Departments of Neurosurgery (JEB, JAW) and Diagnostic Radiology (ZLD), Allegheny General Hospital, and Departments of Radiology and Neurological Surgery (CAJ, JAH), Presbyterian University Hospital, Pittsburgh, Pennsylvania Neurosurgery 30; 949-953, 1992 ABSTRACT: The direct surgical treatment of intracranial aneurysms is not always possible, especially in posterior circulation aneurysms. This is usually because of their complex anatomy and location next to the skull base and brain stem, where proximal vascular control is usually not attainable. Four patients at our institution underwent intraoperative transfemoral catheterization of the basilar artery with a nondetachable endovascular balloon for proximal control of the basilar artery. The flow control in the basilar artery was excellent and facilitated the surgery. Before surgery, each patient underwent the placement of a 10-cm 8-French femoral introducer sheath and were taken to the operating room where they were placed in a supine position and a subtemporal or pterional craniotomy was performed. After the initial exposure and before aneurysm manipulation, a nondetachable silicone balloon catheter was passed through an introducer catheter and was placed into the rostral basilar artery, using flow direction, microguidewires, and angiographic "road-mapping" techniques. In two patients, temporary basilar occlusion was used to collapse the aneurysm and to facilitate clip placement. In the third patient, intraoperative aneurysm rupture occurred and was controlled by temporary basilar artery occlusion. Using intraoperative angiography, complete aneurysm obliteration and vessel patency was confirmed in all four patients. All patients made a complete recovery except for initial postoperative third nerve palsies in three patients. This technique achieves intraoperative control of the basilar artery proximal to an aneurysm by the use of a nondetachable occlusive balloon in the basilar artery. An added benefit is the ease with which intraoperative angiography can be obtained in this context. The simultaneous combination of interventional neuroradiological and surgical techniques may provide more definitive and safer treatment than either modality alone. KEY WORDS: Balloon occlusion; Basilar artery; Catheter; Cerebral aneurysm; Intraoperative angiography
SUMMARY OF PATIENTS Four patients were admitted who had subarachnoid hemorrhage from ruptured basilar artery aneurysms. All four were women, ages 18, 26, 54, and 58 years. Three aneurysms were located at the basilar apex, and one originated between the right posterior cerebral and superior cerebellar arteries. All four aneurysms measured 1.5 to 2 cm in diameter. At the time of surgery, all patients were alert and without deficit except for bilateral oculomotor nerve palsy in one patient and a unilateral oculomotor nerve palsy in another. Technique On the morning of surgery, each patient was brought to the radiology suite where an 8-French sheath (Radiofocus Introducer B Kit, Terumo Corp., Tokyo, Japan) was placed into the right femoral artery. A slow infusion of heparinized saline was begun, and the patient was transported to the operating room. The patient was placed in a supine position on a radiolucent operating table in a standard Mayfield headholder. The head was positioned with rotation suitable for a standard subtemporal or pterional approach, with access to the groin maintained for catheterization. Before draping the patient, the operative site was radiographically visualized in the anteroposterior projection with Carm fluoroscopy to assure a proper angiographic picture and that the headholder apparatus did not obscure visualization of the intracranial contents. After the subtemporal or pterional craniotomy and initial exposure of the basilar artery region was performed but before manipulation of the aneurysm, further surgical dissection was briefly suspended. The radiology team then inserted an 8-French introducer catheter (Introducer Catheter Set, Interventional Therapeutics Corp., South San Francisco, CA) coaxially through the right femoral artery sheath into the cervical portion of the left vertebral artery, using standard angiographic techniques and portable digital
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
AUTHOR(S): Bailes, Julian E., M.D.; Deeb, Ziad L., M.D.; Wilson, John A., M.D.; Jungreis, Charles A., M.D.; Horton, Joseph A., M.D.
