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Unruptured brain AVMs (bAVMs) remain a controversial subject for practicing neurosurgeons, especially in the light of ARUBA and other observational studies. This retrospective study aims to analyze our experience with unruptured bAVMs to see whether it is beneficial in the long-term and how it corresponds to large literature trials. The study comprised 160 adult patients with unruptured bAVMs surgically treated in Burdenko NMC (Moscow) in 2009-2017. Mean age: 33.4 ± 10леÑ. Clinical presentations were: seizures in 99 (61.9%), chronical headaches-49 (30.6%), ischemic symptoms-4 (2.5%), asymptomatic in 8 (5%) patients. Spetzler-Martin scale: I-18 pt. (11.3%), II-71 pt. (44.4%), III-60 pt. (37.5%), IV-11 pt. (6.8%). Good outcomes (mRS = 0-2) at discharge were achieved in 149 (93.1%), satisfactory (mRS-3)-9 (5.6%). Follow-up was complete for 97 (60.6%) patients, mean-59.3 (13-108 month). Excellent outcomes (mRS = 0-1) reached in 94.8%. For epilepsy patients, Engel I outcome was found in 50 (84.8%); for chronic headaches, 43 (66.1%) patients reported improvement. Postoperative visual field defects were followed in 22 of 55 (40%), complete recovery was reported in 6 (27%) and partial recovery in 8 (36%) patients. Overall, our results support the conclusion that surgery for low-grade bAVMs (S-M I-II) is a beneficial, low-risk option.
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Malformações Arteriovenosas Intracranianas , Radiocirurgia , Adulto , Encéfalo , Humanos , Malformações Arteriovenosas Intracranianas/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Endovascular coiling techniques have emerged as an alternative and effective approach for treating intracranial aneurysms. However, in some cases, previously coiled aneurysms may require secondary treatment with surgical clipping, presenting a more complex challenge compared with the initial intervention.1,2 We present the case of a 39-year-old man with a residual class III Raymond-Roy occlusion partially coiled aneurysm at the left middle cerebral artery bifurcation (Video 1). Faced with the risks of rerupture, the patient underwent microsurgical treatment after providing consent. Despite successful initial microsurgical clipping, postoperative complications arose due to coil protrusion into the middle cerebral artery bifurcation, resulting in thrombotic occlusion of the frontal M2 branch. Emergency repeat microsurgical intervention and administration of a thrombolytic agent were performed to address complications, ultimately preserving blood flow. Subsequent endovascular placement of a flow-diverting stent 7 weeks after discharge confirmed complete occlusion of the aneurysm. The patient had no neurological deficit on follow-up. When planning microsurgical clipping of an aneurysm previously treated with coils, it is critical to consider coil placement, as there is a risk of prolapse if the coil is in the neck of the aneurysm. Thrombosis of the cerebral arteries is a potential complication of microsurgical clipping of partially coiled intracranial aneurysms, and injection of a fibrinolytic agent into thrombosed arterial branches may be an effective intraoperative method for treating intra-arterial thrombosis.3 This case illustrates the challenges associated with treating partially coiled aneurysms, highlighting the significance of careful planning when considering microsurgical treatment.
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Modern neuroimaging methods do not completely rule out false diagnoses of intracranial aneurysms which can lead to an unwarranted operation associated with risks of complications. However, surgical interventions for falsely diagnosed aneurysms are quite rare. The purpose of this study is to demonstrate two clinical cases of false-positive aneurysms and a systematic review of the literature dedicated to the incidence and etiology of false-positive aneurysms, identifying risk factors associated with false-positive aneurysms. A literature search in two databases (PubMed and Web of Science) using keywords "mimicking an intracranial aneurysm", "presenting as an intracranial aneurysm", "false positive intracranial aneurysms", and "neurosurgery" was conducted. A total of 243 papers were found in the initial search in two databases. Sixteen papers (including 20 patients) were included in the final analysis. There were 10 women and 10 men. The most common location of false-positive aneurysms was the bifurcation of the middle cerebral artery (MCA). In the posterior circulation, false-positive aneurysms were identified either on the basilar artery, or at the vertebro-basilar junction. The main causes of false intracranial aneurysm diagnosis included artery occlusion with vascular stump formation, infundibular widening, fenestration, arterial dissection, contrast extravasation, and venous varix. In conclusion, summarizing the results of our analysis, we can say that surgical interventions for false-positive aneurysms are an underestimated problem in vascular neurosurgery. Despite extremely rare published clinical observations, the actual frequency of erroneous surgical interventions for false-positive aneurysms is unknown.
