Cranial base approaches to posterior circulation aneurysms

1997 ◽  
Vol 87 (4) ◽  
pp. 544-554 ◽  
Author(s):  
J. Diaz Day ◽  
Takanori Fukushima ◽  
Steven L. Giannotta
Keyword(s):  
Surgical Management ◽  
Cranial Base ◽  
Posterior Circulation ◽  
Management Options ◽  
Content Type ◽  
Technical Challenge ◽  
Complex Aneurysms ◽  
Posterior Circulation Aneurysms ◽  
Vertebrobasilar Circulation ◽  
Fine Print

✓ Aneurysms arising from the posterior circulation, especially when they are large and complex, continue to present a technical challenge. The development of cranial base strategies and principles has added to surgical management options. The authors used one of four cranial base approaches for the treatment of 30 patients with large and/or complex aneurysms arising from the vertebrobasilar circulation. These approaches included the extradural temporopolar, combined petrosal, retrolabyrinthine—transsigmoid, and the extreme-lateral inferior transtubercular exposure. The indications, technique, and results of each approach in this series are discussed, and a management paradigm is suggested for such aneurysms.

scholarly journals Cranial base approaches to posterior circulation aneurysms

1997 ◽  
Vol 3 (2) ◽  
pp. E1
Author(s):  
J. Diaz Day ◽  
Takanori Fukushima ◽  
Steven L. Giannotta
Keyword(s):  
Surgical Management ◽  
Cranial Base ◽  
Posterior Circulation ◽  
Management Options ◽  
Technical Challenge ◽  
Complex Aneurysms ◽  
Posterior Circulation Aneurysms ◽  
Vertebrobasilar Circulation

Aneurysms arising from the posterior circulation, especially when they are large and complex, continue to present a technical challenge. The development of cranial base strategies and principles has added to surgical management options. The authors used one of four cranial base approaches for the treatment of 30 patients with large and/or complex aneurysms arising from the vertebrobasilar circulation. These approaches included the extradural temporopolar, combined petrosal, retrolabyrinthine-transsigmoid, and the extreme-lateral inferior transtubercular exposure. The indications, technique, and results of each approach in this series are discussed, and a management paradigm is suggested for such aneurysms.

Comparison between perimesencephalic nonaneurysmal subarachnoid hemorrhage and subarachnoid hemorrhage caused by posterior circulation aneurysms

2003 ◽  
Vol 98 (3) ◽  
pp. 529-535 ◽  
Author(s):  
Jose F. Alén ◽  
Alfonso Lagares ◽  
Ramiro D. Lobato ◽  
Pedro A. Gómez ◽  
Juan J. Rivas ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Clinical Syndrome ◽  
Posterior Circulation ◽  
Ct Scans ◽  
World Federation ◽  
Content Type ◽  
Unenhanced Ct ◽  
Posterior Circulation Aneurysms ◽  
Fine Print

Object. Some authors have questioned the need to perform cerebral angiography in patients presenting with a benign clinical picture and a perimesencephalic pattern of subarachnoid hemorrhage (SAH) on initial computerized tomography (CT) scans, because the low probability of finding an aneurysm does not justify exposing patients to the risks of angiography. It has been stated, however, that ruptured posterior circulation aneurysms may present with a perimesencephalic SAH pattern in up to 10% of cases. The aim of the present study was twofold: to define the frequency of the perimesencephalic SAH pattern in the setting of ruptured posterior fossa aneurysms, and to determine whether this clinical syndrome and pattern of bleeding could be reliably and definitely distinguished from that of aneurysmal SAH. Methods. Twenty-eight patients with ruptured posterior circulation aneurysms and 44 with nonaneurysmal perimesencephalic SAH were selected from a series of 408 consecutive patients with spontaneous SAH admitted to the authors' institution. The admission unenhanced CT scans were evaluated by a neuroradiologist in a blinded fashion and classified as revealing a perimesencephalic SAH or a nonperimesencephalic pattern of bleeding. Of the 28 patients with posterior circulation aneurysms, five whose grade was I according to the World Federation of Neurosurgical Societies scale were classified as having a perimesencephalic SAH pattern on the initial CT scan. The data show that the likelihood of finding an aneurysm on angiographic studies obtained in a patient with a perimesencephalic SAH pattern is 8.9%. Conversely, ruptured aneurysms of the posterior circulation present with an early perimesencephalic SAH pattern in 16.6% of cases. Conclusions. This study supports the impression that there is no completely sensitive and specific CT pattern for a nonaneurysmal SAH. In addition, the authors believe that there is no specific clinical syndrome that can differentiate patients who have a perimesencephalic SAH pattern caused by an aneurysm from those without aneurysms. Digital subtraction angiography continues to be the gold standard for the diagnosis of cerebral aneurysms and should be performed even in patients who have the characteristic perimesencephalic SAH pattern on admission CT scans.

