Preventing cerebral vasospasm after aneurysmal subarachnoid hemorrhage with agressive cisternal clot removal

Transcription

1 FPⅡ-1 Preventing cerebral vasospasm after aneurysmal subarachnoid hemorrhage with agressive cisternal clot removal Nakao Ota, Kosumo Noda, Hiroyasu Kamiyama, Rokuya Tanikawa Sapporo Teishinkai Hospital Background and Purpose Subarachnoid clot is the strongest predictor of cerebral vasospasm. Our purpose was to analyze the relationship between the number of postoperative cisternal clots and cerebral vasospasm and to assess the efficacy of surgical clot removal. Methods The subjects were 158 aneurysmal subarachnoid hemorrhage (SAH) patients. All underwent clipping with cisternal clot removal. The pre- and postoperative number of clots was semiquantitatively analyzed using computed tomography (CT), and cerebral vasospasm and its severity were analyzed using magnetic resonance angiography (MRA) in a blind fashion. Factors related to cerebral vasospasm and poor outcome were retrospectively analyzed. Poor outcome was defined as modified Rankin Scale scores (mrs) 3. Results Symptomatic cerebralvasospasm (SCV) was observed in 6 (3.8%) patients. Angiographic vasospasm (AVS) was observed in 38 (24.1%). A year after the operation, 82.9% had mrs of 0 to 2. The postoperative number of clots was significantly (P<0.005) related to SCV (adjusted odds ratio (OR): 6.447; 95% confidence interval (CI): ), AVS (OR: 2.634; 95% CI: ), and poor outcome (OR: 2.103; 95% CI: ). Poor outcome was also related to age over 65 (OR: 6.658; 95% CI: ) and WFNS Grade (OR: 1.732; 95% CI: ). Conclusions Surgically removing as many clots as possible in the acute stage can decrease SCV and reduce AVS severity. Irrigation should be performed on all approachable cisterns.

2 FPⅡ-2 Surgical outcomes of proximal middle cerebral artery aneurysms Dong-Jun Lim, Sung-Kon Ha, Sung-Won Jin, Won-Hyoung Kim, Yong-Su Chung Neuro, Ansan Hospital, Korea University Medical Center We report a series of 49 patients with saccular proximal middle cerebral artery (MCA) aneurysms. Between 2010 and 2018, 189 patients had MCA aneurysms and 60 had proximal MCA ones. Eleven patients, who didn t undergo, were excluded from this study. Of the 49, 29 (59%) were female. The average age was 51.4 years old. The aneurysms were classified into two groups; the superior wall type (23 cases) and the inferior wall type (26 cases). 28 (57.1%) patients had ruptured M1 aneurysms. The incidence of multiple aneurysms was high (22 patients, 45%). 43 (94%) had aneurysms sized less than 10 mm in diameter. Intracerebral hematomas (ICH) were recognized in 13 (27%) patients. 34 (69%) patients showed favorable outcome 3 months after. Overall mortality and morbidity rates were 6.1% and 24.5% respectively. The most common cause of morbidity & mortality was initial ICH. Patients with poor Hunt-Hess (H-H) grade on admission showed worse outcome (p=0.002). Patients without ICH revealed better outcome (p=0.004). Operation-related morbidity was higher in patients with superior wall type aneurysms, which is related with lenticulostriate arteries, than those with inferior wall type. The surgical morbidity might be related to the anatomical factors of the aneurysm. It is critical to save lenticulostriate arteries in patients with superior wall type aneurysm.

