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Han HJ, Chung KS, Kim S, Kim JJ, Park KY, Kim YB. Incidence and Characteristics of Cerebral Infarction After Microsurgical Clipping of Unruptured Anterior Circulation Cerebral Aneurysms: Diffusion-Weighted Imaging-Based Analysis of 600 Patients. Neurosurgery 2024:00006123-990000000-01217. [PMID: 38869271 DOI: 10.1227/neu.0000000000003038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/25/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Postclipping cerebral infarction (PCI) remains a major concern after treatment for unruptured intracranial aneurysms (UIAs). However, studies of microsurgical clipping based on diffusion-weighted imaging are limited. We aimed to present the incidence, risk factors, and types of PCI and its radiological and clinical characteristics. METHODS This was a retrospective single-center study in which patients were scheduled to undergo microsurgical clipping for anterior circulation UIAs. The overall incidence and risk factors were calculated. Based on the operation and relevant artery, we categorized PCI on diffusion-weighted imaging into 4 types and presented their radiological and clinical characteristics. RESULTS We reviewed the radiological and clinical data of 605 patients. The overall incidence of PCI was 16.7% (101/605), of which asymptomatic infarction was 14.9% (90/605) and symptomatic infarction was 1.8% (11/605). Hypertension (adjusted odds ratio [aOR], 2.258; 95% confidence interval [CI]: 1.330-3.833), temporary clipping (aOR, 1.690; 95% CI: 1.034-2.760), multiple aneurysm locations (aOR, 1.832; 95% CI: 1.084-3.095), and aneurysm dome size (aOR, 1.094; 95% CI: 1.006-1.190) were independent risk factors for PCI. Type II (perianeurysmal perforator) infarction was the most common type of PCI (48.6%) and the most common cause of symptomatic infarction (72.7%). Types II and III (distal embolic) infarctions correlated with atherosclerotic changes in the aneurysm wall and temporary clipping (62.4% and 70.6%, respectively). The type IV (unrelated) infarction group had a higher incidence of systemic atherosclerosis (55%). CONCLUSION Microsurgical clipping is a safe and viable option for the treatment of anterior circulation UIAs. However, modification of the surgical technique, preoperative radiological assessment, and patient selection are required to reduce the incidence of PCI.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kamath VG, Hande M. Reappraising the neurosurgical significance of the pterion location, morphology, and its relationship to optic canal and sphenoid ridge and neurosurgical implications. Anat Cell Biol 2020; 52:406-413. [PMID: 31949979 PMCID: PMC6952692 DOI: 10.5115/acb.18.200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 04/20/2019] [Accepted: 07/07/2019] [Indexed: 11/27/2022] Open
Abstract
Frontolateral craniotomy procedures have advanced from conventional craniotomy to mini-craniotomy, and to contemporary keyhole surgery. In this context, it is important for the neurosurgeon to precisely locate the pterion. The distance of the pterion center from midpoint of zygomatic arch and posterolateral margin of frontozygomatic suture was studied bilaterally in 50 whole adult skulls in Indian ethnic group. The depth of optic canal and sphenoid ridge from the pterion was recorded bilaterally in fifty cut adult skulls and fifteen three-dimensional computed tomography scans. The suture length, thickness, and morphology were studied. The data were analyzed using SPSS software, two-tailed Student's t test, binary logistic regression and receiver operating characteristic curve for sexual dimorphism. The pterion center was located at a mean distance of 37.02 mm above the midpoint of zygomatic arch, 28.20 mm behind the posterolateral margin of frontozygomatic suture, 42.73 mm lateral to the optic canal and 10.59 mm from the sphenoid ridge. The location did not exhibit sexual dimorphism. In 20% cases the pterion center was 40 mm or more above the midpoint of the zygomatic arch and in 5% cases 35 mm or more posterior to the posterolateral margin of frontozygomatic suture. The mean suture length was 10±3 mm. The mean thickness at the center of the pterion was 3.52±1.45 mm. The commonest variety was sphenoparietal followed by frontotemporal, epipteric, and stellate types. A thorough knowledge of these dimensions has innumerable neurosurgical implications in resection of sellar, parasellar, and paraclinoid tumors and circulatory aneurysms.
