Halo traction combined with posterior-only approach correction for cervical kyphosis with Neurofibromatosis-1: minimum 2 years follow-up

Abstract Background Surgical management of cervical kyphosis in patients with NF-1 is a challenging task. Presently, anterior-only (AO), posterior-only (PO) and combined anterior-posterior (AP) spinal fusion are common surgical strategies. However, the choice of surgical strategy and application of Halo traction remain controversial. Few studies have shown and recommended posterior-only approach for cervical kyphosis correction in patients with NF-1. The aim of this study is to evaluate the safety and the effectiveness of halo Traction combined with posterior-only approach correction for treatment of cervical kyphosis with NF-1. Methods Twenty-six patients with severe cervical kyphosis due to NF-1 were reviewed retrospectively between January 2010 and April 2018. All the cases underwent halo traction combined with posterior instrumentation and fusion surgery. Correction result, neurologic status and complications were analyzed. Results In this study, cervical kyphosis Cobb angle decreased from initial 61.3 ± 19.7 degrees to postoperative 10.6 ± 3.7 degrees (P<0.01), with total correction rate of 82.7%, which consist of 45.8% from halo traction and 36.9% from surgical correction. JOA scores were improved from preoperative 13.3 ± 1.6 to postoperative 16.2 ± 0.7 (P<0.01). Neurological status was also improved. There was no correction loss and the neurological status was stable in mean 43 months follow-up. Three patients experienced minor complications and one patient underwent a second surgery. Conclusion Halo traction combined with PO approach surgery is safe and effective method for cervical kyphosis correction in patients with NF-1. A satisfied correction result, and successful bone fusion can be achieved via this procedure, even improvement of neurological deficits can also be obtained. Our study suggested that halo traction combined with PO approach surgery is another consideration for cervical kyphosis correction in patients with NF-1.

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Continuous Incremental Heavy Halo Traction Combined with Posterior-only Approach for Severe Cervical Kyphosis with Neurofibromatosis-1.

10.21203/rs.2.15877/v1 ◽

2019 ◽

Author(s):

Chaofeng Guo ◽

Hongqi Zhang ◽

Zhenhai Zhou ◽

Jinyang Liu ◽

Ang Deng

Keyword(s):

Posterior Instrumentation ◽

Neurological Status ◽

Neurofibromatosis 1 ◽

Neurological Deficits ◽

Cervical Kyphosis ◽

Kyphosis Correction ◽

Halo Traction ◽

Key Words Neurofibromatosis ◽

Correction Result

Abstract Background Surgical management of cervical kyphosis in patients with NF-1 is a challenging task. Presently, anterior-only (AO), posterior-only (PO) and combined anterior-posterior (AP) spinal fusion are common surgical strategies. However, the choice of surgical strategy and application of Halo traction remain controversial. Few studies have shown and recommended posterior-only approach for cervical kyphosis correction in patients with NF-1. The aim of this study is to evaluate the safety and the effectiveness of Continuous-Incremental-Heavy Halo Traction (CIH-HT) combined with posterior-only approach for treatment of cervical kyphosis with NF-1. Methods 19 patients with severe cervical kyphosis due to NF-1 were reviewed retrospectively between January 2010 and April 2017. All the cases underwent CIH-HT combined with posterior instrumentation and fusion surgery. Correction result, neurologic status and complications were analyzed. Results In this study, cervical kyphosis Cobb angle decreased from initial 63.0 ± 21.0 degrees to postoperative 10.8 ± 4.0 degrees(P＜0.01),with total correction rate of 92%, which consist of 44% from CIH-HT and 48% from surgical correction. JOA scores were improved from preoperative 13.6±1.6 to postoperative 16.0±1.0(P＜0.01). Neurological status was also improved. There was no correction loss and the neurological status was stable in mean 3.7 years follow-up. The incidence of complications was 36.8% (7/19). Six patients underwent local complications and one patient underwent a second surgery. Conclusion CIH-HT combined PO approach is safe and effective method for cervical kyphosis correction in patients with NF-1. A satisfied correction result, and successful bone fusion can be achieved via this procedure, even improvement of neurological deficits can also be obtained. Our study suggested that CIH-HT combined PO approach is another consideration for cervical kyphosis correction in patients with NF-1. Key words : Neurofibromatosis-1; Cervical kyphosis; Continuous-Incremental-Heavy Halo Traction; posterior-only approach;

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The lateral infratrigeminal transpontine window to deep pontine lesions

Journal of Neurosurgery ◽

10.3171/2014.11.jns141116 ◽

2015 ◽

Vol 123 (3) ◽

pp. 699-710 ◽

Cited By ~ 5

Author(s):

Paolo Ferroli ◽

Marco Schiariti ◽

Roberto Cordella ◽

Carlo Boffano ◽

Simone Nava ◽

...

