rujptured posterior fossa aneurysms and

16 Pages·2005·3.13 MB·English

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RUJPTURED POSTERIOR FOSSA ANEURYSMS AND s
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THEIR SURGICAL TREATMENT* hia
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From the Maida ValeHospitalforNervous Diseases,London ub
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The use of vertebral angiography in the investi- aneurysms in the Newcastle series. The incidenced
gation of subarachnoid haemorrhage has enabled shows a tendency to a reduction in recent series as
the presence of posterior fossa aneurysms to be which has been ascribed to exclusion of aneurysms 1
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detected during life. The clinical and radiological due to syphilitic and atheromatous changes. Walsh.1
localization of aneurysms in this site is now of (1957) in a surgical series of cases of subarachnoid13
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these lesions are operable. Certain anatomical angiography was not carried out as a routine. Anp.2
features which will be discussed later should render incidenceof15% onthebasilar-vertebralcirculation2
their surgical treatment in some ways easier than wasacceptedbyWaltonandWalsh,butifaneurysms.3.2
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on the vertebral artery, the basilar artery, and their subarachnoid haemorrhage due to posterior fossda A
branches up to the basilar bifurcation. Aneurysms aneurysms may be found in the literature. Dand byyug
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compared with those situated below the tentorium. of subarachnoid bleeding into the posterior fossaw
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Before the use of vertebral angiography, the due to a laterally situated aneurysm of the basilarlo
diagnosis of posterior fossa aneurysm was usually artery,whichproducedhomolateralpaininthehead,ad
made at necropsy after death due to subarachnoid followed by loss of consciousness with stertoroused
haemorrhage, or occasionally on surgical exposure, breathingandfourconvulsiveattacks,withrecovery. fro
when an aneurysm had presented as a space- He considered that abrupt losses of consciousness,m
occupying lesion in the posterior fossa. Some respiratory disturbances with hypersecretion ofh
aneurysms were symptomless in life, and then were mucus, and weakness ofthe legs were characteristicttp
accidental findings in death due to other causes. ofdysfunction ofthe lower brain-stem. ://jn
The figures of incidence may be obtained from Focal cranial nerve signs mentioned by Waltonn
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published series of cases of subarachnoid haemor- (1956) in his review ofcases from the literature and.b
rhage. McDonald andKorb (1939) reviewed 1,023 the Newcastle series, included nystagmus, externalm
cases of intracranial aneurysm from the literature rectus and facial palsies, premonitory attacks ofj.c
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including 786examples ofrupture, and ofthose 143 vertigo, and deafness. Pain in the trigeminalm
(18%)wereonthebasilar-vertebraltrunks. Richard- territory wasacommon feature ofaneurysms onthe o/
son and Hyland (1941) in a series ofpersonal cases internal carotid artery and its terminal branches,n F
which contained 27 ruptured aneurysms, found that but ipsilateral headache was mentioned in onee
six, or 22%, were in the posterior fossa. Walton patient with a basilar aneurysm lying in the leftbru
(1956) included eight (65%) among 122 ruptured cerebello-pontine angle. Contraction of the pupils,a
although a well recognized feature of pontinery 2
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November, 1957. 0
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SURGICAL TREATMENT OF POSTERIOR FOSSA ANEURYSMS 203 ro
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been observed by Robertson (1949) to cause con- fossa arterial lesions are probably untreatable, still e
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vulsions, plastic disorders of tone, and fluctuating tends to influence our attitude to further investiga- ro
hemiparesis. He found that fits of a tonic type tion and to dissuade us from performing vertebral su
might result if blood clot formed on the ventral angiography routinely afternegativecarotid arterio- rg
surface of the brain-stem. Brain (1955) considered grams. Walton (1956), after reviewing a variety of P
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that quadriplegia and various forms of "crossed papers dealing with the surgical treatment of y
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paralyses" might occur due to a leaking basilar aneurysms, made the following statement: "Al- hia
