The authors report experience using GDC (Guglielmi detachable coil) for the treatment of the cerebral aneurysmal remnant following incomplete surgical clipping. All four patients in whom surgical clipping didn't result in complete obliteration of the aneurysmal sac were anterior circulation aneurysmal remnants. In three patients, aneurysmal remnants were diagnosed by routine follow-up angiography, and one case by recurrent subarachnoid hemorrhage. In all patients, remnants of the aneurysm were completely obliterated by embolization using GDC. There was no neurological morbidity and mortality associated with the treatment. Endovascular treatment of the cerebral aneurysmal remnants may be a effective and safe option for patients in whom surgical clipping does not result in complete obliteration of the aneurysmal sac.
Aneurysm ; Angiography ; Follow-Up Studies ; Humans ; Intracranial Aneurysm* ; Mortality ; Subarachnoid Hemorrhage ; Surgical Instruments

There is increasing evidence that thrombin is directly involved in the pathogenesis of cerebral edema after intracerebral hemorrhage. Some authors emphasize that early removal of hematoma using plasminogen activator can be an effective intervention that interrupts the cascade of events leading to increasing edema formation and white matter injury. Recently, there are many reports of the edema intensification following plasminogen activator-induced lysis of the intracerebral clot. The author reports a case who showed protracted perihematomal edema after hematoma evacuation and fibrinolysis therapy with urokinase. Considering that the benefit obtained from fibrinolysis therapy may be offset by an accentuation of its toxic edematous effect, further investigation into the use of urokinase for hematoma evacuation should be undertaken.
Brain Edema ; Cerebral Hemorrhage ; Edema* ; Fibrinolysis* ; Hematoma ; Plasminogen ; Plasminogen Activators ; Thrombin ; Urokinase-Type Plasminogen Activator*

A 64-year-old female presented with subarachnoid hemorrhage due to rupture of a rare true posterior communicating (P-com) artery aneurysm, which is arising from P-com artery itself. A saccular aneurysm was successfully clipped. An awareness of this rare aneurysm is stressed in order to avoid operative complications.
Aneurysm ; Arteries ; Female ; Humans ; Intracranial Aneurysm* ; Middle Aged ; Rupture ; Subarachnoid Hemorrhage

A 64-year-old female presented with unconscious state after sudden onset headache, nausea and vomiting. Computed tomography showed acute subdural hematoma (SDH) over the left convexity without subarachnoid hemorrhage. 3D-CT angiogram showed a saccular aneurysm at the junction of A2-A3 of the left anterior cerebral artery. Surgery for decompressive craniotomy and aneurysmal neck clipping was performed. In operative field, the left distal anterior cerebral artery was abnormally elongated toward the frontal pole and located not in the pericallosal cistern but on the cortical surface and the rupturing point was located in the adhesive portion of aneurysmal sac and arachnoid membrane near the falx. Pure acute SDH without subarachnoid hemorrhage (SAH) caused by ruptured aneurysm is extremely rare. Rupture of an aneurysm adhered to either the dura or falx and located in the subdural space may cause pure SDH. In our case, abnormally elongated location of artery may be related to this adhesion and rupture of aneurysm to subdural space. Therefore, ruptured intracranial aneurysm should be considered as a cause of non-traumatic SDH. Immediate removal of the SDH and aneurysmal clipping is recommended in such patients, even those in poor neurological condition.
Adhesives ; Aneurysm ; Aneurysm, Ruptured ; Anterior Cerebral Artery* ; Arachnoid ; Arteries ; Craniotomy ; Female ; Headache ; Hematoma, Subdural, Acute* ; Humans ; Intracranial Aneurysm* ; Membranes ; Middle Aged ; Nausea ; Neck ; Rupture* ; Subarachnoid Hemorrhage ; Subdural Space ; Unconsciousness ; Vomiting

OBJECTIVES: When the supraclinoid portion of internal carotid artery (ICA) is shortened, the anterior clinoid process may have to be partially removed to secure adequate exposure and proximal control of the ICA in posterior communicating artery (P-com) aneurysm. The goal of this study is to investigate, with direct measurement, the relationship between the length of the supraclinoid ICA and aneurysm formation in P-com segment. MATERIAL AND METHODS: The author measured intraoperatively the length of the supraclinoid ICA of patients with P-com aneurysm and compared that of patients with anterior communicating artery (A-com) aneurysm and middle cerebral artery (MCA) bifurcation aneurysm (n=7 each). Additionally, the length of M1 portion of the MCA and A1 portion of the anterior cerebral artery was measured with image analyzer on CT angiogram and also compared that in the same patients. RESULTS: The length of the supraclinoid ICA was 11.6+/-.6 mm and it was similar to that reported at autopsy. The length of the supraclinoid ICA in patients with P-com aneurysm was shorter than that of A-com aneurysm (Student T test, p<0.001) and MCA aneurysm (Student T test, p<0.05). CONCLUSION: It is now generally accepted that aneurysm is acquired lesion, resulting from a complicated interplay of anatomical, hemodynamic, and degenerative factors. These preliminary results suggest when the supraclinoid portion of ICA is shortened, more hemodynamic stress may be produced to anatomically proximally located P-com segment at higher flow rates than other locations of anterior circulation, resulting in aneurysm formation of P-com segment.
Aneurysm ; Anterior Cerebral Artery ; Arteries ; Autopsy ; Carotid Artery, Internal* ; Hemodynamics ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery

