Application of a rigid endoscope to the microsurgical management of 54 cerebral aneurysms: results in 48 patients

Restricted access

Object. To enhance visual confirmation of regional anatomy, endoscopy was introduced during microsurgery for cerebral aneurysms. The risks and benefits are analyzed in the present study.

Methods. The endoscopic technique was used during microsurgery for 54 aneurysms in 48 patients. Forty-three aneurysms were located in the anterior circulation and 11 were in the posterior circulation. Thirty-eight aneurysms (70.4%) had not ruptured. All ruptured aneurysms in the present series produced Hunt and Hess Grade I or II subarachnoid hemorrhage.

After initial exposure achieved with the aid of a microscope, the rigid endoscope was introduced to confirm the regional anatomy, including the aneurysm neck and adjacent structures. The necks of 43 aneurysms were clipped using microscopic control or simultaneous microscopic/endoscopic control. After clipping, the positions of the clip and nearby structures were inspected using the endoscope.

Use of the neuroendoscope provided useful information that further clarified the regional anatomy in 44 cases (81.5%) either before or after neck clipping. In nine cases (16.7%), these details were available only with the use of the endoscope. In five cases (9.3%), the surgeons reapplied the clip on the basis of endoscopic information obtained after the initial clipping. There were two cases in which surgical complications were possibly related to the endoscopic procedures (one patient with asymptomatic cerebral contusion and another with transient oculomotor palsy).

Conclusions. It is the authors' impression that the use of the endoscope in the microsurgical management of cerebral aneurysms enhanced the safety and reliability of the surgery. However, there is a prerequisite for the surgeon to be familiar with this instrumentation and fully prepared for the risks and inconveniences of endoscopic procedures.

Article Information

Address reprint requests to: Hiroshi Takimoto, M.D., Ph.D., Department of Neurosurgery, Suita Municipal Hospital, 2–13–20 Katayama-cho, Suita, Osaka 564–0083, Japan.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 1. Angiographic, microsurgical, and endoscopic views (with accompanying illustrations) obtained in a 59-year-old woman with a nonruptured right ICA—PCoA aneurysm. a: Preoperative angiography demonstrating the small right ICA—PCoA aneurysm projecting laterally. b: Alhough the aneurysm is clearly exposed when viewed using the microscope, the offspring of the PCoA behind the aneurysm are not visible. c: Introduction of the endoscope provides an excellent view behind the aneurysm, distinguishing all adjacent vessels from their offspring. An = aneurysm; CN2 = optic nerve; Endo = endoscope; IC = internal carotid artery; Pcom = posterior communicating artery.

  • View in gallery

    Case 2. Angiographic, microsurgical, and endoscopic views (with accompanying illustrations) obtained in a 54-year-old man with a nonruptured right ICA—OA aneurysm. a: Preoperative angiography demonstrating the small right ICA—OA aneurysm projecting medioventrally. b: Even after partial resection of the anterior clinoid process, the aneurysm neck, covered by the optic nerve and the ICA itself, is not confirmed. c: The endoscope, introduced lateral to the ICA, demonstrates that the neck is located entirely distal to the fibrous ring. FR = fibrous ring; SV = sylvian vein.

  • View in gallery

    Case 3. Angiographic, microsurgical, and endoscopic views (with accompanying illustrations) obtained in a 66-year-old woman with incidental left MCA and right BA—SCA aneurysms. a: Preoperative angiography demonstrating the right BA—SCA aneurysm. The lesion was exposed with the aid of the microscope via a right orbitozygomatic approach. b: The endoscope is introduced through the space lateral to the ICA. Visualization of the dorsal surface of the BA adjacent to the aneurysm neck is achieved with the endoscope. c: Two distinct perforating vessels arise from the BA close to the aneurysm. PCA = posterior cerebral artery; perf = perforating arteries.

  • View in gallery

    Case 4. Angiographic, microsurgical, and endoscopic views (with accompanying illustrations) obtained in a 68-year-old man with a ruptured ACoA aneurysm and nonruptured bilateral MCA and right VA aneurysms. a: Preoperative angiography demonstrating a right VA fusiform aneurysm. The VA aneurysm is exposed with the aid of the microscope via the transcondylar route. b: The endoscope is introduced into the space between the vagal and spinal accessory nerves. c: Clear visualization of the whole length of the aneurysm including its distal end is achieved with the endoscope. CN9, 10 = glossopharyngeal and vagal nerve; CN11 = accessory nerve; CN12 = hypoglossal nerve; PICA = posterior inferior cerebellar artery.

References

1.

