Download PDF
Cent Eur Neurosurg 2007; 68(3): 151-154
DOI: 10.1055/s-2007-984460
Case Report

© Georg Thieme Verlag KG Stuttgart · New York

Intraoperative Angiography for Hunterian Ligation of a Recurrent Basilar Aneurysm

Intraoperative Angiographie bei Ligation nach Hunter eines rezidivierten BasilarisaneurysmasO. Bozinov 1 , L. J. Kim 2 , R. F. Spetzler 2
  • 1Department of Neurochirurgie, Philipps Universitaet, Marburg, Germany
  • 2Department of Neurosurgery, Barrow Neurological Institute, Arizona, United States
Further Information

Publication History

Publication Date:
30 July 2007 (online)

    Permissions and Reprints

Abstract

Cerebral aneurysms often recur after selective endovascular treatment with detachable coils and are usually treated by recoiling. Sometimes, however, surgical treatment is required, and application of the clip can be difficult. Evacuation of embolic material risks injuring eloquent structures or perforators, especially in the posterior circulation. In such cases parent vessel occlusion for reversal of flow might be an option. If collateral flow is adequate, an additional bypass is not required. When using this technique, known as Hunterian ligation, intraoperative monitoring such as electrophysiological monitoring and intraoperative angiography can be of great help and are advisable. We describe this procedure and related intraoperative considerations in one case report.

Zusammenfassung

Zerebrale Aneurysmen können nach erfolgtem Coiling rezidivieren und werden meist mit einem erneuten Coiling verschlossen. Manchmal ist jedoch auch eine chirurgische Intervention notwendig und das Platzieren eines Clips kann sich auch schwierig gestalten. Ein Herausschneiden des embolischen Materials birgt das Risiko der Verletzung von eloquenten Strukturen oder Gefäßen, dies trifft insbesondere auf den hinteren Kreislauf zu. In solch einem Fall kann der Verschluss des Hauptgefäßes zur Flussumkehr eine Alternative darstellen. Bei ausreichend vorhandenem kollateralem Fluss ist ein zusätzlicher Bypass nicht notwendig. Bei dieser Ligation nach Hunter ist ein intraoperatives Monitoring sehr hilfreich. Neben den elektrophysiologischen Möglichkeiten ist gerade auch die intraoperative Angiographie hier von großer Bedeutung. Wir beschreiben diese Kombination der Techniken und die Überlegungen in einem illustrierten Fall.

