Intracranial aneurysms

They are abnormal dilatations located in cerebral arteries. They are located generally in the emergency zones of the branches of main arteries and especially during his tour of the subarachnoid cisternal.

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

Intracranial aneurysms are in relatively frequently autopsies, but to date they are diagnosed primarily when they break and produce Subarachnoid.

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


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

La presencia de aneurisma 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

Congenital theory believes that the basic cause of aneurysm formation is the discontinuity of the smooth muscle layer of the tunica media of the arteries, especially in an area of ​​bifurcation. As there is less resistance in these outbreaks it would occur as long arterial degeneration and sacculation.

The fact that there intracranial aneurysms in family, in identical twins and in patients with genetically-determined diseases like mind renal poliquística, Marfan syndrome, sí­ndrome de Ehler-Danlos tipo IV o pseudoxantoma elástico, 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, including fragmentation of the internal elastic layer, apparently related to hemodynamic stress phenomenon.



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

According to the etiology:

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

– Aneurismas fusiformes o ateroscleróticos (Figure 2), not occur in output branches but undertake an entire segment of the wall of a main blood vessel as intracranial carotid, vertebral artery or the basilar. Se aso

CIA frequently atherosclerosis and hypertension. Paintings most often cause compression on cranial nerves, on other vessels or brain parenchyma.

– Or infectious aneurysms “mycotic”. It is considered this terminology to injuries caused by bacterial emboli or rarely fungal (8). It has been found at a frequency of 4% (1) and it is associated with subacute bacterial endocarditis, in immunocompromised patients or, or individuals who use drugs. They tend to be distal circulation, more frequently in distal branch of the middle cerebral artery (Figure 3 a-c) and more multi-frequency.

– Traumatic aneurysms, They are considered less frequently to 1%. Usually it is pseudoaneurysms as part of its structure is brain tissue (9). They are associated with penetrating head injury (by dagger-like object or projectile gun); but they can also be seen in closed head injury. The latter is most common and can produce injury proximal main vessel such as the carotid artery in the petrous or cavernous or distal arteries can occur in cortical suffering trauma fracture depressed skull.

– Tumor aneurysms. Occur in cases of tumor embolic disease such as atrial myxoma or brain lesions in tumor infiltrating the arterial wall and lead to the formation of an aneurysm (Figure 4 a-b).

According to size (29):

– Little: less than 6 mm

– Medium: 6-15 mm

– Big: 16-25 mm

– Giant: more than 25 mm


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

Vertebrobasilar aneurysms are present in the system 5 a 15% case (Figura 5a-c).

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

In 101 consecutive patients carriers of cerebral aneurysms, served for a year in the Neurosurgery Department of the Hospital Edgardo Rebagliati Martins National Social Health Insurance Lima-Peru, he found a total of 144 Aneurysms. Of these, 111 (90,97%) They 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 aneurysms total 144 (26,3%).

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

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

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

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

4. NATURAL HISTORY cerebral aneurysms

Unruptured brain aneurysm, asymptomatic

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

The other situation occurs when fortuitously show aneurysms arterial tree besides the aneurysm has ruptured.

In these circumstances it has been shown by studies Jane (18) the annual breakdown is 1% and the risk significantly depending on the size of the aneurysm. The over 10 mm in size are at higher risk.

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

Figure 2. Vertebro system angiographic study showing fusiform basilar aneurysm of the basilar vertebrobasilar system.

Figura 3a. Digital subtraction angiography of internal carotid artery aneurysm showing distal circulation (<–) silviano 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, shows aneurysm dependent pericallosal left artery was within the tumor mass(meningioma) observed in Figure 4b. Note tenuous pedicle or aneurysmal neck.

Figura 4b. Computed tomography of the brain in axial section showing tumor image injury turned out to be meningioma. The patient came to clinical picture compatible with cerebral hemorrhage. During surgery it was found inside tumor aneurysm shown in Figure 4a.(Cortesí­a Dr. Hugo Llerena-Hospital E.Rebagliati)

Figura 5a. Angiografí­a de territorio vértebro basilar, It shows saccular basilar artery bifurcation aneurysm, dome projected forward.