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Neyazi B, Siblini A, Frantsev R, Özkan N, Sandalcioglu IE, Sure U, Maslehaty H. The role of the Sylvian fissure configuration and the vascular anatomy on different bleeding patterns in ruptured middle cerebral artery aneurysms. Clin Neurol Neurosurg 2019; 189:105572. [PMID: 31786430 DOI: 10.1016/j.clineuro.2019.105572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/20/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Ruptured middle cerebral artery (MCA) aneurysms are one of the causes of subarachnoid (SAH) or intracerebral hemorrhage (ICH) but the factors associated with the bleeding type are unknown. The aim of the study was to analyze the association of the morphological variations of the Sylvian fissure (SF) and vascular parameters on occurrence of different bleeding patterns in patients with ruptured MCA aneurysms. PATIENTS AND METHODS The data of consecutive 202 patients with ruptured MCA aneurysm of two centers were included for analysis. Patients were divided into three groups: Group 1 with SAH, Group 2 with accompanying ICH and Group 3 with intrasylvian hemorrhage (ISH). The SF was divided into five types according to the previously described classification. Analyzed vascular parameters were aneurysm size, localization, presence of a daughter aneurysm, shape, and angulation of the aneurysm sac. RESULTS A total of 202 patients (141 female, 61 male, mean age 52.4 yr) were included in this study. 67 patients (33.2%) had a SAH, 122 (60.4%) an ICH and 13 (6.4%) presented with ISH. Statistical analysis showed a significant association of narrow and twisted SF types 4 and 5 (p < 0.001) and temporal angulation of the aneurysm (p = 0.030) for occurrence of ICH. All other vascular parameters showed no significant association for any kind of hemorrhage. CONCLUSION Our results allow the conclusion that the complex SF types 4 and 5, as well as the temporal angulation of the aneurysm sac are associated with the occurrence of ICH in ruptured MCA aneurysms.
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Affiliation(s)
- Belal Neyazi
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany.
| | - Ali Siblini
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Roman Frantsev
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Neriman Özkan
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - I Erol Sandalcioglu
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Homajoun Maslehaty
- Department of Neurosurgery, University Hospital Essen, Essen, Germany; Department of Neurosurgery, Nordstadt Hospital, Hannover, Germany.
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Wade R, Plaisant O, Guédon A, Diop AD, Ndiaye A, Manyacka P, Gaye M, Ba S, Ndiaye A, Dia A. Morphology of the lateral fossa of the brain (sylvian valley): anatomo-radiological aspects and surgical application. Surg Radiol Anat 2019; 41:639-655. [PMID: 30955058 DOI: 10.1007/s00276-019-02228-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/20/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The knowledge acquired on the lateral fossa of the brain (LFB) is heterogeneous and incomplete. Our goal was to provide a morphological description of the LFB and analyze the impact of these descriptions on the surgical approach of the region. METHODS The morphology of LFB was studied on 40 cerebral hemispheres of 20 right-handed subjects aged 18-55 years with an MRI of 1.5 T. The anatomo-radiological identification of the two section levels preceded the description of the shapes of the LFB. From these landmarks, the forms presented by the LFB were identified and described on each of the transverse, sagittal and frontal planes. The comparison of the proportion of shapes made it possible to identify the typical shapes at each section level and on each section plane. RESULTS The average age of the subjects was 33 years with extremes of 19 and 54 years including 7 women and 13 right-handed men. According to the plane and the level of section, 6 typical morphologies of the LFB have been described, 2 of which were identical. The forms did not vary according to the cerebral hemisphere or the sex of the subject. The set of typical morphologies made it possible to determine a reference subject called NSK which presented the greatest number of typical morphological characteristics. CONCLUSION Knowledge of LFB anatomical imaging is of paramount importance in the pre-surgical evaluation of pathologies in this region. The reference subject will be used for our future biometric and three-dimensional manual reconstruction work in this region.
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Affiliation(s)
- Racky Wade
- Laboratory of Anatomy and Organogenesis, Faculty of Medicine, Pharmacy and Stomatology, Cheikh Anta Diop University, Post Box 5885, 10700, Dakar, Senegal. .,Research Unit for the Development of Anatomy and Imaging (URDIA) EA 4465, Department of Numerical, Surgical, Radiological and Experimental Anatomy, Paris Descartes-Sorbonne Paris Cité University, Paris, France.