Keyword(s):

Retrospective Study ◽

Surgical Intervention ◽

Neurological Deficits ◽

Critical Area ◽

Surgical Indications ◽

Surgical Strategies ◽

Csf Leakage ◽

New Knowledge ◽

Pontine Lesion

OBJECT Surgery of brainstem lesions is increasingly performed despite the fact that surgical indications and techniques continue to be debated. The deep pons, in particular, continues to be a critical area in which the specific risks related to different surgical strategies continue to be examined. With the intention of bringing new knowledge into this important arena, the authors systematically examined the results of brainstem surgeries that have been performed through the lateral infratrigeminal transpontine window. METHODS Between 1990 and 2013, 29 consecutive patients underwent surgery through this window for either biopsy sampling or for removal of a deep pontine lesion. All of this work was performed at the Department of Neurosurgery of the Istituto Nazionale Neurologico "Carlo Besta", in Milan, Italy. A retrospective analysis of the findings was conducted with the intention of bringing further clarity to this important surgical strategy. RESULTS The lateral infratrigeminal transpontine window was exposed through 4 different approaches: 1) classic retrosigmoid (15 cases), 2) minimally invasive keyhole retrosigmoid (10 cases), 3) translabyrinthine (1 case), and 4) combined petrosal (3 cases). No deaths occurred during the entire clinical study. The surgical complications that were observed included hydrocephalus (2 cases) and CSF leakage (1 case). In 6 (20.7%) of 29 patients the authors encountered new neurological deficits during the immediate postoperative period. All 6 of these patients had undergone lesion removal. In only 2 of these 6 patients were permanent sequelae observed at 3 months follow-up. These findings show that 93% of the patients studied did not report any permanent worsening of their neurological condition after this surgical intervention. CONCLUSIONS This retrospective study supports the idea that the lateral infratrigeminal transpontine window is both a low-risk and safe corridor for either biopsy sampling or for removal of deep pontine lesions.

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Surgical treatment of tuberculosis of spine: Nepalese experience

Grande Medical Journal ◽

10.3126/gmj.v1i1.22400 ◽

2019 ◽

Vol 1 (1) ◽

pp. 8-20

Author(s):

Binod Bijukachhe ◽

Chester E. Sutterlin

Keyword(s):

Surgical Treatment ◽

Posterior Instrumentation ◽

Spinal Tuberculosis ◽

Disease Process ◽

Neurological Status ◽

Abscess Drainage ◽

Ct Guided ◽

Radiological Criteria ◽

Early Return

Introduction : Spinal tuberculosis treatment goal is eradication of the disease, neurological protection, and deformity prevention. Accepted indications for conservative or surgical management of the disease are still lacking. The purpose of this study was to classify disease based on pre- and post-treatment clinical and radiological criteria to help management. Material and methods : Out of 101 patients, retrospectively reviewed between 2007 and 2015, seventy adult patients (44 males, mean age 29 years, range 16-76) were included in the study. Patients were evaluated clinically for pain, deformity and neurological status while radiological evaluation included sagittal deformity, vertebra destruction and number of vertebrae involvement. 60 patients underwent surgery (abscess drainage, 2; anterior radical debridement and fusion, 12; anterior debridement + posterior instrumentation, 26; posterior instrumentation, 20) All patients were given anti-tuberculous treatment for 12 months. Mean follow up period was 44.9 months (range: 6-108 months). Result: Pre-treatment pain (Visual analogue score, VAS 0-10, mean 7.52) improved by 0.99 at last follow up. Number of vertebrae involved ranged from 1 to 15 (mean 4.2). 38 patients had obvious clinical deformity with Cobb angle mean 36.6° (range 10°-130°). Deformity was corrected at mean of 17.5° (range: -60° to 90°) at last follow up. There were two ASIA A, eight ASIA B, five ASIA C, four ASIA D and 51 patients with ASIA E neurology at the time of presentation. One patient with ASIA A neurology remained same even after decompression while other patient died on the day of surgery. Out of 8 patients with ASIA B neurology six patients improved to ASIA E, one patient remained same and one patient deteriorated to ASIA A. In ASIA C group, three patients improved to ASIA E. One patient deteriorated to ASIA A. All four patients with ASIA D neurological status improved to ASIA E. And all 51 patients with pre-operative ASIA E status remained same but one deteriorated to ASIA C. Eight patients had deformity progression, two patients had deep vein thrombosis, two patients had superficial wound infection and one patients had recurrent cold abscess. Two patients died due to associated co-morbidities. Based upon the clinical and radiological pre- and post-operative findings; Uncomplicated spines were managed conservatively or with abscess drainage (USG or CT – guided). Complicated spines were managed with posterior instrumentation and complex spines were managed with anterior / posterior procedure (posterior only approach) Conclusion: Based upon the outcome of treatment of spinal tuberculosis, conservative treatment results in healing of the disease process with residual deformity while surgical treatment in selected cases results in early pain alleviation, spinal balance, neurologic protection and eventually early return to work.

