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Esmaeeli S, Motayagheni N, Bastos AB, Ogilvy CS, Thomas AJ, Pollard R, Buhl LK, Baker MB, Phan S, Hassan O, Fehnel CR, Eikermann M, Shaefi S, Nozari A. Propofol-Based Anesthesia Maintenance and/or Volatile Anesthetics during Intracranial Aneurysm Repair: A Comparative Analysis of Neurological Outcomes. J Clin Med 2023; 12:6954. [PMID: 37959418 PMCID: PMC10648155 DOI: 10.3390/jcm12216954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Volatile and intravenous anesthetics have substantial effects on physiological functions, notably influencing neurological function and susceptibility to injury. Despite the importance of the anesthetic approach, data on its relative risks or benefits during surgical clipping or endovascular treatments for unruptured intracranial aneurysms (UIAs) remains scant. We investigated whether using volatile anesthetics alone or in combination with propofol infusion yields superior neurological outcomes following UIA obliteration. METHODS We retrospectively reviewed 1001 patients who underwent open or endovascular treatment for UIA, of whom 596 had short- and long-term neurological outcome data (modified Rankin Scale) recorded. Multivariable ordinal regression analysis was performed to examine the association between the anesthetic approach and outcomes. RESULTS Of 1001 patients, 765 received volatile anesthetics alone, while 236 received propofol infusion and volatile anesthetics (combined anesthetic group). Short-term neurological outcome data were available for 619 patients and long-term data for 596. No significant correlation was found between the anesthetic approach and neurologic outcomes, irrespective of the type of procedure (open craniotomy or endovascular treatment). The combined anesthetic group had a higher rate of ICU admission (p < 0.001) and longer ICU and hospital length of stay (LOS, p < 0.001). Similarly, a subgroup analysis revealed longer ICU and hospital LOS (p < 0.0001 and p < 0.001, respectively) in patients who underwent endovascular UIA obliteration under a combined anesthetic approach (n = 678). CONCLUSIONS The addition of propofol to volatile anesthetics during UIA obliteration does not provide short- or long-term benefits to neurologic outcomes. Compared to volatile anesthetics alone, the combination of propofol and volatile anesthetics may be associated with an increased rate of ICU admission, as well as longer ICU and hospital LOS.
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Affiliation(s)
- Shooka Esmaeeli
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (R.P.); (S.S.)
- Department of Anesthesiology, Boston Medical Center, Boston University, Boston, MA 02118, USA; (S.E.); (M.B.B.)
| | - Negar Motayagheni
- Heart Transplant Program, Cedars-Sinai California Heart Center, Beverly Hills, CA 90211, USA;
| | - Andres Brenes Bastos
- Department of Anesthesiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT 06510, USA;
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA;
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ 08103, USA;
| | - Richard Pollard
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (R.P.); (S.S.)
| | - Lauren K Buhl
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Hanover, NH 03766, USA
| | - Maxwell B Baker
- Department of Anesthesiology, Boston Medical Center, Boston University, Boston, MA 02118, USA; (S.E.); (M.B.B.)
| | - Sheshanna Phan
- Department of Internal Medicine, University of New Mexico Hospital, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA;
| | - Omron Hassan
- Department of Internal Medicine, Freeman Hospital, Joplin, MO 64804, USA
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Critical Care, Pain Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA;
| | - Shahzad Shaefi
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (R.P.); (S.S.)
| | - Ala Nozari
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (R.P.); (S.S.)
- Department of Anesthesiology, Boston Medical Center, Boston University, Boston, MA 02118, USA; (S.E.); (M.B.B.)
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Tatezawa R, Sugiyama T, Gotoh S, Shindo T, Ikeda H, Hokari M, Takizawa K, Nakayama N, Fujimura M. Possible Delayed Foreign Body Reactions against Titanium Clips and Coating Materials after Unruptured Cerebral Aneurysm Surgery. Neurol Med Chir (Tokyo) 2023; 63:482-489. [PMID: 37648536 PMCID: PMC10687670 DOI: 10.2176/jns-nmc.2023-0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 09/01/2023] Open
Abstract
Delayed foreign body reactions to either or both clipping and coating materials have been reported in several small series; however, studies in the titanium clip era are scarce. This study aims to survey the contemporary status of such reactions to titanium clips and coating materials. Among patients who received a total of 2327 unruptured cerebral aneurysmal surgeries, 12 developed delayed intraparenchymal reactions during outpatient magnetic resonance imaging (MRI) follow-up. A retrospective investigation was conducted. The patients' average age was 58.6 (45-73) years, and 11 were women. The aneurysms were located in the middle cerebral artery (n = 7), internal carotid artery (n = 4), or anterior communicating artery (AComA, n = 1). In 10 patients, additional coating with tiny cotton fragments was applied to the residual neck after clipping with titanium clips; however, only the clipping with titanium clips was performed in the remaining two. The median time from surgery to diagnosis was 4.5 (0.3-60) months. Seven (58.3%) patients were asymptomatic, and three developed neurological deficits. MRI findings were characterized by a solid- or rim-enhancing lobulated mass adjacent to the clip with surrounding parenchymal edema. In 11 patients, the lesions reduced in size or disappeared; however, in one patient, an AComA aneurysm was exacerbated, necessitating its removal along with optic nerve decompression. In conclusion, cotton material is a strongly suspected cause of delayed foreign body reactions, and although extremely rare, titanium clips alone may also induce such a reaction. The prognosis is relatively good with steroid therapy; however, caution is required when the aneurysm is close to the optic nerve, as in AComA aneurysms.