Endovascular treatment of ruptured posterior circulation aneurysms using electrolytically detachable coils

1997 ◽  
Vol 87 (3) ◽  
pp. 374-380 ◽  
Author(s):  
Douglas A. Nichols ◽  
Robert D. Brown ◽  
Kent R. Thielen ◽  
Fredric B. Meyer ◽  
John L. D. Atkinson ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Balloon Occlusion ◽  
Additional Treatment ◽  
Posterior Circulation ◽  
Parent Artery ◽  
Content Type ◽  
Detachable Coils ◽  
Posterior Circulation Aneurysms ◽  
Fine Print

✓ The authors report their experience using electrolytically detachable coils for the treatment of ruptured posterior circulation aneurysms. Twenty-six patients with 28 posterior circulation aneurysms were treated. All patients were referred for endovascular treatment by experienced vascular neurosurgeons. Patients underwent follow-up angiography immediately after treatment, 1 to 6 weeks posttreatment, and 6 months posttreatment. Six-month follow-up angiograms obtained in 19 patients with 20 aneurysms demonstrated that 18 (90%) of the 20 aneurysms were 99 to 100% occluded, one aneurysm (5%) was approximately 90% occluded, and one aneurysm (5%) was approximately 75% occluded. The patient with the aneurysm that was approximately 75% occluded needed additional treatment, consisting of parent artery balloon occlusion, and was considered a treatment failure (3.8% of patients). There was one treatment-associated mortality (3.8%) but no treatment-associated serious neurological or nonneurological morbidity in the patient group. There was no recurrent aneurysm rupture during treatment or during the mean 27-month follow-up period. Endovascular treatment of ruptured posterior circulation aneurysms with electrolytically detachable coils can be accomplished with low morbidity and mortality rates. The primary goal of treatment—preventing recurrent aneurysm—can be achieved over the short term. Endovascular coil occlusion will play an important role in the treatment of ruptured posterior circulation aneurysms, particularly if long-term efficacy in preventing recurrent aneurysm hemorrhage can be documented.

Aneurysms of the posterior circulation: detection and treatment planning using volume-rendered three-dimensional helical computerized tomography angiography

2005 ◽  
Vol 103 (6) ◽  
pp. 1018-1029 ◽  
Author(s):  
J. Pablo Villablanca ◽  
Adina Achiriolaie ◽  
Parizad Hooshi ◽  
Neil Martin ◽  
Gary Duckwiler ◽  
...  
Keyword(s):  
Treatment Planning ◽  
Ct Angiography ◽  
Computerized Tomography ◽  
Treatment Options ◽  
Significant Proportion ◽  
Posterior Circulation ◽  
Content Type ◽  
Computerized Tomography Angiography ◽  
Posterior Circulation Aneurysms ◽  
Fine Print