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Krónikus dialízis kapcsán kialakult destruktív cervicalis spondylarthropathia esete

Ideggyógyászati Szemle ◽

10.18071/isz.74.0211 ◽

2021 ◽

Vol 74 (5-6) ◽

pp. 211-215

Author(s):

Balázs Berta ◽

Hedvig Komáromy ◽

Attila Schwarcz ◽

Béla Kajtár ◽

András Büki ◽

...

Keyword(s):

Bone Graft ◽

Vertebral Body ◽

Posterior Instrumentation ◽

Plate Fixation ◽

Neurological Deficits ◽

Pulmonary Insufficiency ◽

Unstable Fracture ◽

Pathologic Fractures ◽

Vertebral Bodies

A case of a 61-year-old male patient suffered chronic renal failure and dialysed for 23 years with destructive cervical spondylarthropathy is presented. The patient presented with sudden onset of cervical pain radiating into his shoulders without neurological deficits. CT and MRI of the cervical and thoracic spine revealed severe destructive changes and compressive fractures of C6 and C7 vertebrae which caused the narrowing of the nerve root canals at these levels. A 360-degree fixation was performed to treat the unstable fracture and the patient’s pain (C6 and C7 corpectomy, autolog bone graft replacement of the two vertebral bodies, anterior plate fixation and posterior instrumentation with screws and rods). Postoperatively the patient had no significant pain, no neurological deficit and he was able to manage independent life himself. During the immediate follow-up CT of the neck showed the satisfactory position of the bone graft and the metal implantations. The 6 months follow-up CT revealed the anterior migration of the two screws from the Th1 vertebral body and 2 mm ventral elevation of the caudal end of the plate from the anterior surface of the Th1 vertebral body. The 1-year follow-up could not be performed because the patient died due to cardio-pulmonary insufficiency. This is the second Hungarian report of a chronic dialysis related severe spondylarthropathy which may cause pathologic fractures of the vertebral bodies. The typical radiological and histological findings are discussed. This disease affect patients’ quality of life and the conservative treatment alone seems to be ineffective in most cases. Based on the literature and personal experiences, the authors suggest 360-degree fixation of the spine to provide sufficient stability for the vertebrae of ”bad bone quality”, and early mobilisation of the patient can be achieved.

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Delayed postoperative neurological complication in a patient with congenital kyphoscoliosis: recovered by revision of the 4-rod instrumentation technique

Journal of Neurosurgery Spine ◽

10.3171/2013.8.spine121160 ◽

2013 ◽

Vol 19 (5) ◽

pp. 595-599 ◽

Cited By ~ 1

Author(s):

Pooya Javidan ◽

Nima Kabirian ◽

Gregory M. Mundis ◽

Behrooz A. Akbarnia

Keyword(s):

