Clinical presentation and management of giant anterior communicating artery region aneurysms

2000 ◽  
Vol 92 (2) ◽  
pp. 267-277 ◽  
Author(s):  
Stephen P. Lownie ◽  
Charles G. Drake ◽  
Sydney J. Peerless ◽  
Gary G. Ferguson ◽  
David M. Pelz
Keyword(s):  
Clinical Presentation ◽  
Mass Effect ◽  
Anterior Communicating Artery ◽  
Treatment Alternative ◽  
Intraluminal Thrombus ◽  
Content Type ◽  
Exact Test ◽  
Aneurysm Neck ◽  
Temporary Clipping ◽  
Fine Print

Object. The authors reviewed their 20-year experience with giant anterior communicating artery aneurysms to correlate aneurysm size with clinical presentation and to analyze treatment methods.Methods. In 18 patients, visual and cognitive impairment were quantitated and clinical outcome was categorized according to the Rankin scale. Statistical analysis was performed using Fisher's exact test.Conclusions. At least 3.5 cm of aneurysm mass effect was required to produce dementia in the patient (p = 0.0004). Dementia was usually caused by direct brain compression by the aneurysm rather than by hydrocephalus. Optic apparatus compression occurred with smaller aneurysms (2.7–3.2 cm) when they pointed inferiorly.Aneurysm neck clipping was possible in half of the cases. Special techniques, including temporary clipping, evacuation of intraluminal thrombus, tandem and/or fenestrated clipping, and clip reconstruction were often required. Occlusion of or injury to the anterior cerebral artery (ACA) was the main cause of poor outcome or death.Proximal ACA occlusion, even of dominant A1 segments with small or no contralateral A1 artery, was an effective treatment alternative and was well tolerated as a result of excellent leptomeningeal collateral circulation.

Intracranial cavernous angioma: presentation and management

1986 ◽  
Vol 64 (5) ◽  
pp. 720-723 ◽  
Author(s):  
Patricio Tagle ◽  
Isidro Huete ◽  
Jorge Méndez ◽  
Sergio del Villar
Keyword(s):  
Cerebellopontine Angle ◽  
Unusual Case ◽  
Clinical Presentation ◽  
Ct Scanning ◽  
Cavernous Angioma ◽  
Mass Effect ◽  
Ct Scans ◽  
Content Type ◽  
Neurological Signs ◽  
Fine Print

✓ Thirteen cases of cerebral cavernous angiomas are reported, and their radiological and pathological features are reviewed. The clinical presentation was variable: 53.8% of patients had seizures, 30.8% intracerebral hemorrhage, and 15.4% focal neurological signs, including one unusual case that presented as a cerebellopontine angle tumor. The computerized tomography (CT) scans were abnormal in all cases. Angiography was positive only when there was mass effect due to associated hematoma. Surgery was performed in 12 cases with good results. The prognosis of the 13 cases was favorable, with no mortality in this series. These data suggest that the combination of a recent seizure disorder with a hyperdense intracerebral nodule on the CT scanning should alert the neurosurgeon to the possibility of a cavernous angioma.

Unruptured aneurysms presenting with mass effect sypmtoms: response to endosaccular treatment with Guglielmi detachable coils.

1998 ◽  
Vol 89 (6) ◽  
pp. 956-961 ◽  
Author(s):  
Tim W. Malisch ◽  
Guido Guglielmi ◽  
Fernando Viñuela ◽  
Gary Duckwiler ◽  
Y. Pierre Gobin ◽  
...  
Keyword(s):  
Cranial Nerve ◽  
Mass Effect ◽  
Guglielmi Detachable Coils ◽  
Intraluminal Thrombus ◽  
Duration Of Symptoms ◽  
Content Type ◽  
Wall Calcification ◽  
Detachable Coils ◽  
Fine Print

