✓ The authors review their experience with the bifrontal interhemispheric approach in 603 cases of single anterior communicating artery (ACoA) aneurysms and describe the operative technique. With this approach, the olfactory tracts are dissected, and both A1 segments of the anterior cerebral arteries are identified subfrontally. The interhemispheric fissure is then dissected and A2segments are followed from the distal portion toward the ACoA complex. Following the administration of a combination of mannitol, vitamin E, and dexamethasone, a temporary clip is placed on at least the dominant A1 segment prior to dissection of the aneurysm itself. Once the aneurysm has been completely freed from the surrounding structures, the neck is ligated and clipped. If the aneurysm ruptures during surgery, temporary clips are placed on both A1 and A2 segments bilaterally and the operation proceeds in a completely dry field. With this method, it is possible to occlude any of the intracranial vessels for up to 40 minutes within 100 minutes of drug administration.
To prevent the possibility of rerupture and the development of vasospasm in the period before aneurysm surgery, the authors have adopted a policy of performing ultra-early operations within 48 hours of the onset of symptoms. Among the 257 cases operated on during the 9 years since 1975, one-fifth have been operated on within 48 hours of rupture, and the in-hospital mortality rate has been only 4.3% (11 cases). Follow-up studies have shown that 87% of the 246 surviving patients have returned to useful lives.
MizoiKYoshimotoTSuzukiJ: Experimental study of new cerebral protective substances — functional recovery of severe, incomplete ischaemic brain lesions pretreated with mannitol and fluorocarbon emulsion.Acta Neurochir56:157–1661981Acta Neurochir 56:
OgawaKSatoHSakuraiYet al: [Treatment for cerebral vasospasm with mannitol and angiotensin II-induced hypertensionIwabuchiT (ed): Proceedings of the 11th Japanese Conference on Surgery of Cerebral Stroke.Tokyo: Neuron1982253–258(Jpn)Proceedings of the 11th Japanese Conference on Surgery of Cerebral Stroke.
PoolJL: Timing and techniques in the intracranial surgery of ruptured aneurysms of the anterior communicating artery.J Neurosurg19:378–3881962Pool JL: Timing and techniques in the intracranial surgery of ruptured aneurysms of the anterior communicating artery. J Neurosurg 19:
SuzukiJKwakROkudairaY: The safe time limit of temporary clamping of cerebral arteries in the direct surgical treatment of intracranial aneurysm under moderate hypothermia.Tohoku J Exp Med127:1–71979Tohoku J Exp Med 127:
YaşargilMGFoxJLRayMW: The operative approach to aneurysms of the anterior communicating arteryKrayenbühlH (ed): Advances and Technical Standards in Neurosurgery.New York/Wien: Springer-Verlag19752113–168Advances and Technical Standards in Neurosurgery.
YoshimotoTSuzukiJ: Temporary clipping — prolongation of the time of occlusion by mannitolPiaHWLangmaidCZierskiJ (eds): Cerebral Aneurysms.Berlin/Heidelberg/New York: Springer-Verlag1979382–392Cerebral Aneurysms.