崔源生 台中榮民總醫院神經外科 surgical treatment of aneurysms of the anterior wall of...
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崔源生 台中榮民總醫院神經外科
Surgical Treatment of Aneurysms of the Anterior
Wall of the Internal Carotid Artery
Anatomy: ICA:5 segments:
– Cervical
– Petrous
– Cavernous
– Clinoidal
– Supraclinoid
Morphology:
Pathology:
No internal elastic lamina and media
The gap was covered with thin adventitia and fibrinous tissue, not composed of thick adventitia or collagenous tissue as ordinarily seen in an berry aneurysm wall
Pathology:
Pathogenesis:
Atherosclerosis: – (Stehbens,et al:The pathology of
intracranial arterial aneurysms and their complications, Intracranial Aneursyms, 1983, Vol 1)
Dissecting:
Anterior Wall Aneurysm
Dorsal type, Blister-like aneurysm Low incidence Small size Thin wall No neck High intraoperative bleeding rate High morbidity & mortality
Diagnosis: It’s difficult to detect anterior wall
aneurysm on angiograms, in large part because of their small size and unusual location.(Shigeta et al, 6 (30%) negative in 20 pts)
It’s of great importance to evaluate collateral circulation because ICA sacrifice at surgery is relative common with these aneurysms.
Case 1: angiogram (AP+Lat)
Case 1: angiogram (oblique)
Case 2: angiogram
Case 2:
Case 2: CTA
OP Findings:Video
Textbook-Management of Cerebral Aneurysms (2004)
Poor outcome of Anterior Wall ICA Aneurysms:
Aneurysm protruding from the dorsal wall of internal carotid arteryFukuo Nakagawa, et al.J of Neurosurgery 65:303-308, 1986 5 year period, 8 cases/460 ANs
Blood blisterlike aneurysms of the internal carotid arteryMasamitsu Abe, et al.J of Neurosurgery 89:419-424,1998 1981-1997, 6 cases/488 ANs
Abe series: Clipping on wrapping
Aneurysms at nonbranching sites in the supraclinoid portion of the internal carotid artery:Internal carotid artery trunk aneurysmsAkira Ogawa, et al.Neurosurgery 47:578-586, 2000
5 year period, 48 cases/7408 ANs
Ogawa series-outcome:
New method for obliterative treatment of an anterior wall aneurysm in the internal carotid artery: Encircling silicone sheet clip procedure-Technical case report
Yasutaka Kurokawa, et al.Neurosurgery 49:469-472, 2001
Techinical note:
Surgical management: Possible trapping of parent artery
Exposure of cervical ICA for proximal control
Wide open of Sylvian fissure
Little frontal lobe traction
Clip placement parallel to the ICA axis
Necessary to catch the adjacent carotid artery wall with the neck
Temporary clipping to reduce aneurysm turgor
Clipping on wrapping
Endovascular may be an alternative option
Thank you