ICA Bifurcation Aneurysms

90 Pages·2017·2.3 MB·English

by  Dr Pankaj

INTERNAL CAROTID ARTERY BIFURCATION ANEURYSMS,
ASSESSMENT OF CLINICAL PROFILE AND OUTCOME OF
SURGICAL TREATMENT: A RETROSPECTIVE STUDY

THESIS

SUBMITTED IN PARTIAL FULFILLMENT FOR DEGREE OF
M.Ch NEUROSURGERY
(2015 - 2017)

OF THE
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY,
TRIVANDRUM, INDIA

DR. PANKAJ SHIVHARE

DEPARTMENT OF NEUROSURGERY
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY
TRIVANDRUM, INDIA
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND
TECHNOLOGY
TRIVANDRUM, INDIA

CERTIFICATE
This is to certify that the work incorporated in this thesis titled
“Internal Carotid Artery Bifurcation Aneurysms, Assessment Of Clinical Profile And
Outcome Of Surgical Treatment: A Retrospective Study”
for the degree of
M.Ch NEUROSURGERY
has been carried out by Dr. Pankaj Shivhare under my supervision and guidance.
The work done in connection with this thesis has been carried out by the
candidate himself and is genuine.

Dr. Mathew Abraham
Professor& Head
Principal Guide

Department of Neurosurgery, SCTIMST, Trivandrum.
DECLARATION

I hereby declare that this thesis titled “Internal Carotid Artery Bifurcation
Aneurysms, Assessment Of Clinical Profile And Outcome Of Surgical Treatment: A
Retrospective Study” is a consolidated report based on a bonafide study during
the period 1st January 2011 to 31st December 2015 has been prepared by me
under the supervision and guidance of Prof Mathew Abraham, Prof and Head,
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences
and Technology, Thiruvananthapuram.
The thesis is submitted to SCTIMST in a partial fulfilment of rules and regulations
of M.Ch Neurosurgery examination

Date: 6/10/2017 Dr Pankaj Shivhare
Place: Thiruvananthapuram
ACKNOWLEDGEMENT

I am indebted to guidance of Prof. Mathew Abraham, Professor and Head of the
Department of Neurosurgery, has been invaluable and I am extremely grateful and
indebted for his contributions and suggestions, which were of invaluable help during the
entire work. He will always be a constant source of inspiration to me.
I owe a deep sense of gratitude to Prof. Suresh P Nair, former Head, Department of
Neurosurgery for his invaluable advice, encouragement and guidance, without which this
work would not have been possible. His critical remarks, suggestions, helped me in
achieving a high standard of work.
I am deeply indebted to Dr. Easwer H. V., Dr. Krishnakumar K., Dr. George Vilanilam,
DrJayanandSudhir, Dr. Prakash Nair and Dr. Tobin George and I thank them for their constant
encouragement and support.
I am grateful for my colleagues, Drs. Shashank, Gopikrishnan and Bimal as well as
my juniors and seniors who have made this work possible.
I owe a thanks to Dr. Savith Kumar and Dr. Ritu Garg for the significant amount of
the labor and support during the writing of this work.
I am blessed to have a supportive wife and family who encouraged and actively
supported throughout the long day working on this project.
Last but not the least, I owe a deep sense of gratitude to all the patients who put
their faith in us and without whom this work would not have been possible.
INDEX

Section Page No.
Introduction 1
Aims And Objectives 4
Materials And Methods 6
Review Of Literature 11
Results 35
Discussion 51
Conclusions 62
Bibliography 64
Annexures 74
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes

INTRODUCTION

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ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes

INTRODUCTION
Internal carotid artery (ICA) bifurcation aneurysms are not very
common. The incidence among the adults accounts up-to 5% of all
intracranial aneurysms. (1–3) ICA bifurcation aneurysms represent more,
almost 40% of all intracranial aneurysms in patients less than 20 years (4,5)
and also have an increased ultimate chance of a bleed. (6,7) These
aneurysms tend to be more common in male in comparison to the other
aneurysms of the ICA. (7,8) Surgical management of these aneurysms are
likely to be more difficult compared to other types of ICA aneurysms,
because of the multiple perforators originating from the anterior cerebral
artery (ACA), middle cerebral artery (MCA), anterior choroidal artery, and
posterior communicating artery (PcomA) (9–11) which can come in the way
and can become problematic during microdissection of the aneurysm
(3,12)
The first neurosurgeon to treat an ICA aneurysm by direct surgery,
(wrapping it with a piece of muscle) in 1933 was Dott. (13) This was also
the first surgical attempt to treat an intracranial aneurysms. (14) Since
then, despite the advances in the field of micro-neurosurgery, aneurysms
at this location have remained difficult to treat. The micro-neurosurgical
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ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes

exposure and clipping of ICA bifurcation aneurysms can be demanding due
to: (a) the need for deep retraction to achieve exposure, (15) (b) high
position with respect to the skull base, (c) attachment of the dome to the
surrounding brain parenchyma, (d) large number of perforators
surrounding the base and/or the dome, and (e) the relatively high risk of
intraoperative rupture. The orientation of the aneurysm dome affects the
clipping, with the posterior orientation being the most difficult. Precise
dissection in the 3D anatomy of ICA bifurcation and the surrounding
perforators requires not only experience and microsurgical skill but also
the patience to work on the aneurysm base under the repeated protection
of temporary and pilot clips. (16)

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ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes

AIMS & OBJECTIVES

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ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes

AIMS AND OBJECTIVES

To study the
• Clinical profile
• Imaging features
• Intra-operative findings
• Post-operative outcome in patients who underwent surgery for
angiographic evidence of ICA bifurcation aneurysm followed upto
minimum period of 6 months.
• The primary outcome studied would be of quality of life and
independence achieved at 6 months. Which would be assessed using
the modified Rankin score.

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