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Surgical approach to giant intracranial aneurysms

Operative experience with 80 cases

Thoralf M. Sundt Jr. and David G. Piepgras

and damage to perforating vessels. The former occurred primarily in ICA bifurcation aneurysms, the latter in BAC lesions. Both of these types of complications were related to clip migration, which in turn was produced from the disparity in tissues of the hard aneurysm and soft artery. A stronger clip is required for this type of surgery. The relatively low morbidity from ICA ligation and combined bypass is attributable to the extensive use of intraoperative CBF monitoring. This has been an important adjunct to the procedure. Nevertheless, the amounts of flow

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Waro Taki, Shogo Nishi, Kohsuke Yamashita, Akiyo Sadatoh, Ichiro Nakahara, Haruhiko Kikuchi and Hiroo Iwata

artery was occluded; in each case, complete angiographically verified occlusion of the aneurysm was achieved. In one cavernous aneurysm, a combined bypass procedure and parent arterial occlusion was performed. In this patient, the occlusion test was positive and therefore temporary occlusion of the ICA could not be tolerated. Three weeks after extracranial-intracranial bypass, occlusion became possible and the ICA was occluded. TABLE 2 Results of endovascular treatments in 19 cases of giant aneurysm * Case No. Location Embolic

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Tetsuro Kawaguchi, Shigekiyo Fujita, Kohkichi Hosoda, Yoshiteru Shose, Seiji Hamano, Masaki Iwakura and Norihiko Tamaki

the collateral vascular beds to enlarge to compensate for the reduced CBF; 6 therefore there is no reserve dilation of the vessels after the administration of acetazolamide in the ischemic area. 46 A PET study indicated that neovascularization developed when the cortex was under misery perfusion (decreased CBF and increased OEF and CBV), which was corrected by bypass surgery. 3, 31 The improvement of PET findings in childhood moyamoya disease has been reported both for the cortex and the basal ganglia after indirect or combined bypass surgery. 6 We defined the

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Masatou Kawashima, Albert L. Rhoton Jr., Necmettin Tanriover, Arthur J. Ulm, Alexandre Yasuda and Kiyotaka Fujii

intracranial aneurysms. 25, 27, 31, 32, 34, 47, 53, 57, 60, 61 At present, endovascular techniques, with or without combined bypass surgery, offer an alternative therapy for the treatment of patients with complex and giant posterior circulation aneurysms. 13, 19, 20 Nevertheless, there are contraindications for endovascular treatment, including a partially thrombosed aneurysm and a wide aneurysm neck. Most of these aneurysms present treatment challenges with the use of the direct clipping procedure. Cerebral revascularization procedures are then applied to the treatment of

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Jae Hyo Park, Park In Sung, Dae Hee Han, Seong Hyun Kim, Chang Wan Oh, Jeong-Eun Kim, Hyun Jib Kim, Moon Hee Han and O-Ki Kwon

the waiting period without definitive treatment or after incomplete treatment. If vasospasm developed, it was often impossible to apply any definitive treatment, such as ICA trapping or combined bypass–trapping, because of the high risk of ischemia. Our experience suggests that ICA BBAs should be treated with definitive methods at the earliest opportunity because an aggravated clinical condition caused by rebleeding and vasospasm can deprive one of a chance to save the patient. Long-term cerebral ischemic risk is one of the major potential problems of ICA

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Tae Sung Park

of outcome studies of direct, indirect, and combined bypass procedures. From this review, it is clear that the neurosurgical interventions for MMD in the pediatric population are probably beneficial, but the advantages of one particular technique over another remains undetermined. In interpreting data from the reported outcome studies, one must consider that idiopathic MMD may not be the same disease as MMD associated with other disorders such as Down syndrome and so forth. Outcome reports from Asian countries included only idiopathic MMD, whereas those from the

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Anand Veeravagu, Raphael Guzman, Chirag G. Patil, Lewis C. Hou, Marco Lee and Gary K. Steinberg

multiple cranial bur holes for cerebral revascularization. 40 This technique was developed after vasculogenesis was observed in patients with ventriculostomies requiring cranial bur holes. Thus, strategically placed bur holes in areas of cerebral hypoperfusion might aid in stimulating vascular formation between underlying cortex and dura mater, effectively providing an arterial supply to hypoxic areas of the brain. Outcomes of Direct, Indirect, and Combined Bypass Techniques The direct technique is generally accepted as providing immediate vascularization to the

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Paolo Ferroli, Elisa Ciceri, Alessandro Addis and Giovanni Broggi

. In the patient in the present case, both the complete absence of an aneurysm neck and the outflow artery arising from the dome of the aneurysm suggested a combined bypass–endovascular parent vessel occlusion strategy. In 2005 Kim et al. 13 reported a similar case and concluded that “the use of pericallosal artery–pericallosal artery side-to-side bypass followed by parent vessel occlusion offers an elegant solution for the treatment of distal ACA aneurysms that are not amenable to primary clip ligation or endovascular occlusion.” As the demands of vascular

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Marcus Czabanka, Peter Vajkoczy, Peter Schmiedek, and Peter Horn

Functional rCBF studies were conducted in adult patients and consisted of the measurement of rCBF at rest and after the application of acetazolamide (15 mg/kg body weight) using stable xenon–CT technology (Diversified Diagnostic Products, Inc.). Cerebrovascular reserve capacity was calculated as described elsewhere in detail. 9 Table 1 summarizes the clinical and demographic characteristics of our patient population. TABLE 1: Summary of demographic and clinical characteristics of adult and pediatric patients with MMD treated with combined bypass

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Koji Kamijo and Toru Matsui

necessity for combined bypass surgery should be judged based on the results of balloon test occlusion. Whether such procedures could be tolerated under the likelihood of cerebral vasospasm is doubtful, however, even though some patients might tolerate acute ICA occlusion without bypass immediately after surgery as a result of the test occlusion. This line of reasoning renders EC-IC bypass indispensable in patients undergoing ICA sacrifice to treat BBAs during the acute period as well as during subsequent periods. Baskaya et al. 2 have described a series of 4 patients