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Giant Intracranial Aneurysms: Therapeutic Approaches PDF

173 Pages·1988·10.187 MB·English
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Yves Keravel Marc Sindou Giant Intracranial Aneurysms Therapeutic Approaches In Collaboration with G.Debrun· Ph. Decq . EG.Diaz· V.Dolenc J. Duquesnel . A. Gaston . Y Guegan . I Huppert C. Marsault . Ph. Mercier . I Moret . ER. Nelson IP. Nguyen . G. Perrin . J. Pialat Foreword by M.G. Ya~argi1 With 123 Figures Springer-Verlag Berlin Heidelberg NewY ork London Paris Tokyo Professor Dr. YVES KERAVEL Service de Neurochirurgie de l'Hopital Henri-Mondor 51, Ave. du Marechal-de-Lattre-de-Tassigny F-94000 Creteil, France Professor Dr. MARC SINDOV Hopital Neurologique et Neurochirurgical Pierre Wertheimer 59, BId. Pinel, F-69003 Lyon, France Originally published in French under the title "Les anevrysmes geants intracraniens. Approches therapeutiques" © Masson, Paris 1984 Revised and enlarged edition translated by S. Rao ISBN-13: 978-3-642-83173-7 e-ISBN-13: 978-3-642-83171-3 DOl: 10.1007/978-3-642-83171-3 Library of Congress Cataloging-in-Publication Data. Anevrysmes geants intracraniens. English. Giant intracranial aneurysms. Translation of: Les anevrysmes geants intracranien. Bibliography: p. Includes index. 1. Intracranial aneurysms - Surgery. I. Keravel, Y. (Yves), 1944-- . n. Sindou, M. (Marc), 1943- . Ill. Debrun, G. IV. Title. [DNLM: 1. Carotid Artery Diseases - complications. 2. Cerebral Aneurysm - surgery. WL 355 A5799] RD594.2.A5413 1987 617'.481 87-26321 ISBN-13: 978-3-642-83173-7 (V.S.) This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcast ing, reproduction on microfilms or in other ways, and storage in data banks. Duplicatioq of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. © Springer-Verlag Berlin Heidelberg 1988 Softcover reprint of the hardcover 1st edition 1988 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. Product Liability: The publisher can give no guarantee for information about drug dosage and applica tion thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 2122/3130-543210 Foreword The first aneurysms explored by such pioneers of neurosurgery as Cushing and Dandy were the giant intracranial aneurysms. These giant aneurysms present many therapeutic difficulties and, because of their unique anatomical features and size, may present in a multitude of ways. With the advent of specialized imaging techniques such as computed tomography (CT), mag netic resonance imaging (MRI) and selective angiography, preoperative diag nosis today is most often accomplished without difficulty. However, com pletely thrombosed giant aneurysms may mimic other lesions with mass effect (such as basilar meningiomas, chordomas or chondromas) and their true anatomical shapes and relations to other cranial structures can only be ascer tained by direct operative inspection. Due to their morphological features (thrombosed, nonthrombosed, par tially thrombosed, fusiform), anatomical variations and difficult locations, giant aneurysms present new challenges for the modern neurosurgeon. Al though microsurgical techniques have rendered direct surgical treatment of giant intracranial aneurysms safer, elimination of the aneurysm without dis turbing the hemodynamics continues to be problematic. Some of these lesions have relatively small necks and can therefore be clipped fairly easily. Others have large necks, are fusiform, or contain perforators; how best to treat these lesions is a question still unresolved by presentday neurosurgery. The authors have presented and discussed the pathology and hemody namics as related to the mechanism of formation of giant intracranial aneu rysms. They have included neuroradiological techniques (especially CT, MRI and arteriography) as pertinent in the management of these difficult vascular lesions. They have carefully reviewed the various clinical approaches for treatment of giant intracranial aneurysms. Finally they have summarized guidelines for management of treatment according to clinical and anatomical considerations. The authors have provided a work of superior all-round quality which should be considered a valuable reference for the serious neurosurgeon. M.G. Y A~ARGIL Preface This work, devoted to the difficult problem of the management of giant intracranial aneurysms, is based on the combined experience of the authors, the cooperative study of the French-Speaking Neurosurgical Society, and a review of the world literature published during the last 12 years. The study was previously published in a French monograph entitled" Les anevrysmes geants intracraniens: approches therapeutiques", published by the French-Speaking Neurosurgical Society in 1984 in Neurochirurgie [30 (Suppl 1) 1-128]. In the present book, new cases have been added from the authors' personal experience, the literature review has been updated to 1985, and several chapters have been