Intracranial aneurysms

Son dilataciones anormales localizadas en las arterias cerebrales. Se ubican por lo general en las zonas de emergencia de las ramas de arterias principales y especialmente durante su recorrido por el espacio subaracnoideo cisternal.

Se debate aún la exacta etiologí­a, ya que hay factores que hacen sospechar etiologí­a adquirida mientras que otros apoyan la teorí­a genética como en caso de la ocurrencia de aneurismas en enfermedades del tejido conectivo y los casos de aneurismas en familiares.

Los aneurismas intracraneales se encuentran en las autopsias con relativa frecuencia, pero hasta la fecha se les diagnostica principalmente cuando se rompen y producen la .

En estas circunstancias pueden producir la muerte del 10 al 15% de personas antes de recibir atención médica (1), y la tasa de a 30 dí­as es de 46% (2).

1. INCIDENCIA

En series de autopsias se reporta una prevalencia promedio de 5% (3). Mediante estudios angiográficos realizados en voluntarios se ha encontrado que el 6,5% de personas tiene aneurismas (4), pero la frecuencia de aneurismas que se rompen es mucho más baja.

La presencia de aneurisma cerebral y el fenómeno de ruptura se incrementa con la edad, especialmente entre la cuarta y séptima década de vida. Son raros los casos de aneurismas que se presentan en la niñez: 2% (33).

2. PATOGENIA

La teorí­a congénita considera que la causa básica de la formación de un aneurisma es la discontinuidad de la capa muscular lisa de la túnica media de las arterias, especialmente en una zona de bifurcación. Al existir menos resistencia en estos focos se producirí­a con el tiempo mayor degeneración arterial y saculación.

El hecho de que existan aneurismas intracraneales en familiares, en gemelos idénticos y en pacientes con enfermedades genética-mente determinadas como renal poliquí­stica, sí­ndrome de Marfan, sí­ndrome de Ehler-Danlos tipo IV o pseudoxantoma elástico, sugiere en un grupo un factor genético en su origen (5).

La teorí­a alternativa propone que el aneurisma formado es predominantemente el resultado de cambios degenerativos de la pared arterial y que son adquiridos con la edad y algunas veces hipertensión arterial (6, 7). Así­ puede verse proliferación de la í­ntima, degeneración de la elástica y cambios ateroscleróticos.

En la actualidad se considera que los aneurismas nacen como resultado de un déficit congénito de la capa muscular de las arterias cerebrales, al que se agrega en etapas postnatales cambios histológicos degenerativos de la pared arterial, que incluyen fragmentación de la capa elástica interna, aparentemente relacionada a fenómeno de estrés hemodinámico.

3. CLASIFICACIÓN

Etiology

Los aneurismas intracraneales pueden clasificarse de acuerdo a diferentes factores. Así­:

De acuerdo a su etiologí­a:

Aneurismas saculares, que constituyen el 80 a 90%, y se ubican en la zona de emergencia de ramas de los vasos principales cuando discurren por el espacio cisternal. Tienen un sector que es el cuello del aneurisma y otro que es el fondo (Figure 1).

Aneurismas fusiformes o ateroscleróticos (Figure 2), que no ocurren en salida de ramas sino que comprometen todo un segmento de la pared de un vaso arterial principal como la carótida intracraneal, la arteria vertebral o la basilar. Se aso

cia con frecuencia a aterosclerosis e hipertensión arterial. Ocasionan con mayor frecuencia cuadros de compresión sobre cranial, sobre otros vasos o sobre el parénquima cerebral.

Aneurismas infecciosos omicóticos”. Se considera con esta terminologí­a a las lesiones causadas por émbolos bacterianos o muy raramente por hongos (8). Se le ha encontrado en una frecuencia de 4% (1) y está asociado a endocarditis bacteriana subaguda, o en pacientes inmunocomprometidos, o en individuos que consumen drogas. Tienden a ser de circulación distal, con mayor frecuencia en ramas distales de la arteria cerebral media (Figure 3 a-c) y con mayor frecuencia múltiple.

Aneurismas traumáticos, son considerados con una frecuencia menor al 1%. Por lo general se trata de pseudoaneurismas ya que parte de su es tejido cerebral (9). Se ven asociados a trauma penetrante de cráneo (por objeto punzo-cortante o por proyectil de arma de fuego); pero también pueden verse en traumatismo craneal cerrado. En este último es más común y se puede producir lesión de porción proximal de vaso principal como la arteria carótida en su porción petrosa o cavernosa o puede ocurrir en arterias distales corticales que sufren trauma por fracture craneal deprimida.

