Cerebral Aneurysms: Advances in Diagnosis and Therapy

483 Pages·1979·19.742 MB·English

by  F. John Gillingham (auth.), Professor Dr. Dr. h.c. Hans Werner Pia, Dr. Charles Langmaid, Dr. Jan Zierski (eds.)

Cerebral Aneurysms
Advances in Diagnosis and Therapy
Edited by
H. W. Pia C. Langmaid J. Zierski
With 265 Figures
Springer-Verlag
Berlin Heidelberg New York 1979
Professor Dr. Dr. h.c. Hans Werner Pia
Direktor der Neurochirurgischen Universitats-Klinik
KlinikstraBe 29, 6300 Giessen (Germany)
Dr. Charles Langmaid
174, Lake Road East, Roath Park,
Cardiff, CF2 5NR (Great Britain)
Dr. Jan Zierski
N eurochirurgische Un iversitats-Klinik
KlinikstraBe 29, 6300 Giessen (Germany)
lSBN-13: 978-3-642-67165-4 e-1SBN-13: 978-3-642-67163-0
001: 10.1007/978-3-642-67163-0
Library of Congress Cataloging in Publication Data. Main entry under title: Cerebral aneurysms.
Papers presented at a workshop held in GiessenlBad Nauheim, Mar. 4-5, 1977.
Bibliography: p. Includes index.
1. Intracranial aneurysms--Surgery--Congresses. 2. Intracranial aneurysms--Diagnosis--Congresses.
I. Pia, Hans Werner. II. Langmaid, Charles, 1913-III. Zierski, Jan, 1940-
RD594.2.C47 617'.413 79-19216
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2127/3140-543210
Preface
Microsurgery has brought about important changes and progress in the treatment of cere
bral aneurysms in recent years. Only 12 years ago McKissock, one of the most experienced
surgeons in the treatment of aneurysms pompared the results of operative and nonoperative
treatment. He found that mortality and morbidity of cerebral aneurysms was not significantly
affected by whether the patients have been operated upon or not. This view is held by
many neursurgeons, and was confirmed by results of the Co-operative Study in 1969. In the
review on treatment of aneurysms in Progress in Neurological Surgery in 1969, techniques
such as encasement with plastic compounds, piloinjection, stereotactic copper or electric
thrombosis and metallic thrombosis and profound hypothermia in anaesthesia were listed.
In general, these techniques now seem to be of little more than historical interest.
Progress in recent yeats has been so enormous that one may perhaps gain the impreSSion
that the main problems in the treatment of aneurysms have been solved and that there are
no more to be surmounted. This is dangerous and complacent thinking, such as Lord
Moynihan indulged in during the thirties. For this reason we thought that the time had
come to assemble a group of experts who could discuss the various unsolved and contro
versial problems of aneurysm surgery in the friendly and relaxed atmosphere of a "work
shop". Recent technical progress has led to a reappraisal of some old questions and stimu
lated new concepts in the diagnosis, treatment, prophylaxis and rehabilitation of patients
with cerebral aneurysms.
This workshop, which was held in Giessen/Bad Nauheim on March 4th and 5th 1977, is
the third of its kind; it follows previous ones on the topics of cerebral angiomas (1974) and
spinal angiomas (1975).
Reports on morphology, aetiology, natural history and problems of rupture and growth
of aneurysms were followed by the presentation of ideas on the classification of aneurysms,
and this formed the basis of the discussions. The discussions indicated various means of
detailed, microsurgical, topographic description of aneurysms according to the site of ori
gin, projection and relations to neighbouring structures. In spite of progress in the field of
clinical pathology and pathophysiology of subarachnoid bleeding, arterial spasm, general
and local cerebral blood-flow disturbances and hydrocephalus, many problems remain un
solved. Basic questions in this field, as well as prophylaxis and conservative therapy were
discussed.
Further development of angiographic examination with magnification angiography,
angiotomography, selective and supraselective angiography, intraoperative angiography and
the introduction of computer tomography have all improved the local and topographic
diagnosis of the aneurysm and its complications. One of the main topics was the operative
treatment of aneurysms. The decrease of operative mortality and morbidity and modifica
tions in the timing of operation have changed the indications and contraindications for
operative treatment. Operative progress is connected with progress in anaesthesia. Hypo-
v
tension has become increasingly significant. The techniques, possibilities and the limita
tions of anaesthesia for aneurysmal surgery were also presented.