Object. Embolization of intracranial aneurysms by using Guglielmi detachable coils (GDCs) is proving to be a safe method of protecting aneurysms from rupture. Occasionally, patients with unruptured intracranial aneurysms present with symptoms related to the aneurysm's mass effect on either the brain parenchyma or cranial nerves. In the present study, the authors conducted a retrospective review to evaluate the response to GDC embolization in a series of 19 patients presenting with cranial nerve dysfunction due to mass effect. Methods. Aneurysms were classified by size, shape, wall calcification, and amount of intraluminal thrombus. Patients were classified by duration of symptoms prior to GDC treatment (range < 1 month to > 10 years). Clinical assessment was performed within days of the GDC procedure and at later follow-up appointments (range 1–70 months, mean 24 months). In the immediate post-GDC period, four patients experienced worsening of cranial nerve deficits. Two of the four patients had transient worsening of visual acuity, which later improved to better than baseline status. Another patient who had presented with headache and seventh and eighth cranial nerve deficits from a vertebrobasilar junction aneurysm had improvement in these symptoms, but developed a new diplopia. The fourth patient had worsening of her visual acuity, which had not resolved at the 1-month follow-up examination; this patient later underwent surgical decompression. Conclusions. On late follow-up review, the response was classified as complete resolution of symptoms in six patients (32%), improvement in eight patients (42%), no significant change in four patients (21%), and symptom worsening in one patient (5%). Patients with smaller aneurysms and those with shorter pretreatment duration of symptoms were more likely to experience an improvement in their symptoms following GDC treatment, although statistical significance was not reached in this series (p = 0.603 and p = 0.111, respectively). The presence of aneurysmal wall calcification (six patients) or intraluminal thrombus (12 patients) showed no correlation with the response of mass effect symptoms in these patients.

Treatment of anterior communicating artery aneurysms: complementary aspects of microsurgical and endovascular procedures

2003 ◽  
Vol 99 (1) ◽  
pp. 3-14 ◽  
Author(s):  
François Proust ◽  
Bertrand Debono ◽  
Didier Hannequin ◽  
Emmanuel Gerardin ◽  
Erick Clavier ◽  
...  
Keyword(s):  
Morbidity And Mortality ◽  
Anterior Communicating Artery ◽  
Fisher Exact Test ◽  
Content Type ◽  
Exact Test ◽  
Excellent Outcome ◽  
Group A ◽  
Permanent Morbidity ◽  
Group B ◽  
Fine Print

Object. Endovascular and surgical treatment must be clearly defined in the management of anterior communicating artery (ACoA) aneurysms. In this study the authors report their recent experience in using a combined surgical and endovascular team approach for ACoA aneurysms, and compare these results with those obtained during an earlier period in which surgical treatment was used alone. Morbidity and mortality rates, causes of unfavorable outcomes, and morphological results were also assessed. Methods. The prospective study included 223 patients who were divided into three groups: Group A (83 microsurgically treated patients, 1990–1995); Group B (103 microsurgically treated patients, 1996–2000); and Group C (37 patients treated with Guglielmi Detachable Coil [GDC] embolization, 1996–2000). Depending on the direction in which the aneurysm fundus projected, the authors attempted to apply microsurgical treatment to Type 1 aneurysms (located in front of the axis formed by the pericallosal arteries). They proposed the most adapted procedure for Type 2 aneurysms (located behind the axis of the pericallosal arteries) after discussion with the neurovascular team, depending on the physiological status of the patient, the treatment risk, and the size of the aneurysm neck. In accordance with the classification of Hunt and Hess, the authors designated those patients with unruptured aneurysms (Grade 0) and some patients with ruptured aneurysms (Grades I–III) as having good preoperative grades. Patients with Grade IV or V hemorrhages were designated as having poor preoperative grades. By performing routine angiography and computerized tomography scanning, the causes of unfavorable outcome (Glasgow Outcome Scale [GOS] score < 5) and the morphological results (complete or incomplete occlusion) were analyzed. Overall, the clinical outcome was excellent (GOS Score 5) in 65% of patients, good (GOS Score 4) in 9.4%, fair (GOS Score 3) in 11.6%, poor (GOS Score 2) in 3.6%, and fatal in 10.3% (GOS Score 1). Among 166 patients in good preoperative grades, an excellent outcome was observed in 134 patients (80.7%). The combined permanent morbidity and mortality rate accounted for up to 19.3% of patients. The rates of permanent morbidity and death that were related to the initial subarachnoid hemorrhage were 6.2 and 1.5% for Group A, 6.6 and 1.3% for Group B, and 4 and 4% for Group C, respectively. The rates of permanent morbidity and death that were related to the procedure were 15.4 and 1.5% for Group A, 3.9 and 0% for Group B, and 8 and 8% for Group C, respectively. When microsurgical periods were compared, the rate of permanent morbidity or death related to microsurgical complications decreased significantly (Group A, 11 patients [16.9%] and Group B, three patients [3.9%]); Fisher exact test, p = 0.011) from the period of 1990 to 1995 to the period of 1996 to 2000. The combined rate of morbidity and mortality that was related to the endovascular procedure (16%) explained the nonsignificance of the different rates of procedural complications for the two periods, despite the significant decrease in the number of microsurgical complications. Among 57 patients in poor preoperative grade, an excellent outcome was observed in 11 patients (19.3%); however, permanent morbidity (GOS Scores 2–4) or death (GOS Score 1) occurred in 46 patients (80.7%). With regard to the correlation between vessel occlusion (the primary microsurgical complication) and the morphological characteristics of aneurysms, only the direction in which the fundus projected appeared significant as a risk factor for the microsurgically treated groups (Fisher exact test: Group A, p = 0.03; Group B, p = 0.002). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (χ2 = 6.13, p = 0.01). Conclusions. The direction in which the fundus projects was chosen as the morphological criterion between endovascular and surgical methods. The authors propose that microsurgical clip application should be the preferred option in the treatment of ACoA aneurysms with anteriorly directed fundi and that endovascular packing be selected for those lesions with posteriorly directed fundi, depending on morphological criteria.