aneurysm, and that the head retraction was likely though occasionally posteriorly situated aneurysms try
taonbaenecuornsypsimcuionutshewhpoesntehraieormofrorsshaa.ge resulted from mhaajvoeribteyenofotpheorsaeteodnutphoenbawsiiltahrsaunccdesmsa,ntyheongrtehate : firs
Accounts ofsurgical treatment usually consist of vertebral and cerebellar arteries are not at present t p
reports of a single case. Dandy (1944) wrote of a operable". Walsh (1957) also commented that "few ub
large aneurysm on the vertebral artery which was cases of posterior fossa aneurysms are at present lis
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shelledouteasilybutthepatientdiedfromtheeffect amenable to surgical treatment". e
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ofhigh pressure in the posterior fossa. Six success- Theoretical considerations, however, suggest that a
ful operations have been reported. Schwartz (1948) these aneurysms should not present insuperable s 1
described the excision of an aneurysm on an technicaldifficulties. Firstbecausetheyareprimarily 0
aberrant artery related to the internal auditory "subarachnoid" aneurysms lying free in the subar- .11
artery. Rizzoli and Hayes (1953) recorded one case achnoid space, so that little retraction of brain is 36
of a posterior inferior cerebellar aneurysm. The necessary to expose them. Secondly both vertebral /jn
patient presented with bilateral sixth nerve palsies arteries are visible for most oftheir course through np
and multiple subhyaloid haemorrhagesinthe fundi. aposterior fossa approach, andthere is a good deal .2
2
The location ofthe aneurysm in the posterior fossa ofroom for surgical manoeuvre. The whole length .3
was suspected by the presence ofhydrocephalus on ofthe basilar artery can be clearly seen by a trans- P.20
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recovery eventually followed. Norlen and Barnum Finally when treating aneurysms on the vertebral d b Au
titdnhreeectaohtmsempuecrsnceatesmssseoiffouylneoanareenxdcdeilssapcirarogcinekbieovdnefgrstywaeminbptrathalonmmueaasutncrielycuesr,rmyeslaimnoedfnbaayftlthseaeor vanerertcteeersbysraaarlnydatroittesorcbycrlatouncdmheaetishn,ettavhieensrseeblli.sooadlwfalyoswtshheouolpdpoistibtee y copyrighgust 1959
posterior inferior cerebellar artery in a man aged 26 t.. D
who was alive and well six years later. Case Material o
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Two cases of aneurysm of the posterior inferior In view of the rather negative attitude towards n
cerebellar artery treated surgically have been surgical treatment, it was felt worth while to record loa
described by DeSaussure, Hunter, and Robertson six consecutive cases of ruptured posterior fossa de
(oc1c9i5p8i)t.al hTehaedacfhires,t hpaatdieunnt,usuianlafdodciatliosnymtpotosmesveraet anAeursyescmonodpegrraotuepd oofnssiuxccceasssfeusllsye.lected at random d fro
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circle ofWillis. The authors in both cases adopted Morley Hospital and are included by kind permis- p
the procedure of "trapping" the aneurysm between sion of Mr. Wylie McKissock, and one case came .bm
proximal and distal clips with occlusion of the to necropsy at Maida Vale Hospital. It must be j.c
posteriorinferiorcerebellar artery. Theyconsidered stressed that Group II are not to be regarded as a o
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ttohatthethreismkiolfdfautratxhiear hwaheimcohrrrhesauglet.ed was preferable conTthreolsisteuraiteisonmsedoifctahlelyantereuartyesd.msinGroupsIandII on/
Uihlein and Hughes (1955) reported exploration are shown in Table I. F
of 14 aneurysms on the basilar-vertebral system. Thecases inGroupIareillustratedinlinedrawings eb
Eight ofthe 14patients died ofaneurysmal rupture, ofvertebral arteriograms (Fig. 1). ru
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butno definitive treatment wasundertaken forthese The vertebral trunk in the region ofthe origin of ry
lesions. the posterior inferior cerebellar artery was the 2
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Although factual information about these commonest site. No significant predominance with , 2
aneurysms is increasing, the view that posterior regardto sidewasshownbythewholeseries. 0
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FIG. 1.-Vertebral arteriograms ofthesix patients submitted to surgery. 2
5
aneCuasreysm o(nC.tGh.e).r-iAgnhttersuop-eproisotrercieorrebeplrloajrecatritoerny.to show the frCoamsethe2r(iCg.hCt.)si.d-eAnotfertoh-epobsastielrairorartveireyw.anTdhgeivaenseourriygisnmtaoritshees , 20
posteriorcerebral andsuperior cerebellar trunks. 2
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cerebellar arteryarises from theapex oftheaneurysm with the Case6(P.McM.).-Lateral view showing the sac whicb con- u
distaltrunkofthevertebral. smrieasltgasntoiufomna.shdiiplTahttoeattiphooenstoseafrcitoharesviiennfretCreaibosrrealcNeaorre.tbeer5l.yljaurstarwtietrhyinhatshetfhoersaammeen est.
