Alberto Pasqualin, TRATTAMENTO CHIRURGICO DEGLI ANEURISMI DI BIFORCAZIONE DEL CIRCOLO ANTERIORE

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1 TRATTAMENTO CHIRURGICO DEGLI ANEURISMI DI BIFORCAZIONE DEL CIRCOLO ANTERIORE Alberto Pasqualin, SSO Neurochirurgia Vascolare e Istituto di Neurochirurgia Azienda Ospedaliera Universitaria di Verona

2 ADJUNCTS IN SURGERY OF INTRACRANIAL ANEURYSMS Temporary clipping of afferent vessel Various clip arrangements and remodeling of the sac Intraop. neurophysiological monitoring Intraop. flow measurement (Charbel s probe)

3 TEMPORARY CLIPPING: RISK FACTORS FOR STROKE Age > 50 years Hunt-Hess grades IV-V temporary occlusion > 10 min continuos occlusion J. Neurosurg 97: 836 (2002)

4 MORE FREQUENTLY EMPLOYED CLIPPING TECHNIQUES Lawton MT, Seven Aneurysms: Tenets and Techniques for Clipping (Thieme 2011)

5 NEUROPHYSIOLOGICAL MONITORING IN ANEURYSM SURGERY 1990: 134 pts, only SEP monitored (Schramm et al, Neurosurgery 26:61) 1993: 97 pts, only SEP monitored; all with temporary clipping (Mizoi & Yoshimoto, Neurosurgery 33:434) 2003: 108 pts, initial experience with MEP monitoring (Suzuki et al, J. Neurosurg 98:507) 2004: 100 procedures, combined monitoring of SEP, MEP and microvascular doppler (Neuloh & Schramm, J. Neurosurg 100:389) 2006: 119 pts, only MEP monitoring 2007: 122 pts, only SEP monitoring 2010: 111 pts, only MEP monitoring (Szelenyi et al, J. Neurosurg 105:675) (Penchet et al, Acta Neurochir 149:357) (Irie et al, J. Neurosurg Anesthesiol 22:247) 2010: 98 pts, combined monitoring of SEP and MEP (Yeon et al, J. Neurol Sci 293:29) 2012: 691 procedures, only SEP monitoring (historical series) (Wicks et al, Neurosurgery 70:1114)

6 Raabe et al, Neurosurgery 52:132 (2003)

7 UNRUPTURED An. RUPTURED An. A1 tract 30.9 ± ± 10.9 A2 tract 22.8 ± ± 11.5 M1 tract 39.2 ± ± 14.5 M2 tract 21.0 ± ± 11.7 M3 tract 13.5 ± ± 11.0 Supraclin. ICA 42.0 ± ± 23.0 Pericallosal A ± ± 4.6 PICA 12.2 ± 7.1

8 TYPES OF BIFURCATION ANEURYSMS OF THE ANTERIOR CIRCULATION Aneurysms of the main division of the middle cerebral artery (MCA) Aneurysms of the internal carotid bifurcation Aneurysms at a proximal division of the middle cerebral artery (MCA) Aneurysms at the main branching of the pericallosal artery

9 Aneurismi «di biforcazione» sul tratto M1

10 52 yr-old man; unruptured right MCA aneurysm (at proximal division, with superior projection) PATIENT ID: RIAT0713

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12 Postop angiography PATIENT ID: RIAT0713

13 27 yr-old man; unruptured right MCA aneurysm (at proximal division)

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16 Exclusion with 2 clips; intraoperative flowmetry Postop CT and angiography No postoperative deficits

17 Aneurismi sulla divisione principale della cerebrale media

18 DIFFERENT TYPES OF MCA BIFURCATION From: CEREBROVASCULAR DISEASE (H.H.Batjer et al, eds) Lippincott, Philadelphia 1997 (pp )

19 Divisione CM: a T asimmetrica

20 58 yr-old woman; unruptured right MCA bifurcation aneurysm PATIENT ID: BOLU1209

21 Flowmetry during surgery Postop CT and angio; no neurological deficit PATIENT ID: BOLU1209

22 Divisione CM: «a freccia»

23 76 yr-old man wioth recent gait disturbances; incidental discovery of large unruptured left MCA aneurysm (note arrow-shaped MCA division) PATIENT ID: RIED0214

