The management of ruptured C6 aneurysms remains controversial. Detailed long-term outcome data are still lacking. Thus the present study provided a detailed long term follow-up for a ...multidisciplinary approach combining microsurgical clipping, endovascular embolisation and parent artery occlusion with/without bypass protection.
In our single centre analysis of 64 consecutive patients, indications for microsurgery were: superior aneurysm projection, giant/large or wide necked aneurysms and aneurysms at branching sites. Indications for embolisation were: narrow necks, neck calcification, close aneurysm relation to the clinoid process or adhesion to the distal dural ring, and aneurysm location in the concavity of the carotid siphon curve.
23 patients (35.9%) underwent microsurgery, 38 patients (59.4%) embolisation and three patients (4.7%) parent artery occlusion under bypass protection. Retreatment was required in 20.9% (surgery 8.7%, endovascular 31.6%). Procedure related transient complications occurred in 10.9% (surgery 13.0%, endovascular 10.5%). Procedure related permanent morbidities occurred in 6.3% (surgery 8.7%, endovascular 5.3%), including visual deficits in 4.7% (surgery 4.4%, endovascular 5.3%). One endovascular patient died. Angiographic follow-up (29.2 (SD 31.9) months) revealed total aneurysm occlusion in 94.4% of the surgical and 82.9% of the endovascular patients. Clinical follow-up (58.7 (SD 47.6) months) showed 73.4% of the population reaching Glasgow Outcome Scale 4-5, these data being equivalent to the International Subarachnoid Aneurysm Trial (ISAT) outcomes.
Based on favourable neuroradiological and ophthalmological outcomes, microsurgery is recommended for superiorly projecting aneurysms, especially aneurysms involving the ophthalmic artery, and for giant/large or wide necked aneurysms. Based on stable aneurysm occlusion and excellent clinical outcomes, embolisation can be recommended for inferiorly/medially projecting small, narrow necked aneurysms.
This report describes the management of a fusiform peripheral middle cerebral artery aneurysm by endovascular parent artery occlusion under bypass protection. Localization of the recipient cortical ...artery was accomplished after craniotomy by superselective injection of diluted ICG dye via a microcatheter positioned proximal to the aneurysm. This report demonstrates that superselective ICG angiography can be a beneficial alternative technique to identify the best anastomosis site intraoperatively.
Computerized methods have been introduced for more objective quantification of angiographic occlusion rate and coil density as parameters of successful embolization. This study aimed 1) to evaluate ...this new computerized method for angiographic occlusion rating and coil density calculations by comparison with corresponding histometric parameters from retrieved human aneurysms, and 2) to compare the new computerized method with the present standard of subjective angiographic occlusion rating.
From 14 postmortem-retrieved human aneurysms, angiographic occlusion rate was determined by contrast medium attenuation-gradient distinction on digital subtraction angiographs after Guglielmi detachable coil (GDC) embolization. Angiographic coil density was calculated, approximating aneurysms as ellipsoid and coils as cylindric volumes. On surface-stained histologic ground sections of the respective aneurysms, the occluded aneurysm area and coil area were measured. Then, we calculated and compared the histometric occlusion rates and coil densities with the corresponding angiographic parameters by using the Wilcoxon paired signed-rank test and the Spearman rank correlation.
Computerized angiographic occlusion rates (75%-100%) showed good correlation (r = 0.799; P < .01) with histometric occlusion-rates (61%-100%), resulting in no statistically significant differences (P = .2163). With 5.1% (+/-3.8), the mean difference between computerized angiographic occlusion rates and histometry was substantially lower compared with 10.7% (+/-8.7) mean difference between subjective angiographic estimations and histometry. Calculated angiographic coil density (13%-32%) significantly differed from histometric coil density (8%-35%; P < .05).
For recanalized aneurysms, computerized angiographic occlusion rating showed better correspondence with histometry compared with subjective angiographic occlusion rating. Clinical application of this new tool may lead to more objective cutoff values for re-embolization indications. The value of coil density calculations seems limited by the approximation of the aneurysms as ellipsoid volumes.
Local intra-arterial lysis using recombinant tissue plasminogen activator (rTPA) was performed in a 6 and 2/3-year-old patient with major cardioembolic ischemic stroke 48 hours after intracardiac ...surgery. Selective application of 2.5 mg rTPA (0.11 mg/kg body weight) resulted in recanalization of the occluded cerebral vasculature with good neurologic recovery.
Les anévrismes complexes représentent une catégorie difficile de pathologies cérébro-vasculaires nécessitant des plans de traitement individuels et souvent complexes. Les thérapies standard telles ...que les techniques endovasculaires et le clipping microchirurgical représentent souvent des options insuffisantes en raison des taux de récidive élevés et des risques de complications élevés. Pour les anévrismes complexes de l’ACI (e.a. anévrisme géant) notre centre offre depuis 20 ans une alternative hybride standardisée : un traitement microchirurgical et endovasculaire combiné réalisé par un EC-IC bypass suivi de l’occlusion de l’ ACI. L’objectif de cette étude rétrospective est de présenter les résultats cliniques et radiologiques dans notre centre spécialisé.
