Postoperative Clipping Status after a Pterional versus Interhemispheric Approach for High-Positioned Anterior Communicating Artery Aneurysms.

OBJECTIVE: When treating high-positioned anterior communicating artery (ACoA) aneurysms, pterional-transsylvian and interhemispheric approaches are both viable options, yet comparative studies of these two surgical approaches are rare. Accordingly, this retrospective study investigated the surgical results of both approaches. METHODS: Twenty-four patients underwent a pterional approach (n=11) or interhemispheric approach (n=13), including a unilateral low anterior interhemispheric approach or bifrontal interhemispheric approach, for high-positioned ACoA aneurysms with an aneurysm dome height >15 mm and aneurysm neck height >10 mm both measured from the level of the anterior clinoid process. The clinical and radiological data were reviewed to investigate the surgical results and risk factors of incomplete clipping. RESULTS: The pterional patient group showed a significantly higher incidence of incomplete clipping than the interhemispheric patient group (p=0.031). Four patients (36.4%) who underwent a pterional approach showed a postclipping aneurysm remnant, whereas all the patients who experienced an interhemispheric approach showed complete clipping. In one case, the aneurysm remnant was obliterated by coiling, while follow-up of the other three cases showed the remnants remained limited to the aneurysm base. A multivariate analysis revealed that a pterional approach for a large aneurysm with a diameter >8 mm presented a statistically significant risk factor for incomplete clipping. CONCLUSION: For high-positioned ACoA aneurysms with a dome height >15 mm and neck height >10 mm above the level of the anterior clinoid process, a large aneurysm with a diameter >8 mm can be clipped more completely via an interhemispheric approach than via a pterional approach.

Intraoperative Use of Endoscope, a Valuable, Adjunctive Tool for the Surgical Management of Anterior Communicating Artery Aneurysm Surgery: Our Institutional Experience.

BACKGROUND: Anterior communicating (A-com) artery region is very complex; perforators are not always visualized on the microscope. The neuroendoscope with its higher magnification, better observation, and additional illumination can provide us information that may not be available with the microscope in aneurysm surgery. OBJECTIVE: The objective was to study the use of endoscope in surgical management of A-com aneurysm surgery and its advantages, whether and how it changes operative management. MATERIALS AND METHODS: We studied 25 serial cases of A-com aneurysm at Bantane Hospital, Fujita University, Japan, from November 2018 to October 2019. Once aneurysm was exposed, we did preclipping indocyanine green (ICG) study and examination with endoscope. After clipping, we again did ICG and endoscopic assessment. Preclipping and postclipping endoscopic information was used and necessary changes were made in the operative decisions. Whether endoscope gives any additional information over microscope and ICG which led to change in the operative decision was assessed. RESULTS: In six out of 25 A-com aneurysm patients, the use of endoscope has given additional information over microscope, and ICG leading to change in the operative plans such as readjustment of the clip/application of the second clip or release of perforator compromise. CONCLUSION: Simultaneous endoscopic and microscopic guidance can reveal important information hidden from the microscope. Thus, this method increases the safety and durability of the A-com aneurismal clipping.

Anterior Communicating Artery Aneurysm Uncommon Hemorrhagic Presentation: Case Report

Intracranial aneurysm rupture causes subarachnoid hemorrhage in 80% of the cases, and it may be associated with intracerebral hemorrhage and/or intraventricular hemorrhage (IVH) in 34% and 17% of the patients, respectively. However, on rare occasions, aneurysm rupturemay be present causing isolate intracerebral hemorrhage or IVH without subarachnoid hemorrhage. We describe an unusual case of an anterior communicating aneurysm rupture presented with IVH, without subarachnoid hemorrhage. Although isolated IVH is rare, aneurysm rupture is a possible condition. Patients presenting with head computed tomography revealing IVH without subarachnoid hemorrhage should be promptly investigated with contrasted image exam to identify and treat possible causes, even in the absence of subarachnoid hemorrhage.

Are Anterior Communicating Aneurysms Truly Anterior Communicating Aneurysms? An Observational Study.

