Electrophysiological influence of temporal occlusion of the parent artery during aneurysm surgery

Object The object of this study was to investigate patients with cerebral infarction in the area of the perforating arteries after aneurysm surgery. Methods The authors studied the incidence of cerebral infarction in 1043 patients using computed tomography or magnetic resonance imaging and the affected perforating arteries, clinical symptoms, prognosis, and operative maneuvers resulting in blood flow disturbance. Results Among 46 patients (4.4%) with infarction, the affected perforating arteries were the anterior choroidal artery (AChA) in nine patients, lenticulostriate artery (LSA) in nine patients, hypothalamic artery in two patients, posterior thalamoperforating artery in five patients, perforating artery of the vertebral artery (VA) in three patients, anterior thalamoperforating artery in nine patients, and recurrent artery of Heubner in nine patients. Sequelae persisted in 21 (45.7%) of the 46 patients; 13 (28.3%) had transient symptoms and 12 (26.1%) were asymptomatic. Sequelae developed in all patients with infarctions in perforating arteries in the area of the AChA, hypothalamic artery, or perforating artery of the VA; in four of five patients with posterior thalamoperforating artery involvement; and in two of nine with LSA involvement. The symptoms of anterior thalamoperforating artery infarction or recurrent artery of Heubner infarction were mild and/or transient. The operative maneuvers leading to blood flow disturbance in perforating arteries were aneurysmal neck clipping in 21 patients, temporary occlusion of the parent artery in nine patients, direct injury in seven patients, retraction in five patients, and trapping of the parent artery in four patients. Conclusions The patency of the perforating artery cannot be determined by intraoperative microscopic inspection. Intraoperative motor evoked potential monitoring contributed to the detection of blood flow disturbance in the territory of the AChA and LSA.

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Lateral transorbital approach: an alternative microsurgical route for supratentorial cerebral aneurysms

Journal of Neurosurgery ◽

10.3171/2019.9.jns191683 ◽

2021 ◽

Vol 134 (1) ◽

pp. 72-83 ◽

Cited By ~ 1

Author(s):

Murat Ulutas ◽

Kadir Çinar ◽

Ihsan Dogan ◽

Mehmet Secer ◽

Semra Isik ◽

...

Keyword(s):

Anterior Communicating Artery ◽

Parent Artery ◽

Target Area ◽

Aneurysm Surgery ◽

Operative Field ◽

Anterior Circulation ◽

Anterior Clinoid Process ◽

Broad Perspective ◽

Lateral Orbitotomy ◽

Orbital Wall

OBJECTIVETransorbital approaches for neurosurgery have recently attracted attention and several anatomical studies have aimed to improve these techniques, but significant deficiencies in clinical practice remain, especially for aneurysm surgery. The authors present an alternative microsurgical route and the results of an analysis of patients with intracranial aneurysms who underwent a lateral transorbital approach (LTOA) using lateral orbito-zygoma-sphenotomy (LOZYGS).METHODSThe clinical and surgical results of a series of 54 consecutive patients with 1 or more aneurysms who underwent surgery via LTOA are reported. A lateral orbitotomy was performed after making a 3-cm skin incision parallel to the lateral orbital rim. A second bone flap, which included the zygoma and sphenoid bones that form the lateral orbital wall, was removed. The lesser sphenoid wing, including the anterior clinoid process, was fully drilled, except in cases of middle cerebral artery (MCA) aneurysms. Cisternal dissection was performed using the classic microsurgical technique starting from the proximal Sylvian fissure and carotid cistern. After the aneurysm was clipped following microsurgical principles, the dura mater was closed in a watertight fashion and 2-piece bone reconstruction was achieved.RESULTSSixty aneurysms in 54 patients were clipped using the LOZYGS route. Twenty-one aneurysms were located on the MCA, 30 on the anterior communicating artery, 8 on the internal carotid artery, and 1 at the apex of the basilar artery. The unruptured-to-ruptured aneurysm ratio was 17:43. The operative field was moved to the orbit using the LTOA to avoid interference by bone and muscle tissues. Early proximal control was achieved using a short working distance and direct exposure of the base of the cerebrum, without any requirement for retraction. Because different view angles and surgical corridors were used, no segment of the aneurysm or the parent artery remained unexposed. Therefore, the introduction of additional tools was not required.CONCLUSIONSThe LTOA allowed enhanced broad-perspective exposure of the operative field, early proximal control, and satisfactory surgical freedom. This alternative surgical approach safely exposed the target area and the operative field. The LOZYGS route is safe and effective for the LTOA and microsurgical clipping of anterior circulation aneurysms. According to the authors’ surgical experience and clinical experience, the LTOA can be considered an alternative surgical route to supratentorial aneurysm surgery.

