破裂脳動脈瘤術中破裂の予防法

To explore the feasibility and effect of microsurgical treatment of complex intracranial aneurysms via keyhole approaches. Operation via keyhole approach was performed on thirty-one patients with 42 complex intracranial aneurysms were operated on, including 2 internal carotid artery bifurcation aneurysms, 1 anterior cerebral artery aneurysm, 12 posterior communicating artery aneurysms, 2 anterior choroids artery aneurysms, 7 middle cerebral artery aneurysms, 6 anterior communicating artery aneurysms, 2 basilar artery aneurysms, 2 vertebral artery aneurysms, 4 posterior cerebral artery aneurysms and 4 ophthalmic artery aneurysms, among which were 10 cases with multiple intracranial aneurysms, 14 with giant aneurysms, and 7 with posterior circulation aneurysms, and 4 aneurysms clipped by drilling off anterior clinoid process. Six of the 31 patients who had giant aneurysms came to hospital because of the symptoms, such as dizziness, headache, oculomotor paralysis, loss of vision, etc, and the other 25 patients were grouped according to the subarachnoid hemorrhage (SAH) Grade: 5 in grade I, 12 in grade II, 7 in grade III and 1 in grade IV. Eight patients were operated on after SAH in the early-phase, while 8 in the middle-phase and 9 in the late-phase. The supraorbital subfrontal keyhole approach was used 25 times, the pterional approach 5 times, the subtemporal approach 3 times, and both the suboccipital lateral approach and the retromastoid approach once. 31 of the 42 aneurysms were clipped, 2 mini-aneurysms wrapped, 5 giant aneurysms clipped and resected, 2 aneurysms trapped with thrombotic aneurysm partially resected, 1 aneurysm trapped, while 1 ruptured before operation and untreated. Short-term Glasgow outcome scoring showed good recovery in 27 patients, moderate disability in 2, and death in 2. Operation via keyhole approaches effectively controls the immature rupture of intracranial aneurysm, removes anterior clinoid process, respects giant aneurysm, and reconstructs the parent artery of wide-neck aneurysm. Based on individualized surgical approaches and excellent microsurgical skills, the complex intracranial aneurysms can be treated safely, directly and effectively via minimally invasive keyhole approaches.

Objective The purpose of this study is to assess demographic, clinical, and unique morphological characteristics of distal anterior cerebral artery (DACA) aneurysm. The relation of outcome included Glasgow Outcome Scale (GOS) using various independent variables, Hunt and Hess clinical grade (H&H), Miller Fischer grade, intraoperative rupture, and comparison of outcomes at discharge and last follow-up. Methods Demographic data, aneurysm characteristics, and treatment outcomes were evaluated in 28 ruptured DACA aneurysms operated over a period of 13 years. Association between independent variables and dependent variables (GOS) at discharge and at last follow-up (13 years) was analyzed, and the interrelationship between these factors and outcome was evaluated. GOS was used to assess functional outcomes. Results Over a period of 13 years, 500 patients harboring ruptured intracranial aneurysms were surgically clipped, and out of them 28 patients (5.6%) had ruptured DACA aneurysms. In this series, 20 (71.4%) patients had low grade and 8 (28.6%) had high grade H&H. Out of the 28 patients, 19 (67.8%) had good recovery, 6 (21.5%) were severely disabled, and 3 (10.7%) died at the time of discharge. On the last follow-up (13 years), smoking ( p -value 0.03) and use of temporary clip ( p -value 0.00) were significant predictors for unfavorable outcome. Conclusion The results of our case series show that even with ruptured aneurysm excellent overall outcome after microsurgical clipping can be achieved, even though among cerebral aneurysms, DACA aneurysm is considered to have less favorable outcome. Alcohol consumption and use of temporary clip were the predictors for unfavorable outcome at the time of discharge. On the last follow-up, smoking and use of temporary clip were found to be the risk factors for unfavorable outcome. Although the small sample size of this study is a limitation, smoking and use of temporary clip play an important role on the overall outcome. The aim of this study was to analyze data to determine factors which may influence outcome after surgical clipping of ruptured DACA aneurysms.

