Neurosurgical focus最新文献

Objective: Intracranial aneurysms (IAs) occur in up to 6% of adults, with multiple IAs (MIAs), which are associated with higher clinical risks, occurring in up to one-third of this population. Treatment for MIAs includes open surgical, endovascular, or hybrid techniques. When possible, occlusion of MIAs with a single treatment is ideal. The authors examined the outcomes of single-stage microsurgical treatment of MIAs at their institution as an update to the literature in the endovascular era.

Methods: The authors undertook a retrospective review of the medical records of consecutive patients undergoing single-stage microsurgical treatment of MIAs between January 2014 and May 2024 at a single institution. Patient, aneurysm, treatment, and outcome data were collected.

Results: Fifty-two patients with MIAs (44/52 [84.6%] female, mean age 58.60 ± 9.44 years, mean BMI 30.09 ± 7.76) were included: 39 patients had 2 aneurysms and 13 patients had 3 aneurysms. Of these patients, 30.8% (16/52) presented with aneurysmal subarachnoid hemorrhage (aSAH). Most aneurysms (112/117 [95.7%]) were in the anterior circulation, but 5 (4.3%) were in the posterior circulation. Most aneurysms were saccular (95.7%), and the mean maximal aneurysm dimension was 4.82 ± 2.55 mm. A single craniotomy was used in 50 of 52 (96.2%) patients, but a second craniotomy was required in 2 patients. All IAs were treated with clipping alone. Patients with aSAH had longer hospital and intensive care unit stays than those without aSAH (both p < 0.001). Two patients without aSAH and 4 patients with aSAH experienced vasospasm-related strokes. No other patients experienced postoperative ischemia. Over a mean follow-up of 17.4 ± 20.4 months, 51 of 52 (98.1%) patients had complete aneurysm occlusion, with 1 patient having a small stable neck residual. On follow-up, 50 of 52 (96.2%) patients were functionally independent (modified Rankin Scale score ≤ 2).

Conclusions: Open microsurgery is generally efficacious and safe for the simultaneous treatment of MIAs in appropriately selected patients with and without aSAH.

Objective: The authors aimed to evaluate the role of open cerebrovascular microsurgery for management of failed endovascular therapies for intracranial aneurysms in the modern neurointerventional surgery era.

Methods: To identify patients who underwent open cerebrovascular surgery on brain aneurysms previously treated with endovascular interventions, the medical records of 476 patients who underwent endovascular treatment of intracranial aneurysms at the Brigham and Women's Hospital between 2018 and 2025 were reviewed and analyzed. Clinical, demographic, radiological, and surgical data were collected. The main outcomes included radiographic occlusion rates, complications, neurological functioning at the latest follow-up, morbidity, and mortality.

Results: Twenty-one patients (mean age 54.6 years; 57.1% females) underwent microsurgical treatment following endovascular therapy for intracranial aneurysms. Seventeen aneurysms (81.0%) were initially ruptured. Most aneurysms were located at the anterior communicating artery (33.3%) and posterior communicating artery (19.0%). Prior endovascular modalities included coil embolization only (14 cases), stent-assisted coiling (2 cases), intrasaccular devices (3 cases), flow diversion (1 case), and flow diversion following stent-assisted coiling (1 case). The mean duration between endovascular treatment and open surgery was approximately 37.8 months. Indications for subsequent open surgery included aneurysm residual or recurrence (n = 14), incomplete (n = 2) or failed (n = 2) endovascular treatment, rerupture after endovascular treatment (n = 2), and progressive growth with edema and brainstem compression (n = 1). Microsurgical techniques included clip reconstruction, with the use of bypass techniques in 4 cases. Complete aneurysm occlusion was achieved in all cases based on postoperative imaging, except for 2 patients who required aneurysm clip repositioning directly after surgery. One patient needed coil embolization because of aneurysm recurrence after clip reconstruction. Complications occurred in 6 patients (29%), with death in 2 patients (9.5%). At the last follow-up (mean 21.0 months), 81.0% of patients had a modified Rankin Scale score less than or equal to 2.

Conclusions: Brain aneurysms can be safely managed by endovascular therapy in many cases, but case selection should be tailored to the specific patient anatomy on a case-by-case basis. There remains a significant role for open surgical management of brain aneurysms after failed endovascular therapy, and these cases are increasingly complex and difficult to treat.

Objective: Choosing the side of approach (SoA) in the microsurgical treatment of anterior communicating artery (AComA) aneurysms remains a topic of debate. The aim of this study was to investigate the effectiveness of the open A2 plane as the decisive factor in choosing the SoA.

