scholarly journals Clipping of Multiple Cerebral Aneurysms Through Cranioorbital Zygomatic Approach: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Rami O Almefty ◽  
Walid Ibn Essayed ◽  
Ossama Al-Mefty
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Grave Disease ◽  
Falciform Ligament ◽  
Superior Cerebellar Artery ◽  
Endovascular Coiling ◽  
High Morbidity ◽  
Temporal Fossa ◽  
Unruptured Aneurysms ◽  
Multiple Aneurysms

Abstract Ruptured cerebral aneurysm is a grave disease, with a high morbidity and mortality, mandating securing the aneurysm to eliminate fatal rebleeding.1 Multiple aneurysms are frequent and may occur in approximately 20% of the cases with female prominence.2 The risk of subarachnoid hemorrhage in unruptured aneurysms is higher in patients who had prior ruptured aneurysms.3 Hence, there is an indication of treating all concomitant aneurysms when one is ruptured. We present the case of clipping of 3 aneurysms via a cranioobritozygomatic (COZ) approach including a middle cerebral artery, anterior choroidal artery, and superior cerebellar artery in a patient presenting with subarachnoid hemorrhage and multiple aneurysms with suboptimal morphology for endovascular coiling. We highlight the advantages of the COZ in the clipping of complex posterior circulation aneurysms and the advantage of mobilization of neural structures to gain wider exposure.4-6 The temporal fossa space provided by zygomatic osteotomy allows the outward mobilization of the temporal lobe after freeing it by splitting the Sylvian fissure. The falciform ligament is opened overlying the optic nerve, allowing for safe dissection within the opticocarotid window. The oculomotor nerve is detethered from the dura surrounding its entry into the cavernous sinus. These maneuvers allow for mobilization of the critical neurovascular structures, which widens the operative corridor without undue traction or retraction. The COZ with clinoidectomy shortens and widens the operative field, allows for enhanced maneuverability, improved visualization, and exposure of the clinoidal carotid, and facilitates the release and mobilization of the optic and third nerve. The patient consented to surgery.  Image at 1:40 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998.

scholarly journals Endovascular management of intracranial aneurysms during pregnancy in three cases and review of the literature

2015 ◽  
Vol 21 (6) ◽  
pp. 654-658 ◽  
Author(s):  
Peng Liu ◽  
Xianli Lv ◽  
Youxiang Li ◽  
Ming Lv
Keyword(s):  
Cesarean Section ◽  
Cerebral Aneurysms ◽  
Endovascular Coiling ◽  
Review Of The Literature ◽  
Endovascular Techniques ◽  
Healthy Baby ◽  
Unruptured Aneurysms ◽  
Gestational Week ◽  
Basilar Tip Aneurysm ◽  
Case Basis

We present three cases of cerebral aneurysms (1 unruptured; 2 ruptured) treated with endovascular techniques in pregnancies. The first ruptured case is a 28-year-old female on 20th gestational week. After the endovascular coiling, the patient suffered persistent hemiparesis and delivered a healthy baby by cesarean section. The second ruptured case is a 25-year-old female on 36th week of pregnancy. She died of aneurysm re-rupture after delivery of a healthy baby by cesarean section. The third unruptured case is a 31-year-old woman on the 26th gestational week of pregnancy who died of a giant basilar tip aneurysm after stent-assisted coiling. Ruptured aneurysm obliteration should be prioritized followed by vaginal delivery or cesarean section. The decision regarding the treatment of unruptured aneurysms should be carefully considered on a case-by-case basis. Stent-assisted coiling may be applicable to aneurysm during pregnancy.

scholarly journals Single-stage clipping with bifrontal and bilateral frontotemporal craniotomies for subarachnoid hemorrhage with multiple cerebral aneurysms using Sugita head holding system: A case report