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SURGICAL TREATMENT OF POSTERIOR FOSSA ANEURYSMS 205 ro
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TABLE I e
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SITE OF ANEURYSMS ro
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Case Side iSituation urg
Group I 1 C.G. Right Superiorcerebellarartery P
2 C.C. Left Basilaratoriginofsuperiorcerebellarandposteriorcerebral arteries s
3 J.R. Left Posteriorinferiorcerebellarartery y
4 C.H. Left Aneurysmarisingbyneckfromthevertebralartery ch
65 PM..KM.cM. RLeifgtht OOnntthheevveerrtteebbrraallaarrtteerryyaassllooccaalliizzeeddssaacczc-uullaarrddiillaattaattiioonn iatry
CaGsreosup4,II5, and 6 al7l clDo.sSel.y related toLetfhte origin ofthe pBoasstielrairoartionrfiegriinorocfesruebpeelrliaorracretreerbyellarand posteriorcerebralarteries : firs
98 VG..SS.. LMeifdtdle ABanstielrairoraritnefreyriorcerebellarartery t p
10 R.R. Right Vertebralbasilarjunction ub
I12I JE..JD.. LReifgtht PPoosstteerriioorriinnffeerriioorrcceerreebbeeltllaarraarrtteerryy lis
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Clinical Features were between the ages of40 and 60, the age period s 1
The present series showed a slight female pre- of maximal incidence for this disorder. The sex 0
ponderance ofeightfemalesto fourmales (Table II). and age distribution did not differ therefore from .11
The ages at time ofthe subarachnoid haemorrhage that in subarachnoid haemorrhage from supra- 36
ranged from 35 to 68, and eight of the 12 patients tentorial aneurysms. /jn
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TABLE 2
CLINICAL FEATURES .3.2
Opera- P0
Case IASnietuoerfyofsm Bleeds DCDnsniessfstcuurbbiannFcuuendei-OmcPuepiulsnlt~aEMxotsverren-al' 5th 7th 8th Limbs Ptaas- TsaLDtikiansoecynne Resultrotected2 on 1 A
Bleed bu
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03. cLe.repbosrta.linf. 4 collapse Transient Transient Contra- Weakness 2nd Rcvrt.. Do
- a J.R. cerebellar I fit unequal nystagmus lateral legs Rcvr w
35 1 collapse contracted pain n
.o 4. L. 1 Coma2hr. R. miosis Ptosis P.H. Vertigo Weaklegs lo
o0 r0r_ou-PM.C~..S~M645KH5.c750..5M..VVLVRee.e.rrrttteeebbbrrraaallll ~2 ~ICS3S3162eeofm~mmthhisirra..ccoo~1mmahar.4Ha+e-m C-onitrapcted''anTLPnnar.yt-aoses6ntitsarsshigye~mtnutvhs-tepPLsa.inpigfaatuialnemrumnpeoputaLeroserone VLsermtigi.o lSRWphoe.eressunmesahtsisekho-imersinyl-egLs.h44t fh1o1tu92rhsiReRRceeoccvoovveeerrryyy haded from
7. L.sup. in Semicoma Papill- Contracted Ptosis P.H. Weaklegs ttp
A D.SDcer.cebelPeoarSre1915b.eDD9eeleeppl22iorh5ar.. reo4edeema mmLapLi.pain L.tosnpsaesttic t DCheeastthinfection ://jn
cerebral hemi- 5thdayofillness n
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8. L.ant. inf. 3 Coma 12hr.I Haem. L.hei .b
G.S. andsup. 'recovered and paresis ' Death m
~CoI~a~~~9.~34F~cM~eirdeb~elil~ar T t1 ~~UF~no~cu4ont~ndh.d15~~Poaepadile~lm-a.I~Diyla~ted ~-min TRFwl.iactaccrihmding 6Dteh3tdhay j.com
-'o00.~ RV1..0SR5...2 ab?anRsd.ilbvaearrsti.lar fat3al 3u10nfcimtoinunsnccioonu.s oPaepdilelm-a FUinxeeqdual upper R. qppRlaueragedhisreaiims-i- + aD21d6e0tmahhitoshdusariysonafter on F/
Z 43 Uncon. Ilhr. motor eb
on thday neurone' ru
O 0' E1H1J26...8 cpLRe.o.rsevtvbeererittln..fl.aaarnnidd 21 iDCroomwasy12hr. HHaaeemm.. CCoonnttrraacctteedd C6Bitolhnattreara-l nmuRepo.uptreoorrne,dL.eaf 'wpRa.eraehskeimsile-gs DReeactovhery ary 25
J~.6.2 ceorebeltlar .inComa.latera6tlh L.>R. '' 7thday , 20
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206 HELEN DIMSDALE AND VALENTINE LOGUE ro
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Symptoms and Signs by rapid improvement, and five of these patients e
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WeaknessoftheLegs.-Thisorsuddenfallingwas (Cases 1, 3, 5, 8, and 10) alsoexperiencedconvulsive ro
an initial symptom in five patients. The loss of episodes. su
power was not infrequently transient and might A woman, aged 47 (Case 5), had an epileptiform rg
improve before the patient was prostrated by attack with jerking movements of the arms and Ps
headache. One patient (Case 3) stopped driving his stertorousbreathingattheonsetofthehaemorrhage, yc
car because of leg weakness and nausea before the and later in her illness two generalized convulsions hia
usual symptoms of subarachnoid haemorrhage with "bubbly" respiration, followed by a transient try
adegveedl5o5p,edafateqrumairltedrhoefadaanchhoeufrorlafteoru.r Cdaaysses6,udademnalny fslcaicocuisdnehsesmiopnletghiea.eighOthnedamyaonfi(llCnaesses w3i)thlofsrtotchoinn-g : firs
vomited and lost the use of his legs. A woman at the mouth. Later on the same day, on recovery t p
(Case 4) "flopped" to the floor during a dancing from anaesthesia for carotid and vertebral angio- ub