Methods: This retrospective cohort study analyzed data from 59 patients who underwent microsurgical treatment for AComA aneurysms from 2017 to 2024 at a single institution. For 19 patients, the SoA was dictated by an accompanying pathology such as another aneurysm or intracerebral hemorrhage. For 40 patients, the open A2 plane was determined due to the location of the ipsilateral A2 by preoperative 3D CTA or DSA. Every patient was evaluated with DSA postoperatively.

Results: In superior, anterior, and inferior projecting aneurysms, the posteriorly situated A2 determined the side of the open A2 plane, and in posterior projecting aneurysms, the anteriorly situated A2 directed the approach. Right-sided or left-sided craniotomies were performed for 28 and 12 patients, respectively. The SoA was contralateral to the dominant A1 for 50% of patients, ipsilateral to the dominant A1 for 25%, and there was equal A1 flow for 25% of patients. Two patients, both with inferior orienting aneurysms, experienced early aneurysm rupture. Postoperative DSA showed total neck clipping in 37 of 40 patients.

Conclusions: Choosing the SoA based on the open A2 plane facilitated exposure of the aneurysm neck, with high rates of aneurysm closure via a less complicated clip construction.

Despite the continued evolution of endovascular therapy (EVT), microsurgery will remain not only a viable option for aneurysm management into the foreseeable future, but for many aneurysms, the preferred treatment. However, reduction in surgical case volume in favor of EVT now represents a systemic threat to surgical proficiency by drastically reducing case volumes and creating a training challenge for the next generation, thereby degrading the proficiency of future surgeons. Surgeons who can safely and effectively manage the aneurysms for which surgery remains the superior or only option are at risk of extinction. This review addresses this critical issue as we reach an inflection point in the history of cerebrovascular surgery. The evidence to support EVT or surgical management of aneurysms is critically reviewed in the context of equipoise, a genuine state of uncertainty regarding the superiority of one therapeutic modality over another. This review is not an argument against the immense value of EVT, which has saved countless lives and remains the optimal treatment for many patients. Rather, it is a call for balance, for a recalibration of clinical equipoise, and for the preservation of a complete and robust therapeutic armamentarium.

Objective: Complex middle cerebral artery (MCA) aneurysms pose a significant challenge despite the advancements in interventional materials and microsurgical techniques. A subset of these aneurysms may benefit from surgical revascularization. Identifying a safe and effective intracranial donor artery as another alternative is critical for managing these aneurysms. In this study, the authors evaluate the feasibility, safety, and efficacy in using the anterior temporal artery (ATA) in revascularizing a consecutive series of complex MCA aneurysms.

Methods: Data from patients managed with a bypass structure consisting of the ATA as a donor from January 2010 to June 2023 were obtained from an institutional review board-approved, prospectively maintained database with informed consent from the patients. Bypass patency and aneurysm occlusion were evaluated at discharge, 6 months postoperatively, and then annually or whenever the patient had a neurological symptom.

Results: In 9 patients, bypasses were performed with the ATA for 9 complex MCA aneurysms. All cases attained bypass patency, and no ischemic events occurred during the bypass procedures. The bypass type was classified as a combination bypass in 7 patients and a simple in situ bypass in 2 patients. The most frequently used techniques involving the ATA were side-to-side in situ bypass (6 times in 6 patients) and end-to-side reimplantation (7 times in 4 patients). The mean follow-up period was 40.78 months (range 18-60 months), with an improved or unchanged modified Rankin Scale score in 8 patients at the final follow-up.

Conclusions: The ATA is a safe and versatile donor for intracranial-intracranial revascularization in managing complex MCA aneurysms. However, due to the diversity of angioarchitecture in complex MCA aneurysms, bypass reconstructions with the ATA should be tailored to each case according to the specific characteristics of the vascular anatomy and hemodynamics.

Objective: Giant intracranial aneurysms (GIAs; ≥ 25 mm) are a distinct subset of aneurysms with worse outcomes compared with other aneurysms. The aim of this review was to analyze patient and aneurysm-related factors that influenced management decisions, including the need for bypass procedures, and to assess outcomes, including morbidity and mortality, associated with the procedures.

Methods: This retrospective analysis included patients with GIAs treated microsurgically at a single institution from 2010 to 2023. Aneurysms were classified by location as infraclinoidal internal carotid artery (ICA), supraclinoidal ICA, anterior cerebral artery (ACA), middle cerebral artery (MCA), and basilar artery. Techniques included direct clipping, bypass with trapping, and parent artery ligation. Preoperative imaging included CT, DSA, and balloon occlusion testing. Intraoperative adjuncts, such as indocyanine green video angiography and Doppler ultrasonography, ensured procedural efficacy. Outcomes were measured by the modified Rankin Scale (score ≤ 2 indicating good outcomes), aneurysm obliteration rates, and complication rates. Descriptive statistics were used to compare patients with ruptured versus unruptured aneurysms and those with anterior versus posterior circulation aneurysms.