INTRODUCTION The preferred treatment for intracranial aneurysms is surgical clipping and exclusion from the circulation. In certain cases, because of size, configuration, and/or location, intracranial aneurysms are not amenable to surgical therapy. This is especially true with posterior circulation aneurysms because of the inability to obtain proximal access and control of the parent vessel. Recent developments in interventional radiological techniques for the treatment of intracranial aneurysms have focused on the use of detachable balloons for occlusion of the aneurysm or of the parent vessel itself (2,4,7,8). We report the combination of intraoperative, temporary, proximal vascular occlusion and angiography, using endovascular balloon technology for the treatment of patients with posterior circulation aneurysms. This is an attempt to improve the safety and accuracy of aneurysm clipping by obtaining proximal vessel control and immediate demonstration of results with intraoperative angiographic techniques.
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Neurosurgery 1992-98 June 1992, Volume 30, Number 6 949 Intraoperative Angiography and Temporary Balloon Occlusion of the Basilar Artery as an Adjunct to Surgical Clipping: Technical Note Technical Note
DISCUSSION Of all cerebral aneurysms, those arising from the posterior circulation have traditionally been the most difficult to treat (10). This is primarily related to the complex anatomy of the basilar artery, its major branches and perforators, and the neural structures associated with the brain stem. Occlusion of virtually any of the arterial supply to the midbrain, pons, or medulla may result in a devastating ischemic event and/or death. Direct injury to the brain stem or cranial nerves likewise leads to severe patient compromise. Furthermore, because of the location of the vertebral and basilar arteries and their intimate relationship to the skull base and brain stem, achievement of proximal vascular control of the basilar artery is not accomplished until well into the dissection, is associated with manipulation of vital structures, and often is impossible to attain (12). Access to the parent vessel proximal to a vascular lesion is a basic principle of vascular surgery. The importance of this maneuver is also emphasized because of the propensity of basilar artery aneurysms to rupture intraoperatively at a higher rate than aneurysms in other locations (5). By employing the nondetachable silicone balloon catheter, proximal control of the basilar artery is achieved early in the procedure. With temporary balloon inflation, catastrophic bleeding is prevented, allowing time for definitive or more precise clip application. In addition, in the patients in our series, temporary basilar artery occlusion was successfully used to collapse the aneurysm at the time of clip application, thus making it easier for the clip to properly rest on the aneurysm and the normal neural and vascular structures to be identified. The use of intraoperative angiography requires little deviation in procedure from the usual craniotomy for aneurysms (1,3,4,13). The femoral artery introducer is placed preoperatively, and the patient is placed in a supine position on the operating table. Standard operating equipment is used for the craniotomy, with a radiolucent headholder facilitating the fluoroscopy. After the bony exposure is completed and before the aneurysm is manipulated, the nondetachable balloon is positioned uninflated in the rostral basilar artery. Intraoperative angiograms are taken, if needed, to aid in the localization and after clip placement to ascertain the patency of major arterial branches and complete aneurysm obliteration. Thus, there is no significant logistical or time inconvenience involved with this procedure. The use of temporary balloon occlusion of the basilar artery appears, at least in our limited series, to be well tolerated for brief periods when combined with the administration of cerebroprotective agents. The positioning of the balloon in the rostral basilar artery avoids the majority of arterial perforators to the pons (Fig. 2). In addition, intraoperative hypotension is not required. Catheter-induced mural injury has not occurred in our experience but remains a concern. Embolic complications likewise have not been
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Surgical results All four patients underwent successful clipping of their aneurysms. In each case, intraoperative angiography was used to confirm the completeness of the aneurysm obliteration and the patency of the major arterial branches. In two patients, temporary basilar artery occlusion was used to collapse the aneurysm sac to improve visualization of the anatomy and facilitate clip placement. In another patient, as the microdissection around the neck of the aneurysm proceeded, hemorrhage occurred from the dome of the aneurysm where it was protruding against the clivus. Attempts to control this with gentle pressure with a cottonoid and suction were unsuccessful. With inflation of the basilar artery balloon, we were able to achieve immediate control of the intraoperative hemorrhage and subsequent safe dissection and placement of a clip across the neck of the aneurysm. Because of the size of the aneurysm, it was difficult to visualize the opposite P-1 segment. The clip was applied within 3 minutes of the occlusion of the basilar artery, and the balloon was subsequently deflated. An intraoperative angiogram was immediately obtained that revealed that there was a several millimeter rest of aneurysm neck that remained below the clip. The balloon was again inflated, allowing placement of a second clip proximal to the first. The balloon was deflated, and an intraoperative angiogram was obtained. This time, it revealed a partial compromise of the left P-1 segment. The clips were adjusted several more times with the aid of intraoperative angiography to immediately document a final correct clip placement. The postoperative course of all four patients was unremarkable. At the time of discharge, the patient with bilateral oculomotor nerve palsy had had mild worsening of this deficit but otherwise was normal. One patient had a small thalamic infarct visualized
radiographically but was asymptomatic and neurologically intact.