lesson because her legs gave way. Another woman graphy, he collapsed again with slow stertorous lis
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(Case 7) was found by her husband holding herself breathing. The pupils were contracted and both e
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up by the sink, and did not develop headache till plantarresponsesbecameextensor. Thesupraorbital a
somehourslater. Amanaged62(Case 12)suddenly nerve was compressed to assess the depth ofcoma, s 1
developed weakness of the left leg, which then at which stimulus he suddenly showed free move- 0
spread to the right and was followed by headache ment ofthe limbs, recovered consciousness, became .11
and vomiting. loquacious andsaidhefeltfine. Presumably on this 36
occasion the rapid change in his condition was due /jn
Headache.-Headache was an early symptom in to spasm ofthe basilar artery, followed by return of np
everypatientexceptone(Case8)wholostconscious- the circulation. Stertorous respiration and hyper- .2
2
ness immediately and died in coma. A period of secretion ofmucus were prominent in these attacks, .3
mildheadacheforseveraldaysmightbefollowedby and were also observed inanotherpatient (Case 10) P.20
iiarnrtiestneastvieeornhe,eaeidxnaadcichceeartbiwantagisoanusufwarilatlnhykoschicagienpmsiotarlorfhaatgmteeh.neinognTeshaeelt aasedcivczeourrmsepisvaeniniaettdhteabcaykrpomrcoictnurraurnseoidtohnienrofownitehtehpaettvoiinegdnueten,.ceanoAdfffforocecasalhl rotecte2 on 1
but then became generalized, spreading over the haemorrhage. d b Au
head to thefrontal region. The accompanying neck yg
rtriehgteirdraiectgtyiioownnaowsfautsshueeaxelcaleryptoionofntahmleo.dseaLrmoaectaseliiddzeeaagtsrietoehn,eoaafnnpedauirhnyesaidmn trihoaRngeec,iunrarstehjneutdlHegaveeedlmoboryfrichnoacngrseeca.iso-euRseonfceushrse,raedanancchdees,forfdeeshthaeerbimlooorroa-d- copyrigust 195
awsassocioabtseedrvweidthianntawnoeupraytsiemntos,n tihne osnupeer(iCoarsceere1-) tinhetsheeacneeruerbyrsomssp,inaalndfleuiigdhtwepraetiaenctsom(Cmaosnesf1e,at3u,r5e,o6f, ht.9. Do
bellar artery, and in the other (Case 5) with an 7, 8, 10, and 12) together had 25 haemorrhages. A wn
aneurysm onthevertebral artery. A past history of fatal outcome or crippling neurological disability lo
frontal headache regarded as migraine was given by did not necessarily result. Three patients (Cases 1, ad
three patients (Cases 1, 4, and 5). Case 4 had 3, and 5) each had four haemorrhages, yet survived ed
experienced trigeminal neuralgia on the side of the operation. fro
atrbeunyrpertutiuhrtreyoers.symi.teiHnoofSwCeetanvhsseeeorsrp,yai1lndaitaaestnrtadutlrhibez5aanotcinaeoscnectioonmofpfttahhhneaeieetamrdnoiergeaurmcrhitayungsaaemll rhOhanaFeegumenowsdrourwmsehraaegnOecssu(elCedianu.siee-nRf5te)ootuihranapadsaltugibroeaonrrstassscbuh(ibCnlhaoaysitaeedrslaohl5ia,dse8um,bhoha1ry1er,amhloa1o2rgi)-ed. http://jnm
wasnotalways reliable. Oneman, aged 35 (Case3), from a rightvertebral aneurysm. Papilloedema was np
had experienced right-sided headache for a month, present in threepatients (Cases 7, 8, and 10), one of .bm
aexnadceartbtahteiotni,mebuotftthheeiacnteuusrcyosmmplwaaisnesditoufataendionntetnhsee wsihdeoamst(hCeasheae8m)orsrhhoawgeedapnadpialvlioterdeeomuas hoanemtohrershaamgee j.co
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left vertebral artery. in the other eye. o/
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Loss of Consciousness.-The initial loss of con- CranialNerveSigns.-Abnormalities ofthepupils F
sciousness might be of sudden onset and of up to and ocular movements were the commonest defect eb
36 hours' duration followed by recovery of the of the cranial nerves. Bilateral contraction of the ru
senses. The patient then might become alert and pupils was observed in five patients (Cases 3, 6, 7, ary
cooperative(Cases3,8,and 11). Anoticeablefeature 11, and 12) and unequal pupils in three (Cases 3, 4, 2
odefprtehsesidoinssordienrtihne sleevveelnopfatcioennstcsiowuassnestsh,atfoofllborwieedf adinldat9e)d. pTupwiolspawthiiecnhtsw(eCraeseasls2oainndac9t)ivsehionwetdhewiladtetleyr 5, 20
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SURGICAL TREATMENT OF POSTERIOR FOSSA ANEURYSMS 207 ro
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patient (Case 9) who subsequently died. Sixth though later, especially in the fatal recurrences, e
nerve palsies, which might be unilateral or bilateral, levels of300 mm. and over developed (Table IIl). uro
oWlachtceeurrnarlieuzdniinilgnatsefrioagulnr,uptnahlteeisespntaslassy(sCoawcsaieasstend1o,tw6i,otfh11v,paalalunseidesa1s2o)a.f CEREBROSPITNAABLLEFLIUIIID PRESSURE surg Ps
neighbouring cranial nerves as in one patient (Case C.S.F.Pressureinmm. CaseNo. yc
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1) with trigeminal and eighth nerve lesions in Normal 5 and7 ia