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Advances in Open Microsurgery for Cerebral Aneurysms

Neurosurgery ◽

10.1227/neu.0000000000000193 ◽

2014 ◽

Vol 74 (suppl_1) ◽

pp. S7-S16 ◽

Cited By ~ 56

Author(s):

Jason M. Davies ◽

Michael T. Lawton

Keyword(s):

Minimally Invasive ◽

Endovascular Therapy ◽

Posterior Inferior Cerebellar Artery ◽

Cerebral Aneurysms ◽

Artery Occlusion ◽

Parent Artery ◽

Aneurysm Surgery ◽

Parent Artery Occlusion ◽

Volume Outcome ◽

Clip Occlusion

Abstract BACKGROUND: Endovascular techniques introduced strong extrinsic forces that provoked reactive changes in aneurysm surgery. Microsurgery has become less invasive, more appealing to patients, lower risk, and efficacious for complex aneurysms, particularly those unfavorable for or failing endovascular therapy. OBJECTIVE: To review specific advances in open microsurgery for aneurysms. METHODS: A university-based, single-surgeon practice was examined for the use of minimally invasive craniotomies, surgical management of recurrence after coiling, the use of intracranial-intracranial bypass techniques, and cerebrovascular volume-outcome relationships. RESULTS: The mini-pterional, lateral supraorbital, and orbital-pterional craniotomies are minimally invasive alternatives to standard craniotomies. Mini-pterional and lateral supraorbital craniotomies were used in one-fourth of unruptured patients, increasing from 22% to 28%, whereas 15% of patients underwent orbital-pterional craniotomies and trended upward from 11% to 20%. Seventy-four patients were treated for coil recurrences (2.3% of all aneurysms) with direct clip occlusion (77%), clip occlusion after coil extraction (7%), or parent artery occlusion with bypass (16%). Intracranial-intracranial bypass (in situ bypass, reimplantation, reanastomosis, and intracranial grafts) transformed the management of giant aneurysms and made the surgical treatment of posterior inferior cerebellar artery aneurysms competitive with endovascular therapy. Centralization maximized the volume-outcome relationships observed with clipping. CONCLUSION: Aneurysm microsurgery has embraced minimalism, tailoring the exposure to the patient's anatomy with the smallest possible craniotomy that provides adequate exposure. The development of intracranial-intracranial bypasses is an important advancement that makes microsurgery a competitive option for complex and recurrent aneurysms. Trends toward centralizing aneurysm surgery in tertiary centers optimize results achievable with open microsurgery.

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Endoscope-integrated indocyanine green video-angiography for cerebral aneurysm surgery: a more effective technique

Innovative Neurosurgery ◽

10.1515/ins-2015-0004 ◽

2015 ◽

Vol 3 (3-4) ◽

Author(s):

Ittichai Sakarunchai ◽

Yoko Kato ◽

Yasuhiro Yamada ◽

Thomas Tommy

Keyword(s):