Aneurismas tumorales. Ocurren en casos de enfermedad tumoral embolizante como el mixoma auricular o en lesiones tumorales del cerebro que infiltran la pared arterial y dan lugar a la formación de un aneurisma (Figure 4 a-b).

De acuerdo a su tamaño (29):

Pequeño: menor de 6 mm

Mediano: 6-15 mm

Grande: 16-25 mm

Gigante: over 25 mm

Location:

Los aneurismas saculares son más comunes en el sistema carotí­deo (85 a 95%) y los lugares más frecuentes son:

a) arteria carótida interna, a nivel de la salida de la arteria comunicante posterior

b) arteria cerebral anterior en zona de unión con arteria comunicante anterior

c) bifurcación o trifurcación de arteria cerebral media

d) bifurcación carotí­dea

Los aneurismas del sistema vertebrobasilar están presentes en el 5 a 15% case (Figura 5a-c).

Se ubican con mayor frecuencia en la bifurcación basilar o su tercio distal, y en la zona de emergencia de la arteria cerebelosa posteroinferior (PICA) desde la arteria vertebral.

In 101 pacientes consecutivos portadores de aneurismas cerebrales, atendidos durante un año en el Servicio de Neurocirugí­a del Hospital Nacional Edgardo Rebagliati Martins del Seguro Social de Salud Lima-Perú, se encontró un total de 144 aneurismas. De estos, 111 (90,97%) estuvieron localizados en el sistema carotí­deo y 13 (9,03%) en el vertebrobasilar.

La localización más frecuente fue a nivel de la unión arteria carótida interna con arteria comunicante posterior, 35 aneurismas de un total de 144 (26,3%).

Los aneurismas múltiples, se encontraron en 20 patients (19,8%).

La asociación de aneurisma(s) y malformación arteriovenosa se vio en 10 patients (9,9%).

La frecuencia de aneurismas según localización es mostrada en la Figura 6.

In 15 a 33% de casos de HSA los aneurismas son múltiples, considerándose como tales los casos de pacientes con dos o más lesiones (17).

4. HISTORIA NATURAL DE LOS ANEURISMAS CEREBRALES

Aneurisma cerebral no roto, asintomático

Estas lesiones pueden ser diagnosticadas en dos situaciones. Una que se encuentre el aneurisma en paciente que nunca ha tenido HSA y el hallazgo ha sido fortuito al investigar un sí­ntoma inespecí­fico mediante algún procedimiento de diagnóstico o, en los casos de despistaje por sospecha de aneurismas familiares.

La otra situación ocurre cuando se demuestran fortuitamente aneurismas en árbol arterial además del aneurisma que se ha roto.

En estas circunstancias se ha demostrado por estudios de Jane (18) que la tasa de ruptura anual es de 1% y el riesgo significativamente dependiente del tamaño del aneurisma. Los de más de 10 mm de tamaño tienen mayor riesgo.


Figure 1. Aneurisma sacular dependiente de la arteria cerebral media visible al disecar ls cisura de Silvio.


Figure 2. Estudio angiográfico de sistema vértebro basilar que muestra aneurisma fusiforme del sistema vertebro basilar.


Figura 3a. Angiografí­a con sustracción digital de arteria carótida interna que muestra aneurisma de circulación distal (<–) en artery territory (aneurisma micótico).


Figura 3b. TAC cerebral que muestra front left in this patient 40 años con antecedente del endocarditis bacteriana y que presentó cuadro súbito de afasia y hemiplegia derecha.


Figura 3c. El aneurisma expuesto quirúrgicamente a nivel frontal izquierdo subcortical.


Figura 4a.Angiografí­a carotí­dea izquierda en proyección A-P, muestra aneurisma dependiente de la arteria pericallosa izquierda que se encontraba en el interior de la masa tumoral(meningioma) Figure 4b en observed. Obsérvese muy tenue pedí­culo o cuello aneurismático.