3 FPⅡ-3 Surgical clipping of posterior communicating artery aneurysms with lowriding internal carotid artery- operative nuances Hitoshi Fukuda 1, Yoshitaka Kurosaki 2, Akira Handa 2, Masaki Chin 2, Sen Yamagata 2, Tetsuya Ueba 1 1 Department of Neuro, Kochi University Hospital 2 Department of Neuro, Kurashiki Central Hospital Object. In surgical clipping of posterior communicating artery (PCoA) aneurysms, low-riding internal carotid artery (ICA) may complicate the by limiting the working space. The purpose of this study is to elucidate operative nuances pf PCoA aneurysms with low-riding ICA, focusing on necessities of adjunctive surgical procedures. Methods. A total of 24 patients with PCoA aneurysms who underwent surgical clipping were retrospectively analyzed from a single center, observational cohort database in this study. The aneurysms were categorized into those with low-riding ICA (6 cases) and those with normal ICA (18 cases) groups depending on the angle of the ICA against the skull base bone. Characteristics and operative findings of PCoA aneurysms with low-riding ICA were identified. We also evaluated any correlation of low-riding ICA with the use of adjunctive surgical techniques including anterior clinoidectomy and anterior temporal approach, as well as procedure-related complications. Results. Low-riding ICA was associated with low-positioned aneurysmal neck (p = 0.004, Mann-Whitney U test) and narrower retrocarotid surgical window (p = 0.001). PCoA aneurysms with low-riding ICA were associated with increasing use of anterior clinoidectomy (p = 0.007, chi-squared test) and anterior temporal approach (p = 0.006). Although intraoperative aneurysmal rupture occurred more frequently in the of low-ica group (p = 0.02), no significant difference was observed in the frequency of symptomatic procedure-related complications. Conclusions. Adjunctive techniques including anterior clinoidectomy and anterior temporal approach may be required for safe and effective for the PCoA aneurysms with low-riding ICA.

4 FPⅡ-4 Surgical strategy and clinical results of direct for paraclinoid aneurysms Masayuki Gekka 1, Naoki Nakayama 2, Yasuhiro Ito 2, Kikutaro Toukairin 2, Taku Sugiyama 2, Masahito Kawabori 2, Toshiya Osanai 2, Ken Kazumata 2, Kiyohiro Houkin 2 1 Teine Keijinkai Hospital / Hokkaido University Hospital 2 Hokkaido University Hospital Direct for paraclinoid aneurysms (PA) requires manipulation of the dural ring, optic nerve, ophthalmic artery, and anterior clinoid process. The procedure raises different concerns depending on the aneurysm origin and projection. Despite advancements in endovascular treatment, direct remains valuable considering safety and complete obliteration. Therefore, establishing the methodology and verifying clinical result is essential. Clipping with curved clips allows for an ideal closure line, orthogonal to the internal carotid artery (ICA). The aneurysm orifice is closed circumferentially, thereby, preventing stenosis and allowing complete obliteration. Ideal clip insertion depends on sufficient optic nerve unroofing, anterior clinoidectomy, and dural ring opening to free the ICA and aneurysm. For giant aneurysms or dissection, trapping or proximal occlusion with high- or low-flow bypass is administered (with the sequence being important). The clinical results and surgical strategy of direct for PA were investigated in 103 cases (April 2005 to March 2017) at the Department of Neuro, Hokkaido University. Eighty-two patients with unruptured aneurysms and 21 with ruptured aneurysm (mean age, 54.9 years; range, years) were investigated. Surgery included neck clipping (57 cases), high-flow bypass (36), and low-flow bypass (10). Postoperative imaging confirmed aneurysm obliteration, and no cases of reccurence were observed. The postoperative mortality rate was 0%, with morbidity (impaired vision) in 2 cases (1.9%). [Conclusion] Direct for PA offers favorable complete obliteration, mortality, and morbidity rates with relatively low postoperative visual impairment rates. We will present the perioperative video, treatment strategies, and surgical methods.

