Takao Nagaya

Clinicophysiological Aspect and Treatment in Cases with Spontaneous Carotid-cavernous Fistula

Thirteen cases with spontaneous carotid-cavernous fistula found in our clinic during the last 5 years were analyzed. The age ranged from 24 to 74 years, and 12 were women. Initial symptoms were diplopia in 3 cases, severe orbital pain or headache with nausea and vomiting in 3 cases, dull pain around the orbit in 3 cases, red eye in 2 cases and tinnitus in 2 cases. Sings and symptoms at admission were conjuctival injection in 10 cases, chemosis in 5 cases, exophthalmos ranging from 2 to 9 mm, in 10 cases, bruit in 7 cases, disturbance of ocular movement in 7 cases, impairment of visual acuity in 4 cases, orbital pain or headache in 6 cases and tinnitus in 8 cases. Angiograms showed that in all cases dural branches of the internal carotid artery were contributors to the shunt and in at least 5 cases branches of external carotid artery were also contributors. There were positive correlation between angiographic findings and certain signs and symptoms. In all 3 cases with prominent venous drainage, disturbance of visual acuity and ocular movement were noticed. In another 10 cases, disturbance of visual acuity and ocular movements were found in one case and 4 cases, respectively. Furthermore, in 10 cases with posterior venous drainage via the inferior petrosal sinus, 8 cases complainted of tinnitus, but other 3 cases without showing posterior drainage, did not complain of tinnitus. Cerebral hemodynamic study was performed in 8 cases. In 7 cases rCBF values were normal and the relative shunt rate was small (10 ?? 23%). In another one case rCBF could not be measured because the shunt rate of the affected internal carotid artery was 100%. These results coincided with the angiographic findings. Twelve cases were not operated on and follow-up study ranging from 9 months to 5.2 years were carried out. Clinical symptoms were alleviated in 4 cases and completely disappeared in 8 cases. The follow-up angiography in the latter 3 cases showed disappearance of the shunt. Consequently, in cases with small blood deprivation through the shunt and mild clinical symptoms, conservative treatment is recommended unless exacerbation is not noticed.

Surgical Treatment of Multiple Aneurysms

The authors reviewed surgical results of 618 surgically treated patients with intracranial aneurysms. Multiple aneurysms were observed in 106 (20%) patients. In cases of multiple aneurysms, their policy has been to treat all aneurysms, ruptured and unruptured, in a one-stage operation whenever possible. All aneurysms of 92 patients were treated in one-stage operations. Eighty three (90%) patients improved or remained stationary, 6 (7%) deteriorated, 3 (3%) died postoperatively. The cause of deterioration or death were due to cerebral vasospasm, primary brain damage or surgical procedure for ruptured aneurysms. No significant difference was found in comparing the rupture site of the aneurysm or the timing of the operation in each preoperative clinical grade. Furthermore, all patients were classified into three groups according to the location of the aneurysms. Sixty-two patients had unilateral aneurysms including aneurysms in the midline, i.e. anterior communicating artery aneurysms, distal basilar artery aneurysms and/or bilateral pericallosal artery aneurysms (unilateral group), and 30 patients had bilateral aneurysms (bilateral group). Morbidity and mortality in unilateral group was 6% and 3%, while in bilateral group, 7%, 3% respectively. No significant difference was observed in the bilateral group compared with the unilateral group, and surgical results of each group appeared to be satisfactory. Neither death nor deterioration was found attributable to operative procedure when unruptured aneurysms were added to the surgery for ruptured aneurysms in a one-stage operation. These surgical results for 92 cases were similar to the results in the rest of the 526 cases. Based on these results, the one-stage operation is recommended, whenever possible, for patients with multiple aneurysms, even if bilateral craniotomy is needed.

Surgical Procedures in Cases with Ruptured Anterior Communicating Aneurysms

In general, the results of surgery on anterior communicating aneurysms (ACom AN) is worse than that on internal carotid and middle cerebral aneurysms (IC and MC AN), because of technical difficulty due to the deep location and complex anatomical relationships . Some attempts were made in our hospital to reduce the technical difficulty and improve the surgical results of operation for ACom AN. In this paper, the effect of these attempts was analysed in 208 cases . The timing of the operation and clinical grade were as followes: within 3 days: 67 cases , 4-14 days: 41 cases, over 14 days: 100 cases, I-II: 154 cases, III: 38 cases , IV-V: 15 cases. The operation was carried out by the unilateral pterional approach in all cases . In each case, the side of the approach was determined by angiographic findings except for cases with additional AN and significant hematoma . Craniotomy was performed at the side of the dominant Al in cases where the AN projected forward-downward. In the other cases, the operation was carried out at the side of the deep-seated A2. Use of a temporary clip for a short time and partial removal of gyrus rectus were positively carried out. Craniotomy was performed at the right side in 93 cases (45%) and at the left side in 115 cases (55%). A temporary clip was used in 106 cases (51%) and was significantly frequent in grade II, III cases and in cases operated on within 14 days after SAH. Partial removal of the gyrus rectus was performed in 61 cases (29%) and was significantly frequent in cases where the AN projected upward, grade III, IV cases and cases operated on within 14 days after SAH. Clipping of the AN was performed in all cases. Operatve mortality plus morbidity rate was as follow; I-II: 7%, III: 20%, IVV: 25%. The side of the craniotomy, use of a temporary clip and partial removal of the gyrus rectus caused no significant difference in these rates . The results in cases with AN were almost the same as the results with IC and MC AN. From these results , we can conclude that the side of the craniotomy should be determined by angiographic findings in each case , and use of a temporary clip and partial removal of the gyrus rectus should be carried out actively at the time of the operation for ACom AN.

The Indication for Surgical Treatment in Patients over 60 Years of Age with the Ruptured Intracranial Aneurysm

Fourty-eight cases over 60 years of age with the ruptured intracranial aneurysm were surgically treated. Satisfactory occlusion of the aneurysm with clipping of ligation was attained in 44 cases and plastic coating was performed in 4 cases. In 3 cases with a large intracerebral hematoma, the early operation was carried out and 2 cases died of the gastrointestinal bleeding and progressive cerebral vasospasm after the operation. In 45 cases, the operation was carried out more than 2 weeks after the subarachnoid hemorrhage. In 4 cases (9%), additional neurological symptoms developed after the operation and the occlusion of the main cerebral artery occured in 2 cases out of these cases related to the operative procedure. Three cases (7%) died of rebleeding due to the incomplete clipping, acute emphysema and agranulocytosis respectively. Thirty-five cases were followed up for 3 months to 10 years. At the time of this follow-up study, 25 (71%) were either free from symptoms or only with minor neurological deficits. Seven cases (20%) had moderate to severe symptoms; 4 cases had complications noticed more than 1.5 months after the operation and considered to be unrelated to the surgical maneuvar, 2 cases had various neurological deficits exsisted before the operation and only one case had the deficit related to the operative procedure. Three cases (9%) had died of pulmonary carcinoma and pneumonia 3 months to 10 years after the operation. Eighteen cases, including 10 cases over 65 years of age, were operated with microsurgical techniques more than 2 weeks after the bleeding. In this group, only one case died of agranulocytosis and no case became disabled. These results indicate that the direct intracranial operation using microsurgical techniques should be the first choice of the treatment in aged patients who are able to make a daily living without any complaints and do not have severe complications before the bleeding. Furthermore, even when prolonged initial unconsciousness and arteriosclerosis of intracranial vessels are present, the operation can be performed safely by delicate procedures using microsurgical techniques.