The surgical techniques for treatment of chronic subdural hematoma (CSDH), a common neurosurgical condition, have been discussed in a lot of clinical literature. However, the recurrence proportion after CSDH surgery remains high, ranging from 10 to 20%. The standard surgical procedure for CSDH involves a craniostomy to evacuate the hematoma, but irrigating the hematoma cavity during the procedure is debatable. The authors hypothesized that the choice of irrigation fluid might be a key factor affecting the outcomes of surgery. This multicenter randomized controlled trial aims to investigate whether intraoperative irrigation using artificial cerebrospinal fluid (ACF) followed by the placement of a subdural drain would yield superior results compared to the placement of a subdural drain alone for CSDH.
The authors reviewed 531 patients with cerebral aneurysms treated with Guglielmi detachable coils (GDCs) over 5 years to clarify both the advantages and disadvantages of embolization based on the evidence of complications by aneurysm profile. There were 52 technical complications, 25 of which resulted in unfavorable patient outcomes. Intraoperative rupture, the most serious complication exacerbating the patient's condition, occurred in 19 patients, 4 of whom expired. All of these aneurysms were very small and were mostly located in the AcomA and PICA portions. Thirteen patients encountered thromboembolic complications, 6 of whom were elderly with acute ruptured aneurysms at MCA and the tip of BA. For large or giant aneurysms manifesting the mass effect, particularly those in the ICA-C2 portion compressing the optic nerve, the saccular packing did little to ameliorate the symptoms, and subsequent surgical or endovascular trapping was needed. Therefore, saccular embolization of endovascularly difficult, very small AcomA aneurysms and large C2 aneurysm with visual symptoms should be used sparingly based on a risk-benefit assessment.
We have treated 142 aneurysms with intrasaccular or parent artery occlusions. Selective intrasaccular occlusions were attempted on 109 cases. Total or subtotal saccular occlusion was achieved in 93 of 96 cases. lntrasaccular occlusion could not be achieved in 13 cases because of various reasons such as wide neck, branching from aneurysmal dome, difficult to catheterize, and aneurysm too small. Parent artery occlusion was attempted on 33 cases. Twenty-five patients had giant aneurysms of the internal carotid artery (ICA) at the cavernous portion. The rest of this group had dissecting or fusiform aneurysms of the vertebral artery. Parent artery occlusion was achieved in 30 cases with six ischemic symptoms. High percentage of occlusion rate and low morbidity and mortality for metallic coil embolization prove the efficacy of this endovascular treatment.
We compare the results of detachable coil embolization with those of surgical clipping in patients with basilar tip aneurysms.Surgical clipping was performed in 13 patients (SAIL 11 cases, associated with other ruptured aneurysm: 1 case, incidental: 1 case). The aneurysms varied in size and included 12 small ones and 1 large one.Permanent and/or transient neurological deterioration were observed in 11 cases after operation. Clinical outcome at discharge postoperation showed good results in 6 patients, moderate deficits in 5, severe deficits in 1, and 1 death.Twelve aneurysms were treated by embolization with Guglielmi detachable coil and Interlocking detachable coil under local anesthesia (SAH: 3 cases, associated with other ruptured aneurysm: 3 cases, ischemia: 2 cases, incidental: 4 cases). Eight were large, 2 were giant and 2 were small. Neurological deterioration was observed in 2 cases.No perforation on the procedure occurred. Two coil compactions and 1 posttreatment enlargement were observed.Endosaccular embolization is less invasive than surgical clipping in cases of basilar tip aneurysms. Embolization with detachable coil in ruptured basilar tip aneurysm cases at an early stage may improve clinical outcome.
We report a very rare case of a ruptured intracranial anterior spinal artery (ASA) aneurysm. A 66-year-old man presented with gradually deteriorating occipitalgia and mild conscious disturbance. He had a history of hypercholesteremia and diabetes mellitus. There was no evidence of collagen disease or inflammation reaction in his physical examination and laboratory data. The first computed tomography (CT) scan revealed thick subarachnoid hemorrhage (SAH) in front of the brain stem with a little intraventricular clot. However, the cerebral angiography (CAG) showed no apparent aneurysm other than right vertebral artery (VA) occlusion with collateral circulation. Repeat cerebral angiography gradually disclosed the presence of an ASA aneurysm. Therefore, the ASA aneurysm was clipped through the right lateral suboccipital approach under trans-cranial motor evoked potential (MEP) monitoring on Day 61. The amplitude of MEP did not decrease during the operation. The patient did not neurologically deteriorate after surgery. It is previously reported that spinal artery aneurysm should be treated by direct or endovascular surgery because of the risk of rupture. However, recent reports showed that spinal artery aneurysm sometimes regressed spontaneously if it is not flow related. In this case, because of the right vertebral artery occlusion, the fenestrated ASA received hemodynamic stress by collateral circulation. Ruptured aneurysm of the spinal artery requires precise diagnosis and meticulous handling depending on the individual pathogenesis.