OBJECTIVE: The term anterior communicating (ACom) aneurysm is often broadly used to classify any aneurysm formed on the A1-A2 junction, A1, A2, or ACom arteries. Aneurysm location has been associated with rupture risk, so whether an aneurysm is truly formed on the ACom artery can critically affect treatment decisions. The aim of this study was to reclassify broadly termed ACom aneurysms into 4 subgroups (A1, A2, true ACom, and A1-A2 junction) based on their location. METHODS: A retrospective, pilot study was conducted to identify all consecutive patients with ACom aneurysm managed over the past 4 years in a single center. Using computed tomography angiography, aneurysms were classified into 1 of the 4 subgroups. Additional information was collected on patient demographics, subarachnoid hemorrhages, projections of aneurysm dome, and aneurysm diameter. RESULTS: A total of 48 aneurysms with available computed tomography angiography imaging were included in the final analysis. The reclassification of ACom aneurysms into subgroups resulted in 40 A1-A2 junction, 6 true ACom, 2 A2, and zero A1 aneurysms. A total of 100% versus 80% of true ACom and A1-A2 junction aneurysms ruptured, respectively. All elective coiling procedures were performed on unruptured A1-A2 junction aneurysms. CONCLUSIONS: We found only 13% of the aneurysms initially referred to as ACom to be true ACom aneurysms. A more nuanced approach to ACom aneurysm classification may better guide management strategies.

Endoscopic Endonasal Clipping of Anterior Circulation Aneurysm: Surgical Techniques and Results.

BACKGROUND: Endoscopic endonasal clipping of intracranial aneurysms may use microsurgical techniques as an alternative to the transcranial approach. Here we report a series of patients who underwent microsurgical clipping of anterior circulation aneurysms via an endoscopic endonasal approach (EEA). METHODS: This retrospective chart review included all the patients who underwent standard binostril EEA for aneurysm clipping. Surgical outcomes and complications are noted. The rationality and limitations of this procedure are discussed. RESULTS: Seven patients with 12 aneurysms of the anterior circulation underwent EEA for clipping. These 12 aneurysms consisted of 5 anterior communicating artery (AComA) aneurysms, 4 paraclinoid aneurysms, 1 ophthalmic artery aneurysm, and 2 aneurysm located in the cavernous segment of internal carotid artery (ICA). Nine of the 12 aneurysms were successfully clipped. One giant paraclinoid aneurysm could not be clipped during operation and was coiled in second endovascular stage. The 2 aneurysms located in the cavernous segment of ICA were not clipped intentionally in a single-stage procedure, after weighing the surgical benefit against the difficulty of surgical exposure and feasibility. The proximal control of ICA was achieved in all cases. There was no death, no cerebrospinal fluid leak, or other complications. All patients recovered completely. CONCLUSIONS: EEA can provide direct access for microsurgical clipping of strictly selected anterior circulation aneurysms. All the principles of cerebrovascular surgery must be followed. These procedures require a long learning curve. Only teams with adequate experience in microvascular and endoscopic skull base surgeries should attempt this approach for treating aneurysms.

Pterional-subolfactory Approach for Treatment of High Positioned Anterior Communicating Artery Aneurysms.

OBJECTIVE: The purpose of this study is to compare the surgical outcomes of pterional-subolfactory approach for the high positioned anterior communicating artery (ACoA) aneurysm with the conventional pterional approach. METHODS: Between February 2005 and December 2012, 463 ACoA aneurysms were surgically treated in our institution. Forty eight high positioned ACoA aneurysms were treated with pterional-subolfactory or conventional pterional approach. High positioned ACoA aneurysms were defined as aneurysms located higher than 10 mm above the anterior clinoid process. Pterional-subolfactory approach is a procedure including dissection of olfactory tract and resection of the gyrus rectus inferior and medial to the olfactory tract. Thirty-four of the 48 cases were treated with pterional-subolfactory approach and 14 were treated conventionally. RESULTS: There were 2 postoperative cerebral infarction with the conventional pterional approach, but none with the pterional-subolfactory approach group (p = 0.026). Postoperative digital subtraction angiography revealed significant remnant aneurysm in the conventional pterional approach group. All patients with unruptured aneurysms had good clinical outcomes with Glasgow outcome score of 5. Among ruptured ACoA aneurysm patients, 2 patients with conventional pterional approach had postoperative cerebral infarctions but permanent neurologic deficit was found in only 1 patient. Three patients treated with the pterional-subolfactory approach, who had preoperative ruptured aneurysms had poor clinical outcomes. The mean operation time for the conventional pterional approach was 58 minutes longer than for the pterional-subolfactory approach (p = 0.001). CONCLUSION: We concluded that pterional-subolfactory approach is highly preferable for cases of high positioned ACoA aneurysm, giving a wide and effective operation view.