Key words

intracranial aneurysm - parent vessel occlusion - intraoperative angiography

Schlüsselwörter

Intrakranielle Aneurysmen - Hauptgefäß-Verschluss - Intraoperative Angiographie

References

  • 1 Alexander TD, Macdonald RL, Weir B, Kowalczuk A. Intraoperative angiography in cerebral aneurysm surgery: a prospective study of 100 craniotomies.  Neurosurgery. 1996;  39 10-17
    CrossrefPubMedSearch in Google Scholar
  • 2 Amin-Hanjani S, Ogilvy CS, Buonanno FS, Choi IS, Metz LN. Treatment of dissecting basilar artery aneurysm by flow reversal.  Acta Neurochir (Wien). 1997;  139 44-51
    CrossrefPubMedSearch in Google Scholar
  • 3 Asgari S, Doerfler A, Wanke I, Schoch B, Forsting M, Stolke D. Complementary management of partially occluded aneurysms by using surgical or endovascular therapy.  J Neurosurg. 2002;  97 843-850
    PubMedSearch in Google Scholar
  • 4 Aymard A, Gobin YP, Hodes JE, Bien S, Rufenacht D, Reizine D. et al . Endovascular occlusion of vertebral arteries in the treatment of unclippable vertebrobasilar aneurysms.  J Neurosurg. 1991;  74 393-398
    PubMedSearch in Google Scholar
  • 5 Barrow DL, Boyer KL, Joseph GJ. Intraoperative angiography in the management of neurovascular disorders.  Neurosurgery. 1992;  30 153-159
    CrossrefPubMedSearch in Google Scholar
  • 6 Chiang VL, Gailloud P, Murphy KJ, Rigamonti D, Tamargo RJ. Routine intraoperative angiography during aneurysm surgery.  J Neurosurg. 2002;  96 988-992
    CrossrefPubMedSearch in Google Scholar
  • 7 Deinsberger W, Mewes H, Traupe H, Boeker DK. Surgical management of previously coiled intracranial aneurysms.  Br J Neurosurg. 2003;  17 149-154
    CrossrefPubMedSearch in Google Scholar
  • 8 Derdeyn CP, Moran CJ, Cross DT III, Sherburn EW, Dacey Jr RG. Intracranial aneurysm: anatomic factors that predict the usefulness of intraoperative angiography.  Radiology. 1997;  205 335-339
    PubMedSearch in Google Scholar
  • 9 Heros RC. Intraoperative angiography.  J Neurosurg. 2002;  96 979-980
    PubMedSearch in Google Scholar
  • 10 Horowitz M, Purdy P, Kopitnik T, Dutton K, Samson D. Aneurysm retreatment after Guglielmi detachable coil and nondetachable coil embolization: report of nine cases and review of the literature.  Neurosurgery. 1999;  44 712-719
    PubMedSearch in Google Scholar
  • 11 Klopfenstein JD, Spetzler RF, Kim LJ, Feiz-Erfan I, Han PP, Zabramski JM. et al . Comparison of routine and selective use of intraoperative angiography during aneurysm surgery: a prospective assessment.  J Neurosurg. 2004;  100 230-235
    CrossrefPubMedSearch in Google Scholar
  • 12 Lawton MT, Daspit CP, Spetzler RF. Technical aspects and recent trends in the management of large and giant midbasilar artery aneurysms.  Neurosurgery. 1997;  41 513-520
    CrossrefPubMedSearch in Google Scholar
  • 13 Lawton MT, Quinones-Hinojosa A, Sanai N, Malek JY, Dowd CF. Combined microsurgical and endovascular management of complex intracranial aneurysms.  Neurosurgery. 2003;  52 263-274
    CrossrefPubMedSearch in Google Scholar
  • 14 Leibowitz R, Do HM, Marcellus ML, Chang SD, Steinberg GK, Marks MP. Parent vessel occlusion for vertebrobasilar fusiform and dissecting aneurysms.  AJNR Am J Neuroradiol. 2003;  24 902-907
    PubMedSearch in Google Scholar
  • 15 Little JR, Lesser RP, Luders H. Electrophysiological monitoring during basilar aneurysm operation.  Neurosurgery. 1987;  20 421-427
    PubMedSearch in Google Scholar
  • 16 Lozier AP, Kim GH, Sciacca RR, Connolly Jr ES. Solomon RA. Microsurgical treatment of basilar apex aneurysms: perioperative and long-term clinical outcome.  Neurosurgery. 2004;  54 286-296
    CrossrefPubMedSearch in Google Scholar
  • 17 Martin NA, Bentson J, Vinuela F, Hieshima G, Reicher M, Black K. et al . Intraoperative digital subtraction angiography and the surgical treatment of intracranial aneurysms and vascular malformations.  J Neurosurg. 1990;  73 526-533
    CrossrefPubMedSearch in Google Scholar
  • 18 Mount LA, Taveras JM. Ligation of basilar artery in treatment of an aneurysm at the basilar-artery bifurcation.  J Neurosurg. 1962;  19 167-170
    PubMedSearch in Google Scholar
  • 19 Neuloh G, Schramm J. Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery.  J Neurosurg. 2004;  100 389-399
    CrossrefPubMedSearch in Google Scholar
  • 20 Origitano TC, Schwartz K, Anderson D, Azar-Kia B, Reichman OH. Optimal clip application and intraoperative angiography for intracranial aneurysms.  Surg Neurol. 1999;  51 117-124
    CrossrefPubMedSearch in Google Scholar
  • 21 Pelz DM, Vinuela F, Fox AJ, Drake CG. Vertebrobasilar occlusion therapy of giant aneurysms. Significance of angiographic morphology of the posterior communicating arteries.  J Neurosurg. 1984;  60 560-565
    PubMedSearch in Google Scholar
  • 22 Raabe A, Beck J, Gerlach R, Zimmermann M, Seifert V. Near-infrared indocyanine green video angiography: a new method for intraoperative assessment of vascular flow.  Neurosurgery. 2003;  52 132-139
    CrossrefPubMedSearch in Google Scholar
  • 23 Rozario RA, Stein BM. Ligation of the basilar artery as the definitive treatment for a giant aneurysm of the basilar artery apex: case report.  Neurosurgery. 1980;  6 87-91
    PubMedSearch in Google Scholar
  • 24 Spetzler RF, Riina HA, Lemole Jr GM. Giant aneurysms.  Neurosurgery. 2001;  49 902-908
    CrossrefPubMedSearch in Google Scholar
  • 25 Steinberg GK, Drake CG, Peerless SJ. Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients.  J Neurosurg. 1993;  79 161-173
    PubMedSearch in Google Scholar
  • 26 Tanaka Y, Kobayashi S, Hongo K, Tada T, Nagashima H, Kakizawa Y. Intentional body clipping of wide-necked basilar artery bifurcation aneurysms.  J Neurosurg. 2000;  93 169-174
    PubMedSearch in Google Scholar
  • 27 Wiedemayer H, Sandalcioglu IE, Armbruster W, Regel J, Schaefer H, Stolke D. False negative findings in intraoperative SEP monitoring: analysis of 658 consecutive neurosurgical cases and review of published reports.  J Neurol Neurosurg Psychiatry. 2004;  75 280-286
    PubMedSearch in Google Scholar
  • 28 Zabramski JM, Kiris T, Sankhla SK, Cabiol J, Spetzler RF. Orbitozygomatic craniotomy. Technical note.  J Neurosurg. 1998;  89 336-341
    CrossrefPubMedSearch in Google Scholar
  • 29 Zhang YJ, Barrow DL, Cawley CM, Dion JE. Neurosurgical management of intracranial aneurysms previously treated with endovascular therapy.  Neurosurgery. 2003;  52 283-293
    PubMedSearch in Google Scholar