aawdhndidicthi7)o,an.papneTdahrretedhereapteatt(ihCeenatsosenssseht3o,wo4fe,dthapentodhsai6es)m(oCnrayrsshetasagg4e,mua5ss, 2115003tt0oo0220500 1,2,3,6a1a0nndd182 try: firs
a transient feature, but was sustained in one patient Although subhyaloid haemorrhages are usually t pu
(leCsaisoen,6)aovnertleatberraalladneevuiratyisomn.towards the side ofthe saittturaitbeudtedanetuoryshma,emoorrrtohaagesudfdreonmriaseninancteerreiborrol-y blish
Paraesthesiae in the trigeminal territory in one spinal fluid pressure sufficient to occlude the central ed
patient (Case 5), and cutaneous sensory loss in retinal veins, there did not seem a correlation a
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another (Case 1) developed on the same side as the between the presence of these changes in the fundi 1
ruptured aneurysm. Symptoms referable to the and the cerebrospinal fluid pressure at lumbar 0.1
eighth nerve consisted of rotatory vertigo (Cases 4 puncture. Widespread subhyaloid haemorrhages 1
3
abnedcam5)e, daenadf otnwothoethsiedrepoaftitehnetsru(pCtausreesd a1naeunrdys1m1.) wwehreenptrheesecnetreibnrobsopitnhaleyfelsuidinproensesupraetiweanst 1(4C0asmem5.) 6/jnn
neAurocnoenttryalpaetweraaslofbasceiarlvepdariensifsouorfpaatnieunptpse(rCamsoetso1r, Aornrohtahgeeran(Cdasleeft8-)sidsehdopwaepdilaloerdigehmtavwiittrheoauscehreabermo-- p.22
5, 10, and 11) associated with a hemiparesis. spinal fluid pressure of200 mm. .3.2
EpavtiSidiegennntscsei(noCfatspheeysrLa1im,imd2b,asl.4,-dTi5hs,teus6r,eba7w,nece8r,ew9ab,sil1af0to,euraanlnddiinn12a1)l0.l ppahtaEilleeoncgttrsraop(ehCniaccseeprsheacl2o,orgdr3i,anpgh4s,y waenr(deE.5Ec)a..rGr.i)eS.di-mEiollueatcrtriEno.eEnf.coGeu.-r Protecte02 on 1
the patients at some time in their illness, though in abnormalities were observed in those patients d b Au
poainslnaAefmnietv(uaenCnrtapiiaslrtoaeeitnsee3enpr)dtoasnlo.bsnehelfesyomriaaefpptapoerecreacsrauiersfdri.te(dwCahWaseseenasaknb6ni,ielnas8it,tseira1aol0lf,seytaxhmntepedntls1eoo1gmr)s (otbocurCfcruaaisnspntkeis.staao2nl,feT4ulg,hreeaenyadesnsrmdaabloa5nicr)ozcirewsudmiirantrsglhilinchotgliwaoeesaswemtaotvcrioeonrsnttheshariiegvnsaetbltaeshdsdeiuloeofafrfrto-o1nvp0tereraurtltpieotobaudrnr6iadelc0 y copyright.gust 1959. D
oarppealatrerinnatiansgsochieamtiipoanrewsiitsh(aCasseusdd5enanlodss7)ofmicgohnt- saemcpolnidtsudeanodf tlhaestisnlgowo-nweavetobutrswtos wseacsongdrse.atestThien own
sciousnessorconvulsiveepisode. Thesehemipareses Case 2, a patient with a relatively small aneurysm, loa
were often transient leaving only slightly increased butwhicharosedirectlyfromthe anteriorendofthe de
ptreensdeonnt urnetfillexdees.athAin atohtaalemoflrarchciadgepadruaeplteogriuaptwuarse basTihlaerpahrteenroy.menonofperiodicbursts ofgeneralized d fro
wos"efcavrseaonsesmxieotddfe-"nbtsaphosaerirslaeailnrytshiaceshnaeaorubrarncyhotseremmmr.iaplilineTtgyh1ie0awappwalsatasinbetinaoltrbasts,erereraasvlnp.edodnsiiAenn issntlceomlw.udwianvgesTuhcakserbe(e1n958d)escirnibleedsiobnys ootfhetrheaubtrhaoirns- http://jnm
two patients (Cases 1 and 11) with cranial nerve Radiology.-Bilateral carotid angiography was np
cloaepsspieoossniostfeoslunibmaborsna.echSnseoindisedorhayaneldomsospryirrnhaatmhgieedlawilamsbssu,ignancssoimninmmootnsh;te eaonmnepularonyoystemhd,erainoncdc1ar1siigohpntatciianernotCstaisdewiat1nhgosiuhotogwraerpedvheynaolrienapgbenaottreh-de .bmj.co
oofnetepmapteirenattu(rCeasceont4r)alsahtoewraeldlyimapnadiraebdseanptprveicbiraattiioonn mlaatleirtayl.izIend GornoucpliIniucnaillatfeeraatlurveesrteibnraltharnegeiopgartaipehnyt,s om/
sense in the leg on the side ofavertebral aneurysm. (Cases 1, 5, and 6), filled the aneurysm successfully. n F
Bilateral vertebral angiography was required in e
b
Investigations three patients. In Case 2 vertebral angiography on ru
aftTehrethceeresburboasrpaicnhanlofilduidhaperemsosrurrheaignethweasearalvyaihloaubrlse foinleledsidseatwisafsacutonrsiulcycesfsrfouml,tbhuetotthheebrasvielratrebarnael.urysImn ary 2
iinnitniailnley,caasneds.inTfhivee lpeavteilenwtasswanost2o0f0ammh.ighororledsesr, rCiagshet3v,eratmebarnalwiatrthesreyvewraesriignhjte-cstieddedfifrasctiadlupeaitno, tthhee 5, 20
2
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208 HELEN DIMSDALE AND VALENTINE LOGUE ro
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falselocalizationbyfacialpainandthebasilarartery and in Case 1 ofthis series. The related procedure e
u
filled without showing the aneurysm on the left of"trapping" the aneurysm by a clip on the artery, ro
posterior inferior cerebellar artery. In Case 4, both proximal and distal to the origin of the sac, su
spasm of the intracranial vessels and irregularity of is also a feasible one for dealing with saccular rg
the right vertebral artery was observed butinjection dilatations ofthevertebral artery. Thismethod was P
s
oftheoppositevertebralarteryrevealedtheaneurysm considered for Cases 5 and 6, but the fact that in y
c