Neurological Complication ◽

Posterior Spinal Fusion ◽

Neurological Status ◽

Neurological Deficits ◽

Preoperative Risk ◽

Preoperative Risk Assessment ◽

Rod System ◽

Proximal Extension ◽

Junctional Kyphosis

The authors report a case of progressive congenital kyphoscoliosis in which the patient, a boy, originally underwent combined anterior and instrumented posterior spinal fusion at the age of 7 years and 3 months. Early proximal junctional kyphosis and implant failure mandated proximal extension of implants with 2 new rods connected to the old caudad short rods. At the 3-year follow-up, clinical and CT assessment revealed a thoracolumbar pseudarthrosis for which the patient underwent a 2-stage procedure without complication. Recordings of somatosensory evoked potentials intraoperatively were normal. Twelve hours after surgery, his neurological status started to progressively deteriorate. The patient was brought to the operating room, and the initially achieved correction was reversed by an apex-only exposure of the 4-rod system. After surgery the patient started to show progressive improvement in his neurological function. A final myelography was performed and showed free passage of the dye without evidence of obstruction. Clinically, the patient continued to improve and at his 3-month follow-up had near-complete resolution of his neurological deficits. Findings on his physical examination were normal at the final 12-year follow-up. Despite normal findings on intraoperative neuromonitoring, a delayed neurological deficit can occur after complex spine reconstruction. Preoperative risk assessment, surgical approach, and instrumentation deserve careful attention. Advantages of a 4-rod construct are discussed in this case.

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A controlled anterior sequential interbody dilation technique for correction of cervical kyphosis

Journal of Neurosurgery Spine ◽

10.3171/2014.12.spine14178 ◽

2015 ◽

Vol 23 (3) ◽

pp. 263-273 ◽

Cited By ~ 8

Author(s):

Darryl Lau ◽

John E. Ziewacz ◽

Hai Le ◽

Rishi Wadhwa ◽

Praveen V. Mummaneni

Keyword(s):

Blood Loss ◽

Hospital Stay ◽

Perioperative Outcomes ◽

Cervical Kyphosis ◽

Kyphosis Correction ◽

Estimated Blood Loss ◽

Cord Injury ◽

Significant Correction ◽

The Mean

OBJECT Cervical kyphosis can lead to spinal instability, spinal cord injury, and disability. The correction of cervical kyphosis is technically challenging, especially in severe cases. The authors describe the anterior sequential interbody dilation technique for the treatment of cervical kyphosis and evaluate perioperative outcomes, degree of correction, and long-term follow-up outcomes associated with the technique. METHODS In the period from 2006 to 2011, a consecutive cohort of adults with cervical kyphosis (Cobb angles ≥ 0°) underwent sequential interbody dilation, a technique entailing incrementally increased interbody distraction with the sequential placement of larger spacers (at least 1 mm) in the discectomy and/or corpectomy spaces. The authors retrospectively reviewed these patients, and primary outcomes of interest included kyphosis correction, blood loss, hospital stay, complications, Nurick grade, pain, reoperation, and pseudarthrosis. A subgroup analysis among patients with preoperative kyphosis of 0°–9° (mild), 10°–19° (moderate), and ≥ 20° (severe) was performed. RESULTS One hundred patients were included in the study: 74 with mild preoperative cervical kyphosis, 19 with moderate, and 7 with severe. The mean patient age was 53.1 years, and 54.0% of the patients were male. Mean estimated blood loss was 305.6 ml, and the mean length of hospital stay was 5.2 days. The overall complication rate was 9.0%, and there were no deaths. Sixteen percent of patients underwent supplemental posterior fusion. There was significant correction in cervical alignment (p < 0.001), and the mean overall kyphosis correction was 12.4°. Patients with severe preoperative kyphosis gained a correction of 24.7°, those with moderate kyphosis gained 17.8°, and those with mild kyphosis gained 10.1°. A mean correction of 32.0° was obtained if 5 levels were addressed. The mean follow-up was 26.8 months. The reoperation rate was 4.7%. At follow-up, there was significant improvement in visual analog scale neck pain (p = 0.020) and Nurick grade (p = 0.037). The pseudarthrosis rate was 6.3%. CONCLUSIONS Sequential interbody dilation is a feasible and effective method of correcting cervical kyphosis. Complications and reoperation rates are low. Similar benefits are seen among all severities of kyphosis, and greater correction can be achieved in more severe cases.