Introduction: Distal anterior cerebral artery (DACA) aneurysms are less common and surgical morbidity has been reported relatively high due to intraoperative rupture and narrow surgical field. Endovascular treatment can be alternative to surgery. This study investigated the efficacy and safety of endovascular coiling for ruptured DACA aneurysms comparing with microsurgical clipping. Patients and Methods: Between January 1999 and March 2012, consecutive 94 patients with ruptured DACA aneurysm were treated by surgical clipping (n=52, 55.3%) and endovascular coiling (n=42, 44.7%) in five institutions including only 2 cases of recurrence (2.1%, 1 in clip and 1 in coil). The clinical outcomes of patients and procedure-related complications (intraprocedural rupture and any infarction) were evaluated and compared between two groups. Results: There were 38 males and 56 females (mean age; 55.1 years). Initial Hunt-Hess grade was GII in 25 patients (37.2%), GIII in 36 patients (38.3%), GIV in 12 patients (12.8%), and GV in 11 patients (11.7%), which was significantly higher in coil group (2.77 in clip vs 3.26 in coil, p=0.016). Initial CT scanning showed ruptured DACA aneurysm with ICH (n=35; 37.2%) and hydrocephalus (n=25; 26.6%). Maximal diameter of aneurysm was less than 5mm in 36 (38.3%), 5~10mm in 53 (56.4%), and 10mm and more than in 5 (5.3%). Technical success rate was 100% and complete occlusion or neck remnant of aneurysm was achieved in 87 [92.6%, 49 (96.1%) in clip vs 38 (90.5%) in coil, p=0.404] and incomplete in 6 (6.4%). At discharge, favorable outcome (modified GOS; good and fair) was obtained in 70 [77.8%, 44 (84.6%) in clip vs 26 (68.4%) in coil, p=0.078]. Intraprocedural rupture occurred only in clipping group [6 cases (11.5%), p=0.031]. Any procedure-related infarction occurred in 7 [7.4%, 6 (11.5%) in clip vs 1 (2.4%) in coil, p=0.126]. Intraprocedural thrombus was detected in 5 cases of coil group and most of them were restored by thrombolytic therapy. There was one case of acute rebleeding in coiling group and this patient died. Conclusions: Endovascular coiling was comparable treatment with clipping for ruptured DACA aneurysms.

Endovascular Management of Multiple Dysplastic Aneurysms in a Young Man with an Unknown Underlying Cause: A Case Report and Review of the Literature.

Background: Subarachnoid hemorrhage has a high mortality and morbidity rates, and the cerebral aneurysm is the most common cause. The location of the ruptured cerebral aneurysm is diagnosed by cerebral angiogram and by computed tomography (CT) pattern of the subarachnoid hemorrhage. Objective: To find the incidence of CT pattern of each cerebral aneurysm and the correlation between CT pattern of subarachnoid hemorrhage and each location of cerebral aneurysm. Materials and Methods: The 126 patients with ruptured cerebral aneurysm were included in the present study. The information of the patients and CT were recorded and analyzed. Results: There were 49 male and 77 female patients. The highest location of cerebral aneurysm is anterior communicating aneurysm (59 patients, 47.6%). There were correlations between A region and anterior cerebral and anterior communicating aneurysm, and left D legion and the other location aneurysm. There were correlations between intracerebral hemorrhage and anterior communication, posterior communication cerebral, and anterior cerebral and middle cerebral artery aneurysm. Conclusion: The common location of cerebral aneurysm is anterior communicating artery aneurysm. There are correlations between the most thickness region of A and D region with anterior communicating aneurysm and the posterior circulation aneurysm, and the correlation between intracerebral hemorrhage and anterior communicating aneurysm, posterior communicating aneurysm, and middle cerebral artery aneurysm. Keywords: Subarachnoid hemorrhage, Cerebral aneurysm, Intracerebral hemorrhage, Thickness

Background Cerebral artery vasospasm accounts for the majority of delayed neurological deficits in ruptured aneurysm patients. We report two cases and review the literature" of patients who developed symptomatic vasospasm after treatment for unruptured cerebral artery aneurysms with clip ligation. Pre- and post-operative imaging and studies revealed absence of subarachnoid or focal hemorrhage. Case Description In a series of 104 consecutive cerebral artery aneurysm patients that underwent uncomplicated ligation without intra-operative rupture, two patients developed delayed neurologic deficits due to severe cerebral vasospasm. Both patients had no stigmata of rupture and were treated electively. Post-operative transcranial dopplers and angiography facilitated the early recognition of vasospasm. Permanent neurologic injury was prevented with the use of hypertensive, hemodilution and hyperdynamic (HHH) therapy along with endovascular treatment, intra-arterial papaverine and angioplasty. Conclusion After uncomplicated treatment of unruptured intracranial aneurysms, the cerebral vasculature may proceed to severe vasospasm by an unrecognized mechanism. This can be reversed with institution of HHH and endovascular therapy.