Figura 4b. Tomografí­a Axial Computarizada de cerebro en corte axial que muestra imagen de lesión tumoral que resultó ser meningioma. La paciente acudió por cuadro clí­nico compatible con hemorragia cerebral. Durante la cirugí­a se encontró en el interior aneurisma tumoral mostrado en figura 4a.(-Courtesy of Dr.. Hugo Llerena-Hospital E.Rebagliati)


Figura 5a. Angiografí­a de territorio vértebro basilar, muestra aneurisma sacular de bifurcación arteria basilar, dome projected forward.


Figura 5b. Aneurisma gigante de arteria basilar con domo dirigido dorsalmente.


Figura 5c. Angiografí­a vértebro basilar incidencia lateral, muestra un aneurisma grande dependiente del territorio de la arteria cerebral posterior izquierda.


Figure 6. Diagrama que muestra localización de los aneurismas en 101 pacientes consecutivos de HSA por Aneurisma cerebral(peri-od February 98 Jan 99 HNERM).
-Total aneurysms:144
-NÂ ° of patients with multiple aneurysms:20.
-° In patients with aneurysms asociacióon association MAV:10(9.9%)

Symptomatic cerebral aneurysms, not broken

In monitoring by angiography of patients with cerebral aneurysm has been shown that most increases in size over time (19, 20). They may cause compression of neighboring neural structures. Así­, aneurysms in the intracavernous segment of the carotid artery can produce a picture of installing insidious pain and dysesthesia of the trigeminal area compression V cranial and diplopia for its effect on compression or distortion III, IV or VI cranial nerves.

In cases of aneurysms of the ophthalmic segment of the internal carotid artery (between the ceiling of the cavernous sinus and out of the posterior communicating artery can occur disorder of visual field due to rejection of the optic nerve against the falciform ligament, replicating dura that covers the top face of the optic nerve at the channel, o incluso, if the aneurysm projecting medially on sella, to produce such a chiasmatic syndrome caused by a pituitary tumor (Figure 7 a-b).

Aneurysms of the posterior communicating artery is especially directed backwards and because of the proximity to the nerve common ocular (III), when compressed it, may occur dependent paresis or paralysis of the nerve muscles, ptosis Palpebral y midriasis.

Aneurysm rupture

The event of aneurysm rupture and SAH is therefore an absolutely negative and devastating situation for a patient. It is considered that despite the advances in care in intensive care units (UCI) and advances in surgery and endovascular treatment, almost half of patients die within two months after the stroke (10). Half of the deaths occur as a result of the initial hemorrhage. Among the survivors are good results in the 40%, because many suffer residual neurological morbidity or neuropsychological (11).

Aneurysms occur when breaking subarachnoid hemorrhage or intracerebral hemorrhage dominance. The weakest sector of the aneurysmal wall is the background, and if the location of the aneurysm is entirely cisternal, subarachnoid bleeding will, which is the most common, but if the bottom is inside the brain parenchyma, be intracerebral bleeding, or even intraventricular.

Aneurysms of the anterior cerebral artery junction with anterior communicating, hematoma frequently originates at the base of the frontal lobe (Figura 8a-b) and the middle cerebral artery aneurysms (ACM) internal carotid or do to the temporal lobe (Figura 9a-b).

Aneurysms of the vertebrobasilar system, especially PICA, to invade the fourth ventricle bleeding-ass and, secondarily, other ventricles (Figura 10a-b).

5. Complications postruptura aneurysmal

5.1. Rebleeding

It is the most dramatic and critical event post HSA. The mortality is greater than postresangrado 70% (21). The peak of rebleeding is in primerras 24-48 hours.

The closure of the aneurysm to prevent rebleeding and surgery sooner becomes greater the potential reduction during the high risk period.

If surgery is performed there is an incidence of approximately. 20% possibility of rebleeding in the first 2 weeks (22).

Antifibrinolytic therapy reduces the rate of rebleeding but is associated with increased complications from ischemic neurological deficit (31).

5.2. Vasoespasmo

It is the leading cause of disability after SAH. Generally, ischemic deficit vasospasm develops between the 12th and 5. ° ° day after the initial hemorrhage. The peak is 7.mo I gave-a (23). Although the incidence of angiographic vasospasm is 60-70%, The incidence of neurologic-related symptoms is approximately vasospasm 30% (24) (Figure 11).

The surgery performed before this stage allows to remove blood from the tanks and therefore reduce spasmogenic substances, also be used to hypertensive hypervolemic therapy if signs of ischemia occur postoperatively.