2020 ◽  
Vol 11 ◽  
pp. 76
Author(s):  
Masahito Katsuki ◽  
Naomichi Wada ◽  
Yasunaga Yamamoto
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Artery ◽  
Treatment Strategies ◽  
Cerebral Aneurysms ◽  
Single Stage ◽  
Ruptured Aneurysm ◽  
Left Middle Cerebral Artery ◽  
Multiple Aneurysms ◽  
Single Fixation ◽  
The Right

Background: Subarachnoid hemorrhage with multiple aneurysms is very challenging because it is difficult to identify the ruptured aneurysm. We could not identify the ruptured aneurysm preoperatively, so we decided to treat all of the aneurysms as a single-stage surgery. Case Description: A 79-year-old woman was diagnosed with subarachnoid hemorrhage with multiple cerebral aneurysms at the right distal anterior cerebral artery, left middle cerebral artery, and right internal carotid artery- posterior communicating artery bifurcation. We could not identify the ruptured aneurysm preoperatively. We fixed her head using the Sugita head holding system (Mizuho Co., Ltd., Tokyo) and performed clipping for each aneurysm with bifrontal craniotomy and bilateral frontotemporal craniotomy as a single-stage operation. The last aneurysm seemed ruptured, and clipping for all the aneurysms was successful. She was discharged with a good postoperative course. The Sugita head holding system allowed turning the head of the patient toward the right and left with single fixation, leading to this single-stage operation. Conclusion: Several methods for identifying a ruptured aneurysm from multiple aneurysms have been reported, but under limited medical resources, this procedure would be one of the treatment strategies.

Coil Embolization of Unruptured Middle Cerebral Artery Aneurysms

Neurosurgery ◽  
2011 ◽  
Vol 68 (2) ◽  
pp. 346-354 ◽  
Author(s):  
Byung Moon Kim ◽  
Dong Ik Kim ◽  
Sung Il Park ◽  
Dong Joon Kim ◽  
Sang Hyun Suh ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Primary Treatment ◽  
Aneurysm Rupture ◽  
Endovascular Coiling ◽  
Unruptured Aneurysms ◽  
Permanent Morbidity ◽  
Middle Cerebral Artery Aneurysms

Abstract BACKGROUND: Since the International Subarachnoid Aneurysmal Trial, endovascular coiling has been increasingly used as primary treatment option for ruptured or unruptured aneurysms that are feasible for coiling. OBJECTIVE: To evaluate the feasibility and clinical and angiographic outcomes of coiling for unruptured middle cerebral artery aneurysms. METHODS: The records of 70 consecutive patients with 76 unruptured middle cerebral artery aneurysms who underwent coiling were retrospectively evaluated. RESULTS: Thirty-one aneurysms were treated by single-catheter, 18 by multicatheter, 11 by balloon-assisted, 13 by stent-assisted, and 3 by a combination of multicatheter and balloon-assisted techniques. Coiling was accomplished in 75 but failed in 1 aneurysm. One patient died of consequences of subarachnoid hemorrhage occurring 9 hours after coiling. One intraprocedural aneurysm rupture occurred, which was controlled by further coil insertions and left no sequelae. There were 1 cortical infarction and 1 basal ganglia infarction, both of which recovered completely. Treatment-related permanent morbidity and mortality rates were 0% and 1.4%, respectively. Postembolization control angiography revealed 40 complete, 30 neck remnant, and 5 incomplete occlusions. Clinical follow-up was available in all patients (mean, 25 months; range, 7-105 months). There was no subarachnoid hemorrhage during follow-up, but 1 death resulting from acute myocardial infarction occurred 3 months after coiling. None of the surviving patients had any neurological deterioration. Follow-up angiography was available in 69 aneurysms at 6 to 24 months (mean, 12 months). Three major and 6 minor recurrences were detected. All 3 major recurrent aneurysms were re-treated by coiling without any complications. CONCLUSION: Most unruptured middle cerebral artery aneurysms could be safely treated by coiling with acceptable short-term to midterm outcomes. Our results warrant further study with a longer follow-up period in a larger population.

scholarly journals The Endovascular Management of Superior Cerebellar Artery Aneurysms