Surgical treatment of distal anterior cerebral artery aneurysms

1979 ◽  
Vol 50 (1) ◽  
pp. 40-44 ◽  
Author(s):  
Takashi Yoshimoto ◽  
Keita Uchida ◽  
Jiro Suzuki
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Aneurysm Rupture ◽  
Anterior Communicating Artery ◽  
Parent Artery ◽  
Content Type ◽  
Aneurysm Neck ◽  
Horizontal Portion ◽  
Distal Anterior Cerebral Artery ◽  
Fine Print

✓ Between June, 1961, and September, 1975, the authors operated on 60 patients with aneurysms of the anterior cerebral artery distal to the anterior communicating artery (ACoA) by a direct intracranial approach. It is of utmost importance in the treatment of aneurysms to have control of the parent artery of the aneurysm. This makes it easier and safer to approach the aneurysm neck and to handle possible premature aneurysm rupture. The aneurysms were classified into two types, ascending and horizontal. Aneurysms arising from the origin of the ACoA and including the entire portion of the knee of the corpus callosum were designated as aneurysms of the ascending portion, whereas aneurysms beyond the genu were designated as aneurysms of the horizontal portion. For aneurysms of the ascending portion, bifrontal craniotomy was considered the safest approach. For aneurysms of the horizontal portion, a small parasagittal craniotomy was determined to be sufficient.

Chronic expanding intracerebral hematoma

1986 ◽  
Vol 65 (5) ◽  
pp. 611-614 ◽  
Author(s):  
Eugenio Pozzati ◽  
Giuliano Giuliani ◽  
Giulio Gaist ◽  
Giancarlo Piazza ◽  
Gilberto Vergoni
Keyword(s):  
Clinical Presentation ◽  
White Matter Lesions ◽  
Mass Effect ◽  
Postoperative Hemorrhage ◽  
Intracerebral Hematoma ◽  
Duration Of Symptoms ◽  
Content Type ◽  
Collagenous Tissue ◽  
Perifocal Edema ◽  
Fine Print

✓ The cases of 10 normotensive patients with chronic intracerebral hematomas are reported. The patients' median age at diagnosis was 42 years. The median duration of symptoms was 22 days. Seizures were thepresenting symptom in 50% of the cases. Computerized tomography almost consistently demonstrated ring-shaped lesions with mass effect and perifocal edema. Arteriography revealed that all but one of the lesions were avascular. All patients had superficial white matter lesions, mostly in the frontoparietal region. All patients were treated surgically. Most of the hematomas were encapsulated and contained blood in various stages of organization. The thick capsule consisted of an outer layer of collagenous tissue and an inner layer of granulation tissue. Occult cerebrovascular malformations were detected in two instances. There were two deaths, both related to recurrent postoperative hemorrhage. This entity can present much like a brain malignancy and should be considered in the differential diagnosis of ring-shaped lesions whatever the clinical presentation. Strategies of treatment are discussed.