enriched with new, up-to-date additions. The authors are grateful to S. Rao for the translation and Heidrun Herion and Ursula Davis of Springer-Verlag for their useful advice during prepara tion of this edition. Y. KERAVEL M. SINDOU Foreword to the French Edition* Through Louis MaIisuy's good offices, Yves Keravel and Marc Sindou have asked me to write a brief introduction to their report. This tactful manner of approach, at a time when my name has begun to fade away from the public memory, is most touching. No less moving is the thought that, from beyond the grave, Mr. Wertheimer, one of the founders of the French-Speak ing Society of Neurosurgery, is to witness a gathering of some of his students and myself at a Congress chaired by Jacques de Rougemont, who was also a student of his. And yet, what has a man still to say whose career in neurosurgery was cut short by superannuation 6 years ago? First and fore most, he would be remiss - and in this particular case, it is not just a matter of politeness - if he did not emphasize the rare quality of this work, its thoroughness,and the authors' obvious efforts to understand each problem as it arose. Going beyond the usual pathologic, clinical, diagnostic and therapeutic issues, the authors devote two pithy chapters to the role of anatomical and hemodynamic features in the formation and growth of giant aneurysms. Not content with making deductions from the laws of fluid mechanics, they resort to firsthand experimentation to enrich our knowledge of the modes of flow, of blood turbulence within the aneurysmal sac, and, as a result, of the organization of thrombi or the risks of rupture. Equally laudable are the pains they have taken some chapters later, to give their colleagues an exact picture of the technology of clips, taking care not to overlook the risks attending most of them (except austenic clips) during follow-up by magnetic resonance imagery. Here I should perhaps mention that through out their report the authors have not neglected silk ligatures, the enormous possibilities of which I personally have always valued. One final comment, so as not to overstep the limit fixed for me by the editor. I find altogether praiseworthy the lucid descriptions of recent technical advances (Vinko Dolenc's, for instance, concerning intracavernous aneu rysms). So, also, on the therapeutic plane, is the rigorous analysis of the results of occlusion of the arterial pedicles or their intravascular obliteration with balloons, both of which can be used as a last resort. The latter technique, introduced by Serbinen~o, has been improved upon by G. Debrun so radically that C. Drake hims~lf has not hesitated to use it - which goes to show how very difficult it is to manage giant aneurysms in a not inconsiderable proportion of cases. The handful of neurosurgeons in Europe and elsewhere in the world who, since the latter half of the 1940s, have avoided systematic ligature of the arteries at the cervical level cannot help mentioning the headway made. They used to operate under local anesthesia, that is to say, without tracheal intubation and - at least initially - without the option of controlled hypotension, and with a poorly lit operative field. Only the grim spontaneous * Presented at a meeting of the French-Speaking Neurosurgical Society held in Grenoble June 28-30, 1984. x Foreword to the French Edition course of aneurysms of any size can account for their courage, not to say their rashness. Their faith has now found its reward, and their approach its vindication, in the more numerous safer options that are available to us today. But what will perhaps prove most satisfying to those of us who have reached the end of their careers is to find, in the final chapter setting out the general conclusions of the report, that Sindou and Keravel harbor the same burning faith which drove their predecessors to "forge ahead towards a safer and more efficacious" mode of treating giant intracranial aneurysms. We who are on our way out can draw comfort from them. For my own part, I owe them my warmest and most sincere thanks. EMILE LAlNE Honorary Professor of Neurosourgery Contents Introduction 1 Anatomical Definition 3 Mechanisms of Formation: Pathologic Features In Collaboration with J. PlALAT, J. SZAPIRO JR., C. GARClA-ORJUELA and M. TOMMASI .......... 4 Macroscopic Findings . . . . . . . . . . . . 4 Microscopic and Ultrastructural Findings . . . . 7 Natural History of Giant Intracranial Aneurysms 9 Mechanisms of Formation: Hemodynamic Features In Collaboration with J.P. NGUYEN and N.P. CHAU 12 Review of the Literature 12 Model Experiments 14 Clinical Study 18 Incidence and Distribution 18 Topographic Types 18 Giant Intracranial Aneurysms in Childhood 21 Neuroradiological Features In Collaboration with J. HUPPERT, E. GORMAND, Y. BASCOULERGUE and J. DUQUESNEL . . . . . 23 Plain Skull Radiographs 23 Angiography . . . . . 