Apuzzo MLJHeifetz MDWeiss MHet al: Neurosurgical endoscopy using the side-viewing telescope. Technical note. J Neurosurg 46:3984011977Apuzzo MLJ Heifetz MD Weiss MH et al: Neurosurgical endoscopy using the side-viewing telescope. Technical note. J Neurosurg 46:398–401 1977

2.

Fischer JMustafa H: Endoscopic-guided clipping of cerebral aneurysms. Br J Neurosurg 8:5595651994Fischer J Mustafa H: Endoscopic-guided clipping of cerebral aneurysms. Br J Neurosurg 8:559–565 1994

3.

Heiskanen O: Risks of surgery for unruptured intracranial aneurysms. J Neurosurg 65:4514531986Heiskanen O: Risks of surgery for unruptured intracranial aneurysms. J Neurosurg 65:451–453 1986

4.

Hunt WEHess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14201968Hunt WE Hess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20 1968

5.

International Study of Unruptured Intracranial Aneurysms Investigators: Unruptured intracranial aneurysms—risks of rupture and risks of surgical intervention. N Engl J Med 339:172517331998International Study of Unruptured Intracranial Aneurysms Investigators: Unruptured intracranial aneurysms—risks of rupture and risks of surgical intervention. N Engl J Med 339:1725–1733 1998

6.

King JT JrBerlin JAFlamm ES: Morbidity and mortality from elective surgery for asymptomatic, unruptured, intracranial aneurysms: a meta-analysis. J Neurosurg 81:8378421994King JT Jr Berlin JA Flamm ES: Morbidity and mortality from elective surgery for asymptomatic unruptured intracranial aneurysms: a meta-analysis. J Neurosurg 81:837–842 1994

7.

Ohira TOchiai MKawase Tet al: Computer-assisted endomicroscopic surgery in Tamaki NEhara K (eds): Computer-Assisted Neurosurgery. Tokyo: Springer-Verlag1997 pp 6975Ohira T Ochiai M Kawase T et al: Computer-assisted endomicroscopic surgery in Tamaki N Ehara K (eds): Computer-Assisted Neurosurgery. Tokyo: Springer-Verlag 1997 pp 69–75

8.

Perneczky AFries G: Endoscope-assisted brain surgery: part 1—evolution, basic concept, and current technique. Neurosurgery 42:2192251998Perneczky A Fries G: Endoscope-assisted brain surgery: part 1—evolution basic concept and current technique. Neurosurgery 42:219–225 1998

9.

Perneczky ATschabitschar MResch KDM: Endoscopic Anatomy for Neurosurgery. Stuttgart: Thieme1993 pp 1166Perneczky A Tschabitschar M Resch KDM: Endoscopic Anatomy for Neurosurgery. Stuttgart: Thieme 1993 pp 1–166

10.

Sindou MAcevedo JCTurjman F: Aneurysmal remnants after microsurgical clipping: classification and results from a prospective angiographic study (in a consecutive series of 305 operated intracranial aneurysms). Acta Neurochir 140:115311591998Sindou M Acevedo JC Turjman F: Aneurysmal remnants after microsurgical clipping: classification and results from a prospective angiographic study (in a consecutive series of 305 operated intracranial aneurysms). Acta Neurochir 140:1153–1159 1998

11.

Taneda MKato AYoshimine Tet al: Endoscopic-image display system mounted on the surgical microscope. Minim Invasive Neurosurg 38:85861995Taneda M Kato A Yoshimine T et al: Endoscopic-image display system mounted on the surgical microscope. Minim Invasive Neurosurg 38:85–86 1995

12.

Taniguchi MPerneczky A: Subtemporal keyhole approach to the suprasellar and petroclival region: microanatomic considerations and clinical application. Neurosurgery 41:5926011997Taniguchi M Perneczky A: Subtemporal keyhole approach to the suprasellar and petroclival region: microanatomic considerations and clinical application. Neurosurgery 41:592–601 1997

13.

Van Lindert EPerneczky AFries Get al: The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg Neurol 49:4814901998Van Lindert E Perneczky A Fries G et al: The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg Neurol 49:481–490 1998

14.

Yoshimine TKato ATaniguchi Met al: [Instrumentations for less invasive and safer endoscopic neurosurgery.] Jpn J Neurosurg 7:79861997 (Jpn)Yoshimine T Kato A Taniguchi M et al: [Instrumentations for less invasive and safer endoscopic neurosurgery.] Jpn J Neurosurg 7:79–86 1997 (Jpn)

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 10 10 7
Full Text Views 80 80 18
PDF Downloads 79 79 15
EPUB Downloads 0 0 0

PubMed

Google Scholar