Occlusion of an “accessory” distal anterior cerebral artery during treatment of anterior communicating artery aneurysms

1991 ◽  
Vol 74 (1) ◽  
pp. 133-135 ◽  
Author(s):  
Kevin Gibbons ◽  
Leo N. Hopkins ◽  
Roberto C. Heros
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Anterior Communicating Artery ◽  
Case Histories ◽  
Content Type ◽  
Anterior Communicating Artery Aneurysms ◽  
Artery Segment ◽  
Distal Anterior Cerebral Artery ◽  
Clip Occlusion ◽  
Fine Print

✓ Two cases are presented in which clip occlusion of a third distal anterior cerebral artery segment occurred during treatment of anterior communicating artery aneurysms. Case histories, angiograms, operative descriptions, and postmortem findings are presented. The incidence of this anomalous vessel is reviewed. Preoperative and intraoperative vigilance in determining the presence of this anomaly prior to clip placement is emphasized.

Imaging correlates of successful endoscopic third ventriculostomy

2000 ◽  
Vol 92 (6) ◽  
pp. 915-919 ◽  
Author(s):  
Abhaya V. Kulkarni ◽  
James M. Drake ◽  
Derek C. Armstrong ◽  
Peter B. Dirks
Keyword(s):  
Clinical Success ◽  
Subjective Assessment ◽  
Third Ventriculostomy ◽  
Ventricular Size ◽  
Content Type ◽  
Exact Test ◽  
Subjective Assessments ◽  
Flow Void ◽  
Fine Print

Object. The goal of this study was to determine and compare imaging correlates in pediatric patients who underwent successful or failed endoscopic third ventriculostomies (ETVs). To this end, the authors measured ventricular size changes and the presence of cerebrospinal fluid (CSF) flow void in both groups of children following ETV.Methods. Images obtained in children with hydrocephalus immediately before and at least 30 days after having undergone ETV were reviewed by four independent observers (two blinded and two nonblinded). Each observer independently measured the frontal and occipital horn ratio ([FOR], a reliable and valid measure of ventricular size) and provided a subjective assessment of the presence of a flow void at the ETV site, the degree of periventricular edema, and the amount of CSF over the cerebral hemispheres.There were 29 children whose mean age was 6.6 years at the time of ETV and who had a mean postoperative follow-up period lasting 1.6 years. Postoperatively, the mean reduction in ventricular size (as measured using the FOR) was 7% (95% confidence interval [CI] 3–11%) in cases that were deemed failures (eight patients) and 16% (95% CI 12–20%) in clinically successful cases (21 patients). This reduction was significantly greater in cases of clinical success compared with those that were deemed failures (p = 0.03, t-test). There were no substantial differences between blinded and nonblinded assessments. Flow void was present in 94% of successes and absent in 75% of failures (p = 0.01, Fisher's exact test). The other subjective assessments were not significantly different between the groups of successes and failures.Conclusions. Ventricular size appears to be somewhat reduced in both groups of patients who underwent clinically successful and failed ETV; however, the reduction is significantly greater among clinically successful cases. The presence of a flow void also appears to correlate with clinical success and its absence with clinical failure.

Meningeal melanocytoma

1998 ◽  
Vol 88 (1) ◽  
pp. 116-121 ◽  
Author(s):  
David B. Clarke ◽  
Richard Leblanc ◽  
Gilles Bertrand ◽  
Gilbert R. C. Quartey ◽  
G. Jackson Snipes
Keyword(s):  
Histological Examination ◽  
Posterior Fossa ◽  
Clinical Presentation ◽  
Residual Tumor ◽  
Posterior Fossa Decompression ◽  
Content Type ◽  
Meningeal Melanocytoma ◽  
Radiological Appearance ◽  
Histological Features ◽  
Fine Print