5 FPⅡ-5 Pterional versus superciliary keyhole approach: direct comparison of approach-related complaints and satisfaction in the same patient Jaechan Park Department of Neuro, Kyungpook National University OBJECTIVE: To evaluate and compare the level of patient satisfaction and approach-related patient complaints between a superciliary keyhole approach and a pterional approach. METHODS: Patients who underwent an ipsilateral superciliary keyhole approach and a contralateral pterional approach for bilateral intracranial aneurysms during an 11-year period were contacted and asked to complete a patient satisfaction questionnaire. The questionnaire covered 5 complaint areas related to the surgical approaches, including craniotomy-related pain, sensory symptoms in the head, cosmetic complaints, palpable cranial irregularities, and limited mouth opening. RESULTS: A total of 21 patients completed the patient satisfaction questionnaire during a followup clinic visit. For the superciliary procedures, no craniotomy-related pain, palpable irregularities, or limited mouth opening were reported, and only minor sensory symptoms (numbness in the forehead) and cosmetic complaints (short linear operative scar) were reported (scale 1) by 1 (4.8%) and 3 patients (14.3%), respectively. Thus, the superciliary approach showed better outcomes as regards the incidence of craniotomy-related pain, cosmetic complaints, and palpable irregularities, with a significant betweenapproach difference (p < 0.05). CONCLUSIONS: In successful cases where the primary surgical goal of complete aneurysm clipping without postoperative complications is achieved, a superciliary keyhole approach provides a much higher level of patient satisfaction than a pterional approach, despite a facial wound. For a pterional approach, the patient satisfaction level is affected by the cosmetic results, craniotomy-related pain, and numbness behind the hairline, in order of importance.

6 FPⅡ-6 Anatomical variation of middle meningeal artery origin ophthalmic artery Yu Kinoshita, Rokuya Tanikawa, Kosumo Noda, Nakao Ota, Tomomasa Kondo, Takanori Miyazaki, Kiyotaka Toyoda, Syuichi Tanada, Sadahisa Tokuda, Hiroyasu Kamiyama Department of Neuro, Sapporo Teishinkai Hospital introduction: Middle meningeal artery origin ophthalmic artery (MophA) is a rare but an important anatomical variety of ophthalmic artery (OphA). In literature, detail anatomical classification has not been reported yet. We report the classification of MophA and its incidence. Method: Using multidetector computed tomography angiography, OphA of 1826 sides in 913 cases treated by surgical clipping for unruptured cerebral aneurysms were analyzed preoperatively and postoperatively. Results: MophA was observed in 24 cases, 30 sides (2.6%). These were classified as 2 groups. Type 1; Recurrent meninigeal artery ran into superior orbital fissure (SOF) in 23 sides (77%). Type 2; meinigolacrimal artery ran through the Hyrtl s canal (meningolacrimal foramen) in 7 sides (23%). In this series, there was no MophA related visual disturbance after operation. Discussion:Modified front-temporal craniotomy was performed not to destroy the MophA as below. A key hole is created at just pterion and craniotomy line was made along the sphenoid redge in a V shape. Due to this procedure, we can visualize the distal part of middle meningeal artery and prevent the injury of the MophA. Dural elevation of middle fossa is minimalized for each case. In addition, especially for paraclinoid aneurysms, subdural anterior clinoidectomy is performed followed with wide sylvian fissure dissection. Conclusions: MophA is 2.6% incidence and classified as 2 groups (type-1 77%, type-2 23%). With a careful attention, we can prevent MophA related visual disturbance in both subtypes.

7 FPⅡ-7 Significance of the basal vein of Rossenthal for the distal transsylvian approach - a classification based on embryogenesis Kosumo Noda 1, Rokuya Tanikawa 1, Ariyan Pirayesh Islamian 2, Yousuke Suzuki 1, Shuusei Fukuyama 1, Shuuichi Tanada 1, Tomomasa Kondo 1, Yuu Kinoshita 1, Nakao Ota 1, Hiroyasu Kamiyama 1 1 Department of Neuro, Sapporo Teishinkai Hospital 2 International Neuroscience Institute, Hannover, Germany 3 Department of neuro, Sapporo teishinkai hospital Introduction: The distal transsylvian approach (DTSA) provides excellent view to pathologies around the internal carotid artery (ICA) and the upper basilar artery (BA). However, dissection is impeded in cases where basal bridging veins (BBVs) from the frontal lobe and temporal lobe (i.e. CVT - common vertical trunk, FBBV - frontobasal bridging vein, UV - uncal vein) drain into the sphenoparietal sinus (SPS) and cavernous sinus (CS). The aim of this study was to examine the correlation between the anatomy of the basal vein of Rosenthal (BVR) and the draining pattern of the BBVs, based on embryogenesis. Methods: The anatomy of the frontotemporal BBVs and the BVR (trisegmental classification according to Huang & Wolf) was retrospectively analyzed with preoperative 4D-CTAs and correlated to intraoperative anatomical findings in 97 cases of unruptured ICA and BA aneurysms, microsurgically clipped in our institute. The configuration of the BVR was classified in four types: 1 = mature BVR (segments I-III developed), 2: BVR displays only segment I, 3: BVR displays segments I & II, 4: BVR poorly developed. Results: Mature BVRs were identified on 4D-CTA in 33 cases. In this group, FBBV and/or UV were encountered intraoperatively in 12.1%, CVT in 6.1%. The remaining 64 cases comprised immature BVRs (types 2-4) with prevalence of FBBV/UV in 90.6% and CVT in 70.3%. Conclusion: The anatomy of the BVR affects the drainage pattern of the basal frontotemporal region and may indicate the challenge for microsurgical dissection as well as limitations of the panoramic view in DTSA.