2004 ◽  
Vol 31 (1) ◽  
pp. 53-57 ◽  
Author(s):  
Charles Haw ◽  
Robert Willinsky ◽  
Ronit Agid ◽  
Karel TerBrugge
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
The Other ◽  
Superior Cerebellar Artery ◽  
Poor Grade ◽  
Cerebellar Artery ◽  
Clinical Series ◽  
Recovery Management ◽  
Endovascular Coils

Background:Superior cerebellar artery aneurysms are rare. We present a clinical series of twelve of these aneurysms that were treated exclusively with endovascular coils.Method:A retrospective analysis of a prospectively collected database of cerebral aneurysms treated with coil embolization was performed. Clinical notes and radiological images were reviewed.Results:Twelve superior cerebellar artery aneurysms were treated in eleven patients between 1992 and 2001. Seven patients presented with subarachnoid hemorrhage, two with neurologic deficit, and two had asymptomatic aneurysms. Coiling resulted in complete aneurysm obliteration in six patients and incomplete obliteration in the other six. No subsequent hemorrhage occurred with follow-up between 6 and 119 months (mean follow-up 50 months). Procedural morbidity was one superior cerebellar artery infarct with good recovery. Management morbidity was one middle cerebral artery embolus during a follow-up angiogram that required thrombolysis with a good clinical result. Nine out of 11 patients on follow-up were performing at Glasgow Outcome Scale (GOS) 5. One patient with GOS 3 presented with a poor grade subarachnoid hemorrhage and the other patient with GOS 4 presented with a parenchymal hemorrhage due to an arteriovenous malformation.Conclusion:Endovascular treatment of superior cerebellar artery aneurysms is an effective treatment strategy with low morbidity.

scholarly journals Association between Size and Location with Cerebral Aneurysms Rupture

1969 ◽  
Vol 30 (3) ◽  
pp. 190-196
Author(s):  
Dan Zimelewicz Oberman
Keyword(s):  
Cerebral Aneurysms ◽  
Preventive Treatment ◽  
Cross Sectional Study ◽  
Aneurysm Rupture ◽  
High Morbidity ◽  
Anterior Circulation ◽  
Cross Sectional ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Significant Difference

Introduction: Aneurysm rupture is the most dangerous complication with high morbidity and mortality rate, greater than 40%. Identifying risk factors for aneurysm rupture is extremely important for selecting patients who may truly benefit from preventive treatment. Objective: The aim of this study was to review our patients with ruptured and unruptured intracranial aneurysms and determine if there was an association between the size and location of aneurysms and their rupture. Methods: A cross-sectional study was performed in adult patients with cerebral aneurysm diagnosed from March 2015 to February 2017. Patients were divided into two groups, one with ruptured aneurysms and the other with unruptured aneurysms. Location according to anterior and posterior circulation was recorded. Size was stratified in three categories: (1) less than 7 mm; (2) between 7-12 mm; and (3) bigger than 13 mm in diameters. Results: During this period 80 patients were diagnosed with cerebral aneurysms. A total of 106 aneurysms were identified, 33 aneurysms were ruptured and 73 were unruptured. The mean sizes were 7.88 ± 6.23 mm and 5.35 ± 3.24 mm, respectively. There was statistically significant differences in aneurysm size (p<0.03) between the ruptured and unruptured group. Logistic regression revealed a higher association of rupture of anterior circulation aneurysm when size was ≥ 4mm (p<0.02). Conclusions: There was a significant difference between the size of ruptured and unruptured aneurysm groups. Anterior circulation aneurysms≥4mm revealed a higher association with rupture. This suggest this location should be evaluated more carefully for preventive treatment.

scholarly journals Staged Approach for Stent-Assisted Coiling of Cerebral Aneurysms after Failure of Initial Intra-Saccular Catheterization