IntroductionKeeping microcatheters stable in anterior cerebral artery (ACA) or middle cerebral artery (MCA) aneurysms during coil embolization is crucial in the success of the treatment. We currently use a triple...

Background:Multiple distal anterior cerebral artery (DACA) aneurysms appear as rare findings. Simultaneous treatment of such lesions can be particularly challenging. A report of three aneurysms on the same parent artery has not been reported before. We report a case of three DACA aneurysms treated within one microsurgical operation in a patient with eight aneurysms.Case Description:A 62-year-old woman incidentally presented with multiple various size saccular aneurysms, including tree on the left DACA. One of the DACA aneurysm was located on the A3 segment, and the other two were on the A4 and A5 segments. Ligation of all three of these aneurysms was planned in one operation. A standard anterior interhemispheric approach was utilized. Three aneurysms were successfully clipped using four clips. Intraoperative angiography confirmed aneurysm occlusion with parent artery patency preservation. The patient showed no new postoperative neurological deficit.Conclusion:Clipping multiple DACA aneurysms within a single microneurosurgical operation is a feasible treatment option. Meticulous analysis of preoperative imaging features is crucial for selecting the best, patient-specific treatment strategy.

Unruptured Intracranial Aneurysms.

Multiple Cerebral Aneurysms Associated With Neurofibromatosis Type 1

Objective: To assess the frequency of ruptures of very small cerebral aneurysms, features of the perioperative period and outcomes, in comparison with the rupture of ordinarily sized aneurysms.Material and methods: A comparative analysis of the group of patients with ruptured cerebral miliary aneurysms (n = 18) and the group of patients with ruptured cerebral aneurysms of regular size (n = 308) was carried out. All patients underwent open surgery in the first 3 days after the rupture (osteoplastic craniotomy, microsurgical aneurysm clipping). We compared gender, age of patients, severity of the patient’s condition at the moment of admission, severity of subarachnoid hemorrhage, location of aneurysms, aspect ratio, duration of the operation, frequency of intraoperative ruptures, postoperative mortality.Results: It was found that miliary aneurysm rupture occurs in 5.5% of all patients with cerebral aneurysm rupture. The most common cases of rupture of very small aneurysms were in women (77.7%), with a mean age of 50.8 years. Aneurysms of the anterior communicating artery (66.6%) with a narrow neck (average aspect ratio – 2.1) were the most common. Patients with rupture of very small aneurysms were 7.9% more likely to be admitted in a state of subcompensation or decompensation (Hunt-Hess IV–V), they had massive subarachnoid hemorrhage (Fisher III) 19.6% more often than with ruptured aneurysms of regular size. On average, operations in cases of very small aneurysms lasted 30 minutes less than clipping of ordinary aneurysms, but were complicated by intraoperative rupture twice as often (38.8% and 16.5%, respectively). Postoperative mortality in the group of patients with ruptured miliary aneurysms was 5.7% higher than in patients with ruptured aneurysms of regular size.Conclusion: Rupture of cerebral miliary aneurysms is relatively rare. Women of 50–60 years old with very small aneurysms of the anterior communicating artery with a narrow neck constitute the main group of such patients. Massive subarachnoid hemorrhage and severe condition of patients on admission are more common with miliary aneurysms than with ordinarily sized aneurysms. The small size of the aneurysm and the work near the rupture determine the more frequent contact intraoperative rupture when the neck is exposed as compared to operations on larger aneurysms, which negatively affects the treatment outcomes in this group of patients.

Distal anterior cerebral artery (DACA) aneurysms are rare, and endovascular treatment of these aneurysms is challenging. Thromboembolic events, including silent ischemic events, are one of the most important complications of coil embolization for cerebral aneurysms. The treatment outcomes and predictors of silent ischemic events in coil embolization for unruptured DACA aneurysms were investigated, focusing on the morphological characteristics of aneurysms, especially the inflow angle (IA) and global outflow angle (GOA). A total of 12 patients with 12 unruptured DACA aneurysms, treated with coil embolization at our institute, were retrospectively investigated. Predictors for silent ischemic events were evaluated by comparing diffusion-weighted imaging (DWI)-positive and DWI-negative patients. Silent ischemic events detected on DWI were observed in eight aneurysms (66.7%). Comparison of the morphological characteristics of aneurysms between the two groups showed a significantly smaller GOA in the DWI-positive group than in the DWI-negative group (172.6 ± 17.7° vs. 216.8 ± 16.8°, P < 0.01). A multivariate analysis showed that GOA <195° was a significant predictor of silent ischemic events (P = 0.04; odds ratio: 23.62; 95% confidence interval: 1.11-490.39). A small GOA was a significant predictor of silent ischemic events after coil embolization for unruptured DACA aneurysms. While some patients can be treated safely with minimally invasive coil embolization, it is necessary to consider surgical clipping in patients at high risk of thromboembolic events with coil embolization.

