• Journal of Korean Neurosurgical Society
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• v.52 no.5
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• pp.501-504
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• 2012

Objective : To report our surgical experience using in situ end-to-side bypass for giant serpentine distal anterior cerebral artery aneurysm, unsuitable for microsurgical clipping. Methods : A 49-year-old woman presented with headache and intermittent loss of consciousness. The brain computed tomography scan revealed a partially calcified mass in the interhemispheric fissure. On cerebral angiography, that was giant ($30{\times}18mm$ sized), serpentine aneurysm originating from the A2 to A3 segment of the distal anterior cerebral artery (DACA). The aneurysm was trapped with clips, and the right A3 segment to left A3 segment of DACA, end-to-side in situ bypass was performed. Surgical result was favorable, with no newly developed ischemic event in the acute recovery period. Postoperative angiography showed total occlusion of the aneurysm and good patency, with preserved distal flow. Conclusion : Giant fusiform aneurysms of the DACA are extremely rare and can be particularly challenging to treat. End-to-side A3 : A3 bypass with aneurysm trapping could be a treatment modality for these locations.

• Journal of Korean Neurosurgical Society
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• v.30 no.12
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• pp.1361-1368
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• 2001

Objective : "Paraclinoid" aneurysms include those aneurysms arising from the internal carotid artery between the site of emergence of the carotid artery from the roof of the cavernous sinus and the origin of the posterior communicating artery. The authors reviewed and analysed the results of surgical approaches to paraclinoid aneurysms treated with transcranial surgery and endovascular surgery. Methods : Between January 1998 and May 1999, 14 patients were treated surgically through ipsilateral and contralateral pterional approaches, and anterior interhemispheric approach, and endovascular surgery for paraclinoid aneurysms. All transcranial approaches were performed by same surgeon. The medical records, neuroimaging studies and videotapes which had been recorded operations were reviewed retrospectively. Results : Twelve patients presented with subarachnoid hemorrhage and ICH. Nine of fourteen patients had multiple aneurysms. Thirteen cases were small and one was a large aneurysm. Six patients were treated through ipsilateral approaches, six contralateral pterional approaches, one anterior interhemispheric approach and one primarily by GDC embolization. All aneurysms treated through contralateral approaches were multiple aneurysms. Neck clipping was performed in 9(69.2%) of the thirteen aneurysms, wrapping in four cases, among them three cases were followed by GDC embolization. The surgical outcomes were : Glasgow Outcome Scale(GOS) I 71.4%, GOS II 21.4% and GOS V 7.1%. Conclusion : The surgical approaches to paraclinoid aneurysms should be chosen after careful anatomical evaluation of aneurysm and its neighboring structures. 3D-CT angiography and/or the raw data of MR angiography were useful. This study supports the usefulness of the contralateral approach to paraclinoid aneurysm associated with multiple aneurysms, unruptured and small aneurysms whose dome projecting medially, superiorly and dorsally. The determination of contralateral approach to small and medially projecting paraclinoid aneurysm may be stressful to operator, thus we believe anterior interhemispheric approach is better alternated. Also we recommend the endovascular surgery after reinforcement of aneurym neck and dome in the case with difficulty in clipping.

• Journal of Korean Neurosurgical Society
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• v.58 no.6
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• pp.518-527
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• 2015

Objective : The treatment of complex intracranial aneurysms remains challenging. One approach is the application of surgical flow alteration to treat aneurysms that are neither clippable, trappable, or coilable. The efficacy and limitations of surgical flow alteration have not yet been established. Methods : Cases of complex aneurysms treated with surgical flow alteration (proximal occlusion with or without bypass, distal occlusion with or without bypass and bypass only) were included in this retrospective study. Results : Among a total of 16 cases, there were 7 giant aneurysms (${\geq}25mm$ diameter) and 9 large aneurysms (>10 mm diameter); 15 of 16 aneurysms were unruptured. There were 8 aneurysms located in the anterior circulation, while the other 8 were in the posterior circulation. Aneurysms were treated with proximal occlusion in 10 cases and distal occlusion in 5 cases; in 1 case, the aneurysm occluded spontaneously after bypass without parent artery occlusion. All but 2 cases underwent prior or concurrent bypass surgery. Complete obliteration of the aneurysm at the latest imaging follow-up was shown in 12 of 16 cases (75.0%). Bypass patency was confirmed in 13 of 15 cases (86.7%). Surgery-related morbidity developed in 3 cases (18.8%, Glasgow outcome scale of 4) and all were perforator infarctions. There were no mortalities. Conclusion : Surgical flow alteration resulted in a high rate of aneurysmal obliteration with acceptable morbidity. Although several limitations remained, it could represent an alternative method for treating complex aneurysms.

