Intervention
Endovascular balloon test occlusion with qualitative or quantitative cerebral blood flow and/or carotid artery pressure measurements have been successfully used to assess the hemodynamic risk of permanent or temporary carotid arterial occlusion. This assessment couples the 20-minute clinical occlusion test with a qualitative or quantitative test. Patients who cannot tolerate a balloon occlusion test of the internal carotid may require an extracranial-to-intracranial bypass and subsequent reevaluation before indirect treatment is initiated. The type of bypass is directly related to the flow deficiency.
Patients with frankly failing results during the clinical balloon occlusion test are at the greatest risk and pose the greatest challenge. Patients with an aneurysm in the cavernous sinus in whom the balloon occlusion test fails should be treated during extracranial-intracranial bypass surgery with a superficial temporal artery graft or a saphenous vein graft. The rate of blood flow supplied by a superficial temporal artery is 20-60 mL/min; this may not be enough to accommodate a normal blood flow of 75-120 mL/min through a middle cerebral artery. No collateral blood supply flows through the posterior and anterior communicating arteries. Higher flow rates may be achieved with a saphenous vein graft bypass.
During the past decade, the endovascular treatment of intracranial aneurysms has developed extensively. The original indication—the treatment of giant unclippable intracranial aneurysms— has been extended to include small aneurysms and those that have recently ruptured. The introduction of coils, stents, and newer materials allows for successful treatment of many intracranial aneurysms. Depending on the location, configuration, and characteristics of the aneurysm, consideration should be given to a surgical obliteration or endovascular treatment of an intracranial aneurysm.
It is the author's opinion that a team approach involving the neurosurgeon and the endovascular neuroradiologist is of paramount importance for the successful treatent of these patients. In many patients with intracranial aneurysm, a complex endovascular approach that takes into consideration the use of detachable coils, stents, balloons, and aneurysm neck remodeling increases the probability of a successful aneurysm occlusion. The use of hydrogel-coated coils for the endovascular treatment of intracranial aneurysms offers the theoretical advantages of increased volumetric occlusion, thrombus stabilization, and improved neointimal healing.6,7,8,10,18
After the initial diagnosis of an intracerebral aneurysm, when symptoms or TCD ultrasonographic findings suggest vasospasm, repeat angiography definitively depicts the presence, severity, and location of the vasospasm and the status of the aneurysm. Therapy for the regions of narrowing may then be performed with either balloon angioplasty or an infusion of vasodilators, such as papaverine.
Following subarachnoid aneurysmal hemorrhage, endovascular treatment of vasospasm should be implemented in patients who develop clinical or radiologic symptoms of brain ischemia, in conjunction with increased Doppler velocities, despite maximal medical treatment.5,24 Treatment may be either pharmacologic or mechanical. Calcium and phosphodiesterase inhibitors may be administered. In Europe, intravasular nimodipine is widely used; in North America, nicardipine and verapamil are the major agents used, because intravenous nimodipine has not been approved by the FDA.
Papaverine was the drug of choice in the past; however, papaverine is now considered less desirable owing to its short duration of vasodilatation and the risk of aggravation of increased intracranial pressure. Balloon angioplasty has a long-lasting effect but may be applied only in cases involving spasm of proximal vessels. Complications of its use are rare but may be life threatening. The author recommends the use of a combined approach, including the intra-arterial administration of pharmacologic agents and the use of balloon angioplasty. I also recommend that the approach be maintained and that repeat angioplasty procedures be performed as often as the patient's condition warrants it.5,6,7,25,26,27,28,29,30,31,32
Medicolegal Pitfalls
- With endovascular procedures, complications often occur during puncture. Subintimal threading of the catheter or needle may cause dissection syndromes and subsequent ischemic complications. Neck hematomas may develop, requiring termination of the procedure. Occasionally, a thrombus develops in the punctured artery, requiring surgery on an emergency basis. Neurologic deficits may occur during primary vessel puncture.
- During cerebral angiography, complications include arterial dissection and delayed arterial occlusion; arterial rupture; hemorrhagic infarction; and displacement of the surgical clips from the aneurysmal necks.
- During balloon angioplasty, ischemic complications may occur as a result of excessive occlusion times. Stenosis may also occur because the diameter of the noninflated balloon is equivalent to the vessel's diameter. In this situation, the balloon adds to ischemia of the vasospasm before dilation. Occasionally, the procedure is performed in a patient whose blood flow has been critically reduced before dilation. Only short periods of vasodilation are tolerated. The most feared complication of angioplasty is separation of the balloon from the catheter and its distal migration into the intracranial arterial tree; this most often occurs when a detachable balloon is used to occlude the aneurysm. To prevent ischemic complications, the smallest possible balloon and catheter and be selected, and they should be attached firmly. Dilations should be performed rapidly. Hemorrhagic complications occur because of rupture of the primary vessel or aneurysm.
- Aneurysmal rupture during cerebral angiography may occur as a result of traction, the performance of maneuvers near the aneurysmal neck, or catheter misplacement in the neck of an aneurysm that increases dynamic pressures in the aneurysm. One should always be prepared to perform open craniotomy promptly if the aneurysm ruptures. If a thrombus obstructs the vessel, a fibrinolytic such as urokinase or tissue plasminogen should be used immediately.
- A major source of complications of direct surgical treatment of aneurysms is ischemia. Because of the critical nature of the neural structures supplied by the perforating branches, especially during the surgical treatment of posterior circulation aneurysms, occlusion of the perforating vessels typically causes dramatic symptoms. Maneuvers that ensure the identification and liberation of all perforating branches from the aneurysm sac before clip placement are of paramount importance. Inspection after clip positioning is also crucial to ensure that any proximal vessels continue to fill. Major arterial branch occlusions, although less common, have dramatic consequences as well. These problems most often occur as a result of poor clip placement.
- The morbidity and mortality rates of intraoperative rupture during the surgical treatment of intracranial aneurysms can be significant. The operating surgeon must have access to vascular control; in addition, the surgeon should have a practiced set of steps to avoid this complication and should treat it as quickly and efficiently as possible. Techniques to reduce the incidence of intraoperative aneurysm rupture include the use of sharp dissection and complete dissection of the lesion before any attempt at clip placement. Should intraoperative rupture occur, tamponade is usually the quickest and most effective method of initial management. If tamponade fails to significantly reduce the hemorrhage, temporary arterial occlusion should be considered.
- Cranial nerve deficits are well-recognized deficits that occur after the treatment of intracranial aneurysms. The most common cranial nerve deficit in the treatment for basilar bifurcation or posterior communicating artery aneurysms is a temporary third cranial nerve palsy that results in ptosis and ophthalmoplegia. The likely cause is surgical manipulation. Deficits are usually short lived, and most patients recover within 3 months. Other causes include injury from poor clip placement.
- The frequency of acute hydrocephalus during the first 3 days after aneurysmal SAH is approximately 20%. The proportion of patients who have acute hydrocephalus concurrent with intraventricular hemorrhage is 35-65%. Treatment options for patients with SAH and acute hydrocephalus include observation and ventricular drainage. In patients who are asymptomatic in the early postbleeding period, observation in the presence of ventricular dilatation appears justified; approximately 1 in 3 patients have neurologic deterioration in the following few days.
- Among other injuries, the obstruction of venous drainage is a consequence of excessive retraction or injury to the bridging veins. Obstruction may result in the development of hemorrhagic infarction.
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Further Reading
Keywords
brain aneurysm, cerebral aneurysm, abnormal arterial dilatation, intracranial aneurysm, berry aneurysm, endovascular procedures, radiological diagnoses, Guglielmi detachable coil, GDC