on the left posterior inferior cerebellar artery. both these patients the posterior inferior cerebellar hia
Post-operative angiography in Group I was artery took origin directly from the apex ofthe sac try
lciagrartiuerdeoouft,oenxecevpetrtienbrtahlosaertpeartyiehnatsdwbheeerneepmrpolxoiymeadl parrteecrlyudperdoxtihmealmatnooethuevrsea.c hAadcltipo sounffitchee, vaenrdtebwraasl : firs
(Cases 5 and 6), as spasm of the remaining patent successful in preventing further bleeding. t p
vertebral artery might well have endangered the Some doubt has been cast on the efficacy of this ub
basilar circulation. methodofproximalocclusion ofthevertebral artery lis
h
Vertebral angiography was performed in two for saccular dilatations of its trunk by the experi- e
d
patients (Cases 10 and 11) in Group II; in Case 10 mental work of Bakay and Sweet (1953) and has a
theresultwasequivocal, inCase11 bilateralvertebral been quoted by other authors. Their investigation s 1
angiography showed a tortuous basilar artery and consistedofacuteexperiments(thenumberofwhich 0
a small aneurysm on the left posterior inferior was not stated in the article) carried out during the .11
cerebellar artery. course of operations on patients with posterior 36
Ventriculardilatationwasobservedinthreepatients fossalesions. Thevertebralarterywasoccludedout- /jn
(Cases 3, 7, and 11). Wide-swept anterior cerebral sidetheskullbetweentheocciputandatlas,measure- np
arteries on carotid angiography in Case 7 indicated ments of the blood pressure then being recorded .2
2
enlargement of the ventricles. Ventriculography in from the vertebral artery and posterior inferior .3
Case 3, a man aged 35, who developed ataxia and cerebellarartery,usingaveryfineneedleandelectro-P.20
pdgoeesnmteeernratilioiarzedaifntvfeeernrtisrouirbcualrcaearrcehbdneiollilaadtrathiaaoennmeoudrruryehsamt,goe asfhrcooowmme-da amthdaeenqovumearettteeebrdr.arlopTarhitneerpayruetoshnsourrosenecinosntichdleeuvddeiesddsentlohtfaotrplrtiorgdaeutaictoemneanontfrotecte2 on 1
municating hydrocephalus. A slight ventricular of an aneurysm providing the opposite vertebrald b Au
tdoihnleCaapwtrarhoteitosoiemndncweaaainosrgfifsoatogucurdlnaiopdethsiywn,hweeCaranlestaehchoa1eur1mgr,iihpeaadirtweoomsuimitgsahntdtoevareegelxevocedplaeul6dd8.ea, cvtearrunWtnhekebbrtweahalescraoromtftephraeayprpreirendosuxpliwatmstiaittehoenfltsytbhrtueihneedflesoronacgmcf-elutluelssriizmaoenn.aspersoetfshseustirhaeey copyrighgust 1959
complicating ventricular dilatation, was not of changesfollowingvertebralclippingin patients witht.. D
assistance in visualizing these aneurysms. If uni- normalvasculartone, orevenincreasedtonefollow- o
w
lateral vertebral angiography wasnegative in Group ing a subarachnoid haemorrhage, is open to serious n
I cases, the opposite vertebral artery was injected; question. loa
otherwise it was found that an aneurysm on a Certain practical observations made at operation de
vtehreteobrriaglinaorftetrhyeaptosttheerioursuianlfersiitoer cienrepbreolxlairmiatrytetroy iTnhutshe wprheesnentthseeriveseratreberarleleavratnetrytoitshiscldiipspceuds,siotnh.e d fro
m
might be missed. aneurysmal sac is left situated at the end of a long
h
Ventriculography was required to detect the cul-de-sac in which the blood flow is reversed. At ttp
pferreesnecnecewiotfh hcyirdcruolcaetpiohnaluosf creerseublrtoisnpginfarlomfluiidntebry- o5paenradti6)onwhoenntthheetvweortepbartailenatrsteirnytwhaisssoecrcilesud(eCdastehse ://jn
n
adhesions in the posterior fossa. aneurysmal sac was seen to decrease considerably p
insizeandtheamplitudeofitspulsationdiminished. .b
m
Surgery ofPosterior Fossa Aneurysms In both patients following this procedure ischaemic j.c
The principles ofsurgical treatment ofaneurysms brain-stemsymptomsdeveloped andtherecan be no o
m
itnhethsiusprlaotceanttioorniaalreanseiumirlyasrmst.o tThohsueswthhiecmheatphpoldy toof ignrefaltueerncepdrotohfe tbhlaonodtshiusppltyh.at Fpirnoaxlilmyalin obcoctlhusitohne o/
n
election consists ofthe occlusion by clip or ligature patients there has been no repetition of the F
of the neck of the aneurysm without interference haemorrhagepost-operatively, and one ofthem had eb
withthepatencyoftheparentvessel,aswasachieved hadrepeated severe bleeds. ru
a
in Cases 3 and 4. When the aneurysm arises from It would seem therefore from actual surgical ry
what is considered to be an expendable artery the experience that occlusion within the skull of a 2
5
sac with its segment of vessel may be completely vertebral artery proximal to a ruptured saccular , 2
excised, as in the case reported by Schwartz in 1948 dilatation is an effective method of treatment, and 0
2
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SURGICAL TREATMENT OF POSTERIOR FOSSA ANEURYSMS 209 ro
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thatinpracticethereal dangerliesintheproduction superior cerebellar artery were visualized by a e