Results: Among 77 patients (mean age 44.7 years) with GIAs included in the analysis, 20 had infraclinoidal ICA, 25 had supraclinoidal ICA, 10 had ACA, 20 had MCA, and 2 had basilar artery aneurysms. Sixty-one patients (79.2%) achieved good outcomes, with an overall 96.8% (61/63) complete obliteration rate. Infraclinoidal ICA aneurysms had the lowest morbidity (10%), while supraclinoidal ICA aneurysms had 28% morbidity and 12% mortality. High-flow bypass procedures were required for 24.7% (19/77) of patients. MCA and ACA aneurysms each had a 20% morbidity rate. Overall complications included infarcts (13%, 10/77), persistent hemiparesis/paraparesis (15.6%, 12/77), and infections (1.3%, 1/77). The surgical mortality rate was 5.2% (4/77). Despite a higher proportion of ruptured GIAs (42%, 32/77), this series demonstrated clinical equivalence in microsurgical results compared with contemporary series.

Conclusions: Microsurgical management of GIAs is effective, with high obliteration rates and good outcomes in 79.2% of patients, particularly for anterior circulation aneurysms. Location-specific strategies delivered optimized results, with bypass procedures required in selected cases. Preoperative collateral flow assessment is critical. Despite endovascular advancements in the management of GIAs (which might need retreatment in 20% of patients), microsurgery had a complete occlusion rate of 96.8%, demonstrating superior durability. These findings underscore the role of microsurgery in GIAs, emphasizing tailored approaches to minimize risks.

Objective: Large, giant, and complex anterior communicating artery (ACoA) and A2 anterior cerebral artery (ACA) aneurysms may require a bifrontal interhemispheric approach for better exposure of the aneurysm and bilateral A2-ACA branches and the ability to perform a bypass if needed. The authors sought to investigate the operative techniques and long-term outcomes of ACoA and proximal A2-ACA aneurysms treated with the bifrontal interhemispheric approach.

Methods: The authors reviewed ACoA and proximal A2-ACA aneurysms treated by microsurgical clipping with or without a bypass via the bifrontal interhemispheric approach from 2005 to 2024 as a subset of all ACoA aneurysms surgically treated at their institution. The indications for this approach were 1) a complex neck requiring exposure of bilateral A1 and A2 vessel segments, and/or 2) need for bypass. Demographic, clinical, and radiographic data were collected and reviewed. Aneurysm occlusion, bypass patency, functional outcomes (modified Rankin Scale [mRS] score), and complications were assessed at the 3-month and long-term (> 12 months) follow-up.

Results: Of 383 patients with ACoA or proximal A2-ACA aneurysms treated with microsurgery at the authors' institution, 30 patients met the inclusion criteria. The mean radiographic follow-up was 3.1 years. Sixty percent of patients (18/30) had a subarachnoid hemorrhage. Twenty-five (83.3%) aneurysms were ACoA and 5 (16.7%) were proximal A2-ACA. Bypasses were performed for 16 (53%) aneurysms. Direct side-to-side bypasses were the most common, accounting for 81% (13/16) of all bypasses. Complete aneurysm occlusion was achieved in 90% of aneurysms at the last follow-up. Immediate postoperative patency of the bypass was 100% (16/16). Long-term bypass patency was 87.5% (7/8). Postoperative stroke occurred in 2 patients (6.7%), both of whom recovered with mRS scores < 2 at the 3-month follow-up.

Conclusions: The bifrontal interhemispheric approach offers the ability to expose large and giant ACoA aneurysms and bilateral A2 vessel aneurysms, which allows an operative corridor for possible bypass revascularization. The results of this approach were excellent, with a low rate of aneurysm recurrence and complications.

Objective: Large and giant intracranial aneurysms (LGIA) pose significant surgical challenges due to their complex anatomy, high risk of rupture, and severe morbidity and mortality rates. The aim of this study was to evaluate microsurgical treatment techniques and outcomes for LGIA as an alternative to endovascular treatment methods.

Methods: Intracranial aneurysms treated with microsurgery by a single surgeon from January 2006 to February 2025 were retrospectively analyzed. Demographic data, clinical presentations, aneurysm characteristics, surgical techniques, complications, and outcomes were evaluated. Outcomes were evaluated based on patients' neurological conditions, with functional recovery levels and predictive factors investigated using multivariate logistic regression analysis.