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27 Divisione CM: triforcazione

28 61 yr-old woman with incidental discovery of left MCA trifurcation aneurysm PATIENT ID: FASU0309

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30 Temporary occlusion of M1 tract (1 min) and flowmetry during surgery Postop CT and angiography No neurological deficit PATIENT ID: FASU0309

31 ANEURISMI DELLA DIVISIONE DELLA CEREBRALE MEDIA: ASPETTI ANATOMICI PARTICOLARI MORFOLOGIA COMPLESSA : Colletto largo e base spanciata Morfologia multilobare, spesso asimmetrica Uno o più rami aderenti alla sacca Sacca di grandi dimensioni, con possibile incorporazione dell origine di rami efferenti Placche calcifiche sulle pareti e/o vicino al colletto Trombosi endoluminare

32 Colletto largo

33 67 yr-old man with previous episode of headache; discovery of large MCA aneurysm on MRI; large aneurysmal neck on angiography

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37 Temporary M1 occlusion (4 + 8 min) and flowmetry during surgery Postop CT and angiography No postop deficits

38 Base «spanciata»

39 58 yr-old woman; unruptured right MCA bifurcation aneurysm

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42 Exclusion with 2 clips; transient clipping of M1 tract ( min); flowmetry during surgery Postop CT and angiography No postop deficits

43 Vasi aderenti alla sacca

44 63 yr old man with vertigo; MRI discovery of large (18 mm) aneurysm at the left MCA trifurcation (2 temporal and 1 frontal branch)

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47 Exclusion with 2 curved Sundt clips and 1 straight fenestrated Sugita clip; temporary M1 clipping (8 + 1 min); flowmetry during surgery Transient rt hemiparesis (36 hrs) and confusion; no deficit at discharge

48 61 yr-old woman with frequent headache; incidental discovery of right MCA aneurysm (at the trifurcation) Note arrow-shaped MCA division and possible adherence between sac and medial temporal trunk

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50 Exclusion with multiple clips; temporary clipping of M1 tract (2 + 3 min); intraoperative flowmetry and neurophysiological monitoring Postop CT scan and angiography No neurological deficits in the postop. course

51 Incorporazione dell origine dei vasi efferenti

52 68 yr-old woman presenting with diplopia; large unruptured left MCA aneurysm

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55 Significant remodeling of the sac, during transient M1 occlusion ( min); exclusion with 2 clips; intraop. flowmetry and neurophysiological monitoring Postop CT and angiography No postoperative deficits

56 Pareti calcifiche/ ateromasiche

57 50 yr-old man with epilepsy and large bilateral MCA aneurysms

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60 Exclusion with 2 clips of right-sided aneurysm (with calcified walls and luminar thrombosis); aneurysmectomy No neurological deficit after 1st procedure

61 Trombosi endo-aneurismatica

62 54 yr-old woman with epilepsy; large partially thrombosed rt MCA division aneurysm Note exit of temporal trunk of MCA division from the sac

63 Surgical exclusion with a large Sundt clip, after temporary occlusion of M1 tract (6 min +4 min +1 min); no change in SEPs or MEPs; basal flow values very low on the temporal trunk of division, and unchanged after definitive clipping Postop CT scan and angiography Uneventful postop course

64 Valore del monitoraggio neurofisiologico

65 63 yr-old man previously submitted to surgical removal of right spheno-cavernous meningioma, followed by radiosurgery. Incidental discovery of left MCA aneurysm (at proximal division, with short M1 tract and adjacent perforators)

66 R Biceps R Biceps R Biceps R Ext R Ext R Ext R ABP R ABP R ABP 11:49 Clipping 11:51 MEP drop and clip removal 11:53 MEP restored

67 During surgery, almost complete disappearance of MEPs 2 minutes after positioning of a curved clip on the aneurysmal neck, in spite of normal flow values on efferent MCA branches (18 ml/min on the temporal trunk, 15 ml/min on the frontal trunk) Immediate recovery of MEPs after removal of the clip; final exclusion with an angleshaped clip, sparing a small lenticulo-striate artery originating from the back of the aneurysmal neck; no changes in flow values or MEP thereafter Postop CT scan and angiography Uneventful postop course; no deficits at discharge

