Sh.Sh. Eliava, Yu.M. Filatov, I.A. Sazonov, S.B. Yakovlev, A.S. Heyreddin, S.P. Zolotuhin, A.E. Podoprigora, A.Yu. Lubnin, A.M. Ceytlin, O.B. Sazonova, N.K. Serova, N.V. Kurdyumova, D.N. Okishev, N.L. Martirosyan
Burdenko Research Institute of Neurosurgery, Moscow, Russia
Microsurgery of big and giant aneurysms of ICA is one of the complicated problems of cerebrovascular neurosurgery. In the first run, difficulties, experienced in clipping of such aneurysms, are conditioned by their big size and low location (below the clinoid process) of a proximal part of an aneurysm neck, watched in the majority of cases. Last years were characterized by a higher rate of cases with big and giant aneurysms (25-25%), treated in the Burdenko Research Institute of Neurosurgery; 70% of them were giant aneurysms.
The analyzed series included 91 cases, treated in the above Institute in 1995-2008 and operated with applying intravascular aspiration of blood (IAB). Mean age was 45.3 years. Giant (more than 2.5 cm) and big (1.5-2.5 cm) aneurysms were revealed in 64 (70.3%) and 27 (29.7%) cases, respectively. The disease manifested itself in spontaneous subarachnoid or subarachnoid-parenchymal hemorrhages in the majority of cases (62; 67%). Operation was performed in an acute stage of subarachnoid hemorrhage (SAH) in 14 patients (22.6%). The rest cases were operated in a “cold” period after spontaneous SAH.
We elaborated an anatomic-surgical classification of giant aneurysms, based on a ratio between an aneurysm neck and the ICA walls and its segments, which conditioned tactics and methods of neck clipping. Besides, we considered methods of clipping of aneurysms with a “borderline” localization and a neck, being partially proximal in relation to a distal dural ring of ICA. The analysis of personal experience allowed us to identify 5 causes, which conditioned impossibility of clipping of giant aneurysms with the help of IAB, using open (ICA exposure on a neck) and closed endovasal (occluding-aspirating balloon-catheters) methods. The obtained results demonstrated, that use of IAB had allowed to increase a number of radical operations (3.7 times higher in comparison with the previous years).Clipping of an aneurysm neck was achieved in 77 cases (84.6%); postoperative mortality became 4.3 times lower; its rate was 4.4% (4 cases). The results of surgical treatment were estimated on the basis of the GOS scale. A postoperative rupture of aneurysms took place in 16 cases (17.6%). However, use of IAB made it possible to control bleeding in all the cases and to clip an aneurysm neck quite successfully. Critical analysis of obtained experience permitted to determine main trends (methods) of surgery of big and giant ICA aneurysms. It was done with a special emphasis on further improvement of reliable methods, aimed at creation of interarterial (including wide-profile) anastomoses with subsequent exclusion of ICA. Such methods are an alternative of radical clipping of an aneurysm neck in situation, where IAB turns out to be ineffective.