Surgical and endovascular combined modality of treatment for aneurysms

Most of the aneurysms can be treated successfully with either surgery or endovascular modality alone. But, some complex aneurysms can be better managed with surgical and endovascular combined modality of treatment. This study was done to review combination options, their indications and outcome. Articles in English literature on surgical and endovascular combined modality of treatment for cerebral aneurysms were reviewed and analyzed based on Pubmed search. Followed combination options were used: Surgery followed endovascular therapy: 1. Extracranial to intracranial bypass surgery followed by endovascular parent vessel occlusion. 2. Aneurysm clipping assisted by temporary balloon occlusion with/without suction decompression. 3. Intentional partial clipping for neck reconstruction followed by endovascular aneurysm packing. 4. Clipping as the first treatment. Regrown or partially clipped aneurysm obliterated by endovascular packing. Endovascular therapy followed by surgery: 1. Partial coiling to prevent rebleed followed by delayed definitive clipping. 2. Permanent parent vessel occlusion followed by surgery for decompression in giant aneurysm. 3. Coiling as the first treatment, reanalyzed aneurysm treated with clipping. 4. Coiling and clipping of multiple remote aneurysms. In various published series; combined modality of treatment has shown better results in complex aneurysms as compared to either of the modality alone with less morbidity. Surgical and endovascular combined modality is very useful addition to the armamentarium for the management of complex aneurysms and can be applied in various combinations. When used rationally, this approach offers the best outcome with reduction of treatment morbidity

Application of rigid endoscope to the microsurgery of anterior circulation cerebral aneurysms

To evaluate the usefulness of endoscope during anterior circulation cerebral aneurysm surgery. From June 2004 to June 2005, endoscope was applied in 83 aneurysms of anterior circulation cerebral aneurysm surgeries. There was no mortality in our series and no new neurological deficits occurred after surgery. One aneurysm ruptured during the microsurgical dissection, which was not related to endoscope manipulation. Endoscope provided new information in 28 aneurysms. The clips were re-adjusted in 10 cases after endoscopic examination. Endoscope is useful during anterior circulation cerebral aneurysm surgery. It can provide valuable information which is not available from microscope, it is useful both before and after clipping. Most importantly, it provides information regarding the completeness of neck obliteration and the preservation of important perforators

Fundamentals of AVM surgery: an institutional experience

Arteriovenous malformations [AVM] of the brain are congenital lesions and remain dormant for many years but can haemorrhage, cause seizure or impair brain function. Modern therapeutic modalities for AVM include microsurgery, intravascular neurosurgery and stereotactic radiosurgery. There is significant risk of intraoperative haemorrhage due to abnormal vessels as well as due to change in haemodynamic pattern of surrounding brain after excision. Inadequate coagulation of feeding vessels and draining channels, loss of plane between nidus and normal brain, persistent residual or daughter sinus and inadequate intraoperative blood pressure control are the main causes of haemorrhage. The main important aspect in AVM surgery is to identify the plane between the nidus and normal brain and work around the nidus. It is very important to aggressively reduce intraoperative haemorrhage and prevent or minimize the dilation of abnormal capillaries and arteries on the basis of fundamental surgical strategy, i.e., feeder-nidus-drainer. Adequate control is the key factor in prevention and treatment of haemorrhage. In a period of 8 years, from 1994-2003, our department dealt with 290 cases of AVM. In 212 patients, operative removal was performed, which included 89 cases with intracerebral haematoma. In 39 cases, embolisation and/or gamma knife was preferred