Bifrontal interhemispheric approach to aneurysms of the anterior communicating artery

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✓ 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.

Article Information

Address reprint requests to: Jiro Suzuki, M.D., Division of Neurosurgery, Institute of Brain Diseases, Tohoku University School of Medicine, 1-1 Seiryo-cho, Sendai, Japan.

© AANS, except where prohibited by US copyright law.

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    Diagrams of the interhemispheric approach to aneurysms of the anterior communicating artery.Left: Location of the skin incision and craniotomy. The anterior edge of the bone flap is cut down frontally as close as possible to the orbital edge. Right: Procedure for retrograde exposure of both A2 segments interhemispherically.

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    Vascular anomalies in the anterior communicating artery (Acom) complex.

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References

1.

Crowell RMOjemann RG: Surgical treatment of anterior communicating artery aneurysmsSchmidek HHSweet WH (eds): New York: Grune & Stratton19822829854

2.

Endo SSuzuki J: Experimental cerebral vasospasm after subarachnoid hemorrhage. Development and degree of vasospasm. Stroke 8:7027071977Stroke 8:

3.

Endo SSuzuki J: Experimental cerebral vasospasm after subarachnoid hemorrhage. Participation of adrenergic nerves in cerebral vessel wall. Stroke 10:7037111979Stroke 10:

4.

Fox JL: Intracranial Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag19832750799Fox JL: Intracranial Aneurysms.

5.

French LAChou SNStory JLet al: Aneurysm of the anterior communicating artery. J Neurosurg 24:105810621966J Neurosurg 24:

6.

Graf CJNibbelink DW: Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Report on a randomized treatment study. III. Intracranial surgery. Stroke 5:5576011974Stroke 5:

7.

Hunt WEKosnik EJ: Timing and perioperative care in intracranial aneurysm surgery. Clin Neurosurg 21:79891974Clin Neurosurg 21:

8.

Ishibashi YKonda RYoshimoto Tet al: [The effect of prazosinhydrochloride on cerebral vasospasm — an experimental study.] No Shinkei Geka 23:1331391984 (Jpn)No Shinkei Geka 23:

9.

Kagawa SKoshu KYoshimoto Tet al: The protective effect of mannitol and perfluorochemicals on hemorrhagic infarction: an experimental study. Surg Neurol 17:66701982Surg Neurol 17:

10.

Kodama NHori SKamiyama Ket al: Cervical sympathectomy for cerebral vasospasm after aneurysm ruptureWilkins RH (ed): Cerebral Arterial Spasm. Baltimore: Williams & Wilkins1980680684Cerebral Arterial Spasm.

11.

Kwak RNiizuma HHatanaka Met al: Anterior communicating artery aneurysms with associated anomalies. J Neurosurg 52:1621641980J Neurosurg 52:

12.

Mizoi KYoshimoto TSuzuki J: Experimental study of new cerebral protective substances — functional recovery of severe, incomplete ischaemic brain lesions pretreated with mannitol and fluorocarbon emulsion. Acta Neurochir 56:1571661981Acta Neurochir 56:

13.

Ogawa KSato HSakurai Yet al: [Treatment for cerebral vasospasm with mannitol and angiotensin II-induced hypertensionIwabuchi T (ed): Proceedings of the 11th Japanese Conference on Surgery of Cerebral Stroke. Tokyo: Neuron1982253258 (Jpn)Proceedings of the 11th Japanese Conference on Surgery of Cerebral Stroke.

14.

Owada KHori SSuzuki J: Results of cervical sympathectomy for cerebral vasospasm following aneurysm ruptureSuzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron1979435441Cerebral Aneurysms.

15.

Pool JL: Bifrontal craniotomy for anterior communicating artery aneurysms. J Neurosurg 36:2122201972Pool JL: Bifrontal craniotomy for anterior communicating artery aneurysms. J Neurosurg 36:

16.