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
angiography equipment (OEC-Diasonics, Inc., Salt Lake City, UT). A nondetachable 0.5-ml silicone balloon catheter (1505 NDSB Occlusion Balloon Catheter, Interventional Therapeutics Corp.) was passed through the introducer catheter to a final position in the rostral basilar artery, well distal to the takeoff of the anterior inferior cerebellar arteries. Live subtraction and road-mapping techniques were employed to expedite this catheterization. Continuous heparinized saline perfusion was used to irrigate the potential dead space between the coaxial catheters. Once in final position, test occlusion was performed by contrast injection through the base catheter to ascertain the exact volume required for complete occlusion (Fig. 1). The angiographic equipment was left in position and did not hinder the surgical procedure. Further occlusions were performed with the predetermined balloon inflation volume and without fluoroscopy. Except for test occlusions, inflation of the silicone balloon for temporary occlusion of the basilar artery was limited to 3minute intervals and was preceded by intravenous administration of mannitol (0.25 gm/kg) and a thiobarbiturate (5 mg/kg) for cerebral protection.
4.
5.
6.
7.
8.
9.
10.
11.
12. Received for publication, October 3, 1991; accepted, final form, December 13, 1991. Reprint requests: Julian E. Bailes, M.D., Department of Neurosurgery, Allegheny General Hospital, 320 E. North Avenue, Pittsburgh, PA 15212.
13.
2:167-173, 1981. Foley KT, Cahan LD, Hieshima GB: Intraoperative angiography using a portable digital subtraction unit: Technical note. J Neurosurg 64:816-818, 1986. Fox AJ, Vinuela FA, Pelz DM, Debrun GM, Ferguson GG, Peerless SJ, Girwin JP, Drake CG: Use of detachable balloon occlusion for the treatment of unclippable cerebral aneurysms. AJNR 5:664, 1984 (abstr). Giannotta SL, Oppenheimer JH, Levy ML, Zelman V: Management of intraoperative rupture of aneurysm without hypotension. Neurosurgery 28:531-536, 1991. Hieshima GB, Reicher MA, Higashida RT, Halbach VV, Cahan ULD, Frazee JG, Rand RW, Bentson JR: Intraoperative digital subtraction neuroangiography: A diagnostic and therapeutic tool. AJNR 8:759-767, 1987. Higashida RT, Halbach VV, Dormandy B, Bell J, Hieshima GB: Endovascular treatment of intracranial aneurysms with a new silicone microballoon device: Technical considerations and indications for therapy. Radiology 174:687-691, 1990. Higashida RT, Halbach VV, Dowd CF, Barnwell SL, Hieshima GB: Intracranial aneurysms: Interventional neurovascular treatment with detachable balloons-results in 215 cases. Radiology 178:663-670, 1991. Lin T, Fox AJ, Drake CG: Regrowth of aneurysm sacs from residual neck following aneurysm clipping. J Neurosurg 70:556- 560, 1989. Peerless SJ, Drake CG: Management of aneurysms of the posterior circulation, in Youmans JR (ed): Neurological Surgery. Philadelphia, WB Saunders Co., 1990, pp 1764-1806. Shucart WA, Kwan ES, Heilman CB: Temporary balloon occlusion of a proximal vessel as an aid to clipping aneurysms of the basilar and paraclinoid internal carotid arteries: Technical note. Neurosurgery 27:116119, 1990. Smith RR: Comment on Giannotta SL, Oppenheimer JH, Levy ML, Zelman V: Management of intraoperative rupture of aneurysm without hypotension. Neurosurgery 28:535, 1991. Smith RW: Intraoperative intracranial angiography. Neurosurgery 1:107-110, 1977.