In recent years, considerable progress has been achieved in the treatment of carotid
cavernous aneurysms and carotid-cavernous fistulas. Classic and direct operations and
embolization with inflatable balloons were discussed; indications for each method of
treatment were defined. The special management of aneurysms of the carotid and vertebro
basilar systems was reviewed for every individual location of the aneurysm, including the
special problems of giant, multiple and traumatic aneurysms and the treatment of aneu
rysms in childhood and advanced age.
A special session was devoted to technical problems, with discussion of direct and in
direct occlusive methods, clips and the questions connected with the technical act of
clipping. The management of intraoperative rupture of aneurysms and of intracerebral
haematoma accompanying spontaneous rupture, which still remains a major factor influ
encing mortality, has been influenced by technical improvements. The general survey given
as well as the details regarding current practice, demonstrated the impressive progress which
has been made in the treatment of aneurysms.
The workshop was made possible by the generosity of Dipl. Chern. Dr. med. Bernd Braun
and his brother, Mr. Otto Braun of B. Braun Company, Melsungen. This volume contains
the papers presented and the discussions that took place at the workshop. The interest it
aroused has led to its rapid publication.
The editors take great pleasure in expressing their thanks to the contributors for their
participation and cooperation, and to Springer Verlag for personal and technical aid in
preparing and publishing the proceedings. Special thanks are due to my co-workers,
Drs. E. Grote and J. Zierski, and to Mrs. Klein and Mrs. Walter for their help in preparing
the publication. We hope that this volume, like the previous books on cerebral angiomas
and spinal angiomas, may contribute to improved diagnosis and therapy of cerebral aneu
rysms.
Giessen, August 1979 Hans Werner Pia
Charles Langmaid
VI
Contents
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
1 History of Aneurysm Surgery
F. John Gillingham, Edinburgh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Morphology and Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1 Pathology and Aetiology ofIntracranial Aneurysms
K. Jellinger, Vienna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.2 Factors Related to Growth, Rupture and Spontaneous Healing of
Cerebral Aneurysms
Stig H.M. Nystrom, Oulu ................................ " 20
2.3 Origin, Rupture and Growth of Cerebral Aneurysms: a Clinico
pathological Study
Jiro Suzuki and Hiro Ohara, Sendai ........................... 28
2.4 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 41
3 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 42
3.1 Introduction
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 42
3.2 Extracranial Internal Carotid Aneurysms
Jean Brihaye, Brussels ................................... , 45
3.2.1 Aneurysms of the Cervical Internal Carotid Artery
Jean Brihaye, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 45
3.2.2 Internal Carotid Aneurysms Arising in the Carotid Canal
Jean Brihaye, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 55
3.2.3 Anatomy of the Cavernous Sinus
Dwight Parkinson, Winnipeg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 62
3.2.4 Intracavernous Carotid Aneurysm
Jean Brihaye, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 67
3.2.5 Aneurysms of the ''Cavernous Sinus"
Dwight Parkinson, Winnipeg ............................... , 79
3.2.6 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83
3.3 Intracranial Internal Carotid Artery Aneurysms ................... 83
3.3.1 Internal Carotid Ophthalmic Aneurysms
Beniamino Guidetti, Rome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83
VII
3.3.2 Aneurysms of the Internal Carotid (lCA) Ophthalmic Artery (OA) Junction
Hans WerneJ Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 89
. 3.3.3 Aneurysms of the Internal Carotid Artery (ICA) and Posterior Communi-
cating Artery (PCoA) and Anterior Choroidal Artery (AChA) Region
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 93
3.3.4 Internal Carotid Artery Bifurcation Aneurysms
Laurence P. Lassman, Newcastle-upon-Tyne ..................... 96
3.3.5 Aneurysms of Internal Carotid Artery Bifurcation
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 107
3.3.6 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 108
3.4 Aneurysms of the Anterior Cerebral Artery
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109
3.5 Aneurysms of the Middle Cerebral Artery
Bernard Pertuiset, Paris .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 115
3.5.1 Aneurysms of the Middle Cerebral Artery - Discussion
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 116
3.6 Aneurysms of the Vertebral Artery