8 FPⅡ-8 The efficacy of orbital skeletonization in pterional approach for anterior communicating artery aneurysm Kiyotaka Toyota, Nakao Ota, Kosumo Noda, Sadahisa Tokuda, Hiroyasu Kamiyama, Rokuya Tanikawa Sapporo Teishinkai Hospital Pterional approach and its variations are versatile and useful approaches for neurovascular. They are used to access various pathologies arising from circle of Willis and its surrounding vicinity. The ultimate goal of the pterional approach is to obtain optimal exposure of the pathologies while minimum retraction of the brain. Surgery for anterior communicating artery (AcomA) aneurysms is generally accomplished by pterional or interhemispheric approach, both approaches have disadvantages. The selection of either approach depends on the aneurysm size, projection, and height from the planum sphenoidale. Minimum retraction of frontal lobe and exposure of AcomA complex are required to ensure preservation of the important vessels during via pterional approach. Generally excessive retraction of the frontal lobe is required if the aneurysm location is high or posterior, however excessive frontal retraction has been known to cause postoperative olfactory dysfunction or brain contusion. In standard fronto-temporal craniotomy, flattening of the medial sphenoid wing to the level of meningo-orbital band is usually performed. In our facility, additional egg-shell drilling of lateral and superior orbital wall; orbital skeletonization(os) is frequently used in pterional approach because the lateral and superior orbital wall can often pose obstacles within the surgical corridor in pterional approach. OS provides significant advantage for infero-lateral to superior oblique trajectory which facilitates exposure of AcomA complex without excessive frontal lobe retraction. This simple procedure OS provides simultaneously enough light source and comfortable working angle without excessive frontal lobe retraction and should be helpful for improving surgical outcomes.

9 FPⅡ-9 Clipping of difficult ICA aneurysms in the endovascular era Hideyuki Yoshioka, Kazuya Kanemaru, Koji Hashimoto, Takashi Yagi, Nobuo Senbokuya, Hiroyuki Kinouchi Department of Neuro, University of Yamanashi [Introduction] With the advancement of devices and techniques, indications of endovascular treatment of ICA aneurysms have been expanding. However, clipping is still the most reliable therapy in some cases. In this study, we studied the characteristics of clipping cases for ICA aneurysms in the endovascular era. [Methods] Intracranial ICA aneurysm cases in recent 5 years are included in this study. We studied the reasons for the difficulty of endovascular treatment, and also analyzed the outcomes. [Results] 70 aneurysms were treated by clipping, and 38 aneurysms (paraclinoid 13, IC-PC 13, C1 3, IC- AChA 2, blood blister 7) were judged as difficult for endovascular treatment. In paraclinoid aneurysms, 8 aneurysms with antero-superior projection seemed more suitable for neck clipping, which was performed relatively easily in all cases. On the other hand, 5 aneurysms with postero-medial projection were large and broad neck-types, which required anterior clinoidectomy and multiple clipping technique. In 18 distal ICA aneurysms (large/broad neck 14, fusiform 1, branching from the dome 3), 13 cases were treated by simple neck clipping, but 5 required multiple clipping technique. Blood blister-like aneurysms (anterior wall 5, posterior wall 2) were treated by wrap-clipping. Clinical outcomes were excellent in 34 aneurysms. [Conclusion] Some difficult cases for endovascular treatment are even difficult for clipping; however, these aneurysms were treatable with multiple clipping or wrap-clipping technique.