Nous avons inclus 43 patients présentant des anévrismes complexes de l’ACI, qui ont subi le traitement microchirurgical et endovasculaire combiné décrit ci-dessus à la clinique universitaire de neurochirurgie de Vienne entre novembre 1997 et décembre 2015. Des données de suivi ont été recueillies lors d’examens cliniques et radiologiques.
Au total, 44 procédures de revascularisation (STA-MCA bypass) ont été réalisées. Le temps de suivi clinique moyen était de 54 mois (±51,6). Une perméabilité totale de 93 % et un taux d’occlusion complète de 89 % ont pu être atteints lors du dernier follow-up (analyse toujours en attente).
La thérapie microchirurgicale et endovasculaire combinée pour anévrismes complexes de l’ACI reste une méthode de traitement fiable, même comparée aux nouvelles techniques (par exemple « Flowdiverter »). Les données démontrent qu’une approche de traitement combiné pour ces pathologies intracrâniennes complexes et potentiellement fatales reste une option efficace et sûre et devrait être réservée aux centres hautement spécialisés.
To evaluate whether the objectives of surgical treatment, i.e., prevention of aneurysmal rebleeding, relief of aneurysmal mass effect, and prevention of embolic complications, are met by endosaccular ...coiling treatment applied to giant and very large wide-necked aneurysms.
Thirty patients with 31 giant or very large aneurysms were considered to show unacceptable risk/benefit ratios for open surgery and were treated using the Guglielmi detachable coil (GDC) method between 1992 and 1998.
With endosaccular GDC treatment, 73.3% of the population experienced excellent to good recoveries (Glasgow Outcome Scale scores of 4 or 5), with a 13.3% procedure-related morbidity rate and a 6.7% procedure-related mortality rate. Two hemorrhaging episodes occurred after GDC treatment (annual bleeding rate, 2.5%; 2 hemorrhaging episodes/79.2 patient-yr). Symptoms related to aneurysmal mass effect were improved for 45.5% of the patients presenting with signs of neural compression. Among 23 patients with 24 aneurysms who were available for angiographic follow-up assessment, complete or nearly complete occlusion was observed for 17 aneurysms (71%; angiographic follow-up period, 24.3 +/- 19.6 mo, mean +/- standard deviation). A single total embolization served as definitive treatment for only 12.5% of the giant aneurysms and 31% of the very large aneurysms.
Endosaccular GDC treatment of giant and very large aneurysms was accomplished with procedure-related morbidity and mortality rates comparable to those for open surgery performed by experts. However, because coil stability was unsatisfactory, we suggest that the GDC method should currently be reserved for individuals who are considered poor candidates for open surgery.
We report our experience with 42 patients with 48 cavernous carotid aneurysms, of whom 32 were treated with endovascular techniques and 10 were managed conservatively.
The 48 aneurysms were divided ...into two subgroups by location: 23 were at the C-3 portion of the carotid artery (small, saccular aneurysms with an epidural, partly intracavernous location) and 25 originated at the C4-5 segment (large or giant often fusiform aneurysms with a true intracavernous location). Morphologic features in both groups correlated well with differences in clinical presentation and also influenced therapy. Sixteen of the 25 C4-5 aneurysms (all large or giant) were treated by balloon occlusion of the parent artery, four (with narrow necks) were treated with Guglielmi detachable coils (GDCs), and five were not treated (asymptomatic or minimally symptomatic). Twelve of 13 C-3 aneurysms were treated with GDCs. Ten C-3 aneurysms were not treated.
Ophthalmoplegia resolved or improved in nine of 12 patients treated with parent artery occlusion. All aneurysms treated by carotid occlusion thrombosed. Twelve of the 17 aneurysms treated with GDCs were 100% filled by the coils, four were 80% to 95% filled, and one was only 40% filled. Seven of the 100% filled aneurysms remained completely occluded, two showed slight coil compaction, and in three, follow-up angiography was not available. Among the incompletely filled aneurysms, two remained unchanged, one showed progressive thrombosis, a fourth revealed coil compaction, and in one, follow-up angiography was not available. One thromboembolic stroke and three transient ischemic attacks occurred perioperatively, for a permanent morbidity of 3.5% and a transient morbidity of 9%. There was no mortality. Mean clinical follow-up was 33 months; mean angiographic follow-up of patients treated with GDCs was 11 months.
Surgically difficult cavernous aneurysms can be obliterated by embolization with excellent clinical results. Detachable coils have become an important endovascular tool, especially for narrow-necked cavernous aneurysms of the C-3 segment, which can be protected against rupture in the subarachnoid space in most cases.
Extreme acceleration and deceleration forces as well as axial loading are exerted at the occipito-cervical junction of drivers involved in high-velocity motor vehicle accidents, especially with ...fastened seatbelts. Injury at this level, usually lethal, can go unrecognized despite modern emergency management of the unconscious patient. A precise neurologic and radiographic workup of damage to this area is often not possible or overlooked in the initial phase of such severe trauma. We describe a patient with multiple injuries who sustained a left vertebral artery occlusion associated with a left-sided lateral mass fracture of C1 and a basilar artery occlusion resulting in a locked-in syndrome after an automobile accident.
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