Abordaje transciliar e interciliar para aneurismas del complejo comunicante anterior / Transient and intercervical approach for aneurysms of the anterior connecting complex

Introducción: Los abordajes trans e interciliares son utilizados para distintas patologías de la fosa craneana anterior. En algunos casos puntuales creemos que puede resultar una opción para aneurismas del complejo comunicante anterior. Objetivos: Analizar la casuística de abordajes trans e interciliares utilizados en la resolución de aneurismas del complejo carótido comunicante anterior.Material y método: Se revisó retrospectivamente los casos de aneurismas del complejo comunicante anterior abordados por vía transciliar e interciliar; se analizaron datos epidemiológicos, tamaño aneurismático, abordaje usado, la presencia de espacios subaracnoideos en neuroimágenes previas a la cirugía, Fisher, Hunt Hess, el uso de clipado transitorio, morbimortalidad, complicaciones y resultados cosméticos. Resultados: Se encontraron 6 casos de aneurismas de comunicante anterior operados por vía transciliar y 2 casos por vía interciliar. No hubo predominancia de sexos. La edad promedio fue de 54,6 años. El 62,5% fueron aneurismas chicos, 50% incidentales. Conclusiones: La utilización de este tipo de abordajes resulta útil, en algunos casos de aneurismas del complejo comunicante anterior, siendo importante la selección del caso para este tipo de abordaje. Cumple con el criterio primordial de acceder al vaso madre del aneurisma, permitiendo una exposición desde el inicio de ambas A1 y A2, es rápido su abordaje, es directo, el campo menos profundo y requiere de una familiarización con la anatomía vascular desde una visión frontal, el ser necesario un clipado transitorio los clips quedan lateral a la dirección de trabajo no obstruyendo el mismo.

Purpose: To describe and analyze the experience in the resolution of the anterior communicating aneurysms bytransciliary and interciliary approaches.Methods: Between September 1999 and March 2013, 8 patients with anterior communicating aneurysms wereoperated through transciliary and interciliary approaches.Results: 6 patients were operated through a transciliary approach and 2 patients through a interciliary approach. Therewas no gender predominance. The average age was 54,6 years old. There was a 50% of incidental aneurysms and62,5% of small aneurysms.Conclusion: These approaches can be useful in some cases of anterior communicating aneurysms in which the controlof the parent artery is possible. The corridor of dissection is direct and less deep. If necessary, temporary clipping ofthe A1 and A2 areas are accessible to the surgeon. The study of arachnoidal cistern is essential in the patient selectioncriteria for these approaches.

Pterional-subolfactory Approach for Treatment of High Positioned Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study is to compare the surgical outcomes of pterional-subolfactory approach for the high positioned anterior communicating artery (ACoA) aneurysm with the conventional pterional approach. METHODS: Between February 2005 and December 2012, 463 ACoA aneurysms were surgically treated in our institution. Forty eight high positioned ACoA aneurysms were treated with pterional-subolfactory or conventional pterional approach. High positioned ACoA aneurysms were defined as aneurysms located higher than 10 mm above the anterior clinoid process. Pterional-subolfactory approach is a procedure including dissection of olfactory tract and resection of the gyrus rectus inferior and medial to the olfactory tract. Thirty-four of the 48 cases were treated with pterional-subolfactory approach and 14 were treated conventionally. RESULTS: There were 2 postoperative cerebral infarction with the conventional pterional approach, but none with the pterional-subolfactory approach group (p = 0.026). Postoperative digital subtraction angiography revealed significant remnant aneurysm in the conventional pterional approach group. All patients with unruptured aneurysms had good clinical outcomes with Glasgow outcome score of 5. Among ruptured ACoA aneurysm patients, 2 patients with conventional pterional approach had postoperative cerebral infarctions but permanent neurologic deficit was found in only 1 patient. Three patients treated with the pterional-subolfactory approach, who had preoperative ruptured aneurysms had poor clinical outcomes. The mean operation time for the conventional pterional approach was 58 minutes longer than for the pterional-subolfactory approach (p = 0.001). CONCLUSION: We concluded that pterional-subolfactory approach is highly preferable for cases of high positioned ACoA aneurysm, giving a wide and effective operation view.