| | - Odile Plaisant
- Research Unit for the Development of Anatomy and Imaging (URDIA) EA 4465, Department of Numerical, Surgical, Radiological and Experimental Anatomy, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - Alexis Guédon
- Research Unit for the Development of Anatomy and Imaging (URDIA) EA 4465, Department of Numerical, Surgical, Radiological and Experimental Anatomy, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - Abdoulaye Dione Diop
- Diagnostic and Medical Imaging Center, Fann National University Hospital Center, Dakar, Senegal
| | - Aïnina Ndiaye
- Laboratory of Anatomy and Organogenesis, Faculty of Medicine, Pharmacy and Stomatology, Cheikh Anta Diop University, Post Box 5885, 10700, Dakar, Senegal
| | - Philippe Manyacka
- Laboratory of Anatomy and Organogenesis, UFR 2S, Gaston Berger University, Saint-Louis, Senegal
| | - Magaye Gaye
- Laboratory of Anatomy and Organogenesis, Faculty of Medicine, Pharmacy and Stomatology, Cheikh Anta Diop University, Post Box 5885, 10700, Dakar, Senegal
| | - Sokhna Ba
- Diagnostic and Medical Imaging Center, Fann National University Hospital Center, Dakar, Senegal
| | - Abdoulaye Ndiaye
- Laboratory of Anatomy and Organogenesis, Faculty of Medicine, Pharmacy and Stomatology, Cheikh Anta Diop University, Post Box 5885, 10700, Dakar, Senegal
| | - Abdarahmane Dia
- Laboratory of Anatomy and Organogenesis, Faculty of Medicine, Pharmacy and Stomatology, Cheikh Anta Diop University, Post Box 5885, 10700, Dakar, Senegal
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Meybodi AT, Lawton MT, Rubio RR, Yousef S, Benet A. Contralateral Approach to Middle Cerebral Artery Aneurysms: An Anatomical-Clinical Analysis to Improve Patient Selection. World Neurosurg 2017; 109:e274-e280. [PMID: 28987838 DOI: 10.1016/j.wneu.2017.09.160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND A contralateral approach to aneurysm clipping in cases of bilateral middle cerebral artery (MCA) aneurysms reduces surgical time and cost. However, there is a lack of evidence for objective patient selection. In this study, we assessed the change in surgical freedom along the contralateral MCA to provide objective evidence for patient selection. METHODS Sixteen cadaveric specimens were studied. Through a pterional approach, the surgical freedom was calculated moving distally along the contralateral MCA in 5-mm increments. In addition, in a series of 19 MCA aneurysms clipped contralaterally by the senior author, the average length of the MCA from its origin to the aneurysm neck was measured on angiography. RESULTS In these patients treated via a contralateral approach, the average length of the MCA segment from its origin to the aneurysm neck was 12.4 mm. Starting at the MCA origin, surgical freedom decreased significantly between all adjacent target points except at 5-10 mm from the MCA origin. CONCLUSIONS After the proximal 5 mm, there is no significant decrease in surgical maneuverability within the proximal 10 mm of MCA when approached contralaterally. When compared to the average length of the MCA from its origin to the aneurysm neck in the clinical series, it can be concluded that the first 10 mm (average, 12.4 mm) of the contralateral MCA may be considered a surgical comfort zone for a contralateral approach. This criterion may be useful for patient selection for a contralateral approach in cases of multiple bilateral intracranial aneurysms.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Roberto Rodriguez Rubio
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Sonia Yousef
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Arnau Benet
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA.
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Platz J, Wagner M, Güresir E, You SJ, Konczalla J, de Rochemont RDM, Berkefeld J, Seifert V. Early diffusion-weighted MRI lesions after treatment of unruptured intracranial aneurysms: a prospective study. J Neurosurg 2017; 126:1070-1078. [DOI: 10.3171/2016.2.jns152456] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Diffusion-weighted MRI was used to assess periprocedural lesion load after repair of unruptured intracranial aneurysms (UIA) by microsurgical clipping (MC) and endovascular coiling (EC).
METHODS
Patients with UIA were assigned to undergo MC or EC according to interdisciplinary consensus and underwent diffusion-weighted imaging (DWI) 1 day before and 1 day after aneurysm treatment. Newly detected lesions by DWI after treatment were the primary end point of this prospective study. Lesions detected by DWI were categorized as follows: A) 1–3 DWI spots < 10 mm, B) > 3 DWI spots < 10 mm, C) single DWI lesion > 10 mm, or D) DWI lesion related to surgical access.
RESULTS
Between 2010 and 2014, 99 cases were included. Sixty-two UIA were treated by MC and 37 by EC. There were no significant differences between groups in age, sex, aneurysm size, occurrence of multiple aneurysms in 1 patient, or presence of lesions detected by DWI before treatment. Aneurysms treated by EC were significantly more often located in the posterior circulation (p < 0.001). Diffusion-weighted MRI detected new lesions in 27 (43.5%) and 20 (54.1%) patients after MC and EC, respectively (not significant). The pattern of lesions detected by DWI varied significantly between groups (p < 0.001). Microembolic lesions (A and B) found on DWI were detected more frequently after EC (A, 14 cases; B, 5 cases) than after MC (A, 5 cases), whereas C and D were rare after EC (C, 1 case) and occurred more often after MC (C, 12 cases and D, 10 cases). No procedure-related unfavorable outcomes were detected.
