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Muirhead WR, Layard Horsfall H, Khan DZ, Koh C, Grover PJ, Toma AK, Castanho P, Stoyanov D, Marcus HJ, Murphy M. Microsurgery for intracranial aneurysms: A qualitative survey on technical challenges and technological solutions. Front Surg 2022; 9:957450. [PMID: 35990100 PMCID: PMC9386123 DOI: 10.3389/fsurg.2022.957450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/06/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Microsurgery for the clipping of intracranial aneurysms remains a technically challenging and high-risk area of neurosurgery. We aimed to describe the technical challenges of aneurysm surgery, and the scope for technological innovations to overcome these barriers from the perspective of practising neurovascular surgeons. Materials and Methods Consultant neurovascular surgeons and members of the British Neurovascular Group (BNVG) were electronically invited to participate in an online survey regarding surgery for both ruptured and unruptured aneurysms. The free text survey asked three questions: what do they consider to be the principal technical barriers to aneurysm clipping? What technological advances have previously contributed to improving the safety and efficacy of aneurysm clipping? What technological advances do they anticipate improving the safety and efficacy of aneurysm clipping in the future? A qualitative synthesis of responses was performed using multi-rater emergent thematic analysis. Results The most significant reported historical advances in aneurysm surgery fell into five themes: (1) optimising clip placement, (2) minimising brain retraction, (3) tissue handling, (4) visualisation and orientation, and (5) management of intraoperative rupture. The most frequently reported innovation by far was indocyanine green angiography (84% of respondents). The three most commonly cited future advances were hybrid surgical and endovascular techniques, advances in intraoperative imaging, and patient-specific simulation and planning. Conclusions While some surgeons perceive that the rate of innovation in aneurysm clipping has been dwarfed in recent years by endovascular techniques, surgeons surveyed highlighted a broad range of future technologies that have the potential to continue to improve the safety of aneurysm surgery in the future.
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Affiliation(s)
- W. R. Muirhead
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - H. Layard Horsfall
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - D. Z. Khan
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - C. Koh
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - P. J. Grover
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - A. K. Toma
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - P. Castanho
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - D. Stoyanov
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - H. J. Marcus
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - M. Murphy
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Unilateral approach for bilateral middle cerebral artery aneurysms assisted by preoperative understandings of aneurysm wall properties:2-dimensional operative video. World Neurosurg 2022; 162:42. [PMID: 35314404 DOI: 10.1016/j.wneu.2022.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/11/2022] [Accepted: 03/12/2022] [Indexed: 11/21/2022]
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Panigrahi M, Patel C, Koradia P, Chandrasekhar YBVK. Contralateral Clipping of Multiple Intracranial Aneurysms. Adv Tech Stand Neurosurg 2022; 44:161-173. [PMID: 35107678 DOI: 10.1007/978-3-030-87649-4_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The reported incidence of multiple intracranial aneurysms (MIA) is approximately 7-35% of all intracranial aneurysms. The primary goal in the management of MIAs is to secure the ruptured aneurysm and to treat as many of the remaining lesions as possible without affecting the outcome of the patient. In recent era endovascular treatment is the preferred treatment of multiple bilateral intracranial aneurysms if all aneurysms are amenable to addressed in single stage. But most often all aneurysms were not possible to addressed due to complexity of different aneurysms, technical limitation and infrastructure. In such scenarios options left were two stage sequential craniotomy on either sides and clipping of bilateral aneurysms or unilateral craniotomy and clipping of bilateral MIA. Bilateral two stage surgery or two stage endovascular treatment caries risk of bleeding from one of the untreated aneurysms, morbidity due to two stage and increase the cost of treatment. In properly selected cases of unilateral craniotomy and clipping of bilateral MIA secure the all aneurysm in one stage and decreased morbidity and cost of treatment. When patient selection done meticulously, clipping of MIA including contralateral side aneurysms is feasible and safe.
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Affiliation(s)
- Manas Panigrahi
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.
| | - Chirag Patel
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - Pratik Koradia
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - Y B V K Chandrasekhar
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
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Tsunoda S, Yoshikawa G, Ishikawa O. One-stage Operation with Ipsilateral Two-Piece Craniotomies for a Case of Subarachnoid Hemorrhage with Multiple Intracranial Aneurysms. Asian J Neurosurg 2020; 14:1226-1230. [PMID: 31903368 PMCID: PMC6896625 DOI: 10.4103/ajns.ajns_165_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) with multiple intracranial aneurysms is common, but the difficulties often arise in determining treatment strategy in the acute phase. We experienced a case of SAH with distal anterior cerebral artery aneurysm coexisting with middle cerebral artery and anterior communicating artery aneurysms, in which it was difficult to identify the precise rupture site preoperatively, and both pterional approach and interhemispheric approach were required in the acute phase of SAH. However, we could treat whole aneurysms in one stage and obtained an excellent outcome using our surgical procedure with ipsilateral frontotemporal and frontal parasagittal craniotomies through a single skin incision.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, Showa General Hospital, Tokyo, Japan.,Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Osamu Ishikawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, Japan.,Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Rajagopal N, Yamada Y, Balaji A, Kawase T, Kato Y. Multiples of multiple: Case series of mirror aneurysms and review of literature. Int J Surg Case Rep 2019; 61:141-146. [PMID: 31362238 PMCID: PMC6675932 DOI: 10.1016/j.ijscr.2019.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/14/2019] [Indexed: 11/29/2022] Open
Abstract
Incidentally detected unruptured mirror intracranial aneurysms are on the rise due to advanced imaging modalities. Further studies are required to elucidate theories of development, inheritance pattern and the need for screening of 1st-degree relatives with twin aneurysms. Treatment strategy for mirror aneurysms should be customised based on the location, size, morphology and clinical manifestations of each patient. Randomised control trials that compare [single/multistage] clipping and coiling of mirror aneurysms are necessary to decide the best intervention strategy.