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Symptomatic pseudarthrosis in ochronotic spine: case report

Journal of Neurosurgery Spine ◽

10.3171/2016.5.spine15671 ◽

2017 ◽

Vol 26 (2) ◽

pp. 220-228 ◽

Cited By ~ 3

Author(s):

Abolfazl Rahimizadeh ◽

Housain Soufiani ◽

Valliolah Hassani ◽

Ava Rahimizadeh

Keyword(s):

Neurological Status ◽

Single Stage ◽

Neurological Deficits ◽

Disc Space ◽

Posterior Surgery ◽

Dural Sac ◽

Alternative Approach ◽

Progressive Paraparesis ◽

Anterior Posterior

In this study the authors report the first example of spinal pseudarthrosis in a patient with ochronosis, and they describe the application of posterior-only 360° surgery as an alternative approach to combined anterior-posterior surgery in the management of pseudarthrosis of an ankylosed spine, regardless of its etiology. Spinal involvement in ochronosis produces loss of flexibility and ankylosis of thoracic and lumbar segments. Pseudarthrosis is a serious complication of the diseases that present with ankylosis of the spine. However, its occurrence in ochronotic spine has not been reported previously. Evaluation of progressive paraparesis in a 68-year-old man with ochronosis revealed pseudarthrosis at the T11–12 level. Circumferential dural sac decompression, debridement of the disc space, interbody fusion, and screw-rod fixation were all done via a posterior-only approach. Postoperatively the patient exhibited a marked recovery in terms of pain and neurological status. At the 3-month follow-up, he was able to walk independently. Ochronosis should be included in the etiology of pseudarthrosis. With aggravation of back pain and the appearance of neurological deficits in an already stable patient with any ankylosing disease, pseudarthrosis should be suspected. Furthermore, single-stage, 360°, posterior-only surgery may obviate the need for single-stage or staged anterior-posterior surgical intervention in patients with pseudarthrosis of the thoracic and lumbar spine.

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Thoracic and lumbar tuberculous spondylitis treated by posterior debridement, graft placement, and instrumentation: a retrospective analysis in 19 cases

Journal of Neurosurgery Spine ◽

10.3171/spi.2005.3.6.0450 ◽

2005 ◽

Vol 3 (6) ◽

pp. 450-458 ◽

Cited By ~ 55

Author(s):

Feyza Karagöz Güzey ◽

Erhan Emel ◽

N. Serdar Bas ◽

Selim Hacisalihoglu ◽

Hakan Seyithanoglu ◽

...

Keyword(s):

Spinal Injury ◽

Posterior Instrumentation ◽

Neurological Deficits ◽

Easy Access ◽

Tuberculous Spondylitis ◽

Content Type ◽

The Mean ◽

Posterior Debridement ◽

Fine Print

Object. Surgical treatment of thoracic and lumbar tuberculous spondylitis is controversial. An anterior approach is usually recommended. The aim of the present study was to assess the efficacy of posterior debridement and the placement of posterior instrumentation for the treatment of patients with thoracic and lumbar tuberculous spondylitis. Methods. Nineteen patients with thoracic and lumbar tuberculous spondylitis underwent single-stage posterior decompression and debridement as well as the placement of posterior interbody grafts if necessary, instrumentation and posterior or posterolateral grafts. No postoperative neurological deterioration was noted. One patient died of myocardial infarction on Day 10. The mean follow-up duration, excluding the one death, was 52.7 months (range 16–125 months). In a 70-year-old patient, a single pedicle screw broke after 3 months. All patients were in better neurological condition after surgery and at the last follow-up examination. Neurological deficits were present in only two patients at the last follow up (one American Spinal Injury Association Grade B and one Grade C deficit preoperatively). Three other patients suffered intermittent back or low-back pain. The mean angulation measured in 13 patients with kyphotic deformity was 18.2° (range 5–42°) preoperatively; this was reduced to 17.3° (range 0–42°) after surgery. There was a 2.8° loss of correction (range 2–5°) after 44.3 months (16–64 months). Kyphosis did not progress beyond 15 months in any patient. Conclusions A posterior approach in combination with internal fixation and posterior or posterolateral fusion (with or without placement of posterior interbody grafts) may be sufficient for the debridement of the infection and to allow spinal stabilization in patients with thoracic and lumbar tuberculous spondylitis. This procedure is associated with easy access to the spinal canal for neural decompression, prevention of loss of corrected vertebral alignment in the long term, and facilitation of early mobilization.