10 FPⅡ-10 STA-P2 bypass with aneurysm trapping : Treatment of recanalization of coiled PCA aneurysm Sunghoon Kim, Jaeseung Bang Seoul National University Bundang Hospital Introduction Posterior cerebral artery (PCA) aneurysms are rare and surgically challenging. Proximal parent artery occlusion and revascularization has been considered a feasible treatment option for complex PCA aneurysm. Case description A 50-year-old woman underwent coil embolization for unruptured PCA fusiform aneurysm of the right P1-2 junction in 2008 in another hospital. Aneurysmal dilatation was completely occluded after embolization at that time. However, follow-up angiography 5 years after treatment showed recanalization of the aneurysm at proximal site of embolization. During the subsequent follow-up of 6 years, aneurysm enlarged. Size of aneurysm was 7.7mm X 8.7mm. After failure of stent assisted coil embolization due to P1 stenosis, open was performed. Rt. STA-P2 anastomosis following trapping and removal of the coiled aneurysm were successfully performed through the half and half approach. The patient presented left hemiplegia due to right cerebral peduncle immediately postoperative period. One week after operation, left side motor power was nearly normalized. Postoperative angiography revealed patency of bypass and disappearance of aneurysm. Conclusion Endovascular coil embolization for PCA aneurysm may not be curative, and the coiled aneurysm may recur for a long term follow up. Microsurgical bypass trapping can be considered as the alterative or salvage treatment because of curability.

11 FPⅡ-11 Microsurgical Treatment of Recurrent Intracranial Aneuryms after Coil Embolization; A Report of 24 Cases Jung Hyun Park 1, Won Hee Lee 1, Sung Tae Kim 1, Kun Soo Lee 1, Sung Hwa Paeng 1, Se Young Pyo 1, Hae Woong Jeong 2, Young Gyun Jeong 1, Yong Tae Jung 1 1 Department of Neuro Busan Paik Hospital, School of Medicine, Inje University, Busan, Korea 2 Department of Diagnostic Radiology Busan Paik Hospital, School of Medicine, Inje University, Busan, Korea Objective: In spite of the widespread use of endovascular treatment for intracranial aneurysms, concerns about endovascular treatment, such as possibility of incomplete coiling, low long-term durability, and rebleeding risk, still remain. In this study, we present cases of patients who experienced recurrent aneurysms after coiling and subsequently underwent surgical treatment and reviewed of the literature. Methods: From June, 2012 to august, 2017, 957 consecutive patients who presented with aneurysms which incidental and ruptured were treated using endovascular treatment. We have experienced 24 cases of microsurgical retreatment after coil embolization. Results: Incidence of microsurgical retreatment was 0.025% (24/957). We excluded that just followed up and additional endovascular treatment were used. Of the 24 patients, 10 cases were rebleeding, 1 case was remnant due to rupture during the procedure, and the remaining 13 cases were recanalization and regrowth of the aneurysm. Aneurysm locations were as follows; 12 on the anterior communicating artery; 5 on the posterior communication artery; 4 on the anterior cerebral artery(a2-3); 2 on the anterior wall of internal cerebral artery; 1 on the bifurcation of internal cerebral artery. Direct clipping was performed in 21 cases, and graft interposition bypass with internal trapping was performed 2 cases, last 1 case was performed coil extraction with clipping. Conclusion: In our experience, patients who initially underwent subarachnoid hemorrhage showed a high recurrence rate (21/24) and Aneurysm of anterior communicating artery showed high rate of recurrent (12/24).The case of recurrent aneurysms that previously coiled, microsurgical treatment can be a viable treatment option.