Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Oct 1998
ReviewRevascularization and bypass procedures for cerebral aneurysms.
Revascularization and bypass procedures are useful in the treatment of complex aneurysms. Extracranial to intracranial bypass grafts are used to augment the distal circulation as an adjunct to proximal vessel occlusion for aneurysm treatment. ⋯ Intracranial interposition grafts are used to reconstruct arteries harboring aneurysms that cannot be occluded directly using clip or coil techniques. These techniques in the treatment of cerebral aneurysms are discussed.
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Patients with subarachnoid hemorrhage from ruptured cerebral aneurysms frequently have systemic manifestations including hypovolemia and fluid and electrolyte disturbances in addition to neurologic symptoms. Anesthetic management therefore begins with proper preoperative evaluation and optimization. Anesthetic induction and maintenance are partly dependent on the patient's condition and seek to optimize cerebral perfusion, facilitate surgical exposure, and reduce the risk of intraoperative aneurysm rupture. Cerebroprotective strategy and adjunct monitors may be useful in some institutions.
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The endovascular management of cerebral aneurysms is undergoing revolutionary growth. Recent advances in endovascular surgery including balloon remodeling, revascularization techniques, functional cerebral rearrangement, intracranial stents, treatment for vasospasm and coil design are discussed, as are their future considerations.
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Middle cerebral artery (MCA) aneurysms account for approximately 20% of aneurysmal subarachnoid hemorrhage (SAH). An understanding of MCA anatomy and variations is the key to successful treatment of MCA aneurysms, which may occur on the M1 segment, at the division of the main trunk or on distal branches. ⋯ MCA aneurysms associated with large temporal hematomas may be approached through the superior temporal gyrus. Other aneurysms are best approached with a medial or lateral transSylvian approach.
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Neurosurg. Clin. N. Am. · Oct 1998
ReviewTemporary vascular occlusion during cerebral aneurysm surgery.
Temporary artery occlusion is an effective way to reduce the detrimental effects of intraoperative aneurysm rupture and to facilitate aneurysm dissection. The major risk incurred is of cerebral infarction. Dilemmas in the use of this technique include the amount of time that arterial flow may be interrupted safely and whether or not there is benefit to intermittent reperfusion. Protocol for the use of temporary occlusion is described.