5.3. Hydrocephalus

It can be acute obstruction of the ventricular system by extravasated blood or occur later and in an insidious manner by disorder in CSF absorption. It looks at a frequency of 15 a 21% (1, 32).


Figura 7a. Aneurisma paraclinoideo de arteria carótida interna izquierda con ubicación intrasupraselar. La sintomatologí­a presentada por la paciente era de déficit progresivo de visión.


Figura 7b. Defecto campimétrico producido por compresión quismática debido al aneurisma.


Figura 8a. Hematoma en base de lóbulo frontal izquierdo ocasionado por ruptura de aneurisma de arteria comunicante anterior observada en figura 8b.


8b. El estudio angiográfico carotí­deo derecho demostró que la paciente era portadora de aneurisma de territorio de art.comunicante anterior, con cúpula dirigida hacia la izquierda.


Figura 9a. TAC cerebral que muestra hemorragia subaracnoidea en cisterna carotí­dea y silviana derecha y hemorragia intracerebral temporal por ruptura de aneurisma de Arteria carótida interna a nivel del nacimiento de la arteria comunicante posterior(visible in figura 9b).


Figura 9b.La angiografí­a muestra aneurisma con origen en la arteria carótida interna, en la zona de emergencia de la art.comunicante posterior.


Figura 10a. TAC cerebral que muestra hemorragia panventricular que compromete el IV ventrí­culo así­ como en III ventrí­culo y ventrí­culos laterales. La hemorragia fue causada por aneurisma visible en figura 10b.


Figura 10b. Angiografí­a digital vertebral derecha que muestra aneurisma de arteria vertebral contralateral.
El aneurisma nací­a de la zona de unión de la arteria vertebral con la arteria cerebelosa postero inferior.


Figure 11. Imagen de angiografí­a carotí­dea posición oblicua que muestra diversos territorios arteriales con signos angiográficos de vasoespasmo segmentario.


Figure 12. Imagen de angiotomografí­a cerebral con reconstrucción 3D, que muestra lesión aneurismática dependiente de arteria cerebral posterior izquierda.

6. DIAGNí?Stic

While axial computed tomographic (TAC) is the highest value for the diagnosis of HSA, cerebral angiography so far is the method of choice for identifying brain aneurysms and vascular malformations. It is considered the definitive technique for surgical planning of these lesions (30).

Angiography should be initiated by the side of suspected vascular injury is based on the clinical and brain CT.

Overall angiography should be both carotid arteries and two vertebral. With this diagnosis of multiple aneurysms or arteriovenous malformation association with also described is achieved.

This study should analyze the morpho-logical characteristics of the lesion, size and direction of the aneurysm, relationship with pot afferent, vessels of periferie (especially perforating), neck size. All these data will serve for surgical planning.

It should also be sectorial if there is evidence of vascular spasm or diffuse, luminal defects likely atherosclerotic plaques and collateral circulation via the circle of Willis.

The risks of angiography are low but should be considered. Stroke include, aneurysm rebleeding, hematoma formation in the area PSANS puncture, reaction to contrast material and renal failure. The mortality rate for the exam is 0,1% and the rate of permanent neurological deficit is 0,5% (25).

The angiografí-a for resonance nuclear magnética (JG) or magnetic resonance angiography is an effective method for obtaining diagnostic and vascular morphological and physiological information of high resolution. At the present moment is a noninvasive alternative, virtually risk, High specificity and sensitivity for diagnosis of vascular malformations, cerebral aneurysms (34).

S able to show aneurysms 2-3 mm in diameter, but prospective studies have found that the critical size is 5 mm (26).

b. The method of endovascular aneurysm occlusion therapy with platinum filaments lumen (coils), constitutes an alternative treatment for selected patients.

8. QUIRI TREATMENT?RGICO

There are two positions on the time that surgery should be performed, so that some level of controversy still remains.

One is to surger- “early” it is performed before the 48-72 Subarachnoid hours posthemorragia.

The other is to surger- “Deferred” o tardí­a , usually made from the 10 a 14 dí­as post HSA.

