Surgical approach to giant intracranial aneurysms

Operative experience with 80 cases

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✓ The authors report experience with the surgical management of 80 giant intracranial aneurysms (> 2.5cm in diameter) during a 10-year period in which they performed 594 operations for aneurysms. The overall incidence of giant aneurysms was 13% but varied according to location: 20% of aneurysms of the internal carotid artery (ICA); 13% of middle cerebral artery (MCA) aneurysms; 1% of anterior cerebral artery (ACA) aneurysms; 15% of aneurysms of the basilar artery caput (BAC); and 18% of vertebrobasilar trunk(VB) aneurysms. Twenty-five patients had a subarachnoid hemorrhage (SAH), 49 had mass effect from the aneurysm, and six had ischemic events. There was no apparent difference in results related to the presence or absence of an SAH. Poor results were attributable to the operation except in the two cases of ACA aneurysm in which preexisting dementia persisted. Mortality was 4% and morbidity was 14%, varying from a combined low morbidity-mortality of 8% for ICA lesions to a high of 50% for BAC aneurysms. During the period of the study, different techniques were developed in an attempt to lower the risks of surgery.Ultimately ICA aneurysms were monitored with cerebral blood flow measurements and electroencephalography before and after temporary ICA ligation, then approached following resection of the anterior clinoid or treated with bypass in combination with ICA ligation. Aneurysms of the MCA were either opened during temporary MCA occlusion or resected in combination with a bypass procedure. Bypass grafts and circulatory arrest with extracorporeal circulation may have a role in giant aneurysms of the posterior circulation.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Cerebrovascular Research Center, Room 4-437, Alfred Unit, St. Mary's Hospital, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Upper: Preoperative angiogram, anteroposterior view (left) and lateral view (right), showing a giant carotid-ophthalmic aneurysm. Lower Left and Lower Right: Postoperative angiograms, 1 week after surgery. Note the multiple clips applied in “piggyback” fashion.

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    Case 2. Upper: Preoperative angiogram, showing a giant carotid-ophthalmic aneurysm. Lower: Postoperative angiograms, subtraction films. Lower Left: Two weeks after surgery, performed to evaluate a retro-orbital bruit. Note compression of the internal carotid artery (ICA), apparently caused by retroflexion of the aneurysmal mass. Lower Right: Six months after surgery. The ICA has now returned to a normal caliber.

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    Case 3. Preoperative angiogram showing a giant partially thrombosed aneurysm of the middle cerebral artery.

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    Case 3. Preoperative computerized tomograms. The aneurysm is much larger than it appears on the angiogram. This is commonly the case with giant aneurysms.

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    Case 3. Postoperative angiograms. The aneurysm has been excised, and the middle cerebral artery fills from a double bypass. Arrows point to sites of anastomoses.

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    Case 4. Preoperative computerized tomograms. The aneurysm appears much larger than on the angiogram (not illustrated).

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    Case 4. Postoperative angiogram, after internal carotid artery ligation with a Selverstone clamp, and the bypass procedure. Partially thrombosed aneurysm (which is larger than apparent here) fills through the clamp. The bypass is patent.

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    Sketch of surgical procedure for an internal carotid artery (ICA) aneurysm. A: Scalp incision crosses but does not cut the anterior limb of the superficial temporal artery. The vessel must be preserved for possible bypass (see text). B: The pterional approach is used for ICA and middle cerebral artery aneurysms. The temporalis muscle is incised along its insertion onto the lateral orbital rim and retracted posteriorly without injury to the primary muscle belly. This prevents atrophy of this muscle and an unsightly postoperative cosmetic defect. C: A small craniotomy is augmented by sphenoid wing resection and temporal craniectomy. The temporalis muscle is subtotally partially incised along the zygomatic arch (incision diagramatically exaggerated here) and retracted posteriorly. D: The dura is opened along floor of frontal fossa and tacked over sphenoid wing. This will be subsequently closed with small dural graft or piece of fascia lata. E: Typical giant aneurysm. Note the stretching of the A-1 segment of the anterior cerebral artery. The aneurysm must not be manipulated as the origin of this vessel can be torn. F: The dura is incised over the anterior clinoid process. G: The anterior clinoid is resected with a diamond burr. H: The dural sheath of the ICA is incised with a No. 11 blade knife. The bone is sealed with bone wax, and the cavernous sinus with a collagen preparation. I: The aneurysm is clipped after its base has been dissected away from adjacent structures. J: The aneurysm is aspirated.

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    Sketch of surgical procedure for a middle cerebral artery (MCA) aneurysm. A: The MCA is temporarily occluded. B: The aneurysm is opened and thrombus is removed. C: The aneurysm is converted into a pliable sac and clipped with a strong McFadden clip. Flow is restored. A portion of the base of the aneurysm is preserved to prevent encroachment upon the lumen of the parent artery.

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