Surgical Treatment of Distal Anterior Cerebral Artery Aneurysms with Horizontal Head Position

Abstract

Objective: In the surgery for a distal anterior cerebral aneurysm which is applied with a vertical head position, the dome of the aneurysm makes it difficult the expose the neck and the proximal artery. This study was performed to evaluate the applicability of the alternative contralateral interhemispheric approach with a horizontal head position for clipping these aneurysms. Method: The head of the patient was placed in the horizontal position such that the aneurysm side remained at the top and then tilted 45 degrees superiorly. On the contralateral side, the craniotomy, interhemispheric dissection and clipping were performed in 12 patients with 13 aneurysms. Results: All aneurysms were clipped successfully. Problems in the standard supine position such as the obstruction of the access to the aneurysm neck and the proximal artery by the dome were not encountered. Vasospasm developed in 4 patients and akinetic mutism in 1 patient; postoperative convulsion due to an inadvertent cortical venous injury in one patient resolved with medical treatment. Hydrocephalus developed in 2 patients; one patient needed placement of a ventriculoperitoneal shunt while the other responded to occasional lumbar punctures. Mortality or permanent morbidity did not occur. Conclusion: The horizontal head position may be an alternative for circumventing difficulties posed by the location of distal anterior cerebral artery aneurysms.

Key words

Distal anterior cerebral aneurysm - surgical technique - contralateral interhemispheric approach

References

• 1 Sousa A de, Dantas R, Cardosa G de, Costa B. Distal anterior cerebral artery aneurysms.  Surg Neurol. 1999;  52 128-136
• 2 Hernesniemi J, Tapaninaho A, Vapalahti M, Minna N, Kari A, Luukkonen M. Saccular aneurysms of the distal anterior cerebral artery and its branches.  Neurosurgery. 1992;  31 994-999
• 3 Jomim M, Lesoin F, Lozes G. Prognosis with 500 ruptured and operated intracranial aneurysms.  Surg Neurol. 1984;  21 13-18
• 4 Laitinen L, Senellman A. Aneurysm of pericallosal artery: A study of 14 cases verified angiographically and treated mainly by direct surgical attack.  J Neurosurg. 1960;  17 447-458
• 5 MacKissock W, Paine K W, Walsh L S. An analysis of the results of treatment of ruptured intracranial aneurysms: Report of 772 consecutive cases.  J Neurosurg. 1960;  17 762-776
• 6 Mann K S, Yue C P, Wong G. Aneurysm of pericallosal-callosomarginal junction.  Surg Neurol. 1984;  21 261-266
• 7 Ohno K, Monma S, Suzuki R, Masaoka H, Matsushima Y, Hirakawa K. Saccular aneurysm of the distal anterior cerebral artery.  Neurosurgery. 1990;  27 907-912
• 8 Royand F, Carter L P, Guthkelch A N. Distal anterior cerebral artery aneurysms. In: Carter LP, Spetzler RF, Hamilton MG (eds). Neurovascular Surgery. New York: McGraw-Hill 1995: 717-728
• 9 Sindau M, Pelissou-Guyotat I, Keravel Y, Athayde A A. Pericallosal aneurysms.  Surg Neurol. 1988;  30 434-440
• 10 Wisoff J H, Flamm E S. Aneurysm of the distal anterior cerebral artery and associated vascular anomalies.  Neurosurgery. 1987;  20 735-741
• 11 Yasargil M G, Carter L P. Saccular aneurysm of the distal anterior cerebral artery.  J Neurosurg. 1974;  39 218-223
• 12 Yasargil M G. Surgery of the intracranial aneurysm and results. In: Yasargil MG (ed.). Microsurgery, Vol II, Clinical considerations. Stuttgart: Georg Thieme Verlag 1984: 224-231
• 13 Yoshimoto T, Uchida K, Suzuki J. Surgical treatment of distal anterior cerebral artery aneurysm.  J Neurosurg. 1979;  50 40-44
• 14 Lawton M T, Golfinos J G, Spetzler R F. The transcallosal approach: Experience with 32 patients.  Neurosurgery. 1996;  39 729-735
• 15 Clark K. The occipital transtentorial approach to the pineal region. In: Schmidek HH, Sweet WH (eds.). Operative Neurosurgical Techniques. Orlando: Grune & Statton, Inc 1988: 11-418
• 16 Shevach I, Cohen M, Rappaport Z H. Patient positioning for the operative approach to midline intracerebral lesions: technical note.  Neurosurgery. 1992;  31 154-155
• 17 Nehls D G, Marano S R, Spetzler R F. Transcallosal approach to the contralateral ventricle: Technical note.  J Neurosurg. 1985;  62 304-306
• 18 Ehni G. Interhemispheric and pericallosal (transcallosal) approach to the cingulated gyri, intraventricular shunt tubes, and certainly deeply placed brain lesions.  Neurosurgery. 1984;  14 99-110
• 19 Lanzino G, Wanebo J E, Spetzler R F. Contralateral interhemispheric resection of thalamic cavernous malformations with frameless stereotaxy.  Operative Techniques in Neurosurg. 2002;  5 191-197
• 20 Quinones-Hinojosa A, Chang E F, Khan S A, Lawton M T, McDermott M W. Renal cell carcinoma metastatic to the choroids mimicking intraventricular meningioma.  Can J Neural Sci. 2004;  31 115-120
• 21 Ungersbock K, Perneczky A. Intraventricular aneurysm of the medial posterior choroids artery clipped via contralateral transcallosal approach.  Acta Neurochir (Wien). 1986;  82 24-27
• 22 Kurtsoy A, Kote I S, Koc R K, Akdemir H, Menku A, Tucker B. Successful surgical treatment of a thalamic hydatid cyst with contralateral transcallosal approach: Case report and review of the literature.  Pediatr Neurosurg. 1999;  31 96-99
• 23 Kurtsoy A, Oktem I S, Koc R K, Menku A, Akdemir H, Tucer B. Surgical treatment of thalamic hematomas via the contralateral transcallosal approach.  Neurosurg Rev. 2001;  24 108-113
• 24 Sekhar L N, Chanda A, Morita A. The preservation and reconstruction of cerebral veins and sinuses.  J Clin Neuroscience. 2002;  9 391-399
• 25 Park J, Hamm I S. Anterior interhemispheric approach for distal anterior cerebral artery aneurysm surgery: preoperative analysis of the venous anatomy can help to avoid venous infarction. Acta Neurochir (Wien) 2004 146: 973-977