The reasons behind early surgery or “early” its:

a. If the surger-a is successful, eliminates the risk of rebleeding in a group of patients who have this complication statistically.

b. Once the surgery is much easier to treat vasospasm that occurs in a percentage of patients post HSA, especially after 6 a 8 I gave-as happened the HSA.

c. Washing allows basal cisterns with clot removal, achieving better circulation of cerebrospinal fluid and a decreased risk of hydrocephalus (27).

d. Although the greater surgical mortality, shows that there is a lower mortality in the overall care of patients in whom surgery was performed early (28).

The questioning of early surgery are mainly by the following factors:

– The surgery is performed on more difficult technical conditions for intracranial hypertension, cerebral edema, friable parenchyma and dense clots in tanks. There is increased risk of edema and generate increased parenchymal contusion after surgery.

– There is greater possibility of postoperative vasospasm.

– The risk of intraoperative aneurysm rupture is greater.

Due to these factors, currently managing patients better oriented post clinical conditions HSA (grados To The Hunt II & Hess) and no complex aneurysms, to perform in them-a surger “early”.

Delayed surgery is reserved for patients in levels III, IV y V de Hunt & Hess, those with poor systemic medical conditions, complex aneurysm carriers, Giant vertebrobasilar system or, those showing signs of large cerebral edema in the presence of CT or angiographic vasospasm important.

9. GENERAL TREATMENT OF QUIRI?RGICO

Anesthetic preparation

The patient enters the operating room under effect of premedication with mild sedation and anticholinergic effect. The anesthesiologist placed under monitoring of cardiovascular parameters in blood pressure, heart rate, electrocardiographic, arterial oxygen and carbon dioxide. If you put the saw-central venous.

Thumbnail radial arterial route preference and invasive blood pressure monitoring. At all times sudden changes in blood pressure to be avoided especially in the moment of intubation and placement cranial fixation system.

Administer antibiotic prophylaxis (can be Cefazolin 2 gr I.V.)

Anesthetic induction prior oxygenation. Administration of sodium pentobarbital in increments of progressive 50 a 150 mg hasta 1 gr total. Once the patient asleep, anesthetic agents will be administered by mask. Before intubation muscle relaxant is administered.

Intubation should be very smooth. Keep controlled ventilation mode with approx figures PCO2. 30 mmHg.

During Reconstruction Surgery-a, anesthesiologist be administered at the time that the craniotomy is performed at a dose of mannitol 20% of 0.5 g / kilo / dosis, in order to obtain complete relaxation of the cerebral parenchyma before dural opening.

In some circumstances it is useful to have a spinal catheter to vent Prior to opening the dura, especially in those cases where seen in the cerebral blood occluded by TAC cisterns. In most patients it is sufficient the surgeon withdraws tanks supported by

Relaxation of brain parenchyma that provides technical tesiológica anes-. Ultimately can be performed if evacuation ventricular puncture CSF is ineffective.

The attitude of the anesthesiologist should be to maintain communication with the surgeon. Especially blood pressure control at critical times such as neck dissection or aneurysm sac should be taken into account, These circumstances in which it is preferable to have a state of controlled hypotension Mean arterial pressure (PAM) of 60 mmHg. In case of abrupt rupture aneurismática, MAP will have to go down to figures 20 a 25 mmHg por 2 a 3 minutes, if it is insufficient temporary clipping the afferent vessel.

10. They?TECHNICAL QUIRI?RGICA

Neuroanestesiológicas modern techniques aim to reduce the stress the brain parenchyma while maintaining adequate perfusion pressure while allowing the surgeon exposure and dissection of the aneurysm in the safest way.

Aneurysm surgery should aim to minimize brain damage at the time of dissection and exposure microquirúgica aneurysm and especially ensure total vasopermeability, not only the afferent vessels to injury, but also small perforators are in the periphery.

Position of patient

Most aneurysms surgeries are performed in supine position. This position is the physiological from the point of view of cardiovascular and cerebral perfusion.

Must discreetly raised his head 15 to 20's to enhance venous drainage.

In case of aneurysms of the vertebral artery may be in position laterally oblique (position park bench) or very occasionally seated.

The head position varies according to the location of the aneurysm to operate (Figure 13).

Cranial most frequently used approaches are: Pterional of Yasargil, allowing expose the entire anterior circle of Willis. Should be supplemented with adequate removal of the lesser wing of the sphenoid, in order to realize the least shrinkage of the cerebral parenchyma. Are useful in communicating artery aneurysms previous, internal carotid artery bifurcation, sector proximal middle cerebral artery and basilar bifurcation aneurysms high position.

