phenylephrine-hydrochloride and Intracranial-Aneurysm

The last two decades of neurosurgery have seen flourishing use of the endonasal approach for the treatment of skull base tumors. Safe and effective resections of neoplasms requiring intracranial arterial dissection have been performed using this technique. Recently, there have been a growing number of case reports describing the use of the endonasal approach to surgically clip cerebral aneurysms. We review the use of these approaches in intracranial aneurysm clipping and analyze its advantages, limitations, and consider future directions. Three major electronic databases were queried using relevant search terms. Pertinent case studies of unruptured and ruptured aneurysms were considered. Data from included studies were analyzed. 8 case studies describing 9 aneurysms (4 ruptured and 5 unruptured) treated by the endonasal approach met inclusion criteria. All studies note the ability to gain proximal and distal control and successful aneurysm obliteration was obtained for 8 of 9 aneurysms. 1 intraoperative rupture occurred and was controlled, and delayed complications of cerebrospinal fluid leak, vasospasm, and hydrocephalus occurred in 1, 1, and 2 patients, respectively. Described limitations of this technique include aneurysm orientation and location, the need for lower profile technology, and challenges with handling intraoperative rupture. The endonasal approach for clipping of intracranial aneurysms can be an effective approach in only very select cases as demonstrated clinically and through cadaveric exploration. Further investigation with lower profile clip technology and additional studies need to be performed. Options of alternative therapy, limitations of this approach, and team experience must first be considered.

Topics: Aneurysm, Ruptured; Cerebrospinal Fluid Leak; Humans; Hydrocephalus; Intracranial Aneurysm; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Postoperative Complications; Surgical Instruments; Vasospasm, Intracranial

Vertebral artery aneurysms account for less than 5% of all cerebral aneurysms. They have a high risk of rupture and are associated with threatening clinical outcomes compared with anterior circulation aneurysms.. The endoscopic endonasal transclival approach (EETA) was used. During the temporary clipping, the neck of the aneurysm was dissected, and a permanent clip was applied. The repair of the skull base defect was carried out with the nasoseptal mucoperiosteal flap on the vascular pedicle.. The EETA is a feasible alternative for the clipping of the medially located ruptured vertebral artery aneurysm. EETA can be recommended for centers with a large volume of cerebrovascular and endoscopic neurosurgical procedures.

Topics: Aneurysm, Ruptured; Endoscopy; Humans; Intracranial Aneurysm; Neurosurgical Procedures; Nose; Treatment Outcome; Vertebral Artery

Positioned along the ventral surface of the pons, proximal superior cerebellar artery (SCA) aneurysms account for only 1.7% of all intracranial aneurysms [1]. Unlike more commonly encountered basilar artery aneurysms, patients often experience good outcomes when treated via endovascular coiling or surgical clipping [1,2]. These lesions frequently have a lateral projection and paucity of perforator arteries [2]. With further development of endoscopic endonasal techniques, access to this region is possible via a direct frontal exposure to the ventral brainstem, basilar artery and branching vessels. To date, there are only a limited number of reports describing an endoscopic endonasal transclival (EETC) approach for surgical clipping [3-5]. In this operative video, we detail the surgical clipping of a cerebellar arteriovenous malformation feeding vessel and an associated aneurysm using the EETC approach in a 59-year-old woman who presented with sudden onset of a severe headache. The feeding vessel and aneurysm's midline location, just below the take-off of the SCA made it a good candidate for this surgery. Major steps included in this video include 1) transsphenoidal exposure of and subsequent drilling of the clivus, 2) dural opening into the pre-pontine cistern and dissection of the aneurysm, 3) clipping of the aneurysm, and 4) multi-layered closure of the skull base defect. Overall, the patient tolerated the procedure well and was found to have no residual filling of the aneurysm or the AVM feeding vessel at 2-year follow-up. EETC is a viable surgical option for the treatment of aneurysm located along the midline of the pre-pontine cistern.

Topics: Arteriovenous Malformations; Cerebellar Diseases; Cerebellum; Endoscopy; Female; Humans; Intracranial Aneurysm; Middle Aged; Nose

To assess the feasibility of using an endoscopic-assisted lateral supraorbital (LSO) approach and an endoscopic endonasal transclival approach (EETA) for basilar apex (BAX) aneurysms.. Ten cases with LSO approaches, with or without posterior clinoidectomy and endoscopic assistance, and 10 cases with EETA, with or without drilling of the dorsum sellae, were performed on 20 cadaveric heads. Anatomical exposure and surgical freedom at the BAX were evaluated.. Anatomical exposure provided by the LSO approach was limited to the BAX and ipsilateral posterior cerebral artery (PCA) and increased with a mean value of 5.0 mm after posterior clinoidectomy; the basilar artery, contralateral PCA, and superior cerebellar arteries (SCAs) were visualized in all cases. Accordingly, surgical freedom was larger. Endoscopic assistance provided a significant increase in basilar artery exposure; however, surgical freedom did not increase markedly. The main advantage of EETA was the greatest exposure of the basilar artery. With drilling of the dorsum sellae, anatomical exposure increased by a mean value of 3.4 mm, and provided the greatest amount of surgical freedom and visualization of the basilar artery terminal bifurcation and of the SCAs in all cases.. The endoscopic-assisted LSO approach and the EETA may represent a feasible approach for treatment of BAX aneurysms lying within 5.0 mm below and within 3.4 mm above the dorsum sellae.