Introduction Mirror aneurysms are a rare subtype of multiple aneurysms, located in identical or adjacent arterial segment bilaterally. We report a case series of 3 such patients amongst whom one of them had 3 sets of mirror aneurysms and the other patient had 2 sets of mirror aneurysm on the same arterial segment which has not been reported till date. Methods A retrospective analysis of 3 patients with incidentally detected multiple mirror aneurysms, who were treated with microsurgical clipping and coiling, was conducted. A systematic search was performed using the PUBMED database and relevant articles were reviewed with particular attention to incidence, associated conditions, risk factors and management strategies. Written informed consent was obtained from all of the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. This research work has been reported in line with the PROCESS criteria (Agha et al., 2018). Results All the 3 patients were females with incidentally detected multiple mirror aneurysms. All the 3 patients were known Hypertensives. All the aneurysms were successfully clipped by a multistage, bilateral craniotomy except the one in the cavernous ICA, for which an endovascular procedure is planned. All of them had an uneventful postoperative course with the CT angiogram showing obliteration of all the clipped aneurysms except the one in the cavernous ICA. Conclusions Multiple mirror aneurysms represent a rare occurrence of a diverse pathology. Both these described types of cases have not been reported so far in the literature. The treatment strategy for mirror aneurysms should be determined individually based on the location, size, and morphology of the aneurysms, as well as, on the clinical manifestations of each patient.
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Affiliation(s)
- Niranjana Rajagopal
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India.
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Arun Balaji
- Department of Neurosurgery, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
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Choi HH, Cho YD, Yoo DH, Lee J, Mun JH, An SJ, Kang HS, Cho WS, Kim JE, Han MH. Intracranial Mirror Aneurysms: Anatomic Characteristics and Treatment Options. Korean J Radiol 2018; 19:849-858. [PMID: 30174473 PMCID: PMC6082764 DOI: 10.3348/kjr.2018.19.5.849] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/03/2018] [Indexed: 11/29/2022] Open
Abstract
Objective Mirror aneurysms are generally considered as a subset of multiple aneurysms, defined as aneurysms occurring bilaterally and symmetrically on the same-named vessels. Although not infrequent, the characteristics of mirror aneurysms are not well studied. This investigation was conducted to elucidate the anatomic features of such lesions and examine treatment options. Materials and Methods A retrospective review was conducted, aimed at 172 patients treated for 344 mirror aneurysms between January 2007 and December 2015. Aneurysms of similar nature but in asymmetric locations on the same-named vessels were excluded. All available records were examined and lesion characteristics, as well as treatment outcomes were assessed. Results In study subjects (n = 172), mirror aneurysms most often involved middle cerebral artery bifurcation (n = 83), followed by a paraclinoid internal carotid artery (n = 50) and posterior communicating artery (n = 21). Most of the lesions (95.3%) measured ≤ 10 mm, and in 126 patients (74.6%), the size ratios were > 50%. Of the 344 aneurysms studied, coil embolization was undertaken in 217, surgical clipping in 62, and observation alone (no treatment) in 65. Coil embolization and surgical clipping were done bilaterally in 83 and 12 patients, respectively. In 12 patients, combined coiling and clipping were implemented on each side. Single-stage coil embolization of both the aneurysms was performed in 73 patients, with excellent post-procedural (85.6%) and follow-up (86.8%) occlusive results. There was no procedure-related morbidity or mortality. Conclusion By adopting different treatment strategies to different configurations and vascular sources, mirror aneurysms can be safely and effectively treated. If feasible, single-stage coil embolization should be considered as a reasonable treatment option for mirror aneurysms.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul 06974, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jeongjun Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Korea
| | - Jong Hyeon Mun
- Department of Neurosurgery, Kwangju Christian Hospital, Gwangju 61661, Korea
| | - Sang Joon An
- Department of Neurology, International St. Mary's Hospital, Catholic Kwandong University of Korea College of Medicine, Incheon 22711, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Moon Hee Han
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
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Fully Endoscope-Controlled Clipping Bilateral Middle Cerebral Artery Aneurysm Via Unilateral Supraorbital Keyhole Approach. J Craniofac Surg 2018; 27:2151-2153. [PMID: 28005775 PMCID: PMC5110332 DOI: 10.1097/scs.0000000000003081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Clipping bilateral middle cerebral artery (bMCA) aneurysms via unilateral approach in a single-stage operation is considered as a challenge procedure. To our knowledge, there is no study in surgical management of patients with bMCA aneurysms by fully endoscope-controlled techniques. The author reported a patient with bMCA aneurysms who underwent aneurysms clipping via a unilateral supraorbital keyhole approach by endoscope-controlled microneurosurgery, and the patient had an uneventful postoperative course without neurologic impairment and complication. Furthermore, the author discussed the advantages and adaptation of endoscope-controlled clipping bMCA aneurysms via unilateral supraorbital keyhole approach.
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Arrese I, Sarabia R. Contralateral approach for middle cerebral artery aneurysms with long M1 segment: report of 2 cases. Neurocirugia (Astur) 2012; 23:122-6. [DOI: 10.1016/j.neucir.2012.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 02/27/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Ignacio Arrese
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
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