 2 by the subarachnoid hemorrhage (SAH) grading system. Median nerve SSEP was monitored for middle cerebral or internal carotid artery aneurysms and posterior tibial nerve SSEP for anterior cerebral artery aneurysms. A decrease in the cortical amplitude of more than 50%, compared with control, was considered significant and interventions were then taken to reverse the SSEP. The pre- and postoperative neurologic deficits of each patient were evaluated immediately before and after surgery. No significant difference was found in the incidence of postoperative neurologic complications in the SSEP monitored (15% [9/60]) and unmonitored patients (22% [6/27]). In the SSEP monitored patients, the amplitudes of SSEPs decreased significantly in 14 patients and 4 of these showed neurologic complications. However, SSEP amplitudes were not significantly changed in 46 patients, and 5 of these showed neurologic complications. Significant changes in the amplitude of SSEP might represent neuronal injury, but the absence of change in the SSEP cannot guarantee patient safety. Our results suggest that SSEP monitoring may be useful for detecting the danger of neuronal injury, but that it does not reduce the incidence of neurologic complications in aneurysm surgery.
Adult ; Evoked Potentials, Somatosensory/physiology* ; Female ; Human ; Intracranial Aneurysm/surgery* ; Male ; Middle Age ; Monitoring, Physiologic* ; Nervous System Diseases/physiopathology ; Nervous System Diseases/etiology* ; Nervous System Diseases/diagnosis* ; Surgical Procedures, Operative/adverse effects*