REFERENCES: (1-13) 1.
2.
Batjer HH, Frankfurt AI, Purdy PD, Smith SS, Samson DS: Use of etomidate, temporary arterial occlusion, and intraoperative angiography in surgical treatment of large and giant cerebral aneurysms. J Neurosurg 68:234240, 1988. Debrun G, Fox A, Drake G, Peerless S, Girvin J, Ferguson G: Giant unclippable aneurysms: Treatment with detachable balloons. AJNR
COMMENT It appears only a matter of time until an adequate road-mapping x-ray machine is in every neurovascular operating room. Temporary basilar artery clipping has proven safe and effective, but it may add greatly to the technical difficulties of a very confined space. This technique assures the advantages without the limitations. As experience is
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
3.
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
observed in our patients. Because full systemic anticoagulation is not desirable with craniotomy, heparinized saline is infused locally around the catheter. This technique is successfully used to prevent embolic complications in most intracranial endovascular procedures. Intraoperative cerebral angiography has proven itself to be a valuable adjunct in selected vascular cases (1,3,6,13). In addition to providing a constant ability to visualize the location of the aneurysm, intraoperative angiography appears to minimize, to some degree, the required extent of dissection across to the opposite side and at the distal portion of the basilar artery. Obtaining proximal control of the basilar artery has previously not been possible and has largely contributed to the formidable challenge of this surgery. Shucart et al. (11) recently reported the successful use of proximal vessel balloon occlusion in three patients with internal carotid aneurysms. A fourth patient with a basilar apex aneurysm had unsuccessful catheterization of the basilar artery, and, instead, temporary occlusion of the vertebral artery was employed. It is generally accepted that surgical clipping and complete exclusion of an aneurysm from the cerebral circulation is the preferred treatment when possible (9) . The simultaneous combination of interventional neuroradiological and surgical techniques may constitute better therapy of posterior circulation aneurysms than treatment with either modality alone. This small series highlights the technical aspects of this procedure, and additional experience should determine its ultimate application, safety, and utility. [The radiological technical aspect of this manuscript was accepted by the American Journal of Neuroradiology. It describes three patients for the neuroradiological audience to make them aware of this catheterization technique and balloon technology. The manuscript for Neurosurgery was written with the addition of a fourth patient and describes this procedure from the neurosurgeon's perspective, places it in the armamentarium of surgical therapeutic techniques, and suggests a logical approach to combining intraoperative and endovascular methods.]
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Sean Mullan Chicago, Illinois
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
gained, the time limitations of occlusion will be determined. In this area of frequently generous collateral from the posterior communicating arteries, it may be prolonged and might be determined at surgery by occipital electroencephalography (or possibly by visual evoked potentials). The safety and duration of occlusion could also be obtained by preoperating trial occlusion, possibly at the time of the initial angiography. In the light of these, the need for ischemic protective drugs could be evaluated. The technique is even more applicable to the carotid artery where balloon placement under the aneurysm neck can assure a totally avascular aneurysm approach, and where the temporary occlusion time is usually substantial. Again it can easily be measured, either by preoperative testing, intraoperative monitoring, or both. It is possible to visualize a time where an intravascular, temporary occluding balloon becomes routine in the management of anything but the simplest aneurysm. The authors deserve congratulations.