Comment

These Hunterian ligations for complex basilar artery aneurysms have become rare since the development of endovascular techniques. Nonetheless, there is a substantial data base in the literature, e.g. Steinberg and Drake's account of the London/Ontario series [2]. Furthermore, I think that the recommendation to use SSEPs as a guide for basilar occlusion is dangerous, although critically discussed. One cannot be sure enough, that no critical perforator is compromised. In case of doubt with regard to to lerance of basilar occlusion, Dr. Drake used to occlude the basilar artery in these situations on the awake patient with the help of a small tourniquet. Local anaesthesia is certainly still the best method to monitor endovascular occlusion of critical arteries, such as carotid or vertebral arteries. The surgical variant of therapeutic occlusion is still an acceptable modality for the basilar artery since there are concerns to use balloon or coil occlusion, i.e. perforator compromise and the danger of dislodgement. Dr. Drake's method was somewhat tricky and is not suitable for occasional use. A balloon occlusion test may also be considered as a method to assess to lerance prior to permanent basilar artery occlusion [1].

References

  1. Hartmann A , Conolly ES , Duong DH , Prestigiacomo CJ , Joshi S , Mohr JP , Mast H . Dysarthria during basilar artery balloon occlusion . Neurology 1999 ; Jul 22; 53(2) : 421 - 423

  2. Steinberg GK , Drake CG , Peerless SJ . Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients . J Neurosurgery 1993 ; Aug; 79(2) : 161 - 173
    H.-J. Steiger, Düsseldorf

Correspondence

Dr. O. Bozinov

Philipps Universität

Neurochirurgie

Baldingerstraße

35033 Marburg

Germany

Phone: +49/6421 286 644 7

Fax: +49/6421 286 641 5

Email: bozinov@med.uni-marburg.de