Indocyanine Green ◽

Cerebral Aneurysm ◽

Conventional Technique ◽

Parent Artery ◽

Aneurysm Surgery ◽

Small Vessels ◽

Aneurysm Clipping ◽

Unruptured Cerebral Aneurysm ◽

Deep Area ◽

Perforating Arteries

AbstractMicroscope-integrated indocyanine green video-angiography (mICG-VA) is used as an adjunct to aneurysm surgery in checking for small compromised perforating arteries and the remnant of an aneurysmal neck. A limitation of mICG-VA is the inability to access the deep area where small vessels are located behind the aneurysm sac or the parent artery. The endoscope-integrated ICG-VA (eICG-VA) is not only a tool in obtaining a wide angle of surgical view, but also is a technique to detect real-time blood flow during aneurysm clipping.Patients with an unruptured cerebral aneurysm who had conventional endoscope-assisted microsurgery and eICG-VA were enrolled. We compared the efficacy and additional details of imaging from both types of procedures.The data of seven patients were reviewed. In two cases of small perforating arteries that were hidden by the aneurysm sacs, more details were detected by eICG-VA. While the performance of the conventional technique was limited, the eICG-VA revealed a wide view in the deep area during aneurysm clipping.The eICG-VA provides more details of the aneurysm, especially in small perforating vessels that were hidden by the aneurysm. It can resolve the limitations of the conventional endoscope and mICG-VA.

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Confirmation of blood flow in perforating arteries using fluorescein cerebral angiography during aneurysm surgery

Journal of Neurosurgery ◽

10.3171/jns-07/07/0068 ◽

2007 ◽

Vol 107 (1) ◽

pp. 68-73 ◽

Cited By ~ 71

Author(s):

Kyouichi Suzuki ◽

Namio Kodama ◽

Tatsuya Sasaki ◽

Masato Matsumoto ◽

Tsuyoshi Ichikawa ◽

...

Keyword(s):

Fluorescein Angiography ◽

Cerebral Artery ◽

Cerebral Angiography ◽

Clinical Symptoms ◽

Posterior Inferior Cerebellar Artery ◽

Parent Artery ◽

Aneurysm Surgery ◽

Aneurysm Clip ◽

Perforating Artery ◽

Perforating Arteries

Object The authors performed fluorescein cerebral angiography in patients after aneurysm clip placement to confirm the patency of the parent artery, perforating artery, and other arteries around the aneurysm. Methods Twenty-three patients who underwent aneurysm surgery were studied. Aneurysms were located in the internal carotid artery in 12 patients, middle cerebral artery in six, anterior cerebral artery in three, basilar artery bifurcation in one, and junction of the vertebral artery (VA) and posterior inferior cerebellar artery in one. After aneurysm clip placement, the target arteries were illuminated using a beam from a blue light-emitting diode atop a 7-mm diameter pencil-type probe. In all patients, after intravenous administration of 5 ml of 10% fluorescein sodium, fluorescence in the vessels was clearly observed through a microscope and recorded on videotape. Results The excellent image quality and spatial resolution of the fluorescein angiography procedure facilitated intra-operative real-time assessment of the patency of the perforating arteries and branches near the aneurysm, including: 12 posterior communicating arteries; 12 anterior choroidal arteries; four lenticulostriate arteries; three recurrent arteries of Heubner; three hypothalamic arteries; one ophthalmic artery; one perforating artery arising from the VA; and one posterior thalamoperforating artery. All 23 patients experienced an uneventful postoperative course without clinical symptoms of perforating artery occlusion. Conclusions Because the fluorescein angiography procedure described here allows intraoperative confirmation of the patency of perforating arteries located deep inside the surgical field, it can be practically used for preventing unexpected cerebral infarction during aneurysm surgery.

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Delayed Parent Artery Narrowing Occurring Months after Aneurysm Surgery

Neurosurgery ◽

10.1097/00006123-199506000-00029 ◽

1995 ◽

Vol 36 (6) ◽

pp. 1225???1229 ◽

Cited By ~ 4

Author(s):

Hiroki Kurita ◽

Yoshiaki Shiokawa ◽

Hiromu Segawa ◽

Takaaki Kirino

Keyword(s):

Parent Artery ◽

Aneurysm Surgery

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Cotton-Clipping Technique to Repair Intraoperative Aneurysm Neck Tear: A Technical Note

