Cerebral Aneurysms: Advances in Diagnosis and Therapy PDF
Preview Cerebral Aneurysms: Advances in Diagnosis and Therapy
Cerebral Aneurysms Advances in Diagnosis and Therapy Edited by H. W. Pia C. Langmaid J. Zierski With 265 Figures Springer-Verlag Berlin Heidelberg New York 1979 Professor Dr. Dr. h.c. Hans Werner Pia Direktor der Neurochirurgischen Universitats-Klinik KlinikstraBe 29, 6300 Giessen (Germany) Dr. Charles Langmaid 174, Lake Road East, Roath Park, Cardiff, CF2 5NR (Great Britain) Dr. Jan Zierski N eurochirurgische Un iversitats-Klinik KlinikstraBe 29, 6300 Giessen (Germany) lSBN-13: 978-3-642-67165-4 e-1SBN-13: 978-3-642-67163-0 001: 10.1007/978-3-642-67163-0 Library of Congress Cataloging in Publication Data. Main entry under title: Cerebral aneurysms. Papers presented at a workshop held in GiessenlBad Nauheim, Mar. 4-5, 1977. Bibliography: p. Includes index. 1. Intracranial aneurysms--Surgery--Congresses. 2. Intracranial aneurysms--Diagnosis--Congresses. I. Pia, Hans Werner. II. Langmaid, Charles, 1913-III. Zierski, Jan, 1940- RD594.2.C47 617'.413 79-19216 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under § 54 of the German Copyright Law where copies are made for other than private use, a fee is payable to the publisher. The amount of the fee to be determined by agreement with the publisher. © Springer-Verlag Berlin' Heidelberg 1979 Softcover reprint of the hardcover 1st edition 1979 The use of registered names, trademarks, etc. in this publication does not imply even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. 2127/3140-543210 Preface Microsurgery has brought about important changes and progress in the treatment of cere bral aneurysms in recent years. Only 12 years ago McKissock, one of the most experienced surgeons in the treatment of aneurysms pompared the results of operative and nonoperative treatment. He found that mortality and morbidity of cerebral aneurysms was not significantly affected by whether the patients have been operated upon or not. This view is held by many neursurgeons, and was confirmed by results of the Co-operative Study in 1969. In the review on treatment of aneurysms in Progress in Neurological Surgery in 1969, techniques such as encasement with plastic compounds, piloinjection, stereotactic copper or electric thrombosis and metallic thrombosis and profound hypothermia in anaesthesia were listed. In general, these techniques now seem to be of little more than historical interest. Progress in recent yeats has been so enormous that one may perhaps gain the impreSSion that the main problems in the treatment of aneurysms have been solved and that there are no more to be surmounted. This is dangerous and complacent thinking, such as Lord Moynihan indulged in during the thirties. For this reason we thought that the time had come to assemble a group of experts who could discuss the various unsolved and contro versial problems of aneurysm surgery in the friendly and relaxed atmosphere of a "work shop". Recent technical progress has led to a reappraisal of some old questions and stimu lated new concepts in the diagnosis, treatment, prophylaxis and rehabilitation of patients with cerebral aneurysms. This workshop, which was held in Giessen/Bad Nauheim on March 4th and 5th 1977, is the third of its kind; it follows previous ones on the topics of cerebral angiomas (1974) and spinal angiomas (1975). Reports on morphology, aetiology, natural history and problems of rupture and growth of aneurysms were followed by the presentation of ideas on the classification of aneurysms, and this formed the basis of the discussions. The discussions indicated various means of detailed, microsurgical, topographic description of aneurysms according to the site of ori gin, projection and relations to neighbouring structures. In spite of progress in the field of clinical pathology and pathophysiology of subarachnoid bleeding, arterial spasm, general and local cerebral blood-flow disturbances and hydrocephalus, many problems remain un solved. Basic questions in this field, as well as prophylaxis and conservative therapy were discussed. Further development of angiographic examination with magnification angiography, angiotomography, selective and supraselective angiography, intraoperative angiography and the introduction of computer tomography have all improved the local and topographic diagnosis of the aneurysm and its complications. One of the main topics was the operative treatment of aneurysms. The decrease of operative mortality and morbidity and modifica tions in the timing of operation have changed the indications and contraindications for operative treatment. Operative progress is connected with progress in anaesthesia. Hypo- v tension has become increasingly significant. The techniques, possibilities and the limita tions of anaesthesia for aneurysmal surgery were