- Neurosurgery for Cerebral Aneurysm
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Giant intracranial aneurysms, requiring trapping of the aneurysm, wrapping, clipping, and reconstruction of the parent vessel, and bypass procedures occurred in seven patients. Of the total, 2. Case 5: A year-old male with no comorbidity presented with a history of right-side stroke and was found to have a calcified ring lesion in the middle cranial fossa.
He was referred for angiogram, which revealed a giant partially thrombosed aneurysm Figure 5.
Neurosurgery for Cerebral Aneurysm
He underwent a superficial temporal artery and MCA bypass and trapping of the aneurysm, and had a good postoperative outcome. The average size of aneurysms in the clipping group was 7 mm 2 mm - 4 cm ; the average size of the neck was 4 mm 2 mm - 15 mm.
The average time elapsed between the day of ictus to surgery was 2. Seven patients had giant aneurysms with intramural thrombus, while six patients had ruptured, very small aneurysms. Technical difficulties were encountered in about one-third of the surgical clipping patients such as difficulty in dissecting the sac or neck, injury to the nearby vessels, difficulty in application of the clip due to atherosclerosis in which part of the neck had to be left unclipped to avoid kinking of the parent vessels, and intraprocedural rupture and brain swelling that required decompressive craniectomy.
Postoperative external ventricular drainage was required in 44 patients, and 12 patients required a permanent shunt.
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The average hospital stay in the surgical clipping patients was 13 days. The average cost for treatment of surgical group was Rs 2, 89, Among patients who underwent surgical clipping, Of the total surviving patients, returned to work and 29 patients were able to perform daily activities of living without support but could not return back to work. Poor outcome was found in 30 Of these, 14 patients had disability and required assistance for their activities of daily living. Six patients were severely disabled and bedridden, requiring PEG feeding and Foley catheters.
Ten patients from the surgical group expired. Seven patients died during the admission period, and three patients died within three months of discharge. The patients who had a bad preoperative WFNS score did not fare well and succumbed to death. Of the patients who died, one patient died of myocardial infarction, another patient with HIV failed coiling, and another, who underwent a far lateral approach for vertebral artery dissecting aneurysm, developed septicemia and died.
Intracranial Aneurysm Surgery: Basic Principles and Techniques - كتب Google
Over the three months of follow up, one patient had rebled and had already been operated on for a ruptured PCOM aneurysm. The aneurysm was about 11 mm, clipped with single clip during the first surgery, and there was a residual neck. In the follow-up angiogram, the patient presented with rebleed and underwent an emergency craniotomy and reinforcement of the neck with a second clip.
Postoperatively, the patient improved. The results of the ISAT trial suggested that endovascular coiling gives rise to immediate results that are superior to surgery for the majority of aneurysms 5. There are clear advantages to coiling such as a shorter hospital stay, avoidance of open surgical manipulation of the brain, and the absence of postoperative epilepsy. Most of the patients recovered from these complications and additional procedures.
It is likely that coiling will eliminate most of these complications and additional operations, but there will be patients who will still require treatment for hydrocephalus 6. Nevertheless, it is by no means certain that the long-term outcome of coiling will be as satisfactory as successful clipping of an aneurysm 7 , 8. If a ruptured aneurysm can be fully clipped, as confirmed by postoperative angiography, then the condition may be regarded as cured and the long-term risk of recurrence of the aneurysm is negligible. The same does not apply to coiling. Reformation of the sac and further bleeding is known to occur in a handful of cases, at least in the short term, even if a sac appears to have been completely occluded at the time of initial coiling 9.
The long-term risk of recurrence after coiling is simply not known. In coiling, recanalization is still a significant occurrence when compared to surgical clipping 10 , Recanalization, if significant, often requires retreatment either by re-coiling or surgical clipping. One limitation of this study is its retrospective design, with case selection bias, including both ruptured and unruptured aneurysm. Most of our patients had a good outcome with microsurgical clipping in the management of intracranial aneurysms; hence, despite this endovascular era, we recommend microsurgical clipping as a viable and cost effective alternative in selected cases for the management of intracranial aneurysms.
Aneurysmal subarachnoid hemorrhage: an overview for the practicing neurologist. Semin Neurol. Hemodynamic mechanisms underlying cerebral aneurysm pathogenesis. J Clin Neurosci.
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Incidence of ventricular shunt placement for hydrocephalus with clipping versus coiling for ruptured and unruptured cerebral aneurysms in the Nationwide Inpatient Sample database: to World Neurosurg. The barrow ruptured aneurysm trial: clinical article. J Neurosurg. Risk of recurrent subarachnoid haemorrhage, death or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial ISAT : long-term follow-up.
Lancet Neurol. Risk of shunt-dependent hydrocephalus after occlusion of ruptured intracranial aneurysms by surgical clipping or endovascular coiling: a single-institution series and meta-analysis. Natural history of the neck remnant of a cerebral aneurysm treated with the Guglielmi detachable coil system.
Delayed aneurysm regrowth and recanalization after Guglielmi detachable coil treatment. Case report. Recanalization rates after endovascular coil embolization in a cohort of matched ruptured and unruptured cerebral aneurysms. Interv Neuroradiol. Endovascular treatment of ruptured intracranial aneurysms with detachable coils: long-term clinical and serial angiographic results.
Clinical and angiographic follow-up of ruptured intracranial aneurysms treated with endovascular embolization. Archives of Neuroscience: 3 3 ; e Published Online: April 23, Article Type: Research Article. Received: October 18, Revised: November 21, Accepted: January 2, DOI : This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.
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A simplified guide on the basics of aneurysm surgery from leading vascular surgeons A simplified guide on the basics of aneurysm surgery from leading vascular surgeons Intracranial Aneurysm Surgery: Basic Principles and Techniques is a highly approachable and user-friendly manual that takes a step-by-step approach to explaining the techniques of aneurysm surgery.