Pool JL: Timing and techniques in the intracranial surgery of ruptured aneurysms of the anterior communicating artery. J Neurosurg 19:3783881962Pool JL: Timing and techniques in the intracranial surgery of ruptured aneurysms of the anterior communicating artery. J Neurosurg 19:

17.

Sato SSuzuki J: Anatomical mapping of the cerebral nervi vasorum in the human brain. J Neurosurg 43:5595681975J Neurosurg 43:

18.

Seki HYoshimoto TOgawa Aet al: Effect of mannitol on rCBF in canine thalamic ischemia — an experimental study. Stroke 14:46501983Stroke 14:

19.

Sonobe MSuzuki J: Vasospasmogenic substance produced following subarachnoid haemorrhage, and its fate. Acta Neurochir 44:971061978Acta Neurochir 44:

20.

Suzuki J: Prognosis of 1000 pure saccular aneurysms operated uponPia HWLangmaid CZierski J (eds): Cerebral Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag1979413418Cerebral Aneurysms.

21.

Suzuki JFujimoto SMizoi Ket al: The protective effect of combined administration of anti-oxidants and perfluorochemicals on cerebral ischemia. Stroke 15:6726791984Stroke 15:

22.

Suzuki JKodama NHomma M: New clip and flexible clip forceps for neurosurgerySuzuki J (ed): Cerebral Aneurysms. Tokyo: Neuron1979386388Cerebral Aneurysms.

23.

Suzuki JKodama NYoshimoto Tet al: Ultraearly surgery of intracranial aneurysms. Acta Neurochir 63:1851911982Acta Neurochir 63:

24.

Suzuki JKwak ROkudaira Y: The safe time limit of temporary clamping of cerebral arteries in the direct surgical treatment of intracranial aneurysm under moderate hypothermia. Tohoku J Exp Med 127:171979Tohoku J Exp Med 127:

25.

Suzuki JOnuma TYoshimoto T: Results of early operations on cerebral aneurysms. Surg Neurol 11:4074121979Surg Neurol 11:

26.

Suzuki JYoshimoto T: The effect of mannitol in prolongation of permissible occlusion time of cerebral artery — clinical data of aneurysm surgery. Neurosurg Rev 1:13191979Neurosurg Rev 1:

27.

Suzuki JYoshimoto T: Indication and timing in the surgery of ruptured cerebral aneurysm. Phronesis 36:34481978Phronesis 36:

28.

Suzuki JYoshimoto TKayama T: Surgical treatment of middle cerebral artery aneurysms. J Neurosurg 61:17231984J Neurosurg 61:

29.

Suzuki JYoshimoto TMizoi K: Preservation of the olfactory tract in bifrontal craniotomy for anterior communicating artery aneurysms, and the functional prognosis. J Neurosurg 54:3423451981J Neurosurg 54:

30.

VanderArk GDKempe LC: Classification of anterior communicating aneurysms as a basis for surgical approach. J Neurosurg 32:3003031970J Neurosurg 32:

31.

Wilson CBSpetzler RF: Operative approaches to aneurysms. Clin Neurosurg 26:2322471979Clin Neurosurg 26:

32.

Yaşargil MGFox JLRay MW: The operative approach to aneurysms of the anterior communicating arteryKrayenbühl H (ed): Advances and Technical Standards in Neurosurgery. New York/Wien: Springer-Verlag19752113168Advances and Technical Standards in Neurosurgery.

33.

Yoshimoto TSakamoto TWatanabe Tet al: Experimental cerebral infarction. Part 3: Protective effect of mannitol in thalamic infarction in dogs. Stroke 9:2172181978Stroke 9:

34.

Yoshimoto TSuzuki J: Temporary clipping — prolongation of the time of occlusion by mannitolPia HWLangmaid CZierski J (eds): Cerebral Aneurysms. Berlin/Heidelberg/New York: Springer-Verlag1979382392Cerebral Aneurysms.

35.

Yoshimoto TUchida KKaneko Uet al: An analysis of follow-up results of 1000 intracranial saccular aneurysms with definitive surgical treatment. J Neurosurg 50:1521571979J Neurosurg 50:

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