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Affiliation(s)
- Ryota Tatezawa
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Shuho Gotoh
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | | | - Hiroshi Ikeda
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Masaaki Hokari
- Department of Neurosurgery, Teine Keijinkai Medical Center
| | | | - Naoki Nakayama
- Department of Neurosurgery, Kashiwaba Neurosurgical Hospital
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
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Tanaka R, Liew BS, Yamada Y, Sasaki K, Miyatani K, Komatsu F, Kawase T, Kato Y, Hirose Y. Depiction of Cerebral Aneurysm Wall by Computational Fluid Dynamics (CFD) and Preoperative Illustration. Asian J Neurosurg 2022; 17:43-49. [PMID: 35873850 PMCID: PMC9298587 DOI: 10.1055/s-0042-1749148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction
Preoperative illustration is a part of an important exercise to study the configuration, direction, and presence of any perforations, and is the weakest point in the wall of the cerebral aneurysm. The same illustration is used to study the surrounding brain structures to decide the best and safe surgical approach prior to any surgical procedure. With the evolution of the aneurysm wall study and study of flow dynamic within the involved artery and its aneurysm wall using computational fluid dynamics (CFD), a better surgical plan can be formulated to improve the flow dynamics. As one of the clinical applications of CFD, we propose a study using a composite image that combines preoperative illustration and CFD, which is traditionally widely used in neurosurgery.
Methods and Materials
We study the use of illustrations of the unruptured cerebral aneurysm of internal carotid-posterior communicating (ICPC) artery and anterior communicating artery (AcomA) treated at our hospital. The combinations of both preoperative illustrations and CFD images by using “ipad Pro” were used.
Result and Conclusion
Medical illustration in the preoperative study of unruptured cerebral aneurysm with combinations of CFD and surrounding brain structures is helpful to decide the surgical approaches and successful surgical treatments.
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Affiliation(s)
- Riki Tanaka
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Boon Seng Liew
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Kento Sasaki
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Kyosuke Miyatani
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Fuminari Komatsu
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
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Lingaraju T, Shukla D. Clipping and Coiling with the Same Hand. J Neurosci Rural Pract 2021; 12:613. [PMID: 34737492 PMCID: PMC8559071 DOI: 10.1055/s-0041-1736153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- T.S. Lingaraju
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
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Metayer T, Lechanoine F, Bougaci N, de Schlichting E, Terrier L, Derrey S, Barbier C, Papagiannaki C, Ashraf A, Tahon F, Leplus A, Gay E, Emery E, Briant AR, Vivien D, Gaberel T. Retreatment of previously treated intracranial aneurysm: Procedural complications and risk factors for complications. Neurochirurgie 2021; 68:150-155. [PMID: 34487752 DOI: 10.1016/j.neuchi.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Intracranial aneurysm (IA) is a frequent vascular malformation that can be managed by endovascular treatment (EVT) or microsurgery. A previously treated IA can recanalize, which may require further treatment. The aim of our study was to evaluate procedural complications related to IA retreatment and their risk factors. METHODS All patients retreated for IA between 2007 and 2017 in 4 hospitals were included. We retrospectively reviewed the frequency of procedural complications of IA retreatment, defined as death or≥1-point increase in modified Rankin score 24h after the procedure. We then screened for risk factors of procedural complications by comparing the characteristics of patients with and without complications. RESULTS During the inclusion period, 4,997 IAs were treated in our 4 institutions. Of these, 237 (4.7%) were retreated. 29 (12.2%) had≥1 procedural complication. However, severe complications, defined as death or dependency at 1 month, occurred only in 3 patients (1.3%). The only risk factor for complications was microsurgical clipping as retreatment. CONCLUSIONS Procedural complications during IA retreatment were frequent but, in most cases, retreatment did not lead to death or severe disability. The only risk factor for complications of IA retreatment was clipping as retreatment. However, the design of the study did not allow any conclusion to be drawn as to the optimal means of aneurysm retreatment, and further studies are needed.
