Intracranial aneurysms

Abnormal dilations are located in the cerebral arteries. They are located usually in the emergency zones branches of main arteries and especially during his tour of the subarachnoid space cisternal.

The exact etiology is still discussion, since there are factors that make suspect etiology acquired while others support the genetic theory and in case of the occurrence of aneurysms in connective tissue diseases and cases of aneurysms in family.

Intracranial aneurysms are in relatively frequently autopsies, pero hasta la fecha se les diagnostica principalmente cuando se rompen y producen la .

In these circumstances may result in death of 10 to the 15% people before receiving medical attention (1), y la tasa de mortalidad a 30 days is 46% (2).

1. IMPACT

Autopsy series average prevalence reported 5% (3). By angiography volunteer studies have found that the 6,5% people has aneurysms (4), but the frequency of breaking aneurysms is much lower.

La presencia de cerebral y el fenómeno de ruptura se incrementa con la edad, especially between the fourth and seventh decade of life. Rare cases of aneurysms that occur in childhood: 2% (33).

2. Pathogenesis

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 de las arterias, especially in an area of ​​bifurcation. As there is less resistance in these outbreaks occur with the longest arterial degeneration and sacculation.

The fact that there intracranial aneurysms in family, in identical twins and in patients with genetic diseases-mind determined as polycystic kidney disease, Marfan syndrome, síndrome the Ehler-Danlos tipo IV o pseudoxantoma elastico, a group suggests a genetic factor originally (5).

Alternative theory proposes that the aneurysm formed is predominantly the result of degenerative changes in the arterial wall and that are acquired with age and sometimes hypertension (6, 7). This can be seen intimal proliferation, degeneration of the elastic and atherosclerotic changes.

Today it is considered that aneurysms arise as a result of a congenital deficiency of the muscle layer of the cerebral arteries, histological changes that degenerative arterial wall is added in postnatal stages, which include fragmentation of the internal elastic layer, apparently related to hemodynamic stress phenomenon.

3. CLASSIFICATION

Etiology

Intracranial aneurysms can be classified according to different factors. Así­:

According to its etiology:

– Saccular aneurysms, constituting the 80 a 90%, and are located in the emergency area branches of major vessels when run through the cisternal space. They have a sector that is the neck of the aneurysm and the other is the bottom (Figure 1).

– Fusiform aneurysms or atherosclerotic (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 , the vertebral o la basilar. Se dog

cia often atherosclerosis and hypertension. More frequently cause compression tables on cranial, on other vessels or brain parenchyma.

– Infectious aneurysms or “mycotic”. It is considered this terminology to injuries caused by bacterial emboli or rarely fungal (8). We found him in a frequency 4% (1) and is associated with SBE, in immunocompromised patients or, or individuals who use drugs. Tend to be movement of distal, more frequently in distal branches of the middle cerebral artery (Figure 3 a-c) and more multi-frequency.

– Traumatic aneurysms, are considered less frequently to 1%. Usually it is pseudoaneurysms as part of its structure is brain tissue (9). Se ven asociados a trauma penetrante de cráneo (by dagger-like object or projectile gun); but can also be seen in closed head injury. In the latter it is more common and injury may occur proximal main vessel as the carotid artery or in the petrous or cavernous arteries can occur in cortical distal suffering trauma fracture depressed skull.

– Tumor aneurysms. 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).

According to size (29):

– Small: minor 6 mm

– Medium: 6-15 mm

– Great: 16-25 mm

– Giant: over 25 mm

Location:

Saccular aneurysms are more common in the carotid system (85 a 95%) and the most common sites are:

a) internal carotid artery, the output level of the posterior communicating artery

b) anterior cerebral artery in zone with anterior communicating artery

c) bifurcation or trifurcation of middle cerebral artery

d) carotid bifurcation

Aneurysms of the vertebrobasilar system are present in the 5 a 15% case (Figura 5a-c).

They are located more frequently in the basilar bifurcation or distal third, and in the area of ​​emergency posterior inferior cerebellar artery (PICA) from the vertebral artery.

In 101 consecutive patients carriers of cerebral aneurysms, served for a year in the Department of Neurosurgery Hospital Edgardo Rebagliati Martins National Social Health Insurance Lima-Peru, he found a total of 144 Aneurysms. These, 111 (90,97%) were located in the carotid system and 13 (9,03%) in the vertebrobasilar.

The most common location was at the junction with internal carotid artery posterior communicating artery, 35 total aneurysms 144 (26,3%).

Multiple aneurysms, were found in 20 patients (19,8%).

The association of aneurysm(s) and arteriovenous malformation seen in 10 patients (9,9%).

The frequency location of aneurysms as is shown in Figure 6.

In 15 a 33% HSA cases are multiple aneurysms, regarded as such cases of patients with two or more lesions (17).

4. NATURAL HISTORY OF THE BRAIN ANEURISMAS

Unruptured brain aneurysm, asymptomatic

These lesions can be diagnosed in two situations. An aneurysm that is in patient who has never had HSA and the discovery was fortuitous to investigate a nonspecific symptom using a diagnostic procedure or, in the case of screening for suspected family aneurysms.

The other situation occurs when arterial aneurysms fortuitously show aneurysm addition tree is broken.

In these circumstances it has been shown by studies Jane (18) that the annual breakdown is 1% and risk significantly dependent on the size of the aneurysm. Over the 10 mm in size have higher risk.


Figure 1. Dependent saccular aneurysm of the middle cerebral artery visible to dissect ls Sylvian fissure.