68 Aneurismi della biforcazione carotidea

69 Da Pian et al, Surg Neurol 13: 27 (1980)

70 Sakamoto et al, Acta Neurochir 148: 139 (2006)

71 69 yr-old man; unruptured large left internal carotid bifurcation aneurysm (superior projection) PATIENT ID: POEN0909

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74 Postop angiography PATIENT ID: POEN0909

75 INTERNAL CAROTID BIFURCATION ANEURYSMS: POSTERIOR PROJECTION Da Pian et al, Surg Neurol 13: 27 (1980)

76 36 yr-old man; ruptured right internal carotid bifurcation aneurysm (posterior projection) PATIENT ID: TRPA0696

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78 52 yr-old man presenting with confusion and left hemiparesis Caudate hematoma on CT scan and large right carotid bifurcation aneurysm PATIENT ID: GEEN0203

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82 Temporary occlusion of internal carotid and A1 tract (8 min) and flowmetry during surgery Postop CT and angiography Complete neurological recovery after 2 months PATIENT ID: GEEN0203

83 Aneurismi sulla divisione principale della cerebrale anteriore distale

84 56 yr-old woman with incidental discovery of right ACA aneurysm on CT scan, located at the bifurcation pericallosal /calloso-marginal artery

85 APPROCCIO INTER-EMISFERICO DA DESTRA

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87 Exclusion of aneurysm following temporary clipping of pericallosal artery (2 min 30 sec); intraop. flowmetry Postop CT and angiography No neurological deficits

88 67 yr-old woman; ruptured left pericallosal aneurysm (at origin of calloso-marginal artery) and associated left frontal hematoma PATIENT ID: ORLI0212

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91 SURGERY OF BIFURCATION ANEURYSMS OF THE ANTERIOR CIRCULATION: CONCLUSIONS Preoperative recognition of anatomical complexity factors (neck and branching, adherence/ incorporation of vessels, contact with perforators, thrombosis) Routine use of intraoperative flowmetry, enhancing the safety of clip exclusion In complex cases, exclusion obtained with various clip arrangements For large and/or globous aneurysms, remodeling of the sac with bipolar coagulation very useful, performed during temporary clipping Liberal use of temporary clipping; its association with SEP and especially MEP monitoring strongly advised

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94 LESS EMPLOYED COMPLEX CLIPPING TECHNIQUES Lawton MT, Seven Aneurysms: Tenets and Techniques for Clipping (Thieme 2011)

95 55 yr-old woman with incidental discovery of unruptured left M1 aneurysm, at the origin of the anterior temporal artery PATIENT ID: COCA1015

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97 Postop angiography PATIENT ID: COCA1015

98 75 yr-old man with right hypoacusia from small vestibular neurinoma; incidental discovery of left MCA aneurysm; large aneurysmal neck on angiography, with basal pouch

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100 Temporary occlusion of M1 tract (1 min); intraop. flowmetry and neurophysiological monitoring Postop CT and angiography No postop deficits

101 57 yr-old woman; unruptured right MCA aneurysm (at proximal division); see frontal branch of division, arising at an angle

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103 At surgery, frontal trunk originating (at an angle) from the basal portion of the sac; two perforators coming out from the origin of the frontal trunk; exclusion with one clip; flowmetry during surgery Postop CT and angiography Transient paresis of left arm after surgery, disappearing within 2 months

104 48 yr-old man presenting with epilepsy; large unruptured right MCA bifurcation aneurysm

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108 Significant remodeling of the sac; transient M1 clipping ( min); final exclusion with a curved clip; flowmetry during surgery Postop CT and angiography No postop deficits

109 INTERNAL CAROTID BIFURCATION ANEURYSMS: SUPERIOR PROJECTION Da Pian et al, Surg Neurol 13: 27 (1980)

110 73 yr-old woman; unruptured right internal carotid bifurcation aneurysm (and associated large carotid-cavernous aneurysm) PATIENT ID: POER0210

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113 GROUP 1 GROUP 2 GROUP 3 Grand, Neurosurgery 7: 215 (1980)