Results: Of 127 patients (80 female, mean age 57.9 years) with LGIA included in the analysis, 99 had large (10-24 mm) and 28 had giant (≥ 25 mm) aneurysms. The mean aneurysm size was 18.4 mm. Aneurysms were most commonly located in the middle cerebral artery (41.7%) and were most frequently treated with primary clipping (72.4%), clip reconstruction (12.6%), and bypass (10.2%). The occlusion rate was 94.5% on postoperative imaging. Surgical complications were observed in 13.4% of patients, while nonsurgical complications were observed in 18.9%. The neurological status of 91.3% of patients improved or remained unchanged. Vasospasm was an independent predictor of poor prognosis (p = 0.019).

Conclusions: Microsurgical treatment of LGIA was safe and effective, with high occlusion rates and acceptable morbidity and mortality. Appropriate patient selection, detailed surgical planning, and experienced surgical technique play a critical role in achieving successful outcomes. Despite the increasing use of endovascular techniques, microsurgery remains a fundamental strategy in the management of LGIA.

Objective: The objective was to compare the clinical and surgical outcomes of patients with bilateral intracranial aneurysms treated via a single craniotomy against those treated with bilateral craniotomies.

Methods: A retrospective analysis was conducted on 50 patients who underwent microsurgical clipping of bilateral aneurysms-specifically involving the middle cerebral artery (MCA) or internal carotid artery (ICA)-between 2008 and 2019. Clinical, demographic, and morphological variables were recorded. Clinical outcomes were compared between patients who were treated through a single craniotomy (n = 32) against those who underwent bilateral craniotomies (n = 18). Aneurysm occlusion and rebleeding rates were compared between aneurysms on the basis of whether clipping was performed via an ipsilateral or contralateral approach.

Results: Thirty-seven patients (74%) presented with subarachnoid hemorrhage. A total of 125 aneurysms were included: 84 (67.2%) were clipped ipsilaterally and 41 (32.8%) contralaterally. No significant differences were observed in clinical presentation, duration of surgery, complication rates, length of hospitalization, mortality, or functional outcomes at 6-month follow-up between the two groups. The median (IQR) postoperative hospital stay was 8 (13) days in the single craniotomy group and 14 (12) days in the bilateral craniotomy group, though this difference was not statistically significant (p = 0.054). The intercarotid distance was significantly shorter in the single craniotomy group (p = 0.007). Operative bleeding was greater in the single craniotomy group (p < 0.001). Aneurysms clipped ipsilaterally exhibited significantly greater dome height (p = 0.013) and were more complex (p = 0.003). No significant differences were found in aneurysm occlusion, rebleeding, or reintervention rates between groups.

Conclusions: In patients with bilateral ICA or MCA aneurysms, clipping via a single craniotomy provides clinical outcomes comparable to bilateral craniotomies. Contralateral clipping does not adversely affect occlusion or complication rates, supporting the safety and feasibility of a unilateral surgical approach for safe microsurgical clipping in selected cases of bilateral aneurysms.

Objective: The authors examined the clipping of middle cerebral artery (MCA) aneurysms using the endoscopic transorbital approach (ETOA) with cadavers and in clinical cases to clarify which patients are good candidates based on preoperative imaging data.

Methods: To determine the indications for MCA clipping using an ETOA with superior-lateral orbital rim osteotomy, 10 sides of 5 cadavers were investigated. The clippable range, defined as the horizontal range, and exposure of the middle cranial fossa base, defined as the vertical extent area, were evaluated. To assess the ETOA trajectory in the MCA, the superior and inferior maximal angles based on the nasion-sella line were evaluated during cadaveric dissection. To test the surgical properties for actual use, 2 clinical cases were evaluated.

Results: The bases of the middle cerebral fossa, which were located below the sphenoid ridge, were accessible in all 5 cadavers. The suction tip and clip applier did not conflict with each other when access was made approximately 17.6 ± 3 mm (mean ± SD) laterally from the cranial midline and 6 ± 2 mm from the median temporal bone margin (clippable range). The superior angle was 16.7° ± 7.8°, and the inferior angle was 18.7° ± 9.6°. Two clinical cases underwent procedures using the ETOA. The aneurysms were at the MCA bifurcation in the anterior direction. The clippable ranges of the patients were 29 mm and 31 mm, respectively, and the distances from the midline to the median temporal bone margins were 32 mm and 36 mm. The M1 lengths were 14.5 mm and 17.2 mm, and the maximal diameters of the aneurysms were 3.58 and 3.67 mm.

Conclusions: Clipping using an ETOA is appropriate for MCA aneurysms with anterior, superior, and inferior dome projections. Aneurysms with a horizontal boundary from the anterior clinoid process to the lateral bone margin of the orbital ball and a vertical boundary around and below the sphenoid ridge can be properly clipped using the ETOA.