Operative Neurosurgery ◽

10.1227/neu.0b013e31821343c6 ◽

2011 ◽

Vol 68 (suppl_2) ◽

pp. ons294-ons299 ◽

Cited By ~ 3

Author(s):

Daniel L. Barrow ◽

Robert F. Spetzler

Keyword(s):

Intracranial Aneurysm ◽

Technical Note ◽

Parent Artery ◽

Aneurysm Surgery ◽

Intraoperative Complication ◽

Suction Device ◽

Case Examples ◽

Aneurysm Neck ◽

Clipping Technique ◽

Intraoperative Rupture

Abstract Background: Intraoperative rupture of an intracranial aneurysm is a potentially devastating but avoidable and manageable complication of aneurysm surgery. Objective: To describe a surgical technique that the authors have used successfully to repair a tear at the neck of an intracranial aneurysm, as well as alternative options for managing this intraoperative complication. Methods: The tear on the neck of the aneurysm is covered with a small piece of free cotton and held in place with a suction device to clear the field of blood. The cotton is then clipped onto the tear with an aneurysm clip, using the cotton as a bolster to obliterate the tear. The cotton increases the surface area, allowing the clip to be placed more distally on the neck to preserve patency of the parent artery. Case examples are used to illustrate the technique. Results: Both authors independently have used this technique on several occasions to successfully repair tears at the neck of an aneurysm. Conclusion: Intraoperative rupture of an intracranial aneurysm is a potentially devastating complication, particularly if a tear occurs at the neck. This simple yet effective method has been very useful in repairing a partial avulsion or tear of the neck of an aneurysm.

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Prospective Comparison of Intraoperative Vascular Monitoring Technologies During Cerebral Aneurysm Surgery

Neurosurgery ◽

10.1227/neu.0b013e31820777ee ◽

2011 ◽

Vol 68 (3) ◽

pp. 657-673 ◽

Cited By ~ 58

Author(s):

Andreas Gruber ◽

Christian Dorfer ◽

Harald Standhardt ◽

Gerhard Bavinzski ◽

Engelbert Knosp

Keyword(s):

Digital Subtraction Angiography ◽

Cerebral Aneurysm ◽

Intraoperative Monitoring ◽

Near Infrared ◽

Vascular Imaging ◽

Parent Artery ◽

Digital Subtraction ◽

Aneurysm Surgery ◽

Prospective Comparison ◽

Parent Artery Occlusion

Abstract BACKGROUND: Microscope integrated intraoperative near-infrared indocyanine green angiography (ICGA) provides assessment of the cerebral vasculature in the operating field. OBJECTIVE: To prospectively compare the value of ICGA-derived information during cerebral aneurysm surgery with data simultaneously generated from other intraoperative monitoring and vascular imaging techniques. METHODS: Data from 104 patients with 123 cerebral aneurysms who were operated on were prospectively recorded. Results of intraoperative vascular monitoring and descriptions of how this information influenced intraoperative decision making were analyzed. RESULTS: Clip repositioning was necessary in 30 of 123 aneurysms (24.4%) treated. Parent artery occlusion was documented by microvascular Doppler ultrasound in 4 aneurysms. ICGA disclosed parent artery stenoses not detected by sonography in 7 cases. Neuroendoscopy was used in 13 cases of midline aneurysms to confirm perforator patency after clipping, and disclosed aneurysm misclipping undetected by ICGA and digital subtraction angiography in 1 aneurysm. The information from DSA and ICGA corresponded in 120 of 123 aneurysms operated on (97.5 %). In 1 patient, ICGA underestimated a relevant parent artery stenosis detected by digital subtraction angiography. In 2 patients with relevant aneurysmal misclipping, digital subtraction angiography and ICGA led to conflicting results that could be clarified only when both methods were used and interpreted together. CONCLUSION: The intraoperative monitoring and vascular imaging methods compared were complementary rather than competitive in nature. None of the devices used were absolutely reliable when used as a stand-alone method. Correct intraoperative assessment of aneurysm occlusion, perforating artery patency, and parent artery reconstruction was possible in all patients when these techniques were used in combination.

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