Frontotemporal craniotomy comprehensive gives more exposure to distal middle cerebral artery aneurysms.

The coronal craniotomy is mainly for aneurysms of the pericallosal artery (portion A2, A3).

The craniotomy-a temporary Drake, extension to the middle fossa floor, allows subtemporal approach to aneurysms of the basilar artery tip.

The suboccipital craniotomy with removal of the arch of C1 allows adequate exposure of vertebral artery aneurysms.

The combined subtemporal craniectomy suboccipital craniotomy + petrosectomí the partial-, allows a better approach to aneurysms of the distal third of the basilar artery.

Exhibition microquirúrgica

Opening tanks is performed with support of the surgical microscope. CSF is removed from tank carotid-dea, chiasmatic, Sylvian fissure and opens wide.

If paraclinoid aneurysms should be performed exeresis the anterior clinoid apophyses, the posterior third of the roof of the orbit and optic canal (Figure 14). This allows for maximum exposure of the optic nerve in its course by optical channel and to better expose carotidooftálmicos aneurysms (Figure 15).

In case of aneurysms of the anterior communicating artery is convenient to carry corticectomía of gyrus rectus.

For aneurysms of internal carotid artery bifurcation corticectomía discrete front lid can be performed in the most proximal portion of the Sylvan fissure, taking care not to injure the perforating arteries.

Exposure of the aneurysm

Dissecting aneurysm neck is the most critical time of surgery. Coagulated and sectioned shall arachnoid adhesions and properly dissected afferent vessels.

The placement of the clip should be very accurate, trying to see how far cross enter at least one branch of the clip. If there is resistance must withdraw the clip, as it can be counterpart aneurysm sac and it can be drilled. Additional dissection must be carried out to reposition the clip and.


I) From. pterional(Yasargil)
Aneurysms of ACP, A. with. on. bifurc. carotí­dea bifur. basic(high).


II) Coronal Interhemisférico aneurisma distales de A. anterior cerebral(pericallosa).


III) From. Fronto temporal amplia aneurismas de A. middle cerebral.


IV) From. Temporary(Drake) An. basilar bifurcation(low).


Figura 14a. Muestra aneurisma de ACI(intracavernosa), gigante visible sólo después de retirar la apófisis clinoides anterior y abrir la pared lateral del seno cavernoso derecho.


Figura 14b. Angiografí­a carótida interna derecha incidencia A-P mostrando la lesión aneurismática gigante vista en figura 14a.


a. Imagen intraoperatoria que muestra nervio óptico izquierdo expuesto luego de retirar la apófisis clinnoides anterior. Obsérvese el efecto compresivo y deformación que produce el aneurisma sobre el nervio.


b. Estudio angiográfico preoperatorio que muestra aneurisma de ACI izquierda a nivel de salida de arteria oftálmica. La lesión corresponde al aneurisma visible en figura a.


c. Angiografí­a postoperatoria que demuestra aneurisma clipado.

After placing the clip should be reviewed if the clipping was right and if it is not compressed to the main vessel or one of its branches. Revise even perforating vessels (Figure 16).

If in doubt regarding the proper clipping sac incision and suction recommended content (Figures 17 and 18). Of active bleeding occur should be amended to add additional clipping or clip.

In case of breakdown intraoperatoria, if small, should be placed on one area cotonoid bleeding and vacuum. Generally subsides bleeding and dissection may be resumed.

If bleeding should be sought much volume the afferent vessel and perform temporary clipping of the same, quickly dissecting aneurysm and cliparlo.

If tear proximal aneurysmal neck sector, no option to use Sugita or Yasargil clips, consider Sundt clips or Slim Kees Kees.

Check the condition of the vessels. If postoperative vasospasm can be placed local papaverine solution or Nimodipine.

Leave pieces of Surgicel in cortisectomía area and ensure hemostasis neatly. Cierre the Views', Bone replacement platelet, fragments can be left hemostatic sponge (Gelfoam) epidural level. Closing muscle, galea and skin.

If considered taking into account the patient's neurological conditions prior, that has a high probability of maintaining a level of coma Glasgow under 8 points, or if the patient has also developed obstructive hydrocephalus, it is preferable to leave a measurement system intracranial pressure for better handling of the same, intermittent withdrawal of CSF and pulsed administration of Mannitol, according to the degree of intracranial hypertension.