✓ Meningeal melanocytomas are rare tumors of the central nervous system that are found almost exclusively in the posterior fossa and spinal cord and whose natural history is poorly defined. In this report, the authors review the clinical presentation, radiological appearance, operative findings, and histological features in two cases of meningeal melanocytoma: one cranial and one spinal. Two women, aged 21 and 30 years, were admitted to the hospital 60 years apart: the first because of progressive paraplegia and the second because of slowly progressive hearing loss. The first patient had an extradural tumor that was treated by laminectomy, subtotal resection, and postoperative radiotherapy in 1936. Her symptoms recurred 16 years later and she underwent reoperation of the residual tumor, which was found to have an intradural component. The authors' patient, who presented 60 years later, underwent plain and enhanced computerized tomography and magnetic resonance imaging that demonstrated a large posterior fossa lesion indicative of either an acoustic neuroma or a meningioma. She underwent posterior fossa decompression but only partial excision of the tumor could be accomplished because vigorous bleeding limited the extent of the resection. Surgery was followed by radiotherapy. The residual tumor enlarged despite these measures and required repeated resection 6 months later. At the second operation the tumor was much less vascular, perhaps reflecting the effects of radiotherapy, and was removed almost entirely. The patient died 6 months later from an anticoagulant-related cerebellar hemorrhage. In both cases the lesions were jet black, and histological examination revealed melanin-containing hypercellular tumors with rare mitotic figures. Meningeal melanocytomas are being diagnosed with increased frequency in parallel with improvements in neuroimaging and clarification of histological features. Clinical presentation of patients with these tumors typically occurs in their fifth decade and women are affected twice as often as men. The posterior fossa lesions can mimic acoustic neuromas and meningiomas in location and radiological appearance; however, the internal auditory canal is normal. In the spine, meningeal melanocytomas present with the clinical features of myeloradiculopathy. Diagnosis is made intraoperatively from the gross, jet-black appearance of the tumor and from histological examination. Vascularity, size, and location may render complete resection unfeasible. Because of the tumor's propensity to recur, radiotherapy has been recommended but its role remains to be elucidated.

Stereotaxic occlusion of 22 consecutive anterior communicating artery aneurysms

1980 ◽  
Vol 52 (6) ◽  
pp. 790-793 ◽  
Author(s):  
John F. Alksne ◽  
Randall W. Smith
Keyword(s):  
Anterior Communicating Artery ◽  
Content Type ◽  
Anterior Communicating Artery Aneurysms ◽  
Fine Print

✓ The authors review 22 consecutive cases of anterior communicating artery aneurysms treated by stereotaxic iron-acrylic occlusion. There was no mortality and no rebleeding in this series. The morbidity was low, and 16 of the 22 patients have returned to work. The patients whose aneurysms could be treated transsphenoidally enjoyed the best outcome.

Cerebral oxygen and microdialysis monitoring during aneurysm surgery: effects of blood pressure, cerebrospinal fluid drainage, and temporary clipping on infarction

2002 ◽  
Vol 96 (6) ◽  
pp. 1013-1019 ◽  
Author(s):  
Rupert Kett-White ◽  
Peter J. Hutchinson ◽  
Pippa G. Al-Rawi ◽  
Marek Czosnyka ◽  
Arun K. Gupta ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Cerebrospinal Fluid ◽  
Brain Tissue ◽  
Total Duration ◽  
Wilcoxon Test ◽  
Fisher Exact Test ◽  
Content Type ◽  
The Impact ◽  
Temporary Clipping ◽  
Fine Print

Object. The aim of this study was to investigate potential episodes of cerebral ischemia during surgery for large and complicated aneurysms, by examining the effects of arterial temporary clipping and the impact of confounding variables such as blood pressure and cerebrospinal fluid (CSF) drainage. Methods. Brain tissue PO2, PCO2, and pH, as well as temperature and extracellular glucose, lactate, pyruvate, and glutamate were monitored in 46 patients by using multiparameter sensors and microdialysis. Baseline data showed that brain tissue PO2 decreased significantly, below a mean arterial pressure (MAP) threshold of 70 mm Hg. Further evidence of its relationship with cerebral perfusion pressure was shown by an increase in mean brain tissue PO2 after drainage of CSF from the basal cisterns (Wilcoxon test, p < 0.01). Temporary clipping was required in 31 patients, with a mean total duration of 14 minutes (range 3–52 minutes), causing brain tissue PO2 to decrease and brain tissue PCO2 to increase (Wilcoxon test, p < 0.01). In patients in whom no subsequent infarction developed in the monitored region, brain tissue PO2 fell to 11 mm Hg (95% confidence interval 8–14 mm Hg). A brain tissue PO2 level below 8 mm Hg for 30 minutes was associated with infarction in any region (p < 0.05 according to the Fisher exact test); other parameters were not predictive of infarction. Intermittent occlusions of less than 30 minutes in total had little effect on extracellular chemistry. Large glutamate increases were only seen in two patients, in both of whom brain tissue PO2 during occlusion was continuously lower than 8 mm Hg for longer than 38 minutes. Conclusions. The brain tissue PO2 decreases with hypotension, and, when it is below 8 mm Hg for longer than 30 minutes during temporary clipping, it is associated with increasing extracellular glutamate levels and cerebral infarction.

Sign in / Sign up

Export Citation Format

Share Document