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

Figura 5c. Angiografí­a vértebro basilar incidencia lateral, It is showing a large aneurysm dependent territory of the left posterior cerebral artery.

Figure 6. Diagram showing the location of aneurysms 101 HSA consecutive patients with cerebral aneurysm(February 98 to January period 99 HNERM).
-Total aneurysms:144
-NÂ ° of patients with multiple aneurysms:20.
-NÂ ° patients with aneurysms Asociacioon association MAV:10(9.9%)

Symptomatic cerebral aneurysms, unruptured

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

In cases of ophthalmic segment aneurysms of the internal carotid artery (between the roof of the cavernous sinus and out of the posterior communicating artery disorder visual field can occur for rejection optic nerve against the falciform ligament, withdrawal of dura that covers the upper face of the optic nerve channel level, or even, if the aneurysm extends medially over the sella, chiasm produce similar syndrome to that produced by a pituitary tumor (Figure 7 a-b).

Aneurysms of the posterior communicating artery is especially directed back and due to the proximity to the motor nerve common (III), when compressed it, It can cause paresis or paralysis of muscles of this nerve dependent, ptosis palpebral y midriasis.

Aneurysmal rupture

The event aneurysmal rupture and subsequent HSA is 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, nearly half of patients die within two months after stroke (10). Half the deaths occur as a result of the initial hemorrhage. Among the survivors are good results in the 40%, because many suffer from neurological morbidity or residual 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 completely cisternal, subarachnoid bleeding be, which it is the most common, but if the Fund is within the brain parenchyma, It is intracerebral bleeding, o incluso intraventricular.

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

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

5. Aneurysmal complications postruptura

5.1. Resangrado

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

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

If surgery is not performed exists an incidence of approximately. 20% possibility of rebleeding in the first 2 weeks (22).

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

5.2. Vasoespasmo

Is a major cause of disability post HSA. as usuall, vasospasm ischemic deficit develops between 5. ° and 12.A th day after initial bleeding. The peak is the day (23). Although the incidence of angiographic vasospasm is 60-70%, the incidence of neurological symptoms related to vasospasm is approximately 30% (24) (Figure 11).

The surgery performed before this step allows removing blood of tanks and therefore reduce espasmogénicas substances, also allows Hypervolemic hypertensive therapy if signs of ischemia occur in the postoperative.

5.3. Hydrocephalus

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

Figura 7a. Paraclinoideo aneurysm of the left internal carotid artery with location intrasupraselar. The symptoms presented by the patient was progressive vision deficit.

Figura 7b. Visual field defect caused 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 a carrier of aneurysm territory of former art.comunicante, domed leftward.

Figura 9a. TAC 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 en figura 9b).

Figure 9b.La angiography shows aneurysm originating from the internal carotid artery, in the emergency area of ​​the 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 aneurysm visible 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 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, showing dependent injury aneurysmal left posterior cerebral artery.


Although computed tomography (TAC) It 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 to be the ultimate technique for surgical planning of these injuries (30).

Angiography can be initiated by the side where it is suspected vascular injury is based on clinical data and cerebral TAC.

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

This study should analyze the morpho-logical characteristics of the lesion, size and direction of aneurysm, regarding afferent vessel, vessels in the periphery (especially piercing), Neck size. All these data will be used for surgical planning.

It should also be seen if there is evidence of sectoral or diffuse vascular spasm, luminal defects likely atherosclerotic plaques and collateral flow through the circle of Willis.

The risks of angiography are low but should be considered. They include stroke, aneurysm rebleeding, hematoma formation or pseudoaneurysm at the puncture site, 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).

Angiography resonance nuclear magnética (Mangroves) or angiography is an effective method for obtaining diagnostic and morphological and physiological vascular high resolution information. At present an alternative noninvasive, virtually no risk, high specificity and sensitivity for the diagnosis of brain aneurysms and vascular malformations (34).