Postoperative Care

Keep light state of hypervolemia. Central venous pressure must be maintained 10 cm water.

Administer medication against him vasoespasmo with intravenous Nimodi-pin for the SNG.

Always maintain mean arterial pressure 90-95 mmHg. Hypotension Avoid the risk of ischemia and irreversible brain injury.

Steroids, Antacid, H2 blockers.

Mantener profilaxis with antibiotic Cefazolin 1 gr each 8 hours 24 a 48 additional hours.

11. THERAPY endovascular

They represent a wide range of innovative therapeutic strategies that target occlusion or exclusion of a cerebral aneurysm through the intraarterial route.

These techniques include the following:

– Participation in internal aneurysm of small metallic filaments: Guglielmi coils and mechanical detachable coils (12)

– Thumbnail minibalones (13)

– Balloon occlusion of the proximal artery in cases of giant aneurysms (14)

– Placing microstent (Covers) intraarterial occlusion for lateral aneurysms (31, 35).

The technique that is offering the best results is the occlusion of the aneurysm with platinum filaments (coils). Aneurysms are most appropriate pedicle.

The current indications for endovascular therapy are referred to cases of aneurysms presenting an excessive surgical difficulty; in cases of instability or neurologic cases with high risk systemic (36).

Aneurysms with excessive surgical difficulty are the trunk of the bifurcation of the basilar artery, Aneurysms of the vertebro basilar junction, aneurysms of the anterior inferior cerebellar artery emergency and aneurysms in the intracavernous carotid artery segment.

Neurological cases include patients instability in degrees 4-5 Ratings Hunt & Hess, with increased pressure intracaneal, or patients with symptomatic vasospasm deterioration.

The high systemic risk include patients with aneurysmal rupture also have box hemodynamic instability, are. respiratory distress, hipoxemia, coagulopatí treatment-as, sepsis, cardiac ischemia, liver failure, renal failure or other multisystem.

The advantage of this technique is that it requires prolonged deep anesthesia, craneotomí­a, brain retraction. Anyway procedures are not without limitations as aneurysms incompletely occluded especially the wide-necked or giant (Complete closure is obtained in less than 40% case) (15), recanalization of the aneurysm due to remodeling of the material used (16% case) (16), or complications inherent to the procedure.


a. Angiografí­a muestra aneurisma de bifurcación basilar con proyección dorsal.


b. El abordaje pterional permite la exposición del aneurisma y disección y clipaje.


c. Estudio angiográfico postoperatorio.


a. Angiografí­a carotidea en incidencia A-P muestra aneurisma de bifurcación de arteria silviana izquierda.


b. A través de un abordaje fronto temporal amplio se expone un aneurisma gigante parcialmente trombosado de la arteria cerebral media, que ocupa í­ntegramente la porcií²n proximal de cisura silviana.


c. Lecho quirúrgico luego de extirpar el aneurisma para revisar la posición de los clips.

Embolization with balls is equally encouraging results with preservation of afferent vessel in cases of aneurysms do not have fresh clots and is being achieved because there are better diagnostic techniques as MRI, best fluoroscopic equipment to, development of new types of balloons and microcatheters. But it is necessary that these techniques are centralized in specialized centers to develop the most in the future this therapeutic alternative.

Tabla 1a

Advantages of surgical clipping

– Known durability of treatment. Known durability of treatment.

– This may be another pathological to present.

– Parenchyma decompresses: Removal

hematoma, L.C.R. the cerebral tejido.

– Blood is removed subarachnoid.

– If woe the anatomí th: main vessel, art. collaterals and perforating.

– If intraoperative contralateral Sangrado.

– A rapidly evolving technolo-.

– Others: Neuroprotection, anesthesia, exposures of the skull base.

Tabla 1b

Disadvantages of surger-a

– In cases of high-grade patients waiting period for surgery exposes patients to a rebleeding.

– Injury direct vessels piercing.

– The temporary occlusion can be risky in segment perforating.

– Brain Shrinkage (difficult and can cause problems in patients with high grade).

– Many exposures require significant retraction (A.Com.ant, apex tronco basilar).

– Spe-cific surgeon: learning curve, experience, training.

Tabla 2a

Benefits of Therapy Coil

– Possibility of treating poor-grade patients.