Ludwig G. Kempe, Charleston. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 119
3.7 Aneurysms of the Basilar ~rtery
Bernard Pertuiset, Paris ................................... 121
3.8 Aneurysms of the Posterior Cerebral Artery
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 123
4 Distribution of Cerebral Aneurysms
Jiro Suzuki and Takashi Yoshimoto, Sendai. . . . . . . . . . . . . . . . . . . . .. 127
5 Clinical Pathology and Pathophysiology .. . . . . . . . . . . . . . . . . . . . . .. 133
5.1 Noninvasive Regional Cerebral Blood Flow Measurement in
Subarachnoid Haemorrhage
John Stirling Meyer, Houston, Texas .......................... 133
5.2 Cerebral Blood Flow in Subarachnoid Haemorrhage
Knut Kohlmeyer, Mannheim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 144
5.3 Subarachnoid Haemorrhage and Cerebral Vasospasm
Eugene S. Flamm and Joseph Ransohoff, New York. . . . . . . . . . . . . . .. 152
5.4 Cerebral Vasospasm: Prediction, Prevention and Protection
Jiro Suzuki, Sendai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 155
5.5 Hydrocephalus Following Subarachnoid Haemorrhage
Lindsay Symon, London . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 162
5.6 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 168
6 Neuroradiological Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 170
6.1 Cerebral Angiography .................................... 170
6.1.1 Classical Angiography
Heinzgeorg Vogelsang, Hannover . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 170
6.1.2 Magnification and Tomography
A. Lino Agnoli, Hans Werner Pia, and Jan Zierski, Giessen ............ 175
VIII
6.1.3 Intraoperative Angiography
Dwight Parkinson, Winnipeg ............................... , 181
6.1.4 Discussion......................................... . .. 184
6.2 Computer Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 184
6.2.1 CAT Findings in Cerebral Aneurysms and Subarachnoid Haemorrhage
Ekkehard Kazner and Wolfgang Lanksch, Mi.inchen . . . . . . . . . . . . . . . .. 184
6.2.2 Value of CAT in Pre-and Postoperative Management of Cerebral
Aneurysms
Ernst Grote, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 190
6.2.3 Discussion ......................... '" . . . . . . . . . . . . . . . .. 195
7 Conservative Treatment ................................. " 197
7.1 Preoperative Treatment of Intracranial Aneurysms
Oskar J. Beck, MUnchen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 197
7.2 Preoperative Management of Ruptured Intracranial Aneurysms with
Antifibrinolytic Treatment
Eugene S. Flamm and Joseph Ransohoff, New York. . . . . . . . . . . . . . .. 200
7.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 202
8 Operative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203
8.1 General Therapeutic Problems . . . . . . . . . ..................... . 203
8.1.1 Grading and Timing of the Operation on ~erebral Aneurysms
Jiro Suzuki, Sendai ..................................... . 203
8.1.2 Indication and Timing of Operation and Vasospasm
Keiji Sano and Isamu Saito, Tokyo .......................... . 208
8.1.3 Discussion ........................................... . 216
8.1.4 Deliberate Hypotension with Sodium Nitroprusside in Neuroanaesthesia
Karam Samii, Bernard Pertuiset, and Paul Viars, Paris .............. . 217
8.1.5 Protective Vascular Mechanisms of the Brain During Profound Arterial
Hypotension
Bernard Pertuiset, Paris .................................. . 218
8.1.6 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
8.2 Special Therapeutic Problems .............................. . 224
8.2.1 Internal Carotid Artery Aneurysms - Cavernous Sinus Aneurysms ...... . 224
8.2.1.1 Surgical Approach to Cavernous Sinus Aneurysms
Dwight Parkinson, Winnipeg ............................... . 224
8.2.1.2 Treatment of Carotid-Cavernous Fistulae and Arterial Aneurysms by
Detachable Balloon
Gerard Debrun, London/Ontario ............................ . 228
8.2.1.3 Post-traumatic Fistulae Between the Internal Carotid Artery and the
Cavernous Sinus
Rene Djindjiant, Paris ................................... . 236
8.2.1.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
8.2.2 Internal Carotid Ophthalmic Artery Aneurysms .................. . 244
8.2.2.1 Treatment and Results for Carotid Ophthalmic Aneurysms
Beniamino Guidetti, Roma ................................ . 244
8.2.2.2 Discussion
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 250
IX
8.2.3 Internal Carotid Posterior Communicating Anterior Choroidal Region
Aneurysms .......................................... . 252
8.2.3.1 Microsurgical Treatment
Keiji Sano, Tokyo ...................................... . 252
8.2.3.2 Technical Aspects
Ludwig G. Kempe, Charleston. . . . . . . . . . . . . . . . . . . . .......... . 260
8.2.4 Internal Carotid Artery Bifurcation Aneurysms .................. . 267
8.2.4.1 Special Therapeutic Problems