Topics: Basilar Artery; Endoscopy; Humans; Intracranial Aneurysm; Nose; Sella Turcica

In the clinical practice of neurosurgery, the endoscopic endonasal approach (EEA) has been the mainstream approach in the management of sellar region diseases. However, clinicians have come to realize that EEA procedure is associated with intraoperative hemorrhage. Due to the limited surgical field and poor proximal control under endoscope, massive hemorrhage always leads to severe complication or even perioperative death. Previously, intraoperative hemorrhage used to be attributed to endoscopic intervention of cavernous sinus or internal carotid artery, but our recent understanding of EEA indicated that preoperatively complicated intracranial aneurysms (IAs) may play a role. In this article, we retrospectively reviewed the baseline characteristics, treatment strategy, pathology, intraoperative findings, as well as radiological profiles of sellar region lesions complicated with IAs. With the focus put on the high comorbidity rate of sellar region lesions and IAs, we did further statistical analysis to sketch the outline of this coexisting circumstance and to emphasize the importance of computed tomography angiography (CTA) as routine EEA preoperative examination. Thorough patient-surgeon communication should be proceeded before the formulation of an individualized treatment strategy.

Topics: Chordoma; Computed Tomography Angiography; Craniopharyngioma; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies

The concomitant presence of an aneurysm in contact with a sellar lesion usually contraindicates a transsphenoidal approach (TSS). Clipping of an intracranial aneurysm is however possible in highly selected cases also through an endoscopic TSS approach, as long as the basic principles of cerebrovascular surgery are respected. We report thus on a case of a patient harboring a Rathke cleft cyst (RCC) and an aneurysm of the carotid artery (ICA) in close contact with the RCC. The anatomical characteristics of both lesions warranted an endoscopic TSS for removal of the RCC and clipping of the aneurysm during the same approach.

Topics: Central Nervous System Cysts; Female; Humans; Intracranial Aneurysm; Middle Aged; Natural Orifice Endoscopic Surgery; Nose

Simultaneous or early sequential rupture of multiple intracranial aneurysms (MIAs) is encountered rarely, with no more than 10 cases having been reported. As a result of its rarity, there are a lot of questions concerning this entity need to be answered.. A 67-year-old woman was admitted to the First Hospital of Jilin University (Eastern Division) from a local hospital after a sudden onset of severe headache, nausea, and vomiting. Head computed tomography (CT) at the local hospital revealed diffuse subarachnoid hemorrhage (SAH) that was concentrated predominately in the suprasellar cistern and interhemispheric fissure. During her transfer to our hospital, she experienced another episode of sudden headache. CT on admission to our hospital revealed that the SAH was increased with 2 isolated hematomas both in the interhemispheric fissure and the left paramedian frontal lobe. Further CT angiography and intraoperative findings were in favor of early sequential rupture of 2 intracranial aneurysms. To further elucidate the characteristics, mechanism, management, and prognosis of this specific entity, we conducted a comprehensive review of the literature.. The mechanism of simultaneous or early sequential rupture of MIAs is still obscure. Transient elevation of blood pressure might play a role in the process, and preventing the sudden elevation of blood pressure might be beneficial for patients with aneurysmal SAH and MIAs. The management of simultaneously or early sequentially ruptured aneurysms is more complex for its difficulty in responsible aneurysm determination, urgency in treatment, toughness in intraoperative manipulation and poorness in prognosis.

Topics: Adult; Aneurysm, Ruptured; Endoscopes; Female; Humans; Intracranial Aneurysm; Magnetic Resonance Imaging; Nose

The purpose of this study was to explore the endoscopic endonasal approach to the anterior communicating artery complex.. Anatomic, morphometric analysis of human cadaver heads.. Fifteen latex-injected adult cadaver heads.. The anatomic boundaries of the operative field and the dimensions of exposure of the anterior communicating artery (ACoA) complex were measured and clip placement feasibility was assessed.. Exposure of the ACoA and bilateral A1 and A2 segments was accomplished in all 15 cadaver heads. Average length of the exposed ACoA was 3 ± 1 mm, the left A1 was 5 ± 3 mm and right A1 was 5 ± 1 mm, while the A2 segment was 5 ± 2 mm bilaterally. The average distance from the alar floor to the ACoA was 95 mm, while proximal lateral limit measured between the alar floor margins was 36 mm. The distal lateral limit as defined by the distance between the lateral most exposed margins of the chiasm was 19 mm. Clip placement was accomplished for the ACoA and the A1 and A2 segments bilaterally in all specimens.. The endoscopic, endonasal transtuberculum, transplanum approach is an anatomically feasible alternative to treating select aneurysms of the ACoA complex.