It is capable of displaying aneurysms 2-3 mm diameter, but prospective studies have found that the critical size is 5 mm (26).

b. The procedure for endovascular occlusion of the aneurysm therapy using platinum filaments lumen (coils), It is an alternative treatment for selected patients.


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

One is surgery “early” it is performed before the 48-72 horas posthemorragia subaracnoidea.

The other is surgery “Deferred” the tardía , usually it made from the 10 a 14 dí­as post HSA.

The reasons behind early surgery or “early” son:

a. If the surgery is successful, the risk of rebleeding is removed in a group of patients who have this complication statistically.

b. Once the surgery is much easier to treat vasospasm that occurs in a proportion of patients post HSA, especially after 6 a 8 HSA occurred days.

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

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

Challenges to early surgery are mostly by the following factors:

– The surgery is performed under more difficult technical conditions for intracranial hypertension, brain edema, friable parenchyma and dense clots in tanks. There is a greater risk of increased parenchymal edema and generate bruising after surgery.

– There is a greater possibility of postoperative vasospasm.

– The risk of intraoperative aneurysm rupture is greater.

Because of these factors, currently managing patients better it oriented post clinical conditions HSA (Grades I and II Hunt & Hess) and no complex aneurysms, to perform surgery on them “early”.

Delayed surgery is reserved for patients at levels III, IV and V of Hunt & Hess, those with poor systemic medical conditions, carriers complex aneurysms, or giant vertebrobasilar system, those showing signs of great cerebral edema in TAC or presence of significant vasospasm on angiography.


Anesthetic preparation

The patient enters the operating room under effect of premedication with light sedation and anticholinergic effect. The anesthesiologist will place it under monitoring of cardiovascular parameters blood pressure, heart rate, registro electrocardiográfico, blood pressure of oxygen and carbon dioxide. It will be placed via central venous.

Placing radial arterial line preference and invasive blood pressure monitoring. At all times sudden changes in blood pressure should be avoided especially when intubation and placement of cranial fixation system.

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

Anesthesia was induced with preoxygenate. Administration of sodium pentobarbital in progressive increments 50 a 150 mg to 1 gr total. Once the patient is asleep, anesthetic agents will be administered by mask. Before intubation is administered muscle relaxant.

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

During surgery, the anesthesiologist will be administered at the time that the craniotomy is performed at a dose of mannitol 20% de 0,5gr/kilo/dosis, in order to obtain further relaxation of the brain parenchyma before dural opening.

In some circumstances it is useful to have a spinal catheter for evacuating CSF prior to opening the dura, especially in those cases where seen in the cerebral blood occluded by TAC cisterns. In most patients CSF is sufficient that the surgeon removes the cisterns supported by

The relaxation of brain parenchyma offering technical anes-tesiológica. Ultimately ventricular puncture may be performed if the evacuation of LCR is not effective.

The attitude of the anesthesiologist should be to maintain communication with the surgeon. especially controlling blood pressure at critical times like neck dissection or aneurysm should be taken into account, in these circumstances it is preferable to have a state of controlled hypotension Mean Arterial Pressure (PAM) of 60 mmHg. If abrupt aneurysm rupture, MAP will have to drop to figures 20 a 25 mmHg por 2 a 3 minutes, if it is insufficient temporary clipping the afferent vessel.


Neuroanestesiológicas modern techniques aimed at reducing the tension of brain parenchyma 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 full vessel permeability, not only the afferent vessels to injury, but also small perforators are in the periphery.

Position of patient

Most aneurysms surgeries performed in supine position. This position is the physiological from the cardiovascular standpoint and cerebral perfusion.

You should quietly raised his head 15 to 20's to enhance venous drainage.

If the vertebral artery aneurysms position may be oblique side- (posición de park bench) or very occasionally seated.

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

Cranial approaches are most frequently used: Pterional Yasargil, allowing expose the entire anterior circle of Willis. It should be supplemented with adequate removal of the lesser wing of the sphenoid, to realize the least retraction brain parenchyma. It is useful in aneurysms of anterior communicating artery, internal carotid artery bifurcation, sector proximal middle cerebral artery and basilar bifurcation aneurysms in the upper position.