• Journal of Korean Neurosurgical Society
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• v.66 no.6
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• pp.652-663
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• 2023

Objective : This study compared the quality of recovery (QoR) after minicraniotomy for clipping of unruptured intracranial aneurysms (UIAs) between patients with and without scalp nerve block (SNB). Methods : Patients were randomly assigned to the SNB (SNB using ropivacaine with epinephrine, n=27) and control (SNB using normal saline, n=25) groups. SNB was performed at the end of surgery. To assess postoperative QoR, the QoR-40, a patient-reported questionnaire, was used. The QoR-40 scores were measured preoperatively, 1-3 days postoperatively, at hospital discharge, and 1 month postoperatively. Pain and intravenous patient-controlled analgesia (IV-PCA) consumption were evaluated 3, 6, 9, and 12 hours and 1-3 days postoperatively. Results : All QoR-40 scores, including those measured 1 day postoperatively (primary outcome measure; 155.0 [141.0-176.0] vs. 161.0 [140.5-179.5], p=0.464), did not significantly differ between the SNB and control groups. The SNB group had significantly less severe pain 3 (numeric rating scale [NRS]; 3.0 [2.0-4.0] vs. 5.0 [3.5-5.5], p=0.029), 9 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.048), and 12 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.035) hours postoperatively. The total amount of IV-PCA consumed was significantly less 3 hours postoperatively in the SNB group (2.0 [1.0-4.0] vs. 4.0 [2.0-5.0] mL, p=0.044). Conclusion : After minicraniotomy for clipping of UIAs, SNB reduced pain and IV-PCA consumption in the early postoperative period but did not improve the QoR-40 scores.

• Journal of Korean Neurosurgical Society
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• v.30 no.7
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• pp.891-895
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• 2001

Objective : Although surgical clipping of intracranial aneurysm is the definite method of treatment, there remains a small number of patients in whom surgical clipping is not technically possible. In such difficult cases, surgeon has to consider other therapeutic alternatives. In this report, we analyze our aneurysmal cases treated by wrapping and coating method and evaluate their surgical outcome and follow-up results. Method : Among the total of 877 patients operated from 1990 to 1999 for intracranial aneurysms at our hospital, 40 cases(4.6%) were treated by wrapping and coating method. They included 24 cases of single ruptured aneurysms and 16 with unruptured ones in multiple aneurysms. Wrapping with temporalis muscle and/or muslin gauze and coating with bioadhesive agent such as fibrin glue were performed. Result : Wrapping and coating method was performed mostly to the anterior communicating artery aneurysm (35%), and mostly because of the broad-based neck of an aneurysm(43%). At the time of discharge, 30 out of 40 patients(80%) showed favourable outcome and three cases died. The patients were monitored for average of 37 months(3-75 months). Among 24 cases with single ruptured aneurysm, 4 cases(17%) had early rebleeding within 6 months from the initial hemorrhage, and such rebleeding occurred within the first postoperative month in 3 cases. However, there was no rebleeding after the 6 months. Among 16 patients whose aneurysms were unruptured ones, none of them showed bleeding episode. Conclusion : It seems likely that the wrapping and coating method would be some help to prevent the rebleeding of an intracranial aneurysm. In order to obtain more accurate results regarding the efficacy of such method, it will be necessary to perform a multi-center study for longer follow-up periods and various wrapping and coating materials.

• Journal of Korean Neurosurgical Society
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• v.30 no.sup1
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• pp.128-132
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• 2001

Aneurysm of the basilar artery trunk are rare and the surgical approach is very difficult because of the complexity of surgical anatomy around the basilar trunk and the vulnerable adjacent neurovascular structures. The development of brain CT and MRI makes the accurate diagnosis and produces the improvement of surgical approaches at the lesion of the skull base. One of the surgical approaches of basilar trunk aneurysms, the retrolabyrinthine presigmoid transtentorial transpetrosal approach to the aneurysm of the basilar trunk has some advantages of minimal retraction of cerebellum and temporal lobe, intact auditory and facial nerve function by the preservation of the vestibulocochlear and facial nerves, a preservation of sigmoid sinus and vein of Labbe and a relatively good operation field. We had a good result with this approach for the patient of basilar trunk aneurysm and reported the case with the review of literatures.