The objective of aneurysm surgery is to exclude the aneurysm from the circulation while preserving blood flow distal to the lesion. In certain situations, the aneurysm neck cannot be clipped safely or the parent vessel reconstructed, primarily in large or giant size with incorporation of parent vessels or perforating arteries, calcification at the aneurysm base, and fusiform or dissecting aneurysms. In such cases, occlusion of the parent vessel is a treatment of option. In many patients, however, sacrifice of the parent artery has an associated risk of ischemic stroke. Therefore, sacrifice of the parent vessel can be supplimented with distal revascularization to provide the necessary distal blood flow while allowing the aneurysm to be trapped. The indications, options, and surgical approaches are described with review of literatures. Finally the authors' experiences of revascularization in 7 patients with unclippable aneurysms are reported.
Aneurysm ; Aneurysm, Dissecting ; Arteries ; Humans ; Intracranial Aneurysm* ; Neck ; Parents ; Stroke

No abstract available.
Aneurysm*

Surgical treatment of posterior circulation aneurysms are still challenging to the neurosurgeons, requiring highly skilled hands. Patients with intracranial aneurysms operated on from January 1984 to January 2003 have been reviewed retrospectively. During that period 104 patients with 110 posterior circulation aneurysms underwent operation in our institute. Among them 47 patients had 49 aneurysms at the basilar bifurcation. The posterior cerebral artery aneurysms (PCEAA) 11, the superior cerebellar artery aneurysms (SCAA) 18, the anterior inferior cerebellar aneurysms (AICAA) 6, the vertebral artery aneurysms (VAA) 8 and the posterior inferior cerebellar artery aneurysms (PICAA) 18. The surgical approaches for BBAA, SCAA and PCEAA (proximal to P4) were pterional route in 70 aneurysms and subtemporal in 4. Modified pterional approach was suitable for most of such aneurysms. For lower basilar trunk aneurysms (AICAA and VBJA), both far lateral suboccipital craniectomy and petrosal presigmoid approach had been tried and the presigmoid one seemed to be the choice of approach. The author achieved aneurysmal neck clipping in the 82 (73%) aneurysms, wrapping in other 15 and proximal clipping in the other 13. The operative mortality and morbidity were 6% and 17% each, which were comparable to the other series. Concerning surgical complications, transient oculomotor palsies were most frequent (38%), followed by transient hemiparesis, thalamic infarction, status epilepticus and peripheral infarction of the parent-arterial territory.
Aneurysm* ; Arteries ; Hand ; Humans ; Infarction ; Intracranial Aneurysm ; Mortality ; Neck ; Paralysis ; Paresis ; Retrospective Studies ; Status Epilepticus ; Vertebral Artery

Middle cerebral artery (MCA) aneurysms account for approximately one-fifth of aneurysmal subarachnoid hemorrhage. The preferred treatment of these aneuryms is microsurgical clipping because of their peripheral location, large neck-to-fundus ratio, incorporation of major branches into the aneurysmal wall, and high incidence of intracerebral hematoma. MCA aneurysms can be approached surgically using one or two of three basic techniques; medial transsylvian, lateral transsylvian and superior temporal gyrus approach. In this presentation, selection of surgical approaches and the surgical techniques to minimize the neurovascular structures are described. Management outcomes by using these techniques is also presented.
Aneurysm ; Hematoma ; Incidence ; Intracranial Aneurysm* ; Middle Cerebral Artery* ; Subarachnoid Hemorrhage

Patients with anterior cerebral artery aneurysm (ACA) make up one third of all those presenting with subarachnoid hemorrhage. Aneurysms in this location may be subclassified according to their projection in relationship to the proximal ACA, distal ACA, and anterior communicating artery. These lesions exhibit a great variation in morphology, size, projection, and relationship with efferent and afferent vasculature. This focus eliminates unnecessary operative manipulation and prepares the surgeon for any crisis that might arise. With this concept in mind, the author has tried to convey my insights into the operative techniques for successful clipping of ACA aneurysm.
Aneurysm* ; Anterior Cerebral Artery* ; Arteries ; Humans ; Intracranial Aneurysm ; Subarachnoid Hemorrhage