The wide frontotemporal craniotomy give more exposure to distal middle cerebral artery aneurysms.

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

The temporal craniotomy Drake, con extensión a piso de media, subtemporal approach allows for aneurysms of the basilar artery tip.

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

The combined subtemporal suboccipital craniotomy craniotomy + petrosectomía parcial, allows a better approach to aneurysms of the distal basilar artery.

Microsurgical exposure

The opening of tanks is done with the help of a surgical microscope. Withdraws cistern LCR carotid, chiasmal, and opens wide the Sylvian fissure.

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

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

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

Exhibition aneurysm

Aneurysmal neck dissection is the most critical time of surgery. It should be coagulated and transected arachnoid adhesions and afferent vessels dissected properly.

Positioning the clip must be very accurate, trying to see how far they go into depth of at least one of the branches of the clip. If there is resistance must withdraw the clip, as it may be counterpart aneurysm sac and it can be drilled. Further dissection should be performed and reposition the clip.

I) Ab. pterional(Yasargil)
ACP aneurysms, A. with. ant. bifurc. carotid Bifur. basilar(High).

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

III) Ab. Fronto temporal A wide aneurysms. cerebral media.

IV) Ab. Temporal(Drake) An. basilar bifurcation(low).

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

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

a. Intraoperative image showing optic nerve left exposed after removing the previous processes clinnoides. Note the compressive effect and deformation that produces the aneurysm on the nerve.

b. Preoperative angiography showing left ICA aneurysm output level ophthalmic artery. It corresponds to the lesion visible in figure aneurysm.

c. Postoperative angiography showing aneurysm clipping.

Once placed the clip should be reviewed if the clipping was adequate and if not compressing the main vessel or any of its branches. Revise even perforating vessels (Figure 16).

If there is doubt about the good clipping incision and suction bag is recommended content (Figures 17 and 18). To present the clipping active bleeding should be amended or added additional clip.

If rupture intraoperative, if small, cotonoid should be placed on one area of ​​bleeding and suck. Usually it gives bleeding and dissection may be resumed.

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

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

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

Leave Surgicel fragments in cortisectomía area and ensure hemostasis neatly. Closing meninge, replacement of bone plate, They can be left hemostatic sponge fragments (Gelfoam) a nivel epidural. Closing muscle, galea and skin.

Considering considering neurological conditions prior patient, that has a high probability of maintaining a scale coma Glasgow less than 8 points, or if the patient has also developed an obstructive hydrocephalus, it is preferable to leave a measurement system intracranial pressure for better handling thereof, LCR intermittent withdrawal and administration of mannitol pulses, according to the degree of intracranial hypertension.

Postoperative treatment

Keep lighter fluid overload state. The central venous pressure should be maintained in 10 cm water.

Vasospasm administer medication with intravenous Nimodi-pine or SNG.

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

Steroids, antacids, bloqueadores H2.

Keep antibiotic prophylaxis with cefazolin 1 gr cada 8 hours 24 a 48 additional hours.


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

These techniques are as follows:

– Inserting aneurysm inside small metal filaments: Guglielmi coils and mechanically detachable coils (12)

– Placing minibalones (13)

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

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

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

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

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

Cases of neurological patients include instability in degrees 4-5 classification of Hunt & Hess, with increased pressure intracaneal, or patients with symptomatic vasospasm impairment.

The high systemic risk include patients with aneurysmal rupture box also they have hemodynamic instability, are. respiratory distress, hypoxemia, coagulopathy treatment, sepsis, cardiac ischemia, liver failure, kidney or other multisystem failure.