u
ofanexcessivefallinbloodpressurewithsubsequent transtentorial approach. This was carried out ro
ischaemia of the brain-stem, although it was through a craniotomy flap exposing the posterior, su
recoverable in both these patients. The risk of temporal, and occipital regions. This area ofbrain rg
thrombosis of the basilar artery following vertebral was then elevated, as far as possible preserving the Ps
ligation must be mentioned, as this has been con- veins draining into the superior petrosal sinus, the yc
sidered a contraindication by DeSaussure and his tentorium then being incised a few millimetres hia
colleagues (1958). The recent case discussed by behind its petrous attachment and avoiding damage try
tdehsecmribiend bwyhiFcrhencthhisancdomHpaliinceasti(o1n950o)cacnurdrwedaswnaost htoemtihsephfeoruertthhenbearsviel.araOrnterryetarnadctiitnsgbrtahenchceersebceolulladr : firs
comparable, as the vertebral-basilar circulation was thenbeclearly seen,theonlyobstruction toexposure t p
hypertrophied to supply a vascular meningioma. being the fifth, seventh, and eighth cranial nerves, ub
Anothermethodoftreatmentconsistsofwrapping and in Case I the fifth nerve had to be divided in lish
asheetofmuscleroundtheaneurysm. Thistechnique order to mobilize the sac on the superior cerebellar ed
was adopted in Case 2, because both the posterior artery. a
cerebral and superiorcerebellar arteries on thesame One disadvantage of this approach was that a s 1
csiodnesiwdeerreedfotuhnatd tooccalruissieonfroofm tthhee saanc,euarnydsmitwwiatsh chloemaroendyumpouisn ohneemtioantohpreieawienevkasr.iably resulted, but 0.11
3
these two vessels carried too high risk ofinfarction. 6
Ipifrnadciftcoiarctaelad,n.attohmiiscalprorceeadsuonrse omthaeyr moectchaosidosnaalrley nbote arfatpTehirymetahnefdorhoapSeeumrroagrterirhonya.gs-ehTohauesldptrhbieencpipapetlrieefnottrh'mastedcaorantsdeirstioiooognn- /jnnp.2
permits was followed as far as possible. However, 2.3
Surgical Approach.-The six patients in this series as will be seen from Table IV, the time that elapsed .2
twsueercrgheinciaaqllule,ocpheeaxricaretpetudtifulopirzoinCngasinecot4nh,veetnshitetitominnoagsltposraientcaeienostnthceintaiscae lbfoerntogwmeere1n2inhttoheeurrvlsaalssitnhwCaeaersmeeorm5rahtioangl1ey9adcnaadyussoeipdnerCbaaytsieotnh4e.vawrTaihieetd Protecte02 on 1
cihnrdouncoeldo.gically, in which hypothermia was also vbeerttweeberanl tahretepreirofgroarmmsa,ncaendofinthethrceaerotoifdtahensde tshiex d by Aug
braATnnwceohuermsyestmhwseordesonofetxshpuelrogirvceeardlteabtprhaplrroouaagrcthherwieeasreauanniddloapttteheredai.lr poactcEiuaerrnrlteysdidtdisuahrgoinunolsgidtsbhieissnioinmttpeerodvrattlha.anttfuirnthtehrehameamnoargrehmaegnets copyrigust 195
posterior fossa craniectomy, and even in Case 4 of these patients. Ruptured posterior fossa ht.9. D
where the sac was shown by arteriography to be aneurysms bleed repeatedly and are dangerous due o
situated far anteriorly in the fossa, relatively little to the risk of infarction of the pons, haemorrhage wn
difficulty in access was experienced. into the brain-stem and cerebellum, and organiza- lo
a
On the other hand, aneurysms on the basilar and tion of blood clot in the posterior fossa. Although d
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TABLE IV m
OPERATIVE RESULTS h
ttp
Case IlDloanfeyss IBnLteearevdasl BlNeooef.ds OCpoenrdaiatttiioonn Convalescence Interval Activity ResidualDefects ://jnn
p
C.1G.. 21st da1y6s 4 Good Uninterrupted yea7rs Full o5ptehrsaetnisoonr.ySlloisgshtfcoolnltorwaicntgusreechtioomno-at .bm
2. 15th 15 1 Good Uninterrupted 18 Full lNaotenrealfacialmuscles j.co
C.C. days months m
3. 9th 2 4 Poor Dementiaduetocommuni- 2 Light Nystagmoid jerks. Slight difficulty o/
J.R. days catinghydrocephalus years work inbalancingononeleg n
4. 19th 19 1 Good Uninterrupted I Full Initial weakness ofleft trapezius Fe
C.H. days year b
M.5K.. 9th ho1u2rs 4 Poor Diisfcfhiaceulmti.a. BrTarianc-hseteomtomy mon1t8hs Impaired Low visual acuity. Ataxiaofgait ruary
6. 1Oth 10 2 Fair Difficult 2 Light Horizontal nystagmus 2
P.McM days Brain-stemischaemia years work Reduction of cutaneous sensibility 5
Tinrfaeccthieoontomyforrespiratory ibmeplaoiwrekdneientoofesR. leg. Joint sense , 20
2
3
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210 HELEN DIMSDALE AND VALENTINE LOGUE ro
l N
the disturbances of consciousness and limb pareses Kremer (1958) regards weakness and collapse of e
u
may betransient, thepatient'smentalityandgeneral the legs at the onset as a manifestation of distur- ro
condition deteriorate with each bleed and chest bance ofthecerebellarconnexions in the brain-stem su
infection tends to supervene. knockingout theY-fibre servo loops. rg
Cases 3 and 5 were operated on the ninth day of The severity ofthesubhyaloid haemorrhages may Ps
