Individualization of the operative access in cerebral aneurysms clipping

Abstract

Objective – to individualize the craniotomy stage during cerebral aneurysm (CA) clipping taking into account topographic-anatomical and clinical features.

Materials and methods. A retrospective analysis of microsurgical operations on CA in 430 patients (244 (56.7 %) women and 186 (43.3 %) men) who were treated at the SI «Romodanov Neurosurgery Institute» in the period from 1998 to 2016 was made. The average age of patients at the fist diagnosis was 49 years. The complex of diagnostic measures included clinical neurological examination, instrumental (neuroimaging and invasive) and laboratory research. All patients had clinical manifestations of the disease at the time of hospitalization.

Results. Hemorrhagic type of the disease was in 372 (86.5 %) patients. There are 329 (76.5 %) parents were operated in acute period, 43 (10.0 %) – in cold. The following clinical manifestations were observed in non-ruptured CA (58 (13.5 %): acute cerebrovascular accident by ischemic type – 20 (4.7%) cases, pseudotumor manifestation – 34 (7.9%), asymptomatic CA – 4 (0.9%). CA localization: complex of the Anterior Cerebral Artery – Anterior Communicative Artery – 145 (33.7 %) cases, different segments of Internal Carotid Artery – 98 (22.8%), bifurcation of M1-M2- segment of Middle Cerebral Artery – 112 (26.1% ), distal parts of Anterior Cerebral Artery – 72 (16.7 %), Basal Artery Bifurcation – 3 (0.7 %). 94 (21.9 %) urgent operations (according to vital signs), 235 (54.6 %) urgent and 101 (23.5 %) planned were made. The following craniotomy accesses were applied: the anterior interhemispheric – in 64 (14.9 %) cases, standard pterional – in 208 (48.4 %), advanced pterional – in 104 (24.2 %), pterional «key hole» type – in 8 (1.9 %), orbit zygomatic – in 6 (1.3 %), pteriaonal with anterior clinoidectomy – in 32 (7.4 %), cross-sectional – in 8 (1.9 %).

Conclusions. The choice of optimal craniotomic access during CA clipping is depend on the type of disease clinical manifestations, the anatomical form and volume of intracranial hemorrhage, the localization and geometric parameters of CA, the anatomical ratio of the parameters of CA with bone structures of the skull base.