CONCLUSIONS
According to the specific techniques, lesion patterns differ between MC and EC, whereas the frequency of new lesions found on DWI is similar after occlusion of UIA. In general, the lesion load was low in both groups, and lesions were clinically silent.
Clinical trial registration no.: NCT01490463 (clinicaltrials.gov)
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Affiliation(s)
| | - Marlies Wagner
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | | | - Se-Jong You
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | | | | | - Joachim Berkefeld
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
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Maslehaty H, Deuschl C, Kleist B, Göricke S, Sure U, Müller O. Computed Tomography- and Magnetic Resonance Image-based Analysis of the Anatomical Variations of the Sylvian Fissure and Characteristics of the Middle Cerebral Artery. Clin Pract 2017; 7:890. [PMID: 28243427 PMCID: PMC5304263 DOI: 10.4081/cp.2017.890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/30/2016] [Indexed: 11/23/2022] Open
Abstract
The aim of this cross sectional anatomical study is to determine the distribution of the defined anatomical variations of the Sylvian fissure (SF) in a normal population and to analyze its bilateral superposable presentation. Furthermore, we examined the course of the middle cerebral artery (MCA) and the division of the MCA branches in relation to the SF types. A total of 300 cranial CT scans - 100 CT angiography datasets and 86 MRIs of patients without intracranial pathologies - were reviewed. The SF was categorized in five types based on Yasargils description and our previous publication. The length, diameter and branches of the MCA were measured and compared to the SF types. SPSS 23.0 for Windows® was used for statistical analysis. We analyzed data of 300 patients (171 male, 129 female; mean age 51.6years). Symmetric and mirror-imaged coherence of the SF was found in 266 patients (88.7%, χ2(8)=3.04, p=0.932). The distribution of the SF types showed significant differences in patients younger than 60 years compared to older patients. A bifurcation was observed in 72.0%. A trifurcation was observed in 12.0% and a false bifurcation in 16.0% of patients. There was no significant difference of the measured diameters or length of the M1 segments according to the SF types. In this CT and MRI based anatomical study we could show that a twisted and narrow SF occurred more frequently in patients younger than 60 years of age. The SF has a high congruence intra-individually. The anatomical condition might influence the size and configuration of the proximal MCA, which in turn might influence the surgeon's choice of the approach to the SF. Preoperative evaluation on the basis of the presented data, may help to decide for an appropriate approach to the SF.
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Affiliation(s)
| | | | | | - Sophia Göricke
- Department of Radiology, University Hospital Essen , Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen , Germany
| | - Oliver Müller
- Department of Neurosurgery, University Hospital Essen , Germany
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Nam TK, Park YS, Byun JS, Park SW, Kwon JT. Use of Three-Dimensional Curved-Multiplanar Reconstruction Images for Sylvian Dissection in Microsurgery of Middle Cerebral Artery Aneurysms. Yonsei Med J 2017; 58:241-247. [PMID: 27873519 PMCID: PMC5122643 DOI: 10.3349/ymj.2017.58.1.241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/04/2016] [Accepted: 10/04/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The purpose of this study was to introduce a method of using three-dimensional (3D) curved-multiplanar reconstruction (MPR) images for sylvian dissection during microsurgical treatment of middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS Forty-nine patients who had undergone surgery for MCA aneurysms were enrolled. We obtained the 3D curved-MPR images along the sphenoid ridge using OsiriX MD™ imaging software, compared sylvian dissection time according to several 3D MPR image factors, and investigated the correlations between these images and intraoperative findings. RESULTS Utilizing preoperative information of the sylvian fissure (SF) and peri-aneurysmal space on 3D curved-MPR images, we could predict the feasibility of sylvian dissection for a safe surgery. 3D curved-MPR images showed several features: first, perpendicular images to the sylvian surface in the same orientation as the surgeon's view; second, simultaneous visualization of the brain cortex, vessels, and cisternal space; and third, more accurate measurement of various parameters, such as depth of the MCA from the sylvian surface and the location and width of the SFs. CONCLUSION In addition to conventional image studies, 3D curved-MPR images seem to provide useful information for Sylvian dissection in the microsurgical treatment of MCA aneurysms.