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Anterior expandable strut cage replacement for osteoporotic thoracolumbar vertebral collapse

Journal of Neurosurgery Spine ◽

10.3171/spi.2006.4.6.454 ◽

2006 ◽

Vol 4 (6) ◽

pp. 454-462 ◽

Cited By ~ 48

Author(s):

Kenzo Uchida ◽

Shigeru Kobayashi ◽

Hideaki Nakajima ◽

Yasuo Kokubo ◽

Takafumi Yayama ◽

...

Keyword(s):

Neurological Status ◽

Neurological Deficits ◽

Vertebral Body Replacement ◽

Vertebral Collapse ◽

Expandable Cage ◽

Cage Subsidence ◽

The Mean ◽

Type 3

Object The authors investigated the usefulness of using an expandable cage strut in anterior reconstruction after osteoporotic vertebral collapse in patients with neurological deficits. Methods Twenty-eight patients who had undergone expandable cage strut–augmented anterior thoracolumbar reconstruction participated in a follow-up review for a mean of 4.9 years. Radiographs were reviewed for kyphosis, lateral tilt of the implant, cage subsidence, the presence of a solid fusion mass, and instrumentation failure. Changes in neurological status and visual analog scale (VAS) pain score, as well as technique-related complications, were examined. The mean angles ± the standard deviations of kyphosis correction 4 to 6 weeks after surgery and at final follow-up examination were 10.4 ± 7.6° and 5.6 ± 6.0°, respectively. The mean subsidence of the expandable cage within the adjacent vertebrae was 2.5 ± 3.0 mm at the final follow-up examination. Neurological improvement at the final follow up was more significant in patients with Type 1 (wedge-type) than Type 2 (flat-type) (p = 0.037) or Type 3 (concave-type) (p = 0.006) vertebral collapse. Follow-up VAS scores were significantly higher in patients with Type 1 than Type 3 collapse (p = 0.012). In all cases the authors observed solid union with incorporation of the cage. There were no surgery-related complications. Conclusions An expandable titanium cage strut seems useful in vertebral body replacement in patients with osteoporotic thoracolumbar collapse. Favorable results were obtained in cases of Type 1 collapse (wedge type) in which the middle and posterior columns remained comparatively intact.

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Anatomical and Clinical Outcomes after Endovascular Treatment for Unruptured Cerebral Aneurysms

Interventional Neuroradiology ◽

10.1177/159101990200800406 ◽

2002 ◽

Vol 8 (4) ◽

pp. 367-376 ◽

Cited By ~ 11

Author(s):

B. J. Kwon ◽

M. H. Han ◽

C.W. Oh ◽

K. H. Kim ◽

K-H Chang

Keyword(s):

Clinical Outcome ◽

Endovascular Treatment ◽

Cerebral Aneurysms ◽

Neurological Status ◽

Neurological Deficits ◽

Anterior Circulation ◽

Unruptured Aneurysms ◽

Unruptured Cerebral Aneurysms ◽

Anatomical Outcomes

To describe the immediate and follow-up anatomical outcomes as well as procedure-related morbidity after endovascular procedures for unruptured cerebral aneurysms, we reviewed 68 patients with 78 unruptured aneurysms treated with detachable coils from may 1996 to february 2002. Angiograms were retrospectively reviewed for the nature of the aneurysms and the degree of therapeutic obliteration. Periprocedural complications, immediate clinical outcome and long-term neurological status were analyzed. Immediate anatomical outcomes were complete in 35 aneurysms (45%); residual neck in 24 (31%), partial contrast filling in 17 (22%), and failed embolization in two (2%). Of 27 aneurysms with follow-up angiography, 12 of the 13 aneurysms that were completely occluded in the initial treatment were still completely occluded at the end of a mean follow-up period of 17 months. Periprocedural complications were thromboembolic (n = 6), haemorrhagic (n = 3), coil protrusion (n = 7) and other unrelated complications (n = 3). Only two patients, with thromboembolic complications were moderately disabled with permanent neurological deficits in immediate clinical outcome, and their condition improved to independent in 1.5 and three months each. Small aneurysms and posterior circulation location showed more protective immediate results than aneurysms of large and anterior circulation after endovascular treatment (p values: 0.01 and 0.02). Our experiences of endovascular treatment for unruptured cerebral aneurysms were comparable to the results of recent series. Endovascular treatment for small posteriorly located aneurysms produced significantly better results than for large anteriorly located lesions.

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