Object. The aim of this study was to determine whether computerized tomography (CT) angiography could be used to identify and characterize aneurysms of the posterior circulation and guide optimal treatment selection, and how data obtained using this method compared with intraoperative findings. Methods. Patients suspected of harboring brain aneurysms underwent CT angiography and digital subtraction (DS) angiography; the results were prospectively interpreted by blinded independent evaluators. All patients with posterior circulation aneurysms were consecutively enrolled in the study. After treatment, neurosurgeons and endovascular therapists evaluated the ability of CT and DS angiography to demonstrate features of the lesions important for triage between treatment options (Wilcoxon signed-rank test) and to allow for coil or clip preselection and complete treatment planning (McNemar test of proportions), while using intraoperative findings as the basis of truth. In 242 patients overall, CT angiography detected 38 aneurysms and two aneurysmal blisters in 32 patients. The sensitivity of CT angiography in revealing posterior circulation aneurysms was 100% compared with DS angiography, with no false-positive results. Furthermore, CT angiography was sufficient as the sole study at triage for 65% of the posterior circulation aneurysms (26 of 40 lesions; p < 0.001), including 62% of the complex lesions (p < 0.001), and permitted coil or clip preselection in 74% of treated cases (20 of 27 cases; p < 0.002). Results of CT angiography revealed information about mural calcification and intraluminal thrombus not available on DS angiography, which affected patient care. Conclusions. In this study population, CT angiography was comparable to DS angiography in the detection and characterization of aneurysms of the posterior circulation. Computerized tomography angiography was used successfully to triage patients between endovascular and neurosurgical treatment options in a significant proportion of cases and permitted treatment planning in more than 70% of treated cases.

The poor prognosis of ruptured intracranial aneurysms of the posterior circulation

1995 ◽  
Vol 82 (5) ◽  
pp. 791-795 ◽  
Author(s):  
Wouter I. Schievink ◽  
Eelco F. M. Wijdicks ◽  
David G. Piepgras ◽  
Chu-Pin Chu ◽  
W. Michael O'Fallon ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Initial Period ◽  
Posterior Circulation ◽  
Medical Record Linkage ◽  
Anterior Circulation ◽  
Content Type ◽  
Clinical Series ◽  
Posterior Circulation Aneurysms ◽  
Fine Print

✓ The first 48 hours after aneurysmal subarachnoid hemorrhage are critical in determining final outcome. However, most patients who die during this initial period are not included in hospital-based studies. We investigated the occurrence of subarachnoid hemorrhage in a population-based study to evaluate possible predictors of poor outcome. All patients diagnosed with aneurysmal subarachnoid hemorrhage between 1955 and 1984 were selected for analysis of mortality in the first 30 days using the medical record—linkage system employed for epidemiological studies in Rochester, Minnesota. One hundred and thirty-six patients were identified. The mean age of these 99 women and 37 men was 55 years. Rates for survival to 48 hours were 32% for the 19 patients with posterior circulation aneurysms, 77% for the 87 patients with anterior circulation aneurysms, and 70% for the 30 patients with a presumed aneurysm (p < 0.0001). Rates for survival to 30 days were 11%, 57%, and 53%, respectively, in these three patient groups (p < 0.0001). Clinical grade on admission to the hospital, the main variable predictive of death within 48 hours, was significantly worse in patients with posterior circulation aneurysms than in others (p < 0.0001). The prognosis of ruptured posterior circulation aneurysms is poor. The high early mortality explains why posterior circulation aneurysms are uncommon in most clinical series of patients with subarachnoid hemorrhage. The management of incidentally discovered intact posterior circulation aneurysms may be influenced by these findings.

Stent-assisted angioplasty of intracranial vertebrobasilar atherosclerosis: an initial experience

2000 ◽  
Vol 92 (5) ◽  
pp. 771-778 ◽  
Author(s):  
Peter A. Rasmussen ◽  
John Perl ◽  
John D. Barr ◽  
Georges Z. Markarian ◽  
Irene Katzan ◽  
...  
Keyword(s):  
Alternative Therapy ◽  
Signs And Symptoms ◽  
Antiplatelet Agents ◽  
Posterior Circulation ◽  
Occlusive Disease ◽  
Stent Insertion ◽  
Initial Experience ◽  
Content Type ◽  
Vertebrobasilar Artery ◽  
Fine Print