The advantage of this technique is that it requires prolonged deep anesthesia, craniotomy, brain retraction. However the procedures are not without limitations as incompletely occluded aneurysms especially wide neck or giant (complete occlusion is obtained in less than 40% case) (15), recanalization of the aneurysm due to remodeling 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. AP incidence carotid angiography showing bifurcation aneurysm left Sylvian artery.

b. Through a comprehensive approach frontotemporal a partially thrombosed giant aneurysm of the middle cerebral artery is exposed, that occupies the entire proximal porcií²n of Sylvian fissure.

c. Surgical bed after removing the aneurysm to check the position of the clips.

Balloon embolization is equally encouraging results with preservation of afferent vessel aneurysms in cases with no fresh clots and is being achieved because there better diagnostic techniques such as MRI, Best fluoroscopy equipment, development of new types of balls and Microcatheters. But it is necessary that these techniques are centralized in specialized centers to develop to the maximum in the future this therapeutic alternative.

Table 1a

Advantages of surgical clipping

– Known durability treatment. Known durability treatment.

– It may be another condition present.

– Unzip parenchyma: withdrawal

hematoma, L.C.R. or brain tissue.

– subarachnoid blood is removed.

– Se ve la anatomí­a: main vessel, art. collaterals and perforating.

– intraoperative bleeding is controlled.

– Technology is evolving rapidly.

– Other Ones: Neuroprotección, anesthesia, exhibitions skull base.

Table 1b

Disadvantages of Surgery

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

– Direct injury of perforating vessels.

– Temporary occlusion may be risky in segment perforator.

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

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

– Specific surgeon: curve , experience, training.

Table 2a

Advantages of Coil Therapy

– Possibility of treating poor patients degree.

– Less anesthesia time.

– Multiple aneurysms can be treated in different vascular territories.

– Very acceptable risk of complications.

– It can be combined with angioplasty..

– It may be only palliative (obliterar la zona rota).

– Rapidly developing technology and improvement.

Table 2b

Disadvantages Coil Therapy

– Durability of treatment not yet known.

– During the procedure can cause complications (injury or hemorrhagic stroke or vasospasm).

– Recurrence can be high in some types of aneurysm.

– Increased risk of thromboembolic complications.

– Substantial risk of need for retreatment.

– More expensive than surgery if required repeated.

– Potential need for anticoagulation.

– Especifica therapist endovascular: learning curve, experience, training.

What treatment to choose: surgery or endovascular therapy

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

It must therefore take into account the advantages and disadvantages of each treatment modality (draw 1 and 2), the clinical condition of the patient and the anatomical characteristics of the aneurysm to choose one or the other therapy.

a. Posicií²n right side carotid angiogram, showing large aneurysm of the aorta segment oftálmicoÂ.

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

c. Open aneurysm clipping and to evacuate its contents.

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

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

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

c. Because the clip was rejected by the aneurysmal neck, huneriana same ligation was performed.
Light and decreased neck.

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

c. Estado angiográfico postcolocación de 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 that 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 the surgical techniques should also be seen as an option to extend the treatment of patients with inoperable aneurysms or high surgical risk (Figure 19).

With the availability of both treatments??high quality microsurgical endovascularâ?? for treating aneurysms, clinicians may expect better results in the future, greater than 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, They do not want to make any intervention, but I'm reviews every three months and not based on whether or grows decide what to do, I would like to have an opinion of a vascular neurosurgeon who is involved surgically, thank you.

  2. guadalupe sanchez says:

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  3. cesar says:

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

  4. Marielen says:

    Hello Goodnight!! I operated for an aneurysm in the right carotid artery was placed me 2 clips de titanio!! I would like to know what precautions should I take q,another aneurysm may occur?? q I care rates!!! thank you

    • diana rivers says:

      I also operated and I 5 titanium coil so care must be segunmi Pasova quiet life neurosurgeon are strictly forbidden to smoke and take care of if you suffer from high presio clear that aneurysms can appear otors ami aparecierom tires me more in other places with them still live luck and you do not have the need to be operated again is very risky Beware

    • ISABEL says:

      I detected 2 Aneurysms one on each side and one 7.5ml measured., They found in carotid cavernous area and I suggest to open skull operation.
      I respect your opinion ineteresa.

  5. beatriz says:

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

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