Figure 2. Angiographic study of vertebro basilar system showing fusiform aneurysm of the basilar system vertebro.


Figura 3a. Digital subtraction angiography of internal carotid artery aneurysm showing distal circulation (<–) en artery territory (mycotic aneurysm).


Figura 3b. Brain CT showing left frontal hemorrhage in this patient 40 years with a history of bacterial endocarditis and presented sudden onset of aphasia and right hemiplegia.


Figura 3c. The aneurysm surgically exposed left frontal subcortical level.


Figure 4a.Angiografía left carotid in AP, dependent aneurysm shows left artery was pericallosa within the tumor mass(meningioma) Figure 4b en observed. Note tenuous pedicle or aneurysmal neck.


Figura 4b. Computed Axial Tomography brain axial sectional image showing tumor lesion that proved meningioma. The patient presented with clinical symptoms compatible with cerebral hemorrhage. During surgery was found inside tumor aneurysm shown in Figure 4a.(-Courtesy of Dr.. Hugo Llerena-Hospital E.Rebagliati)


Figura 5a. Angiography of vertebral basilar territory, shows saccular basilar artery bifurcation aneurysm, dome projected forward.


Figura 5b. Giant basilar artery aneurysm dome directed dorsally.


Figura 5c. Angiography vertebro basilar lateral incidence, shows a large aneurysm dependent territory of the left posterior cerebral artery.


Figure 6. Diagram showing the location of aneurysms 101 consecutive patients with SAH cerebral aneurysm(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 in area by compressing the trigeminal cranial nerve V 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, withdrawal of covering the upper 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 motor nerve common (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. Paraclinoideo aneurysm of left internal carotid artery with location intrasupraselar. The symptoms presented by the patient had progressive vision deficits.


Figura 7b. Visual field defect produced by compression from the aneurysm quismática.


Figura 8a. Hematoma in the left frontal lobe base that caused by ruptured anterior communicating artery aneurysm seen in Figure 8b.


8b. The right carotid angiography showed that the patient was infected aneurysm territory of former art.comunicante, with dome pointing left.


Figura 9a. CT brain showing subarachnoid hemorrhage in carotid cistern and sylvian right temporal intracerebral hemorrhage from ruptured aneurysm of internal carotid artery at the birth of the posterior communicating artery(visible in figura 9b).


Figure 9b.La angiography shows aneurysm originating from the internal carotid artery, Area emergency back art.comunicante.


Figura 10a. TAC cerebral hemorrhage panventricular showing that compromises the fourth ventricle and in the third ventricle and lateral ventricles. The bleeding was caused by visible aneurysm in Figure 10b.


Figura 10b. Digital right vertebral angiogram showing contralateral vertebral artery aneurysm.
The aneurysm was born of the junction of the vertebral artery and the posterior inferior cerebellar artery.


Figure 11. Image skew carotid angiography showing different arterial territories with angiographic signs of segmental vasospasm.


Figure 12. Image of cerebral angiography with 3D reconstruction, dependent showing aneurysmal lesion of the left posterior cerebral artery.

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 opening prior LCR dural, especially in those cases where seen in the cerebral blood occluded by TAC cisterns. In most patients it is enough that the surgeon removes LCR cisterns 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 floor media, 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) Interhemispheric distal coronal aneurysm A. anterior cerebral(pericallosa).


III) From. Fronto temporal A wide aneurysms. middle cerebral.


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


Figura 14a. Displays ACI aneurysm(intracavernosa), Giant visible only after removing the anterior clinoid apophysis and open the side wall of the cavernous sinus right.


Figura 14b. Right internal carotid angiogram showing the incidence AP giant aneurysmal lesion seen in Figure 14a.


a. Intraoperative image showing optic nerve left exposed after removing the anterior apophyses clinnoides. Note the compressive effect and deformation occurs on the nerve aneurysm.


b. Preoperative angiography showing left ICA aneurysm output level ophthalmic artery. Corresponds to the lesion visible on figure aneurysm.


c. Postoperative angiography showing aneurysm clipping.

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. Angiography shows basilar bifurcation aneurysm with dorsal projection.


b. The pterional approach allows exposure of the aneurysm and dissection and clipping.


c. Postoperative angiographic study.


a. Carotid angiography shows incidence AP bifurcation aneurysm left sylvian artery.


b. Through extensive fronto temporal approach a partially thrombosed giant aneurysm of the middle cerebral artery is exposed, which occupies the entire proximal silviana porcií²n of fissure.


c. Surgical bed after removing the aneurysm to check the position of the 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. Right carotid angiogram lateral posicií²n, showing large aneurysm of this artery segment oftálmicoÂ.


b. Aneurysm (*) exposed in surgery, arises from the anterior aspect of the carotid artery.


c. Aneurysm clipping and open to evacuate its contents.


d. Postoperative right carotid angiogram shows disappearance of the aneurysm image maintaining patent carotid artery.


a. Left carotid angiography in lateral position shows a large aneurysm in carotid artery, segment paraclinoideo, in a woman 67 years presented subarachnoid hemorrhage box.


b. In exposing the aneurysm was found that the aneurysmal neck encontrba very calcified(marked changes ateromatosos).


c. Because the clip was rejected by the aneurysmal neck, huneriana same ligation was performed.
He declined so-Neck Light.


d. With the reduced aneurysmal neck was feasible to place inside the aneurysm colis.


c. State angiographic postcolocación of coils. Note excluding aneurysm with preservation of the artery.

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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