Object. Patients with intracranial vertebrobasilar artery (VBA) atherosclerotic occlusive disease have few therapeutic options. Unfortunately, VBA transient ischemic attacks (TIAs) herald a lethal or devastating event within 5 years in 25 to 30% of patients. The authors report their initial experience with eight patients in whom medically refractory TIAs secondary to intracranial posterior circulation atherosclerotic occlusive lesions were treated with stent-assisted angioplasty.Methods. Eight patients (six men), ranging in age from 43 to 77 years, experienced signs and symptoms of VBA insufficiency despite combination therapy with warfarin and antiplatelet agents. Angiographic studies revealed severe distal vertebral (four patients), proximal basilar (one patient), or proximal and midbasilar stenoses (three patients). Aspirin and clopidogrel were administered for 3 days before primary angioplasty and stent placement, and this regimen was maintained by the patients on discharge. Patients underwent heparinization during the procedure and were given a bolus and 12-hour infusion of abciximab. A neurologist specializing in stroke evaluated all patients before and after the procedure.The VBAs in all patients were successfully revascularized with 7 to 28% residual stenosis. Six patients experienced no neurological complications. One patient died the evening of the procedure due to a massive subarachnoid hemorrhage. Two patients had groin hematomas, one developed congestive heart failure, and one had transient encephalopathy. All surviving patients are asymptomatic up to 8 months postoperatively.Conclusions. Although primary intracranial VBA angioplasty with stent insertion is technically feasible, complications associated with the procedure can be life threatening. As experience is gained with this procedure, it may be offered routinely as an alternative therapy to patients with medically refractory posterior circulation occlusive disease that may develop into catastrophic VBA insufficiency.

Surgical management of spinal cord hemangioblastomas in patients with von Hippel—Lindau disease

2003 ◽  
Vol 98 (1) ◽  
pp. 106-116 ◽  
Author(s):  
Russell R. Lonser ◽  
Robert J. Weil ◽  
John E. Wanebo ◽  
Hetty L. Devroom ◽  
Edward H. Oldfield
Keyword(s):  
Spinal Cord ◽  
Surgical Management ◽  
Postoperative Outcome ◽  
Tumor Location ◽  
Neurological Dysfunction ◽  
Autosomal Dominant Disorder ◽  
Content Type ◽  
Von Hippel Lindau ◽  
Vhl Disease ◽  
Fine Print

Object. Von Hippel—Lindau (VHL) disease is an autosomal-dominant disorder frequently associated with hemangioblastomas of the spinal cord. Because of the slow progression, protean nature, and high frequency of multiple spinal hemangioblastomas associated with VHL disease, the surgical management of these lesions is complex. Because prior reports have not identified the factors that predict which patients with spinal cord hemangioblastomas need surgery or what outcomes of this procedure should be expected, the authors have reviewed a series of patients with VHL disease who underwent resection of spinal hemangioblastomas at a single institution to identify features that might guide surgical management of these patients. Methods. Forty-four consecutive patients with VHL disease (26 men and 18 women) who underwent 55 operations with resection of 86 spinal cord hemangioblastomas (mean age at surgery 34 years; range 20–58 years) at the National Institutes of Health were included in this study (mean clinical follow up 44 months). Patient examination, review of hospital charts, operative findings, and magnetic resonance imaging studies were used to analyze surgical management and its outcome. To evaluate the clinical course, clinical grades were assigned to patients before and after surgery. Preoperative neurological status, tumor size, and tumor location were predictive of postoperative outcome. Patients with no or minimal preoperative neurological dysfunction, with lesions smaller than 500 mm3, and with dorsal lesions were more likely to have no or minimal neurological impairment. Syrinx resolution was the result of tumor removal and was not influenced by whether the syrinx cavity was entered. Conclusions. Spinal cord hemangioblastomas can be safely removed in the majority of patients with VHL disease. Generally in these patients, hemangioblastomas of the spinal cord should be removed when they produce symptoms or signs.

Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

1999 ◽  
Vol 90 (4) ◽  
pp. 651-655 ◽  
Author(s):  
Marc S. Schwartz ◽  
James I. Cohen ◽  
Toby Meltzer ◽  
Michael J. Wheatley ◽  
Sean O. McMenomey ◽  
...  
Keyword(s):  
Skull Base ◽  
Free Flap ◽  
Cranial Base ◽  
Csf Leak ◽  
Content Type ◽  
Lateral Skull Base ◽  
Csf Leakage ◽  
Radial Forearm ◽  
Microvascular Free Flap ◽  
Fine Print

Object. Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage.Methods. Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation.Conclusions. Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to “low-volume” defects.