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BACKGROUND: Patients with intracranial aneurysms often have comorbidities that require them to take acetylsalicylic acid (ASA). In recent years, many patients with aneurysms have been prescribed ASA to prevent aneurysm enlargement. ASA is also prescribed to patients with intracranial aneurysms in preparation for surgical revascularization. METHODS: From 2016 to 2021, 64 patients underwent microsurgical aneurysm clipping without revascularization, and an additional 20 patients underwent extracranial to intracranial (EC-IC) bypass. The following parameters were analysed: the frequency of hemorrhagic complications, the blood loss volume, the duration of surgery and inpatient treatment, the change in hemoglobin level (Hb), hematocrit (Ht), erythrocytes, and clinical outcomes according to the modified Rankin scale (mRS). RESULTS: At the time of surgery, laboratory-confirmed effect of the ASA was registered in 22 patients (main group). In 42 patients, the ASA was not functional on assay (control group). Hemorrhagic complications were noted in two patients in the ASA group. In both cases, the hemorrhagic component did not exceed 15 ml in volume and did not require additional surgical interventions. Statistical analysis showed no significant differences in hemorrhagic postoperative complications. CONCLUSION: Taking low doses of acetylsalicylic acid during planned microsurgical clipping of cerebral aneurysms does not affect intraoperative blood loss volume, risk of postoperative hemorrhagic complications, length of stay in the hospital, or functional outcomes.
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OBJECTIVE: Analysis of results of surgical treatment of 112 patients with large and giant anterior cerebral artery (ACA) aneurysms. METHODS: This is the largest clinical series of large and giant ACA aneurysms ever reported. Retrospective analysis of medical charts, radiographic studies, and intraoperative videos was performed. Univariate and multivariate analysis of relations among 3 types of outcomes (complete aneurysm occlusion, ischemic complications, and clinical outcomes) and predicting factors was performed. RESULTS: Most aneurysms were communicant (84.8%). Aneurysms of the A1 segment and distal segments (A2-A5) were encountered rarely. Complete aneurysm occlusion (class I) was shown in 95 cases (90.5%). In 4 patients, only exploration and wrapping were performed because of severe atherosclerosis and chronic intraluminal thrombi. Partial occlusion (class III) was shown in 2 patients, and neck residual (class II) in 4 patients. Cerebral ischemia developed in 29 patients postoperatively. Occlusion or injury of the A1 segment and anterior communicating artery perforators and recurrent branch of Heubner were the most common reason for ischemic complications. At follow-up, 97 patients (86.6%) had favorable outcomes. Ten patients (8.9%) had unfavorable outcomes because of postoperative complications. CONCLUSIONS: Microsurgery provides effective and relatively safe occlusion of complex ACA aneurysms. Direct clipping can be applied in most cases independent of their precise location. In certain cases, alternative methods can be safely used. According to multivariate analysis, giant aneurysm size, aneurysm-related mass effect, involvement of large arterial branches in the aneurysm wall, and intraoperative complications were significant predicting factors for ischemic complications.
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Aneurisma Intracraniano , Artéria Cerebral Anterior/diagnóstico por imagem , Artéria Cerebral Anterior/cirurgia , Angiografia Cerebral , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Microcirurgia/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
A 57-year-old man who had previously suffered a transient episode of retrograde amnesia was admitted to the vascular department of the Burdenko Neurosurgical Center. Computed tomography angiography revealed a complex trifurcation aneurysm of the right middle cerebral artery (MCA) bifurcation. There were no clear focal symptoms after the neurologic examination. The patient underwent a right-sided craniotomy to approach the Sylvian fissure and MCA branches. The MCA aneurysm with 2 lobes had been exposed. One of the M2 branches densely adhered to the aneurysm dome. Attempts of the M2 separation along the dome stopped because there was a high risk of injury to the M2, the aneurysm, or both. To cutoff M2 without bleeding from the aneurysm, a curved clip was used, which we called an insulating clip. After this manipulation, it was already possible to try the neck closing with additional clips, however, according to manual sensations, we were not sure that the insulating clip would not shift and there would be no bleeding. The insulating clip interfered with the final clipping and should have been removed. Temporal aneurysmorrhaphy was used to ensure that the surgeon's manipulations were not complicated by bleeding. This also acted as a guarantee that, in the event of bleeding, the rupture would not spread to the neck of the aneurysm. Thus the M2 cutting-off with an insulating clip and temporal aneurysmorrhaphy were options that allowed for adequate final clipping. There were no intraoperative or postoperative complications. The patient remained neurologically intact and was discharged 7 days after surgery (Figure 1).
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Aneurisma Intracraniano/cirurgia , Artéria Cerebral Média/cirurgia , Procedimentos Neurocirúrgicos/métodos , Aneurisma Roto/etiologia , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Complicações Intraoperatórias/terapia , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Instrumentos Cirúrgicos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: The insertion of an external ventricular drainage (EVD) is one of the most frequently used neurosurgical procedures. It is performed to adjust intracranial hypertension in cases of severe craniocerebral injury, acute posthemorrhagic hydrocephalus, meningitis, and oncological diseases related to impaired circulation of cerebrospinal fluid circulation (CSF). METHODS: In 2020, three patients with subarachnoid aneurysmal hemorrhage underwent insertion of an EVD navigation percutaneous stereotaxic device. Three cases introduced. RESULTS: In all cases, satisfactory EVD functioning was noted during the surgery and during the early postoperative period. The EVD insertion procedure took an average of 10 min. The EVD insertion route calculations using the software took about 5-15 min. No cases showed any infection, hemorrhagic complications, or EVD dysfunction. According to the control brain computed tomography data, the catheter position was satisfactory and corresponded to the target coordinates in all cases. CONCLUSION: The use of the device, with its high accuracy and efficiency, can reduce the incidence of unsatisfactory EVD implantation cases in patients with neurosurgical pathology.