Pterional-subolfactory Approach for Treatment of High Positioned Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study is to compare the surgical outcomes of pterional-subolfactory approach for the high positioned anterior communicating artery (ACoA) aneurysm with the conventional pterional approach. METHODS: Between February 2005 and December 2012, 463 ACoA aneurysms were surgically treated in our institution. Forty eight high positioned ACoA aneurysms were treated with pterional-subolfactory or conventional pterional approach. High positioned ACoA aneurysms were defined as aneurysms located higher than 10 mm above the anterior clinoid process. Pterional-subolfactory approach is a procedure including dissection of olfactory tract and resection of the gyrus rectus inferior and medial to the olfactory tract. Thirty-four of the 48 cases were treated with pterional-subolfactory approach and 14 were treated conventionally. RESULTS: There were 2 postoperative cerebral infarction with the conventional pterional approach, but none with the pterional-subolfactory approach group (p = 0.026). Postoperative digital subtraction angiography revealed significant remnant aneurysm in the conventional pterional approach group. All patients with unruptured aneurysms had good clinical outcomes with Glasgow outcome score of 5. Among ruptured ACoA aneurysm patients, 2 patients with conventional pterional approach had postoperative cerebral infarctions but permanent neurologic deficit was found in only 1 patient. Three patients treated with the pterional-subolfactory approach, who had preoperative ruptured aneurysms had poor clinical outcomes. The mean operation time for the conventional pterional approach was 58 minutes longer than for the pterional-subolfactory approach (p = 0.001). CONCLUSION: We concluded that pterional-subolfactory approach is highly preferable for cases of high positioned ACoA aneurysm, giving a wide and effective operation view.

Analysis on the efficacy and surgical techniques of anterior communicating aneurysms in 158 cases / 中国综合临床

Objective To explore the efficacy, operation timing and techniques of surgical treatment in patients with the anterior communicating aneurysms. Methods We retrospectively analyzed the surgical procedures and effectiveness of 158 patients with anterior communicating aneurysms. Ten of the 158 cases were combined with aneurysms in other branches. All patients had experienced SAH (5 cases were not relevant to anterior communicating aneurysm) and received incarceration of aneurysms through the orbit-pterion approach. Preoperative Hunt-Hess grade;the number of patients with grade Ⅰ,Ⅱ, Ⅲ,Ⅳ and Ⅴ were 24,45,54,31 and 4,respectively. Fourty-four cases received surgery within 3 days after SAH,74 cases within 4 to 14 days,and 40 cases after 14 days. Results According to GOS grade; 138 cases (87. 34% ) recovered with good outcome,9 cases (5.69%) with moderate disability, 6 cases (3.80%) with severe disability, and 5 death (3. 16%, including cases giving up treatment). Among the 138 patients having good outcomes,24 were grade Ⅰ ,42 grade Ⅱ ,47 grade Ⅲ and 25 grade Ⅳ. Thirty-nine cases underwent surgery within 3 days,64 within 3 to 14 days,and 35 after 14 days. Conclusion The surgical timing of anterior communicating aneurysms should be decided according to comprehensive analysis of CT, DSA, and detailed neurologic examination of the patients. Orbit pterion approach is favorable for exposing aneurysms. A series of actions,such as reducing intracranial pressure, cerebral protection and 3H therapy,will help to improve the prognosis of the patients .

Clinical Analysis of the Sellar and Parasellar Lesions using the Bifrontal Basal Interhemispheric Approach

The authors describe the use of the bifrontal basal interhemispheric approach in the clinical analysis of sellar and parasellar lesions. This approach is a more basal modification of the conventional anterior interhemispheric approach extended to the nasion, and most bridging veins are preserved. After dividing the falx at its anterior end, frontal lobes are retracted bilaterally and olfactory nerves are dissected from the frontal lobe to the olfactory trigon. This approach was used ffor operationsinvolving ten patients : in seven, in whom a parasellar tumor had been detected, gross or near-total removal of this large mass was achieved, and three, with aneurysm of the anterior communicating artery aneurysm underwent clipping and aneurysmorrhapy. In one patient with a huge retrochiasmatic tumor, division of the anterior communicating artery was performed. After cutting the anterior communicating artery, no side effects were detected. Visual improvement and preservation of the pituitary stalk was achieved in 86% and 57% of cases, respectively. This approach, progressing from the midline, provided better orientation of the mass and its surrounding structures such as the hypothalamus, optic chiasm, pituitary stalk and perforating arteries. The authors discuss the indications, advantages and disadvantages of the bifrontal basal interhemispheric approach, and include a review of the literature.