Distal anterior inferior cerebellar artery aneurysms

2002 ◽  
Vol 97 (3) ◽  
pp. 692-696 ◽  
Author(s):  
Eric L. Zager ◽  
Ellen G. Shaver ◽  
Robert W. Hurst ◽  
Eugene S. Flamm
Keyword(s):  
Artery Aneurysm ◽  
Distal Segment ◽  
Anterior Inferior Cerebellar Artery ◽  
Management Options ◽  
Content Type ◽  
Von Hippel Lindau ◽  
Cerebellar Artery ◽  
Distal Branch ◽  
Acute Subarachnoid Hemorrhage ◽  
Fine Print

✓ Aneurysms of the distal anterior inferior cerebellar artery (AICA) are rare; fewer than 100 cases have been reported. The authors detail their experience with four cases and present endovascular as well as microsurgical management options. The medical records and neuroimaging studies obtained in four patients who were treated at a single institution were reviewed. Clinical presentations, neuroimaging and intraoperative findings, and clinical outcomes were analyzed. There were three men and one woman; their mean age was 43 years. Two patients presented with acute subarachnoid hemorrhage (SAH), and two presented with ataxia and vertigo (one with tinnitus, the other with hearing loss). Angiographic studies demonstrated aneurysms of the distal segment of the AICA. In one patient with von Hippel—Lindau syndrome and multiple cerebellar hemangioblastomas, a feeding artery aneurysm was found on a distal branch of the AICA. Three of the patients underwent successful surgical obliteration of their aneurysms, one by clipping, one by trapping, and one by resection along with the tumor. The fourth patient underwent coil embolization of the distal AICA and the aneurysm. All patients made an excellent neurological recovery. Patients with aneurysms in this location may present with typical features of an acute SAH or with symptoms referable to the cerebellopontine angle. Evaluation with computerized tomography, magnetic resonance (MR) imaging, MR angiography, and digital subtraction angiography should be performed. For lesions distal to branches coursing to the brainstem, trapping and aneurysm resection are viable options that do not require bypass. Endovascular obliteration is also a reasonable option, although the possibility of retrograde thrombosis of the AICA is a concern.

Surgical management and outcome in patients with radial nerve lesions

2001 ◽  
Vol 95 (4) ◽  
pp. 573-583 ◽  
Author(s):  
Daniel H. Kim ◽  
Andrew C. Kam ◽  
Padmavathi Chandika ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Surgical Management ◽  
Radial Nerve ◽  
Gunshot Wounds ◽  
Suture Repair ◽  
Content Type ◽  
Louisiana State University ◽  
Internal Neurolysis ◽  
End To End ◽  
Grade 3 ◽  
Fine Print

Object. The goal of this paper was to review surgical management and outcomes in patients treated for radial nerve (RN) lesions at Louisiana State University Health Sciences over a period of 30 years. Methods. Two hundred sixty patients with RN injuries were evaluated. The most common mechanisms of injuries involving the RN included fracture of the humerus, laceration, blunt contusions, and gunshot wounds. One hundred and eighty patients (69%) underwent surgery. Lesions not in continuity required primary or secondary end-to-end suture repairs or graft repairs. With the use of direct intraoperative nerve action potential recording, RN injuries in which the lesion was in continuity required external or internal neurolysis or resection of the lesion followed by end-to-end suture or graft repair. A minimum of 1.5 years follow-up review was available in 90% of the patients who underwent surgery. Motor function recovery to Grade 3 or better was observed in 10 (91%) of 11 patients who underwent primary suture repair, 25 (83%) of 30 who underwent secondary suture repair, 43 (80%) of 54 who received graft repair, and 63 (98%) of 64 in whom neurolysis was performed. Sixteen (71%) of 21 patients with superficial sensory RN injury achieved satisfactory pain relief after complete resection of a neuroma or neurolysis. Conclusions. This study clearly demonstrates that excellent functional recovery can be achieved with proper surgical management of RN injuries.

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