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BACKGROUND: The treatment of middle cerebral artery (MCA) giant aneurysms (GAs) represents a challenging task. METHODS: The data for 55 patients treated for MCA GA (≥25 mm) at the N.N. Burdenko NMRCN between 2010 and 2019 were analyZed. RESULTS: The GAs were located in the M1 segment in 11 (20%) patients, MCA bifurcation in 33 (60%), M2 in 7 (12.7%), and M3 in 4 (7.3%). There were 32 (58.2%) saccular and 23 (41.8%) fusiform GAs. MCA GAs were treated with neck clipping (50.9%), clipping with the artery lumen formation (3.6%), bypass surgeries (34.5%), wrapping (3.6%), and endovascular surgery (7.3%). A worsening of the neurologic state in the perioperative period was observed in 50.9% of patients. The complete closure of GA was achieved in 78.2%. Surgery-related mortality was 1.8%. The long-term outcome was favorable in 76.9% of patients. Surgery-related and disease-related plus treatment failures-related mortality was 9.6%. CONCLUSIONS: Microsurgical clipping and bypass surgery are the main operative interventions for MCA GA treatment. These operations are technically complex and are followed by a relatively high percentage of complications. The main tasks that require further investigations are the introduction of new precise diagnostic methods for the collateral circulation assessment in the cortical MCA branches, the perfection of the algorithm for the bypass selection, and investigation of the long-term results of the endovascular and combined treatments. It is of major importance to thoroughly observe the patients long-term after the surgery and ensure the possibility for further angiographic studies.
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Revascularização Cerebral/tendências , Procedimentos Endovasculares/tendências , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Adolescente , Adulto , Idoso , Revascularização Cerebral/efeitos adversos , Revascularização Cerebral/métodos , Criança , Pré-Escolar , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: The setting of external ventricular drainage (EVD) is one of the most frequent procedures in the neurosurgical practice. However, complication risks of this procedure may grow from 5% to 39%. The number of publications concerning the advancement of ventricular drainage setting technique and complication risks identification is increasing year after year. We posed a question on the dependence of complication risks and catheter setting accuracy on the different factors of routine practice of the N. N. Burdenko National Medical Research Center for neurosurgery within the scope of this work. METHODS: The data on patients whose EVD was set in the premotor area in 2019 were collected retrospectively. The surgeons were divided into 3 groups according to their experience valued in years. RESULTS: The result of drainage setting was considered satisfactory if its end was in the frontal horn or body of the ipsilateral ventricle. Generally, 122 patients passed EVD placement during 2019. According to computed tomography scans of the brain, the drainage position was satisfactory in 85 patients (75.9%) and unsatisfactory in 27 patients (24.1%). CONCLUSIONS: The procedures were performed by surgeons with <2 years of experience in 16.1% of cases, 2-5 years of experience in 25% of cases, and >5 years of experience in 58.9% of cases. The complication risk and accuracy of drainage setting do not depend on surgeon experience, type of bone access, and position in the premotor area.
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Ventrículos Cerebrais/cirurgia , Drenagem/efeitos adversos , Drenagem/métodos , Adolescente , Adulto , Idoso , Encéfalo/diagnóstico por imagem , Catéteres , Ventrículos Cerebrais/diagnóstico por imagem , Criança , Pré-Escolar , Competência Clínica , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Córtex Motor/anatomia & histologia , Neurocirurgiões , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ventriculostomia , Adulto JovemRESUMO
BACKGROUND: The choice of surgical approaches and options for the microsurgical vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms repair remains controversial. METHODS: A retrospective analysis of the clinical, surgical, and angiographic data of 80 patients with VA and PICA aneurysms treated from 2012 to 2018 was performed. RESULTS: The aneurysms were saccular in 50 cases (62.5%) and fusiform in 30 cases (37.5%). The median suboccipital craniotomy was the most common approach (73.8%). Retrosigmoid craniotomy was performed in 25% of patients. There were the following types of microsurgical operations: neck clipping (61.25%), clipping with the artery lumen formation (13.75%), trapping (10%), proximal clipping (5%), and deconstruction with anastomosis (10%). Fifty-seven (71.3%) patients were discharged without worsening of the clinical signs after surgery. The most common postoperative neurological disorder was palsy of IX and X cranial nerve revealed in 14 (17.5%) patients. No fatal outcomes or patients in vegetative state were identified. The complete occlusion of PICA and VA aneurysms according angiography was in 77 (96.3%) cases. CONCLUSION: Microsurgical treatment is an effective method for VA and PICA aneurysms. The majority of VA and PICA aneurysms do not require complex basal approaches. A thorough preoperative planning, reconstructive clipping techniques, and anastomoses creation, as well as patient selection based on the established algorithms and consultations with endovascular surgeons, may reduce the number of complications and increase the rate of complete microsurgical occlusion in VA and PICA aneurysms.