Laurence P. Lassman and R.P. Sengupta, Newcastle-upon-Tyne ........ . 267
8.2.5 Anterior Cerebral Artery Aneurysms ......................... . 274
8.2.5.1 Operative Treatment
Hans Werner Pia, Giessen ................................. . 274
8.2.5.2 Discussion
Ludwig G. Kempe, Charleston .............................. . 281
8.2.6 Middle Cerebral Artery Aneurysms .......................... . 286
8.2.6.1 Treatment of Saccular Aneurysms
Bernard Pertuiset, Paris ..... . . . . . . . . . . . . . . . . . . . . . . . . . . .... 286
8.2.7 Addendum: Classification of Vertebro-basilar Aneurysms
Hans Werner Pia, Giessen ................................. . 290
8.2.8 Vertebral Artery Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
8.2.8.1 Operative Treatment
Ludwig G. Kempe, Charleston .............................. . 297
8.2.9 Basilar Artery Aneurysms . . . . . . . . . ........................ . 306
8.2.9.1 Surgery
Bernard Pertuiset, Paris ....... . . . . . . . . . . . . . . . . . .......... . 306
8.2.9.2 Surgery of Upper Basilar Artery Aneurysms. Experience with 11 Cases
Bernard Pertuiset, R. van Effenterre, and G. Robert, Paris ........... . 311
8.2.9.3 Microsurgical Treatment of Vertebro-Basilar Aneurysms
Hans Werner Pia, Giessen ................................. . 319
8.2.9.4 Transoral-Transclival Approach
Keiji Sano, Tokyo ...................................... . 326
8.2.9.5 Discussion
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 329
8.2.10 Posterior Cerebral Artery Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . .. 332
8.2.1 0.1 Operative Treatment
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 332
8.3 Giant Cerebral Aneurysms ................................. 336
8.3.1 Problems in Treatment
Hans Werner Pia and Jan Zierski, Giessen ....................... 336
8.3.2 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 342
8.3.2.1 Management
Keiji Sano, Tokyo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 342
8.3.2.2 Results
Jiro Suzuki, Sendai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 345
8.3.2.3 Serpiginious Giant Aneurysm of the Internal Carotid Artery in a
Young Female
Harald Fodstad and Bengt Liliequist, Umea . . . . . . . . . . . . . . . . . . . . .. 346
8.3.2.4 General Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 350
x
8.4 Multiple Aneurysms ..................................... 352
8.4.1 Treatment
Jiro Suzuki, Sendai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 352
8.4.2 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 363
8.5 Traumatic Aneurysms ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 364
8.5.1 Survey
Albrecht Laun, Giessen ................................... 364
8.5.2 Development of Traumatic True Saccular Aneurysms
Wolfgang Piotrowski, Mannheim ............................. 375
8.6 Aneurysms 0/ Childhood
Alan E. Richardson, London. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 376
8.7 Special Technical Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 379
8.7.1 Surgery of Intracranial Aneurysms - To Clip or not to Clip the Neck
of the Sac
F. John Gillingham, Edinburgh. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 379
8.7.2 Slipping Clip
Laurence P. Lassman, Newcastle-upon-Tyne ..................... 383
8.7.3 Form of Clips
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 384
8.7.4 Coagulation of Aneurysms
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 386
8.7.5 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 388
8.7.6 Temporary Clipping - Prolongation of the Time of Occlusion by Mannitol
Takashi Yoshimoto and Jiro Suzuki, Sendai . . . . . . . . . . . . . . . . . . . . .. 388
8.7.7 Trapping Techniques
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 393
8.7.8 Wrapping Technique - Present Place
Keiji Sano, Tokyo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 393
8.7.8.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 395
8.7.9 Cervical Carotid Artery Ligation
Jean Brihaye, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 395
8.7.9.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 397
8.8 Operative Treatment o/Complications . . . . . . . . . . . . . . . . . . . . . . . .. 398
8.8.1 Intraoperative Aneurysmal Rupture and Reduction by Coagulation
of the Sac
Bernard Pertuiset, Paris ......... . . . . . . . . . . . . . . . . . . . . . . . . .. 398
8.8.1.1 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 401
8.8.2 Intracerebral Haematomas
Keiji Sano, Tokyo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 402
8.8.2.1 Discussion
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 402
9 Prognosis of Operative Treatment ............................ 408
9.1 A 25 Year Study
F. John Gillingham, Edinburgh . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 408
9.2 Summary
Hans Werner Pia, Giessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 412
XI