2021 ◽  
Vol 16 (1) ◽  
pp. 46-51
Author(s):  
Abdulrahman Hamad Al-Abdulwahhab ◽  
Deok Hee Lee ◽  
Yunsun Song ◽  
Dae Chul Suh
Keyword(s):  
Internal Carotid ◽  
Cerebral Aneurysms ◽  
Superior Cerebellar Artery ◽  
Unruptured Aneurysms ◽  
Low Profile ◽  
Cerebellar Artery ◽  
Feasible Option ◽  
Staged Approach ◽  
The Mean

Purpose: Microcatheter navigation into an aneurysm sac can present difficulties through negative interactions between the deployed stent mesh and microcatheter. We hypothesized that endothelialization of the stent mesh would minimize these interactions. We aimed to assess the feasibility of staged coiling after stenting by reviewing our experiences with unavoidably staged embolization cases.Materials and Methods: Between 2011 and 2019, 7 patients (mean age 57.2 years, range 49–76 years) including 5 females, experienced 9 unruptured aneurysms treated with staged stenting and coiling due to unstable microcatheter navigation into the aneurysm after stent placement. The aneurysms were in the paraclinoid internal carotid artery (ICA) (n=3), ophthalmic origin ICA (n=1), superior cerebellar artery origin (n=2), basilar tip (n=2), and the middle cerebral artery bifurcation (n=1). The stents used were the Neuroform Atlas (n=4), Neuroform EZ (n=2), and Low-profile Visualized Intraluminal Support Blue (n=1).Results: The mean interval between stenting and coiling was 15 weeks (range, 12–21 weeks). The average navigation time between the first roadmap imaging and microcatheter insertion in the sac was 14 minutes (range, 8–20 minutes). One aneurysm was occluded without further coiling on follow-up. Staged coiling successfully treated the remaining aneurysms (n=8). No complications were identified.Conclusion: In cases of difficult intra-saccular catheterization, intentional staged coiling may be a feasible option for stent-assisted coiling of the cerebral aneurysms.

scholarly journals Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage

2017 ◽  
Vol 126 (3) ◽  
pp. 805-810 ◽  
Author(s):  
Kimon Bekelis ◽  
Daniel J. Gottlieb ◽  
Yin Su ◽  
Giuseppe Lanzino ◽  
Michael T. Lawton ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Elderly Patients ◽  
Instrumental Variable ◽  
Cerebral Aneurysms ◽  
Treatment Method ◽  
Cost Of Care ◽  
Endovascular Coiling ◽  
Surgical Clipping ◽  
Unmeasured Confounding ◽  
The Impact

OBJECTIVE The impact of treatment method—surgical clipping or endovascular coiling—on the cost of care for patients with aneurysmal subarachnoid hemorrhage (SAH) is debated. Here, the authors investigated the association between treatment method and long-term Medicare expenditures in elderly patients with aneurysmal SAH. METHODS The authors performed a cohort study of 100% of the Medicare fee-for-service claims data for elderly patients who had undergone treatment for ruptured cerebral aneurysms in the period from 2007 to 2012. To control for measured confounding, the authors used propensity score–adjusted multivariable regression analysis with mixed effects to account for clustering at the hospital referral region (HRR) level. An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method. RESULTS During the study period, 3210 patients underwent treatment for ruptured cerebral aneurysms and met the inclusion criteria. Of these patients, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the 1st year after admission for SAH were $113,000 (IQR $77,500–$182,000) for surgical clipping and $103,000 (IQR $72,900–$159,000) for endovascular coiling. When the authors adjusted for unmeasured confounders by using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI $4492–$34,663). CONCLUSIONS In a cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, surgical clipping was associated with increased 1-year expenditures in comparison with endovascular coiling.