• Journal of Korean Neurosurgical Society
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• v.49 no.5
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• pp.287-289
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• 2011

Thalamoperforating artery aneurysms are rarely reported in the literature. We report an extremely rare case of ruptured distal anterior thalamoperforating artery aneurysm which was treated by endovascular obliteration in a patient with occlusion of both the internal carotid arteries (ICAs) : A 72-year-old woman presented with severe headache and loss of consciousness. Initial level of consciousness at the time of admission was drowsy and the Glasgow Coma Scale score was 14. Brain computed tomography (CT) scan was performed which revealed intracerebral hemorrhage in right basal ganglia, subarachnoid hemorrhage, and intraventricular hemorrhage. The location of the aneurysm was identified as within the globus pallidus on CT angiogram. Conventional cerebral angiogram demonstrated occlusion of both the ICAs just distal to the fetal type of posterior communicating artery and the aneurysm was arising from right anterior thalamoperforating artery (ATPA). A microcatheter was navigated into ATPA and the ATPA proximal to aneurysm was embolized with 20% glue. Post-procedural ICA angiogram demonstrated no contrast filling of the aneurysm sac. The patient was discharged without any neurologic deficit. Endovascular treatment of ATPA aneurysm is probably a more feasible and safe treatment modality than surgical clipping because of the deep seated location of aneurysm and the possibility of brain retraction injury during surgical operation.

• Journal of Korean Neurosurgical Society
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• v.60 no.3
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• pp.275-281
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• 2017

Treating diseases in the field of neurosurgery has progressed concomitantly with technical advances. Here, as a surgical armamentarium for the treatment of cerebral aneurysms, the history and present status of the keyhole approach and the use of neuroendoscopy are reviewed, including our clinical data. The major significance of keyhole approach is to expose an essential space toward a target, and to minimize brain exposure and retraction. Among several kinds of keyhole approaches, representative keyhole approaches for anterior circulation aneurysms include superciliary and lateral supraorbital, frontolateral, mini-pterional and mini-interhemispheric approaches. Because only a fixed and limited approach angle toward a target is permitted via the keyhole, however, specialized surgical devices and preoperative planning are very important. Neuroendoscopy has helped to widen the indications of keyhole approaches because it can supply illumination and visualization of structures beyond the straight line of microscopic view. In addition, endoscopic indocyanine green fluorescence angiography is useful to detect and correct any compromise of the perforators and parent arteries, and incomplete clipping. The authors think that keyhole approach and neuroendoscopy are just an intermediate step and robotic neurosurgery would be realized in the near future.

• Journal of Korean Neurosurgical Society
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• v.46 no.1
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• pp.68-70
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• 2009

A case of large aneurysm arising from the distal end of an azygous A2 segment is presented. Multiple clip application inadvertently tore the aneurysmal neck, resulting in near avulsion of a right pericallosal artery origin. After an unsuccessful attempt to repair the avulsion, it was treated by occlusion of the origin of the pericallosal artery and an A4-A4 anterior cerebral artery in situ bypass without neurological deficits. The surgical technique and previous reports onside-to-side in situ bypass are discussed.

• Journal of Korean Neurosurgical Society
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• v.56 no.6
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• pp.496-499
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• 2014

Owing to the focal wall defect covered with thin fibrous tissues, an aneurysm arising from the dorsal wall of the internal carotid artery (ICA) is difficult to manage either surgically or endovascularly and is often associated with high morbidity and mortality. Unfortunately, the definitive treatment modality of such highly risky aneurysm has not yet been demonstrated. Upon encountering the complex intracranial pathophysiology of such a highly precarious aneurysm, a neurosurgeon would be faced with a challenge to decide on an optimal approach. This is a case of multiple paraclinoid aneurysms including the ICA dorsal wall aneurysm, presented with spontaneous subarachnoid hemorrhage. With respect to treatment, direct clipping with a Sundt graft clip was performed after multiple endovascular interventions had failed. This surgical approach can be a treatment modality for a blood blister-like aneurysm after failed endovascular intervention(s).