Direct surgical treatment of giant intracranial aneurysms

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✓ The author has operated on 40 patients with giant intracranial aneurysms, using various surgical approaches. Giant aneurysms predominated in females (3:1) and were most common in the age group 30 to 60 years. Patients presented with subarachnoid hemorrhage (17), visual disturbance (18), chronic headache (14), transient or progressive hemispheric deficit (6), seizure (2), dementia (2), and cerebrospinal fluid rhinorrhea (1). Giant aneurysms were located at the carotid artery (25), the basovertebral artery (8), the anterior communicating artery (5), and the middle cerebral artery (2). Eight of 40 patients had one or more other aneurysms and/or associated arteriovenous malformations. Aneurysms were treated with intramural thrombosis (21), neck occlusion (7), trapping (10), proximal parent artery ligation (1), and aneurysmorrhaphy (1). After as much as 8 years of follow-up, 32 patients (80%) showed complete or marked improvement in signs and symptoms; two patients (5%) had a poor recovery. There were six surgical mortalities (15%).

Giant aneurysms can be treated with respectable results if the surgeon selects the technique best suited to the particular aneurysm. In general, neck occlusion, trapping, and aneurysmorrhaphy are best for giant aneurysms of the anterior circulation, and intramural thrombosis is best for those of the posterior circulation. Extra- and intracranial vascular anastomotic techniques are also of value. For success, a flexible approach is essential.

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Address reprint requests to: Yoshio Hosobuchi, M.D., The Editorial Office, Department of Neurological Surgery, School of Medicine, University of California, 350 Parnassus Avenue, Suite 807, San Francisco, California 94143.

© AANS, except where prohibited by US copyright law.

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Figures

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    Tracings of roentgenograms of giant aneurysms in 40 cases operated on by the author (numbers refer to Table 1).

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    Case 4. Angiograms in 1974 of the right carotid artery, lateral view (left) and anteroposterior view (right), showing a giant carotid-ophthalmic aneurysm.

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    Case 4. Right vertebral angiogram, lateral view (left) and anteroposterior view (center), showing further enlargement of the giant carotid-ophthalmic aneurysm. Left carotid angiogram (right) shows minimal collateral circulation to the right cerebral hemisphere.

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    Diagram of an entrapment maneuver, illustrated with the case of a giant aneurysm of the left carotid artery. The distal branches shown are, from left to right, the posterior communicating, middle cerebral, and anterior cerebral arteries; the ophthalmic and anterior choroidal arteries are not shown. A: The pressure is measured with a No. 27 needle connected by plastic tubing to a strain gauge. When the distal pressure (Δ) is < 50 mm Hg, the pulsatory excursion of the blood pressure is minimal and only systolic pressure is recorded. B: The contents of the aneurysm are aspirated with a No. 20 or 18 needle (connected to suction tubing) inserted obliquely through the wall of the aneurysm.

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    Case 4. Postoperative angiograms, anteroposterior views, of the left carotid (left) and right vertebral artery (right).

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    Case 1. Angiograms of a giant aneurysm of the carotid-ophthalmic artery, lateral views, before (left) and after (right) successful obliteration using two opposed aneurysm clips.

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    Case 25. Angiograms of a giant aneurysm of the anterior communicating artery, lateral view (left) and anteroposterior view (upper right). Lower Right: Postoperative angiogram shows the intact anterior communicating artery, which was preserved by controlled progressive intramural thrombosis using intraoperative arteriograms. The residual dilation of the base was reinforced with muslin.

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    Case 15. Angiograms of a giant aneurysm of the left carotid-ophthalmic artery. Left: Preoperatively, showing occlusion of distal blood flow. Center: Immediately postoperatively, showing marked improvement in the distal blood flow, which was reflected in clinical improvement. Right: Six years postoperatively, showing the aneurysm recanalized, although distal circulation is good. The patient remains asymptomatic except for a residual defect of the left temporal visual field.

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    Case 27. Giant aneurysm of the anterior communicating artery. Left: Computerized tomography scan shows partial thrombosis. Center and Right: Angiograms of the left carotid artery, anteroposterior view: preoperatively, showing both vericollosal arteries filled from the left side only (center); and postoperatively (right), showing the neck thrombosed by means of four stereotaxically placed copper needles (arrow).

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