THE EFFECT OF COILING VERSUS CLIPPING OF RUPTURED AND UNRUPTURED CEREBRAL ANEURYSMS ON LENGTH OF STAY, HOSPITAL COST, HOSPITAL REIMBURSEMENT, AND SURGEON REIMBURSEMENT AT THE UNIVERSITY OF FLORIDA

Neurosurgery ◽  
2009 ◽  
Vol 64 (4) ◽  
pp. 614-621 ◽  
Author(s):  
Brian L. Hoh ◽  
Yueh-Yun Chi ◽  
Margaret A. Dermott ◽  
Paul J. Lipori ◽  
Stephen B. Lewis
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Length Of Stay ◽  
Hospital Costs ◽  
Cerebral Aneurysms ◽  
Hospital Charges ◽  
University Of Florida ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
The University ◽  
Length Of Hospitalization

Abstract OBJECTIVE There are few studies comparing the economic costs and reimbursements for aneurysm clipping versus coiling, and none are from the United States. Our hypothesis predicted that coiling would result in shorter lengths of hospitalization than clipping in patients with unruptured aneurysms and would therefore result in lower hospital charges. However, because of the severity of subarachnoid hemorrhage, there would be no difference in length of hospitalization or hospital charges in patients with ruptured aneurysms. METHODS We compared aneurysm coiling with aneurysm clipping in patients with unruptured and ruptured aneurysms treated at the University of Florida from January 2005 to June 2007 for differences in length of hospitalization, hospital costs, hospital collections, and surgeon collections. Patient demographic and aneurysm characteristic data were obtained from a clinical database. Length of hospitalization, cost, billing, and collection data were obtained from the hospital cost accounting database. Multivariate statistical analyses of length of hospitalization, hospital costs, hospital collections, and surgeon collections were performed using factors including patient age, sex, aneurysm size, aneurysm location, aneurysm treatment, presence of subarachnoid hemorrhage, clinical grade, payor, hospital billing, and surgeon billing. RESULTS There were 565 patients with cerebral aneurysms treated either surgically (306 patients, 54%) or endovascularly (259 patients, 46%). In patients without subarachnoid hemorrhage (unruptured aneurysms) (n = 367), surgery, compared with endovascular treatment, was associated with longer hospitalization (P &lt; 0.001), but lower hospital costs (P &lt; 0.001), higher surgeon collections (P = 0.003), and similar hospital collections. In patients with subarachnoid hemorrhage (ruptured aneurysms) (n = 198), surgery was associated with lower hospital costs (P = 0.011), but similar length of stay, surgeon collections, and hospital collections. Larger aneurysm size was significantly associated with longer hospitalization in the patients with unruptured aneurysms (P &lt; 0.001) and higher hospital costs for both patients with unruptured (P &lt; 0.001) and ruptured (P = 0.015) aneurysms. The payor was significantly associated with hospital costs in patients with ruptured aneurysms (P = 0.034) and length of stay (unruptured aneurysms, P &lt; 0.001; ruptured aneurysms, P &lt; 0.001), hospital collections (unruptured aneurysms, P &lt; 0.001; ruptured aneurysms, P &lt; 0.001), and surgeon collections (unruptured aneurysms, P &lt; 0.001; ruptured aneurysms, P &lt; 0.001) in both patients with unruptured and ruptured aneurysms. A worse clinical grade was significantly associated with higher hospital costs (P &lt; 0.001). CONCLUSION Despite a shorter length of hospitalization in patients with unruptured aneurysms, coiling was associated with higher hospital costs in both patients with unruptured and ruptured aneurysms. This is likely attributable to the higher device cost of coils than clips. The advantages of coiling over clipping would be better realized if the cost of coils could be comparably reduced to that of clips.

Treatment of ruptured and unruptured cerebral aneurysms in the USA: a paradigm shift

2018 ◽  
Vol 10 (Suppl 1) ◽  
pp. i69-i76 ◽  
Author(s):  
Ning Lin ◽  
Kevin S Cahill ◽  
Kai U Frerichs ◽  
Robert M Friedlander ◽  
Elizabeth B Claus
Keyword(s):  
Hospital Mortality ◽  
Cerebral Aneurysms ◽  
Unruptured Aneurysm ◽  
Ruptured Aneurysm ◽  
Teaching Hospitals ◽  
Endovascular Coiling ◽  
Surgical Clipping ◽  
Unruptured Aneurysms ◽  
The Usa ◽  
Over Time