also presented. In recent years, considerable progress has been achieved in the treatment of carotid cavernous aneurysms and carotid-cavernous fistulas. Classic and direct operations and embolization with inflatable balloons were discussed; indications for each method of treatment were defined. The special management of aneurysms of the carotid and vertebro basilar systems was reviewed for every individual location of the aneurysm, including the special problems of giant, multiple and traumatic aneurysms and the treatment of aneu rysms in childhood and advanced age. A special session was devoted to technical problems, with discussion of direct and in direct occlusive methods, clips and the questions connected with the technical act of clipping. The management of intraoperative rupture of aneurysms and of intracerebral haematoma accompanying spontaneous rupture, which still remains a major factor influ encing mortality, has been influenced by technical improvements. The general survey given as well as the details regarding current practice, demonstrated the impressive progress which has been made in the treatment of aneurysms. The workshop was made possible by the generosity of Dipl. Chern. Dr. med. Bernd Braun and his brother, Mr. Otto Braun of B. Braun Company, Melsungen. This volume contains the papers presented and the discussions that took place at the workshop. The interest it aroused has led to its rapid publication. The editors take great pleasure in expressing their thanks to the contributors for their participation and cooperation, and to Springer Verlag for personal and technical aid in preparing and publishing the proceedings. Special thanks are due to my co-workers, Drs. E. Grote and J. Zierski, and to Mrs. Klein and Mrs. Walter for their help in preparing the publication. We hope that this volume, like the previous books on cerebral angiomas and spinal angiomas, may contribute to improved diagnosis and therapy of cerebral aneu rysms. Giessen, August 1979 Hans Werner Pia Charles Langmaid VI Contents Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V 1 History of Aneurysm Surgery F. John Gillingham, Edinburgh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 Morphology and Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.1 Pathology and Aetiology ofIntracranial Aneurysms K. Jellinger, Vienna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.2 Factors Related to Growth, Rupture and Spontaneous Healing of Cerebral Aneurysms Stig H.M. Nystrom, Oulu ................................ " 20 2.3 Origin, Rupture and Growth of Cerebral Aneurysms: a Clinico pathological Study Jiro Suzuki and Hiro Ohara, Sendai ........................... 28 2.4 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 41 3 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 42 3.1 Introduction Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 42 3.2 Extracranial Internal Carotid Aneurysms Jean Brihaye, Brussels ................................... , 45 3.2.1 Aneurysms of the Cervical Internal Carotid Artery Jean Brihaye, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 45 3.2.2 Internal Carotid Aneurysms Arising in the Carotid Canal Jean Brihaye, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 55 3.2.3 Anatomy of the Cavernous Sinus Dwight Parkinson, Winnipeg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 62 3.2.4 Intracavernous Carotid Aneurysm Jean Brihaye, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 67 3.2.5 Aneurysms of the ''Cavernous Sinus" Dwight Parkinson, Winnipeg ............................... , 79 3.2.6 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83 3.3 Intracranial Internal Carotid Artery Aneurysms ................... 83 3.3.1 Internal Carotid Ophthalmic Aneurysms Beniamino Guidetti, Rome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83 VII 3.3.2 Aneurysms of the Internal Carotid (lCA) Ophthalmic Artery (OA) Junction Hans WerneJ Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 89 . 3.3.3 Aneurysms of the Internal Carotid Artery (ICA) and Posterior Communi- cating Artery (PCoA) and Anterior Choroidal Artery (AChA) Region Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 93 3.3.4 Internal Carotid Artery Bifurcation Aneurysms Laurence P. Lassman, Newcastle-upon-Tyne ..................... 96 3.3.5 Aneurysms of Internal Carotid Artery Bifurcation Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 107 3.3.6 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 108 3.4 Aneurysms of the Anterior Cerebral Artery Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109 3.5 Aneurysms of the Middle Cerebral Artery Bernard Pertuiset, Paris .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 115 3.5.1 Aneurysms of the Middle Cerebral Artery - Discussion Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 116 3.6 Aneurysms of the Vertebral Artery Ludwig G. Kempe, Charleston. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 119 3.7 Aneurysms of the Basilar ~rtery Bernard Pertuiset, Paris ................................... 121 3.8 Aneurysms of the Posterior Cerebral Artery Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 123 4 Distribution of Cerebral Aneurysms Jiro Suzuki and Takashi Yoshimoto, Sendai. . . . . . . . . . . . . . . . . . . . .. 127 5 Clinical Pathology and Pathophysiology .. . . . . . . . . . . . . . . . . . . . . .. 133 5.1 Noninvasive Regional Cerebral Blood Flow Measurement in Subarachnoid Haemorrhage John Stirling Meyer, Houston, Texas .......................... 133 5.2 Cerebral Blood Flow in Subarachnoid Haemorrhage Knut Kohlmeyer, Mannheim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 144 5.3 Subarachnoid Haemorrhage and Cerebral Vasospasm Eugene S. Flamm and Joseph Ransohoff, New York. . . . . . . . . . . . . . .. 152 5.4 Cerebral Vasospasm: Prediction, Prevention and Protection Jiro Suzuki, Sendai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 155 5.5 Hydrocephalus Following Subarachnoid Haemorrhage Lindsay Symon, London . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 162 5.6 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 168 6 Neuroradiological Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 170 6.1 Cerebral Angiography .................................... 170 6.1.1 Classical Angiography Heinzgeorg Vogelsang, Hannover . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 170 6.1.2 Magnification and Tomography A. Lino Agnoli, Hans Werner Pia, and Jan Zierski, Giessen ............ 175 VIII 6.1.3 Intraoperative Angiography Dwight Parkinson, Winnipeg ............................... , 181 6.1.4 Discussion......................................... . .. 184 6.2 Computer Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 184 6.2.1 CAT Findings in Cerebral Aneurysms and Subarachnoid Haemorrhage Ekkehard Kazner and Wolfgang Lanksch, Mi.inchen . . . . . . . . . . . . . . . .. 184 6.2.2 Value of CAT in Pre-and Postoperative Management of Cerebral Aneurysms Ernst Grote, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 190 6.2.3 Discussion ......................... '" . . . . . . . . . . . . . . . .. 195 7 Conservative Treatment ................................. " 197 7.1 Preoperative Treatment of Intracranial Aneurysms Oskar J. Beck, MUnchen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 197 7.2 Preoperative Management of Ruptured Intracranial Aneurysms with Antifibrinolytic Treatment Eugene S. Flamm and Joseph Ransohoff, New York. . . . . . . . . . . . . . .. 200 7.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 202 8 Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203 8.1 General Therapeutic Problems . . . . . . . . . ..................... . 203 8.1.1 Grading and Timing of the Operation on ~erebral Aneurysms Jiro Suzuki, Sendai ..................................... . 203 8.1.2 Indication and Timing of Operation and Vasospasm Keiji Sano and Isamu Saito, Tokyo .......................... . 208 8.1.3 Discussion ........................................... . 216 8.1.4 Deliberate Hypotension with Sodium Nitroprusside in Neuroanaesthesia Karam Samii, Bernard Pertuiset, and Paul Viars, Paris .............. . 217 8.1.5 Protective Vascular Mechanisms of the Brain During Profound Arterial Hypotension Bernard Pertuiset, Paris .................................. . 218 8.1.6 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 8.2 Special Therapeutic Problems .............................. . 224 8.2.1 Internal Carotid Artery Aneurysms - Cavernous Sinus Aneurysms ...... . 224 8.2.1.1 Surgical Approach to Cavernous Sinus Aneurysms Dwight Parkinson, Winnipeg ............................... . 224 8.2.1.2 Treatment of Carotid-Cavernous Fistulae and Arterial Aneurysms by Detachable Balloon Gerard Debrun, London/Ontario ............................ . 228 8.2.1.3 Post-traumatic Fistulae Between the Internal Carotid Artery and the Cavernous Sinus Rene Djindjiant, Paris ................................... . 236 8.2.1.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 8.2.2 Internal Carotid Ophthalmic Artery Aneurysms .................. . 244 8.2.2.1 Treatment and Results for Carotid Ophthalmic Aneurysms Beniamino Guidetti, Roma ................................ . 244 8.2.2.2 Discussion Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 250 IX 8.2.3 Internal Carotid Posterior Communicating Anterior Choroidal Region Aneurysms .......................................... . 252 8.2.3.1 Microsurgical Treatment Keiji Sano, Tokyo ...................................... . 252 8.2.3.2 Technical Aspects Ludwig G. Kempe, Charleston. . . . . . . . . . . . . . . . . . . . .......... . 260 8.2.4 Internal Carotid Artery Bifurcation Aneurysms .................. . 