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
Figure 1. A, a digital subtraction angiogram of the cervical vertebral artery is obtained before surgery and should include the origin of the artery. This should be performed with the patient positioned in the surgical position (i.e., with the head turned to the left). This proved important in one patient in whom the vertebral artery was stenotic where it entered the foramen transversarium, accentuated with head rotation to the left. Angiographic road-mapping techniques are an aid to intraoperative catheterization. B, an intraoperative angiogram after the injection of the base catheter reveals the tip of the balloon catheter (arrow). The balloon is attached to the tip distally and is not seen here. C, the balloon (large arrow) is seen in the distal basilar artery beyond the catheter tip (small arrow) after partial inflation with contrast material. D, a postclipping intraoperative angiogram shows the successful obliteration of the aneurysm with preservation of all major basilar artery branches.
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
Figure 2. Artist's drawing illustrating the position of the nondetachable silicone balloon inflated in the rostral basilar artery. The balloon is distal to the majority of the pontine arterial branches and just proximal to the aneurysm neck.
SUMMARY OF PATIENTS Four patients were admitted who had subarachnoid hemorrhage from ruptured basilar artery aneurysms. All four were women, ages 18, 26, 54, and 58 years. Three aneurysms were located at the basilar apex, and one originated between the right posterior cerebral and superior cerebellar arteries. All four aneurysms measured 1.5 to 2 cm in diameter. At the time of surgery, all patients were alert and without deficit except for bilateral oculomotor nerve palsy in one patient and a unilateral oculomotor nerve palsy in another. Technique On the morning of surgery, each patient was brought to the radiology suite where an 8-French sheath (Radiofocus Introducer B Kit, Terumo Corp., Tokyo, Japan) was placed into the right femoral artery. A slow infusion of heparinized saline was begun, and the patient was transported to the operating room. The patient was placed in a supine position on a radiolucent operating table in a standard Mayfield headholder. The head was positioned with rotation suitable for a standard subtemporal or pterional approach, with access to the groin maintained for catheterization. Before draping the patient, the operative site was radiographically visualized in the anteroposterior projection with Carm fluoroscopy to assure a proper angiographic picture and that the headholder apparatus did not obscure visualization of the intracranial contents. After the subtemporal or pterional craniotomy and initial exposure of the basilar artery region was performed but before manipulation of the aneurysm, further surgical dissection was briefly suspended. The radiology team then inserted an 8-French introducer catheter (Introducer Catheter Set, Interventional Therapeutics Corp., South San Francisco, CA) coaxially through the right femoral artery sheath into the cervical portion of the left vertebral artery, using standard angiographic techniques and portable digital
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
AUTHOR(S): Bailes, Julian E., M.D.; Deeb, Ziad L., M.D.; Wilson, John A., M.D.; Jungreis, Charles A., M.D.; Horton, Joseph A., M.D.
INTRODUCTION The preferred treatment for intracranial aneurysms is surgical clipping and exclusion from the circulation. In certain cases, because of size, configuration, and/or location, intracranial aneurysms are not amenable to surgical therapy. This is especially true with posterior circulation aneurysms because of the inability to obtain proximal access and control of the parent vessel. Recent developments in interventional radiological techniques for the treatment of intracranial aneurysms have focused on the use of detachable balloons for occlusion of the aneurysm or of the parent vessel itself (2,4,7,8). We report the combination of intraoperative, temporary, proximal vascular occlusion and angiography, using endovascular balloon technology for the treatment of patients with posterior circulation aneurysms. This is an attempt to improve the safety and accuracy of aneurysm clipping by obtaining proximal vessel control and immediate demonstration of results with intraoperative angiographic techniques.