illness, the former two days and the latter 12 hours besurprising as the source of the bleeding is poste- yc
h
after a fourth haemorrhage. Both were gravely ill riorly situated and the cerebrospinal fluid pressure ia
at the time of operation and had difficult post- isnotinvariably high. Itisimportanttorealizetheir try
mopaerrkaetidveinpteerliloedcst.ualCadseteer3iorreamtaioinnedduceontfouseadcwoimt-h foocscsuarreannceeu,ryostmhserwmiasye dreelsualytifnrdoimagrneopseiantgedpocsatreortiiodr : firs
municating hydrocephalus which required anterior angiography or attempts to find other causes, such t p
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ventriculostomy. Some circulatory disturbance as a haemorrhagic diathesis, before vertebral b
may already have been present in Case 5 as she had angiography is undertaken. lis
h
had two convulsions with bubbly respiration and Haemorrhage in the posterior fossa may produce e
d
transient hemipareses 12 hours before operation. some form ofblock so that the cerebral and spinal a
s
She developed symptoms of bulbar ischaemia post- subarachnoid pressures donotequalize. Taylorand 1
operatively from which she made a slow recovery Whitfield (1936) described a case in whichno blood 0.1
andwasleft withsomeataxia ofgait. Visual failure reached the cerebrospinal fluid and suggested that 1
3
due to subhyaloid haemorrhages is another danger sudden bleedingmightresultinacerebellarpressure 6
of delay, but in Case 5 the damage occurred after cone. Swelling of the cerebellum also can be /jn
n
thefirst haemorrhage. associated with vascular disturbances of the lateral p
Even in gravely ill patients the level of con- tegmentum of the pons as observed by Atkinson .22
sciousness and vital functions after a bleed usually (1949) in operative occlusion of the anterior in- .3
recover to a stage at which neurosurgery can be feriorcerebellarartery. Such mechanisms, however,P.20
uusnedAfesurlt.waikllenb.e seReenpferaotmedthleuambbsatrracptuonfctruesrueltsma(Tyabblee hCsaaovsmeeeoo7nflwsyhhiobcweheendwesmreueelntsiiitpnulaetfaeitdnaflianrctcahtseeisol.nasteTrianhletthebegrmaepionnntsai,lnrotected2 on 1 A
IV) good condition at the time of operation and region, dilatation ofthe lateral ventricles previously bu
aafrabecsAteotnrhcgyereeoafoptefeearsrtaiutgrainewivsfaeirwcreaehnsnieutclsthcs.raaonsfisaisltthneeinrcvleoibnoitcraailontifhneegartaupraerssaetsieoss-f cd3b,eilraoaegobnndedolsli4aen)r.dtthboenysfiolcusarrtsohutgigvdeensttarinivgcelieoo,gfraahnpedhryngiraboteoifovonirne(gFidogefsa.tthh2,e,y copyrighgust 1959
haemorrhage due to posterior fossa aneurysms Ventricular dilatation may result from the pre-t.. D
would lead to the diagnosis being suspected at an sence offirm blood clot in the fourth ventricle and ow
earlier stage, so thatvertebral angiographycould be subarachnoid space, and in thecourse ofa week or n
lo
employed without unnecessary delay. The problem so adhesionsform intheposteriorfossaasdisplayed a
d
whether carotid angiography can be omitted in at operationinCases 3 and4. In theformerpatient e
d
selected caseswillbeconsidered inthe discussion. (ciCracsueit3t)heopoebrsattriuvcetitorneabtymeantvewnatsrirceuqluoisrt-eodmyt.o short fro
m
Discussion The true incidence of posterior fossa aneurysms h
Certain clinical features of the ictus require is difficult to determine until bilateral vertebral ttp
edixsptluarnbaatnicoen,,suacpharatsthferaobmsenncyesotfagsmigunss,ofwcehreenbellaanr asnugbiaorgarcahpnhoyidishcaaermroiredrhoaugte,aswahernoutcianreotiindcaasnegsioo-f ://jn
n
aneurysm associated with one of the cerebellar graphy is negative. Ifthe incidence is of the order p
arteries has ruptured. Elkington (1958) has attri- of 10 to 15%, as has been suggested, it would seem .bm
buted the rarity of frank cerebellar symptoms in highenoughtojustifycompleteangiography. Itwill j.c
basilar occlusion to the rich anastomoses between berealized thatvertebral angiography willofcourse o
m
isnesveenrsailtivveistsyelstoinatnhiosxioar.ganPoerrbheacpasusienofaintesurreylsatmiavle sbuhtoiwonuopfvtahsecuvlearrteblreasilonssupipnlythbeeypoernidphtehrealsudbistterni-- on/
lesions previous ischaemia in the territory of the torial areatowhichthiscommunication isconfined, F
e
affectedvessel hasresulted intheopeningup ofcol- namely, the posterior cerebral trunks and their b
lateral supplies, or compensatory mechanisms have branches in the occipital lobes. The importance of ru
a
developed as in other slowly growing cerebellar thiswideraspectoftheinvestigationofpatientswith ry
lesions. The midline cerebellar syndrome with subarachnoid haemorrhage was emphasized by 2
5
truncal ataxia might not be detected in these Spatz and Bull(1957) when,in 60 patients inwhom , 2
seriously ill patients who cannot be mobilized. bilateral carotid angiograms showed no lesion, 0
2
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