– Under anesthesia time.

– It can treat multiple aneurysms in different vascular territories.

– Very acceptable risk of complications.

– Can be combined with angioplastí-a..

– It may be only palliative (obliterate the area rota).

– Technolo-a rapidly developing and mejorí-a.

Tabla 2b

Disadvantages of therapy Coil

– Durability of treatment not yet known.

– During the procedure can lead to complications (the injury hemorrhagic stroke the vasoespasmo).

– Recurrence can be high in certain types of aneurysm.

– Increased risk of thromboembolic complications.

– Substantial risk of need for retreatment.

– More expensive than surger-whether requires repeated.

– Potential need for anticoagulation.

– Spe-cific endovascular therapist: learning curve, experience, training.

What treatment to choose: the surgery, the endovascular therapy

To date there are no randomized studies comparing surgery and endovascular therapy with coils.

Should thus advantages and disadvantages of each treatment modality be considered (draw 1 and 2), the clinical condition of the patient and the anatomical features of the aneurysm to choose one or the other therapy.


a. Angiograma carótidea derecha posicií²n lateral, que muestra gran aneurisma del segmento oftálmico de esta arteria.


b. Aneurysm (*) expuesto en la cirugí­a, arises from the anterior aspect of the carotid artery.


c. Aneurisma clipado y abierto para evacuar su contenido.


d. Angiografí­a carotí­dea derecha postoperatoria muestra desaparición de la imagen aneurismática manteniendo a la arteria carótida patente.


a. Angiografí­a carotí­dea izquierda en posición lateral que muestra un aneurisma grande en arteria carótida, segment paraclinoideo, in a woman 67 years presented subarachnoid hemorrhage box.


b. En la exposición del aneurisma se encontró que el cuello aneurismático se encontrba muy calcificado(marked changes ateromatosos).


c. Debido a que el clip era rechazado por el cuello aneurismático, se realizó ligadura huneriana del mismo.
He declined so-Neck Light.


d. Con el cuello aneurismático reducido fue factible colocar colis en interior del aneurisma.


c. Estado angiográfico postcolocación de coils. Nótese exclusión de aneurisma con preservación de la arteria.

Because the surgical treatment of cerebral aneurysms has evolved over decades as a way of becoming highly effective and safe therapy and current endovascular therapy techniques have limitations, particularly in treating large aneurysms or wide neck those, the current generation of endovascular techniques can not be considered as a replacement to existing surgical methods.

Endovascular techniques should be considered complementary to surgical techniques should also be seen as an option to extend the treatment to patients with inoperable aneurysms or high surgical risk (Figure 19).

With the availability of both treatments â??microsurgical high quality and endovascularâ?? for treating aneurysms, may expect better results in future clinical, superior to those achieved with one of the methods performed in isolation (37, 38).

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8 Replies

  1. patricia gomez says:

    ask a surgeon, I have an aneurysm in the left internal carotid artery 3mm, not want to do any kind of intervention, but I'm in reviews every three months based on whether or not will decide to do grows, I would like to have an opinion of a vascular neurosurgeon who is involved surgically, thanks.

  2. guadalupe sanchez says:

    where I can buy the following material 1 cateter chaperon 6 fr
    1 introductor nrferial 6fr
    1 microcateter meadway 17
    microguia costumes 14
    2 coils platino
    I can send the address to know how much it costs and buy
    thank you very much I hope your answer

  3. cesar says:

    kisiera know where I can get the clips stop to buy a family cuantoos is urgent thanks kisiera price directions

  4. marielen says:

    hello goodnight!! I operated an aneurysm in the right carotid artery were placed me 2 titanium clips!! I would like to know what precautions should I take q,another aneurysm may appear?? q I care types!!! thanks

    • diana rivers says:

      I have also operated and 5 titanium coil so care must have segunmi neurosurgeon Pasova quiet life are strictly forbidden to smoke and take care of if you suffer from high pressures that may appear clear otors aneurysms ami aparecierom tires me more live in other places they still have no luck and the need to be re-operated is very risky take care

    • ISABEL says:

      I detected 2 aneurysms, one on each side and one measured 7.5ml., found in carotid cavernous area and I suggest to open skull operation.
      I ineteresa its views.

  5. beatriz says:

    hello would like to know how long the clip is removed or points. many thanks excellent item

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