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Neurosurgery 1992-98 June 1992, Volume 30, Number 6 949 Intraoperative Angiography and Temporary Balloon Occlusion of the Basilar Artery as an Adjunct to Surgical Clipping: Technical Note Technical Note
DISCUSSION Of all cerebral aneurysms, those arising from the posterior circulation have traditionally been the most difficult to treat (10). This is primarily related to the complex anatomy of the basilar artery, its major branches and perforators, and the neural structures associated with the brain stem. Occlusion of virtually any of the arterial supply to the midbrain, pons, or medulla may result in a devastating ischemic event and/or death. Direct injury to the brain stem or cranial nerves likewise leads to severe patient compromise. Furthermore, because of the location of the vertebral and basilar arteries and their intimate relationship to the skull base and brain stem, achievement of proximal vascular control of the basilar artery is not accomplished until well into the dissection, is associated with manipulation of vital structures, and often is impossible to attain (12). Access to the parent vessel proximal to a vascular lesion is a basic principle of vascular surgery. The importance of this maneuver is also emphasized because of the propensity of basilar artery aneurysms to rupture intraoperatively at a higher rate than aneurysms in other locations (5). By employing the nondetachable silicone balloon catheter, proximal control of the basilar artery is achieved early in the procedure. With temporary balloon inflation, catastrophic bleeding is prevented, allowing time for definitive or more precise clip application. In addition, in the patients in our series, temporary basilar artery occlusion was successfully used to collapse the aneurysm at the time of clip application, thus making it easier for the clip to properly rest on the aneurysm and the normal neural and vascular structures to be identified. The use of intraoperative angiography requires little deviation in procedure from the usual craniotomy for aneurysms (1,3,4,13). The femoral artery introducer is placed preoperatively, and the patient is placed in a supine position on the operating table. Standard operating equipment is used for the craniotomy, with a radiolucent headholder facilitating the fluoroscopy. After the bony exposure is completed and before the aneurysm is manipulated, the nondetachable balloon is positioned uninflated in the rostral basilar artery. Intraoperative angiograms are taken, if needed, to aid in the localization and after clip placement to ascertain the patency of major arterial branches and complete aneurysm obliteration. Thus, there is no significant logistical or time inconvenience involved with this procedure. The use of temporary balloon occlusion of the basilar artery appears, at least in our limited series, to be well tolerated for brief periods when combined with the administration of cerebroprotective agents. The positioning of the balloon in the rostral basilar artery avoids the majority of arterial perforators to the pons (Fig. 2). In addition, intraoperative hypotension is not required. Catheter-induced mural injury has not occurred in our experience but remains a concern. Embolic complications likewise have not been
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Surgical results All four patients underwent successful clipping of their aneurysms. In each case, intraoperative angiography was used to confirm the completeness of the aneurysm obliteration and the patency of the major arterial branches. In two patients, temporary basilar artery occlusion was used to collapse the aneurysm sac to improve visualization of the anatomy and facilitate clip placement. In another patient, as the microdissection around the neck of the aneurysm proceeded, hemorrhage occurred from the dome of the aneurysm where it was protruding against the clivus. Attempts to control this with gentle pressure with a cottonoid and suction were unsuccessful. With inflation of the basilar artery balloon, we were able to achieve immediate control of the intraoperative hemorrhage and subsequent safe dissection and placement of a clip across the neck of the aneurysm. Because of the size of the aneurysm, it was difficult to visualize the opposite P-1 segment. The clip was applied within 3 minutes of the occlusion of the basilar artery, and the balloon was subsequently deflated. An intraoperative angiogram was immediately obtained that revealed that there was a several millimeter rest of aneurysm neck that remained below the clip. The balloon was again inflated, allowing placement of a second clip proximal to the first. The balloon was deflated, and an intraoperative angiogram was obtained. This time, it revealed a partial compromise of the left P-1 segment. The clips were adjusted several more times with the aid of intraoperative angiography to immediately document a final correct clip placement. The postoperative course of all four patients was unremarkable. At the time of discharge, the patient with bilateral oculomotor nerve palsy had had mild worsening of this deficit but otherwise was normal. One patient had a small thalamic infarct visualized
radiographically but was asymptomatic and neurologically intact.