Topics: Cerebral Arteries; Feasibility Studies; Humans; Intracranial Aneurysm; Neuroendoscopy; Nose; Surgical Instruments

Anterior communicating artery (AcoA) aneurysm is the most common form of intracranial aneurysm. It occurs rarely together with other intracranial lesion. Today, microsurgical techniques and endovascular methods are used in the treatment of these aneurysms. Endoscopic endonasal approach is a useful technique for midline lesions of the skull base and is underpinned with extensive experience. In this article, we present a 72-year-old female patient who underwent endoscopic endonasal transplanum-transtubercular surgery for tuberculum sellae meningioma followed by clipping of the incidental AcoA aneurysm. After complete removal of a tuberculum sellae meningioma via an endoscopic endonasal approach, an anterior and superior projected saccular AcoA aneurysm in the gyrus rectus area was totally clipped successfully via pure endoscopic endonasal transplanum-transtubercular approach, without any damage to parent arteries. The patient was discharged from the hospital within a short period of time without any postoperative complication. Endoscopic endonasal approach is a new paradigm in the treatment of aneurysm. Although this technique cannot be routinely used due to lack of experience, it is an effective and safe method in selected and anatomically appropriate cases. We believe that increased knowledge and experience will create successful results in this approach, and it can offer an alternative method for selected aneurysm cases.

Topics: Aged; Female; Humans; Intracranial Aneurysm; Microsurgery; Natural Orifice Endoscopic Surgery; Nose; Surgical Instruments; Suture Techniques

Transcranial clipping of most posterior circulation aneurysms is one of the most difficult procedures, with high morbidity, and endovascular coiling is an alternative with less risk, but is not devoid of complications and not suitable for all aneurysms. Here we describe four cases of posterior circulation aneurysms clipped via the extended endoscopic endonasal transclival route. To the best of our knowledge, this is the first report of basilar top and posterior cerebral artery aneurysms being clipped endonasally.. Four patients with posterior circulation aneurysms underwent extended endoscopic endonasal transclival clipping of the aneurysm. The age range was 35-70 years. There were two males and two females. Three of the four patients presented after the rupture of aneurysms, and the other patient presented with sudden-onset left hemiparesis probably due to thromboembolism from a large unruptured left posterior cerebral artery (PCA) aneurysm. On evaluation with four-vessel digital subtraction angiography (DSA), two patients had a basilar apex aneurysm, one had a basilar trunk aneurysm, and the other had a PCA (P1) aneurysm. Postoperatively, two patients had good recovery. One patient with a PCA aneurysm and another with a basilar apex aneurysm had fresh postoperative deficits. One patient developed postoperative CSF rhinorrhea.. Endoscopic extended transnasal surgery is an expanding field in neurosurgery with a steep learning curve. With improvement in techniques and instrumentation the use of this approach for clipping posterior circulation aneurysms can become an effective alternative in the treatment of aneurysms.

Topics: Adult; Aged; Endoscopy; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Neurosurgical Procedures; Nose

This paper analysed the rhinoscope's clinical value in microsurgical treatment of intracranial aneurysms. Application of the rhinoscope in 87 patients, only 2 patients had ruptured during operation. However, 11 cases had ruptured in 94 cases without using rhinoscope, P < 0.05, they had a significant difference. By DSA follow-up review, 82 cases of used rhinoscope only 2 cases had remained the aneurysm neck, but 9 cases had the aneurysm neck in 77 cases which had not used the rhinoscope in the microsurgical treatment, P < 0.05, they also had significant difference. The application of rhinoscope in microsurgical treatment of intracranial aneurysms intraoperative, can reduce the risk of the intraoperative aneurysm rupture. It can achieve better clinical effect.

Topics: Adult; Aged; Endoscopy; Female; Humans; Intracranial Aneurysm; Male; Microsurgery; Middle Aged; Nose; Treatment Outcome

The recording of sounds over the orbit of the eye has been found to be useful in the detection of intracranial aneurysms. A hydrophone for auscultation over the eye has been developed and is tested under controlled conditions. The tests consist of measurement over the eyes in three healthy volunteers at rest, during voluntary breathing, during eyeball movements and during sustained orbicular muscular contractions. Furthermore, measurements are performed at the side of the nose. Major features of the hydrophonic transducer are high sensitivity to physiological sounds and a high degree of insensitivity to environmental sounds propagated through the air. It can be concluded that the hydrophone may be useful for the early detection of intracranial aneurysms and also for apnoea detection.

Topics: Auscultation; Eye Movements; Humans; Intracranial Aneurysm; Muscle Contraction; Nose; Orbit; Respiration