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Affiliation(s)
- Taek Kyun Nam
- Department of Neurosurgery, Chung-Ang University Hospital, Seoul, Korea
| | - Yong Sook Park
- Department of Neurosurgery, Chung-Ang University Hospital, Seoul, Korea.
| | - Jun Soo Byun
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Seung Won Park
- Department of Neurosurgery, Chung-Ang University Hospital, Seoul, Korea
| | - Jeong Taik Kwon
- Department of Neurosurgery, Chung-Ang University Hospital, Seoul, Korea
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Surgical Treatment of Middle Cerebral Artery Aneurysms Without Using Indocyanine Green Videoangiography Assistance: Retrospective Monocentric Study of 263 Clipped Aneurysms. World Neurosurg 2015; 84:972-7. [PMID: 26074439 DOI: 10.1016/j.wneu.2015.05.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/24/2015] [Accepted: 05/26/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Middle cerebral artery (MCA) aneurysms represent 20% of intracranial aneurysms. Most (80%) of them are located on the sylvian bifurcation, the seat of hemodynamic turbulence flow. Morbidity and mortality related to surgery of MCA aneurysms are not negligible. MCA vascularization areas are important eloquence functional territorial of Brain tissue. Indocyanine green videoangiography assistance (ICG-VA) is an emergent tool for intraoperative assessment of aneurysmal occlusion and for checking a possible stenosant clip in vascular area. The purposes of this study were to evaluate the safety of clipping procedure in terms of morbidity, mortality, and efficiency of aneurysm occlusion without using ICG-VA, recurrence and bleeding/rebleeding at short and long terms, and angiographic and clinical follow-ups. MATERIAL AND METHODS This study is a monocentric retrospective study performed at Pitié-Salpêtrière-Charles Foix Hospital Center, reporting clinical and angiographic follow-up of consecutive patients treated for MCA aneurysms (ruptured and unruptured) by clipping procedures. From 2002-2012, 251 consecutive patients were admitted at the author's institution for treatment of 263 MCA aneurysms (163 ruptured and 100 unruptured). Procedure-related death and complications were systematically assessed without video-angiography availability. The degree of aneurysms exclusion was evaluated according to the Raymond-Roy scale after the procedure and at long-term angiographic follow-up (mean delay = 36 months). RESULTS The death rate related to aneurysmal exclusion procedure was 1.2%. The major complication rate related to surgery was 5.3%. Postprocedure, an aneurysm occlusion rate Raymond-Roy grade A or B was 95.6%. Neither recanalization controlled clipped aneurysms nor re-aneurysmal rupture was observed in the long-term clinical follow-up (mean time = 83.5 months). The institution's series of surgical outcomes reported 95.6% of complete exclusion and 4.5% incomplete procedures without ICG-VA. A clip of repositioning rate was estimated at 15% when ICG-VA was used. CONCLUSION Surgical management is relatively safe for patients, with an acceptable complication rate in the era when ICG-VA was not yet available. Indeed, the main source of procedural ischemia microsurgery is stenosant clip. To limit the occurrence of malposition, the author's center began using ICG-VA a few months ago and expects to reduce its rate of incomplete occlusion.
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Kovanda TJ, Tubbs RS, Cohen-Gadol AA. Transsylvian selective amygdalohippocampectomy for treatment of medial temporal lobe epilepsy: Surgical technique and operative nuances to avoid complications. Surg Neurol Int 2014; 5:133. [PMID: 25298915 PMCID: PMC4174670 DOI: 10.4103/2152-7806.140651] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 07/03/2014] [Indexed: 11/08/2022] Open
Abstract
Background: A number of different surgical techniques are effective for treatment of drug-resistant medial temporal lobe epilepsy. Of these, transsylvian selective amygdalohippocampectomy (SA), which was originally developed to maximize temporal lobe preservation, is arguably the most technically demanding to perform. Recent studies have suggested that SA may result in better neuropsychological outcomes with similar postoperative seizure control as standard anterior temporal lobectomy, which involves removal of the lateral temporal neocortex. Methods: In this article, the authors describe technical nuances to improve the safety of SA. Results: Wide sylvian fissure opening and use of neuronavigation allows an adequate exposure of the amygdala and hippocampus through a corticotomy within the inferior insular sulcus. Avoidance of rigid retractors and careful manipulation and mobilization of middle cerebral vessels will minimize ischemic complications. Identification of important landmarks during amygdalohippocampectomy, such as the medial edge of the tentorium and the third nerve within the intact arachnoid membranes covering the brainstem, further avoids operator disorientation. Conclusion: SA is a safe technique for resection of medial temporal lobe epileptogenic foci leading to drug-resistant medial temporal lobe epilepsy.
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Affiliation(s)
- Timothy J Kovanda
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - R Shane Tubbs
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama, USA
| | - Aaron A Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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