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
angiography equipment (OEC-Diasonics, Inc., Salt Lake City, UT). A nondetachable 0.5-ml silicone balloon catheter (1505 NDSB Occlusion Balloon Catheter, Interventional Therapeutics Corp.) was passed through the introducer catheter to a final position in the rostral basilar artery, well distal to the takeoff of the anterior inferior cerebellar arteries. Live subtraction and road-mapping techniques were employed to expedite this catheterization. Continuous heparinized saline perfusion was used to irrigate the potential dead space between the coaxial catheters. Once in final position, test occlusion was performed by contrast injection through the base catheter to ascertain the exact volume required for complete occlusion (Fig. 1). The angiographic equipment was left in position and did not hinder the surgical procedure. Further occlusions were performed with the predetermined balloon inflation volume and without fluoroscopy. Except for test occlusions, inflation of the silicone balloon for temporary occlusion of the basilar artery was limited to 3minute intervals and was preceded by intravenous administration of mannitol (0.25 gm/kg) and a thiobarbiturate (5 mg/kg) for cerebral protection.
4.
5.
6.
7.
8.
9.
10.
11.
12. Received for publication, October 3, 1991; accepted, final form, December 13, 1991. Reprint requests: Julian E. Bailes, M.D., Department of Neurosurgery, Allegheny General Hospital, 320 E. North Avenue, Pittsburgh, PA 15212.
13.
2:167-173, 1981. Foley KT, Cahan LD, Hieshima GB: Intraoperative angiography using a portable digital subtraction unit: Technical note. J Neurosurg 64:816-818, 1986. Fox AJ, Vinuela FA, Pelz DM, Debrun GM, Ferguson GG, Peerless SJ, Girwin JP, Drake CG: Use of detachable balloon occlusion for the treatment of unclippable cerebral aneurysms. AJNR 5:664, 1984 (abstr). Giannotta SL, Oppenheimer JH, Levy ML, Zelman V: Management of intraoperative rupture of aneurysm without hypotension. Neurosurgery 28:531-536, 1991. Hieshima GB, Reicher MA, Higashida RT, Halbach VV, Cahan ULD, Frazee JG, Rand RW, Bentson JR: Intraoperative digital subtraction neuroangiography: A diagnostic and therapeutic tool. AJNR 8:759-767, 1987. Higashida RT, Halbach VV, Dormandy B, Bell J, Hieshima GB: Endovascular treatment of intracranial aneurysms with a new silicone microballoon device: Technical considerations and indications for therapy. Radiology 174:687-691, 1990. Higashida RT, Halbach VV, Dowd CF, Barnwell SL, Hieshima GB: Intracranial aneurysms: Interventional neurovascular treatment with detachable balloons-results in 215 cases. Radiology 178:663-670, 1991. Lin T, Fox AJ, Drake CG: Regrowth of aneurysm sacs from residual neck following aneurysm clipping. J Neurosurg 70:556- 560, 1989. Peerless SJ, Drake CG: Management of aneurysms of the posterior circulation, in Youmans JR (ed): Neurological Surgery. Philadelphia, WB Saunders Co., 1990, pp 1764-1806. Shucart WA, Kwan ES, Heilman CB: Temporary balloon occlusion of a proximal vessel as an aid to clipping aneurysms of the basilar and paraclinoid internal carotid arteries: Technical note. Neurosurgery 27:116119, 1990. Smith RR: Comment on Giannotta SL, Oppenheimer JH, Levy ML, Zelman V: Management of intraoperative rupture of aneurysm without hypotension. Neurosurgery 28:535, 1991. Smith RW: Intraoperative intracranial angiography. Neurosurgery 1:107-110, 1977.
REFERENCES: (1-13) 1.
2.
Batjer HH, Frankfurt AI, Purdy PD, Smith SS, Samson DS: Use of etomidate, temporary arterial occlusion, and intraoperative angiography in surgical treatment of large and giant cerebral aneurysms. J Neurosurg 68:234240, 1988. Debrun G, Fox A, Drake G, Peerless S, Girvin J, Ferguson G: Giant unclippable aneurysms: Treatment with detachable balloons. AJNR
COMMENT It appears only a matter of time until an adequate road-mapping x-ray machine is in every neurovascular operating room. Temporary basilar artery clipping has proven safe and effective, but it may add greatly to the technical difficulties of a very confined space. This technique assures the advantages without the limitations. As experience is
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
3.