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Affiliation(s)
- T Metayer
- Department of Neurosurgery, University Hospital of Caen, Avenue de la Côte de Nacre, 14000 Caen, France; Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France.
| | - F Lechanoine
- Department of Neurosurgery, University Hospital of Grenoble, 38000 Grenoble, France
| | - N Bougaci
- Department of Neurosurgery, University Hospital of Nice, 06000 Nice, France
| | - E de Schlichting
- Department of Neurosurgery, University Hospital of Grenoble, 38000 Grenoble, France
| | - L Terrier
- Department of Neurosurgery, University Hospital of Rouen, 76000 Rouen, France
| | - S Derrey
- Department of Neurosurgery, University Hospital of Nice, 06000 Nice, France
| | - C Barbier
- Department of Neurosurgery, University Hospital of Rouen, 76000 Rouen, France; Department of Biostatistics, University Hospital of Caen, Caen, France
| | - C Papagiannaki
- Department of Neuroradiology, University Hospital of Caen, 14000 Caen, France
| | - A Ashraf
- Department of Neurosurgery, University Hospital of Grenoble, 38000 Grenoble, France
| | - F Tahon
- Department of Neuroradiology, University Hospital of Rouen, 76000 Rouen, France
| | - A Leplus
- Department of Neurosurgery, University Hospital of Nice, 06000 Nice, France
| | - E Gay
- Department of Neurosurgery, University Hospital of Grenoble, 38000 Grenoble, France
| | - E Emery
- Department of Neurosurgery, University Hospital of Caen, Avenue de la Côte de Nacre, 14000 Caen, France; Department of Neuroradiology, University Hospital of Grenoble, 38000 Grenoble, France
| | - A R Briant
- Medical School, University of Caen Normandy, 14000 Caen, France; Department of Biostatistics, University Hospital of Caen, Caen, France
| | - D Vivien
- Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France; Department of Neuroradiology, University Hospital of Grenoble, 38000 Grenoble, France
| | - T Gaberel
- Department of Neurosurgery, University Hospital of Caen, Avenue de la Côte de Nacre, 14000 Caen, France; Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France.
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Sugiyama T, Clapp T, Nelson J, Eitel C, Motegi H, Nakayama N, Sasaki T, Tokairin K, Ito M, Kazumata K, Houkin K. Immersive 3-Dimensional Virtual Reality Modeling for Case-Specific Presurgical Discussions in Cerebrovascular Neurosurgery. Oper Neurosurg (Hagerstown) 2021; 20:289-299. [PMID: 33294936 DOI: 10.1093/ons/opaa335] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Adequate surgical planning includes a precise understanding of patient-specific anatomy and is a necessity for neurosurgeons. Although the use of virtual reality (VR) technology is emerging in surgical planning and education, few studies have examined the effectiveness of immersive VR during surgical planning using a modern head-mounted display. OBJECTIVE To investigate if and how immersive VR aids presurgical discussions of cerebrovascular surgery. METHODS A multiuser immersive VR system, BananaVisionTM, was developed and used during presurgical discussions in a prospective patient cohort undergoing cerebrovascular surgery. A questionnaire/interview was administered to multiple surgeons after the surgeries to evaluate the effectiveness of the VR system compared to conventional imaging modalities. An objective assessment of the surgeon's knowledge of patient-specific anatomy was also conducted by rating surgeons' hand-drawn presurgical illustrations. RESULTS The VR session effectively enhanced surgeons' understanding of patient-specific anatomy in the majority of cases (83.3%). An objective assessment of surgeons' presurgical illustrations was consistent with this result. The VR session also effectively improved the decision-making process regarding minor surgical techniques in 61.1% of cases and even aided surgeons in making critical surgical decisions about cases involving complex and challenging anatomy. The utility of the VR system was rated significantly higher by trainees than by experts. CONCLUSION Although rated as more useful by trainees than by experts, immersive 3D VR modeling increased surgeons' understanding of patient-specific anatomy and improved surgical strategy in certain cases involving challenging anatomy.