267 8.2.4.1 Special Therapeutic Problems Laurence P. Lassman and R.P. Sengupta, Newcastle-upon-Tyne ........ . 267 8.2.5 Anterior Cerebral Artery Aneurysms ......................... . 274 8.2.5.1 Operative Treatment Hans Werner Pia, Giessen ................................. . 274 8.2.5.2 Discussion Ludwig G. Kempe, Charleston .............................. . 281 8.2.6 Middle Cerebral Artery Aneurysms .......................... . 286 8.2.6.1 Treatment of Saccular Aneurysms Bernard Pertuiset, Paris ..... . . . . . . . . . . . . . . . . . . . . . . . . . . .... 286 8.2.7 Addendum: Classification of Vertebro-basilar Aneurysms Hans Werner Pia, Giessen ................................. . 290 8.2.8 Vertebral Artery Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 8.2.8.1 Operative Treatment Ludwig G. Kempe, Charleston .............................. . 297 8.2.9 Basilar Artery Aneurysms . . . . . . . . . ........................ . 306 8.2.9.1 Surgery Bernard Pertuiset, Paris ....... . . . . . . . . . . . . . . . . . .......... . 306 8.2.9.2 Surgery of Upper Basilar Artery Aneurysms. Experience with 11 Cases Bernard Pertuiset, R. van Effenterre, and G. Robert, Paris ........... . 311 8.2.9.3 Microsurgical Treatment of Vertebro-Basilar Aneurysms Hans Werner Pia, Giessen ................................. . 319 8.2.9.4 Transoral-Transclival Approach Keiji Sano, Tokyo ...................................... . 326 8.2.9.5 Discussion Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 329 8.2.10 Posterior Cerebral Artery Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . .. 332 8.2.1 0.1 Operative Treatment Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 332 8.3 Giant Cerebral Aneurysms ................................. 336 8.3.1 Problems in Treatment Hans Werner Pia and Jan Zierski, Giessen ....................... 336 8.3.2 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 342 8.3.2.1 Management Keiji Sano, Tokyo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 342 8.3.2.2 Results Jiro Suzuki, Sendai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 345 8.3.2.3 Serpiginious Giant Aneurysm of the Internal Carotid Artery in a Young Female Harald Fodstad and Bengt Liliequist, Umea . . . . . . . . . . . . . . . . . . . . .. 346 8.3.2.4 General Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 350 x 8.4 Multiple Aneurysms ..................................... 352 8.4.1 Treatment Jiro Suzuki, Sendai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 352 8.4.2 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 363 8.5 Traumatic Aneurysms ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 364 8.5.1 Survey Albrecht Laun, Giessen ................................... 364 8.5.2 Development of Traumatic True Saccular Aneurysms Wolfgang Piotrowski, Mannheim ............................. 375 8.6 Aneurysms 0/ Childhood Alan E. Richardson, London. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 376 8.7 Special Technical Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 379 8.7.1 Surgery of Intracranial Aneurysms - To Clip or not to Clip the Neck of the Sac F. John Gillingham, Edinburgh. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 379 8.7.2 Slipping Clip Laurence P. Lassman, Newcastle-upon-Tyne ..................... 383 8.7.3 Form of Clips Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 384 8.7.4 Coagulation of Aneurysms Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 386 8.7.5 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 388 8.7.6 Temporary Clipping - Prolongation of the Time of Occlusion by Mannitol Takashi Yoshimoto and Jiro Suzuki, Sendai . . . . . . . . . . . . . . . . . . . . .. 388 8.7.7 Trapping Techniques Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 393 8.7.8 Wrapping Technique - Present Place Keiji Sano, Tokyo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 393 8.7.8.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 395 8.7.9 Cervical Carotid Artery Ligation Jean Brihaye, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 395 8.7.9.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 397 8.8 Operative Treatment o/Complications . . . . . . . . . . . . . . . . . . . . . . . .. 398 8.8.1 Intraoperative Aneurysmal Rupture and Reduction by Coagulation of the Sac Bernard Pertuiset, Paris ......... . . . . . . . . . . . . . . . . . . . . . . . . .. 398 8.8.1.1 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 401 8.8.2 Intracerebral Haematomas Keiji Sano, Tokyo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 402 8.8.2.1 Discussion Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 402 9 Prognosis of Operative Treatment ............................ 408 9.1 A 25 Year Study F. John Gillingham, Edinburgh . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 408 9.2 Summary Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 412 XI
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