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
observed in our patients. Because full systemic anticoagulation is not desirable with craniotomy, heparinized saline is infused locally around the catheter. This technique is successfully used to prevent embolic complications in most intracranial endovascular procedures. Intraoperative cerebral angiography has proven itself to be a valuable adjunct in selected vascular cases (1,3,6,13). In addition to providing a constant ability to visualize the location of the aneurysm, intraoperative angiography appears to minimize, to some degree, the required extent of dissection across to the opposite side and at the distal portion of the basilar artery. Obtaining proximal control of the basilar artery has previously not been possible and has largely contributed to the formidable challenge of this surgery. Shucart et al. (11) recently reported the successful use of proximal vessel balloon occlusion in three patients with internal carotid aneurysms. A fourth patient with a basilar apex aneurysm had unsuccessful catheterization of the basilar artery, and, instead, temporary occlusion of the vertebral artery was employed. It is generally accepted that surgical clipping and complete exclusion of an aneurysm from the cerebral circulation is the preferred treatment when possible (9) . The simultaneous combination of interventional neuroradiological and surgical techniques may constitute better therapy of posterior circulation aneurysms than treatment with either modality alone. This small series highlights the technical aspects of this procedure, and additional experience should determine its ultimate application, safety, and utility. [The radiological technical aspect of this manuscript was accepted by the American Journal of Neuroradiology. It describes three patients for the neuroradiological audience to make them aware of this catheterization technique and balloon technology. The manuscript for Neurosurgery was written with the addition of a fourth patient and describes this procedure from the neurosurgeon's perspective, places it in the armamentarium of surgical therapeutic techniques, and suggests a logical approach to combining intraoperative and endovascular methods.]
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Sean Mullan Chicago, Illinois
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
gained, the time limitations of occlusion will be determined. In this area of frequently generous collateral from the posterior communicating arteries, it may be prolonged and might be determined at surgery by occipital electroencephalography (or possibly by visual evoked potentials). The safety and duration of occlusion could also be obtained by preoperating trial occlusion, possibly at the time of the initial angiography. In the light of these, the need for ischemic protective drugs could be evaluated. The technique is even more applicable to the carotid artery where balloon placement under the aneurysm neck can assure a totally avascular aneurysm approach, and where the temporary occlusion time is usually substantial. Again it can easily be measured, either by preoperative testing, intraoperative monitoring, or both. It is possible to visualize a time where an intravascular, temporary occluding balloon becomes routine in the management of anything but the simplest aneurysm. The authors deserve congratulations.
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/6/949/2751947 by Universitaetsbibliothek Muenchen user on 28 January 2019
Figure 1. A, a digital subtraction angiogram of the cervical vertebral artery is obtained before surgery and should include the origin of the artery. This should be performed with the patient positioned in the surgical position (i.e., with the head turned to the left). This proved important in one patient in whom the vertebral artery was stenotic where it entered the foramen transversarium, accentuated with head rotation to the left. Angiographic road-mapping techniques are an aid to intraoperative catheterization. B, an intraoperative angiogram after the injection of the base catheter reveals the tip of the balloon catheter (arrow). The balloon is attached to the tip distally and is not seen here. C, the balloon (large arrow) is seen in the distal basilar artery beyond the catheter tip (small arrow) after partial inflation with contrast material. D, a postclipping intraoperative angiogram shows the successful obliteration of the aneurysm with preservation of all major basilar artery branches.
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Figure 2. Artist's drawing illustrating the position of the nondetachable silicone balloon inflated in the rostral basilar artery. The balloon is distal to the majority of the pontine arterial branches and just proximal to the aneurysm neck.