BackgroundIntegration of data from clinical trials and advancements in technology predict a change in selection for treatment of patients with cerebral aneurysm.ObjectiveTo describe patterns of use and in-hospital mortality associated with surgical and endovascular treatments of cerebral aneurysms over the past decade.Materials and methodsThe data are 34 899 hospital discharges with a diagnosis of ruptured or unruptured cerebral aneurysm from 1998 to 2007 identified from the Nationwide Inpatient Sample (NIS). The rates of endovascular coiling and surgical clipping and in-hospital mortality among patients with an aneurysm are examined over a decade by hospital and patient demographic characteristics.ResultsFrom 1998 to 2007, 20 134 discharges with a ruptured aneurysm and 14 765 discharges with an unruptured aneurysm were identified. Over this decade, the number of patients discharged with a ruptured aneurysm was stable while the number discharged with an unruptured aneurysm increased significantly. The use of endovascular coiling increased at least twofold for both groups of patient (p<0.001) with the majority of unruptured aneurysms treated with coiling by 2007. Although whites were more likely than non-whites to undergo coiling versus clipping for a ruptured aneurysm (OR=1.30; 95% CI 1.13 to 1.48) and men with unruptured aneurysms were more likely than women to undergo coiling (OR=1.26; 95% CI 1.13 to 1.40), by 2007 differences in treatment selection by gender and racial subgroups were decreased or statistically non-significant. Over time the use of coiling spread from primarily large, teaching hospitals to smaller, non-teaching hospitals.ConclusionsThe majority of unruptured aneurysms in the USA are now treated with endovascular coiling. Although surgical clipping is used for treatment of most ruptured aneurysms, its use is decreasing over time. Dissemination of endovascular procedures appears widespread across patient and hospital subgroups.

Accuracy in Identifying the Source of Subarachnoid Hemorrhage in the Setting of Multiple Intracranial Aneurysms

Neurosurgery ◽  
2017 ◽  
Vol 83 (1) ◽  
pp. 62-68 ◽  
Author(s):  
Jennifer L Orning ◽  
Sophia F Shakur ◽  
Ali Alaraj ◽  
Mandana Behbahani ◽  
Fady T Charbel ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Endovascular Embolization ◽  
Ruptured Aneurysm ◽  
Multiple Aneurysms ◽  
Microsurgical Clipping ◽  
Computed Tomography Scans ◽  
Rupture Site

Abstract BACKGROUND Subarachnoid hemorrhage cases with multiple cerebral aneurysms frequently demonstrate a hemorrhage pattern that does not definitively delineate the source aneurysm. In these cases, rupture site is ascertained from angiographic features of the aneurysm such as size, morphology, and location. OBJECTIVE To examine the frequency with which such features lead to misidentification of the ruptured aneurysm. METHODS : Records of patients who underwent surgical clipping of a ruptured aneurysm at our institution between 2004 and 2014 and had multiple aneurysms were retrospectively reviewed. A blinded neuroendovascular surgeon provided the rupture source based on the initial head computed tomography scans and digital subtraction angiography images. Operative reports were then assessed to confirm or refute the imaging-based determination of the rupture source. RESULTS One hundred fifty-one patients had multiple aneurysms. Seventy-one patients had definitive hemorrhage patterns on initial computed tomography scans and 80 patients had nondefinitive hemorrhage patterns. Thirteen (16.2%) of the cases with nondefinitive hemorrhage patterns had discordance between the imaging-based determination of the rupture source and intraoperative findings of the true ruptured aneurysm, yielding an imperfect positive predictive value of 83.8%. Of all multiple aneurysm cases with subarachnoid hemorrhage treated by surgical or endovascular means at our institution, 4.3% (13 of 303) were misidentified. CONCLUSION Morphological features cannot reliably be used to determine rupture site in cases with nondefinitive subarachnoid hemorrhage patterns. Microsurgical clipping, confirming obliteration of the ruptured lesion, may be preferentially indicated in these patients unless, alternatively, all lesions can be contemporaneously and safely treated with endovascular embolization.

Sign in / Sign up

Export Citation Format

Share Document