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Affiliation(s)
- Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tod Clapp
- Department of Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Jordan Nelson
- Department of Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Chad Eitel
- Department of Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Hiroaki Motegi
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoki Nakayama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsukasa Sasaki
- Department of Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Kikutaro Tokairin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ken Kazumata
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kiyohiro Houkin
- Department of Emergent Neurocognition, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
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Catapano JS, Fredrickson VL. Commentary: Immersive 3-Dimensional Virtual Reality Modeling for Case-Specific Presurgical Discussions in Cerebrovascular Neurosurgery. Oper Neurosurg (Hagerstown) 2021; 20:E210-E211. [PMID: 33372944 DOI: 10.1093/ons/opaa444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Vance L Fredrickson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, Utah
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Torazawa S, Ono H, Inoue T, Tanishima T, Tamura A, Saito I. Trapping, dome puncture, and direct suction decompression in conjunction with assistant superficial temporal artery- middle cerebral artery bypass to clip giant internal carotid artery bifurcation aneurysm. Surg Neurol Int 2019; 10:205. [PMID: 31768285 PMCID: PMC6826317 DOI: 10.25259/sni_462_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/03/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Very large and giant aneurysms (≥20 mm) of the internal carotid artery (ICA) bifurcation (ICAbif) are definitely rare, and optimal treatment is not established. Endovascular treatments are reported as suboptimal due to difficulties of complete occlusion and tendencies to recanalization. Therefore, direct surgery remains an effective strategy if the clipping can be performed safely and reliably, although very difficult. Case Description: Two cases of ICAbif aneurysms (>20 mm) were treated. Prior assistant superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed to avoid ischemic complications during prolonged temporary occlusion of the arteries in both cases. In Case 1 (22-mm aneurysm), the dome was inadvertently torn in applying the clip because trapping had resulted in insufficient decompression. Therefore, in Case 2 (28-mm aneurysm), almost complete trapping of the aneurysm and subsequent dome puncture was performed, and the aneurysm was totally deflated by suction from the incision. This complete aneurysm decompression allowed safe dissection and successful clipping. Conclusion: Trapping, deliberate aneurysm dome puncture, and suction decompression from the incision in conjunction with assistant STA-MCA bypass can achieve complete aneurysm deflation, and these techniques enable safe dissection of the aneurysm and direct clipping of the aneurysm neck. Direct clipping with this technique for very large and giant ICAbif aneurysms may be the optimal treatment choice with the acceptable outcome if endovascular treatment remains suboptimal.
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Affiliation(s)
- Seiei Torazawa
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan.,Department of Neurosurgery, The University of Tokyo Hospital, Bunkyo-ku, Japan
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo, Japan
| | - Takeo Tanishima
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Akira Tamura
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Isamu Saito
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
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Stapleton CJ, Amin-Hanjani S. Commentary: Microsurgical Clipping of Anterior Choroidal Artery Aneurysms: A Systematic Approach to Reducing Ischemic Complications in an Experience with 146 Patients. Oper Neurosurg (Hagerstown) 2019; 17:E145-E146. [DOI: 10.1093/ons/opz032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/10/2019] [Indexed: 11/14/2022] Open
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10
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Savardekar AR, Patra DP, Narayan V, Bollam P, Guthikonda B, Nanda A. Internal Carotid Artery Bifurcation Aneurysms: Microsurgical Strategies and Operative Nuances for Different Aneurysmal Directions. Oper Neurosurg (Hagerstown) 2018; 15:386-394. [PMID: 29373750 DOI: 10.1093/ons/opx282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 12/08/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Internal carotid artery bifurcation aneurysms (ICAbifAs), comprising approximately 5% of intracranial aneurysms, are characterized clinically by their tendency to occur at a younger age and surgically by the technical difficulties posed by their domes being adherent to the frontal lobe, their location at the apex of the sylvian fissure, and their relation to myriad perforator complexes. OBJECTIVE To review the nuances of technique and operative strategy specific to aneurysmal direction in the light of our experience with ICAbifAs. METHODS ICAbifAs managed at our institute from January 2001 to July 2016 were analyzed. Detailed analysis of clinical data, pre- and postoperative radiology, operative notes and videos, and clinical outcome was done. RESULTS Fifty-one patients with ICAbifAs were treated in the study period out of which 40 patients underwent microsurgical clipping. The median age was 48 yr (range 14-68 yr). Nearly 95% of the patients presented in a good clinical grade (World Federation of Neurological Surgeons grade 1 and 2). At 6-mo follow-up, 36 patients (90%) had good clinical outcome (Glasgow Outcome Scale 4 and 5). According to their direction, ICAbifAs were grouped as anteriorly directed (10 cases), superiorly directed (23 cases), and posteriorly directed (7 cases). Operative techniques and nuances utilized depend on aneurysmal direction and are presented here. CONCLUSION An appropriate surgical strategy based on the direction of ICAbifAs as per the preoperative radiology, meticulous dissection of aneurysmal wall from adjacent perforators, and clip application with the aim of remodeling the ICA bifurcation are integral to achieving a good outcome.
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Affiliation(s)
| | | | | | | | | | - Anil Nanda
- Department of Neurosurgery, LSU-HSC, Shreveport, Louisiana
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