23 Computed Tomography 27 Magnetic Resonance Imaging In Collaboration with F.R. NELSON, J. MORET, L. PICARD, P. DEROME and M.L. AUBIN ..... ' 35 Radionuclide Brain Scanning . . . . . . . 41 Direct Surgical Treatment by Neck Occlusion . . . . . . . . . . . 42 General Technical Considerations In Collaboration with PH. DEcQ . . . . . . . . . . . . 42 Direct Surgical Approaches According to Topographic Type 51 Direct Surgical Treatment by Wrapping and Intravascular Thrombosis 74 Wrapping ...... 74 Intravascular Thrombosis 75 XII Contents Extracorporeal Circulation In Collaboration with Y. GUEGAN and L. GUILLOU 79 Surgical Occlusion of the Carotid Axis (Cervical Common Carotid Artery and Cervical Internal Carotid Artery) 85 Effects of Carotid Occlusion 85 Carotid Artery Occlusion in Giant Aneurysms 89 Surgical Occlusion of the Vertebrobasilar Axis (Vertebral Artery and Basilar Trunk) ..................... . 93 Hemodynamic Effects of Occlusion in the Vertebrobasilar System 93 Results in the Treatment of Giant Aneurysms . . . . . . . . . 93 Intracranial Occlusion of the Parent Artery 97 Proximal Occlusion '. 97 Trapping ..... 98 Tolerance of Occlusion 100 Implantable Vascular Occluder In Collaboration with D. CATHIGNOL 101 Extra-intracranial Bypass 102 Methods . . . . . . . 102 Patency .... . . . 107 Applications in Giant Aneurysms 108 Tests for the Tolerance of Therapeutic Occlusion In Collaboration with G. PERRIN, R. CHACORNAC, D. CATHIGNOL and A. GOUTELLE . . . 114 Methods . . . . . 114 Selection of Patients 117 Management by the Intravascular Approach In Collaboration with G. DEBRUN, A. GASTON and C. MARSAULT 118 Background 118 Materials Used . . . . . . . . . . . . . . 1:18 Methods . . . . . . . . . . . . . . . . . 1'21 Clinical Experience and Therapeutic Indications 128 General Conclusions 138 Bibliography 141 Subject Index 161 Introduction Giant intracranial aneurysms, owing to theirvol an interesting role. Finally, progress in manage ume and anatomical features, have always been ment by the intravascular methods developed by considered as lesions presenting great therapeutic Serbinenko in the USSR, and Debrun in Europe difficulties, such that in the past they were most and later on in the United States has made it possi often approached by indirect methods. A genera ble to achieve occlusion in aneurysms until then tion of neurosurgeons, represented by Norlen and considered difficult of access. Laine in Europe and Drake in North America, Entrusted by the French-speaking Neurosurgi showed that it was possible to manage giant aneu cal Society with the preparation of this mono rysms of some types and in certain localizations graph, we have endeavored to synthesize the cur by direct surgical approach without undue risk. rent therapeutic approaches for the management More recently, several neurosurgeons such as of these malformations. This topic has gained par Sundt and Hosobuchi in the United States, Pertui ticular interest owing to the technological ad set and Yasargil in Europe, and Suzuki, Ishii, and vances of the past 10 years and the spate of papers Sugita in Japan, have proceeded further along this which have appeared recently. path. Besides direct surgical management, which The present report has been based on three has been rendered safer by microsurgical tech sources of information: (a) 80 personal cases niques, methods of occlusion of the parent artery, treated by the authors at the Neurological Hospi where the attendant risks of ischemia can be re tal of Lyon and Henri-Mondor Hospital of Cre duced by prior extra-intracranial bypass, also play teil; (b) 309 observations collected from replies to a questionnaire sent to the members of the French speaking Neurosurgical Society with a view to the preparation of this report (see table below); and (c) a detailed review of the literature over the past 12 years. As is emphasized in its title, this report focuses on the numerous therapeutic approaches which have been proposed for the management of giant intracranial aneurysms. It also analyzes the ana tomical, physiological, clinical, and neuroradio logical data which have been found useful for these approaches. The first chapters, devoted to the pathology and hemodynamics at the level of the parent artery and aneurysmal sac, Stress the mechanisms of for mation and forms of development of this type of aneurysm. An understanding of these phenomena is of paramount importance for determination of the management to be adopted. The clinical study is presented briefly, as a de tailed paper on the topic has recently been pub lished by P. Creissard et al. in the journal Neu rochirurgie (reference 19 in the bibliography to the chapter entitled "Clinical Study"). Giant aneurysm of the left intracavernous carotid artery The chapter concerning the neuroradiological (9 x 6 x 6 cm) filling the entire middle cranial fossa. (Photo graph by courtesy of Professor 1. Poirier) features mainly deals with computed tomography

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