Flow diverters (FDs) are increasingly used for cerebral aneurysms, including distal anterior cerebral artery (DACA) aneurysms, but comparative data between devices in this challenging location are limited. To compare the safety and efficacy of Pipeline, Silk Vista Baby (SVB), and FRED Jr. FDs for unruptured DACA aneurysms and identify predictors of complete occlusion. We retrospectively analyzed 166 patients treated with FDs at 39 centers in 14 countries (2018–2022) from the CRETA registry. Outcomes included aneurysm occlusion (O’Kelly–Marotta [OKM] scale), complications, retreatment, modified Rankin Scale (mRS) scores, and independent predictors of complete occlusion using multivariable Cox regression. Aneurysms were predominantly saccular and located on the pericallosal artery. Complete occlusion (OKM D) was achieved in 73%, and neck remnants (OKM C) in 12%, with no differences across devices. Ischemic complications occurred in 11% (mostly asymptomatic), hemorrhagic complications in 5%, and in-stent stenosis in 17%. Retreatment was performed in 1.3%. At last follow-up, 98% had mRS ≤ 2. Independent predictors of complete occlusion were female sex (HR 1.85), asymptomatic presentation (HR 1.79), smaller aneurysm neck (HR 0.83/mm), radial access (HR 2.20), and aspirin plus ticagrelor therapy (HR 1.84); device type was not predictive. Pipeline, SVB, and FRED Jr. FDs show similar safety and efficacy for unruptured DACA aneurysms. Complete occlusion is influenced by clinical and procedural factors, supporting individualized device selection.

Background: Distal anterior cerebral artery (ACA) aneurysms occur more frequently in the genu portion and much less frequently in the supracallosal portion (A4–A5). This report describes two cases of ruptured cerebral aneurysms occurring at the supracallosal portion successfully treated with coil embolization. Case Description: Case 1 involved a 61-year-old female with sudden-onset headache and vomiting attributed to subarachnoid hemorrhage (SAH). Digital subtraction angiography (DSA) revealed a bihemispheric ACA and aneurysm in the supracallosal portion. Coil embolization was performed, and the patient was discharged without neurological deficit. Case 2 involved a 35-year-old man with severe headache and disturbance of consciousness caused by SAH. DSA showed an aneurysm in A4 of the accessory ACA, and coil embolization was performed. After rehabilitation, he was discharged with a modified Rankin scale score of 2. Conclusion: Coil embolization for a ruptured aneurysm at the supracallosal portion can yield good results if the patient is appropriately selected.

Cerebral aneurysms are occasionally associated with anomalies of the cerebral arteries. Most reports on anomalies of the anterior cerebral artery have been concerned with hypoplasia, fenestration and the infra-optic course of the A1, variant A1 perforators or Heubner's artery, multi-channeled anterior communicating artery, and azygos anterior cerebral artery. Distal anterior cerebral artery (ACA) aneurysms are known to have a poor clinical course and prognosis compared to other supratentorial aneurysms. The presence of the unpaired, distal, postcommunicating (A2) segment of the ACA is very rare in adults. We describe a patient with a ruptured aneurysm arising from the proximal end of the azygos ACA, first surgically treated with clipping and then with endovascular coiling. A 37-year-old woman at 34 weeks' gestation was transferred to our emergency room with sudden onset of severe headache and vomiting. Computed tomography (CT) revealed subarachnoid hemorrhage in the basal cisterna and the sylvian and interhemispheric fissures. Cerebral angiography showed an azygos ACA, a saccular aneurysm at the junction of the azygos ACA and the right A1 segment. A right fronto-temporal craniotomy was performed in the day of admission, and the neck of the aneurysm was clipped. One year later, an angiographic control examination revealed a regrowth of the aneurysm. The patient underwent endovascular treatment with coiling. Aneurysms of the azygos ACA are rare and their pathogenesis and course are still a matter of discussion. Developmental abnormalities or dynamic vessel wall stresses can explain the high incidence of aneurysms in these cases. The association of a rare anatomical variant with an aneurysm in the same location may suggest an embryogenesis alteration in the Willis circulation.