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Only 3 left! Add to Cart. The mortality rates in endovascular coiling and microsurgical clipping groups were similar for patients with large aneurysms. The question about the ideal treatment for specific GIA characteristics remained unanswered. Fraser Fraser, opposed handling GIAs the same way as other aneurysms, and suggested that case-based aneurysm treatment should be applied for GIAs.
Lack of published comparisons stems from diversity of GIAs as one is amenable to endovascular therapy and another for surgery. Such lesions often demand a combined endovascular and microsurgical approach. The full armamentarium should be available to the cerebrovascular team to facilitate a comprehensive treatment method for these lesions. Maximizing efficacy and minimizing risk should always be a goal of effective approach for GIAs.
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Tabulated comparisons of these two methods, based on other publications, elaborate the present controversy in GIA treatment Table 2. Mortality and rehemorrhage rates are similar, but complete occlusion and retreatment rates are higher in endovascular therapy studies.
However, the assessment is valid only when meta-analysis would be performed. Listed series rarely exceed a hundred patients, comprises both patients with ruptured and unruptured GIAs and where different therapy strategies were applied in different publications. It seems impossible to provide one and ultimately the best treatment modality or to perform randomized trials for patients suffering from GIAs. The comparison of treatment results: endovascular versus neurosurgical therapy in GIAs.
The current results for the endovascular treatment of GIAs with parent vessel preservation are not encouraging and are not as favourable as those for smaller aneurysms. However, most GIAs are amenable to endovascular coiling alone, balloon-assisted or stent-assisted coil embolization. Vessel reconstruction, especially in fusiform aneurysms, can be achieved by flow diverting stents.
Nevertheless endovascular therapy is a treatment of choice in the majority of GIAs in most centres. A continuous development of techniques and devices can supersede surgery of GIAs in the future.
Giant Intracranial Aneurysms: Therapeutic Approaches by - ininxiecito.tk
Large neck-to-dome ratio and limited surgical access are the main challenging therapeutic characteristics of GIAs. A part of the parent vessel proximally and distally to GIA, associated perforators, adjacent vessels and neural structures should be identified before GIA securing. These actions are imperative to reduce the consequences of intraoperative GIA rupture. Additionally, skull base surgery can cause severe complications which should be considered preoperatively.
The aim of every craniotomy or craniectomy is an enhanced exposure achieved by removing additional bone and therefore minimizing cerebral retraction. Aneurysm location dictates the appropriate approach Fig. The skull base approaches to GIAs marked in colours recommended by authors: orange — orbitozygomatic; green — pterional; red — modification of pterional approach to aneurysms of BA bifurcation; pink — far lateral; blue — retrosigmoid.
Pterional craniotomy is preferred as it is a routine approach in neurosurgery. Additional opening of the superior orbital fissure should always precede dura incisure. This manoeuvre effectively increases the angle of view, although it can rarely cause postoperative cerebrospinal fluid leakage.
Microsurgical Management of Giant Intracranial Aneurysms
The anterior clinoid process assessment in preoperative CT is strongly recommended. When deemed necessary, optic strut drilling is performed. Intradural anterior clinoid process removal. B ACP removal by the use of high speed drill with small diamond burr. Drilled ACP gives a space for prudent aneurysm neck clipping. BA bifurcation can also be approached by a modification of pterional approach, which is commonly used in our institution Krisht, ; Sloniewski, We do not use extent bone by drilling the whole zygomatic arch but we remove only its upper part.
The anterior clinoid process is occasionally removed while the lateral part of the orbit and zygomatic notch widening by drilling its superior aspect should be performed. These techniques increase the angle of view at about approximately 10 comparing to the classical pterional craniotomy Sloniewski, We always propose the use of limited a far-lateral craniectomy with opening of the foramen magnum and without posterior C1 arch removal.
In our opinion the visualization of cerebellar tonsils via C1 arch osteotomy is not essential while operating most GIAs. Petrosal or transclival approaches are associated with higher complication rates and therefore discontinued for GIA treatment in our institution. A possible cerebrospinal fluid leakage, meningitis, massive intraoperative bleeding outweigh extended exposure. Retrosigmoid approach is not originally intended for posterior circulation GIAs. Using a retrosigmoid craniectomy for GIA surgery should be supported by accessory and temporary endovascular balloon occlusion.
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A variety of microsurgical occlusion techniques are available for vascular neurosurgeons: aneurysm neck clipping, aneurysmectomy, trapping of parent vessel, wrapping aneurysm dome or extra- to intracranial by-pass. Typically, GIAs with well-defined neck are the most feasible for clipping. Vascular clips and microsurgical skills used in GIAs securing are different from those used in smaller aneurysms. A neurosurgeon should prepare before the surgery and be equipped with a complete selection of aneurysm clips: small and large, straight, angled, bayonet, fenestrated, Sugita and Sundt.
One clip usually cannot bring the aneurysm walls together thus several clips or tandem angled fenestrated clips are placed in wide-necked or fusiform aneurysms Fig. These techniques are used to reconstruct the lumen of the afflicted parent vessel. Aneurysm clips have their limitations, whereas the most important in GIA surgery is weak closing forces.
Placing several clips or stacking one on the top of another can prevent clip slippage. B Several straight clips placement. Then it is easier to stack the second clip, usually a straight or bayonet clip. All of the above microsurgical manoeuvres can lead to aneurysm rupture by puncturing the wall by the tip of a blade.
Massive bleeding is a devastating event that results in altered clip positioning, differing from the positioning originally intended.
Aneurysmectomy, followed by clipping, theoretically resolves the compression of GIA on the neural structures. However, the studies of coiled GIAs revealed that neuropathies were caused by the pulsation of the aneurysm Gonzalez, Therefore the aneurysmectomy or thrombosis evacuation may be abandoned. Aneurysm dome incision produces massive bleeding if the aneurysm neck is incompletely clipped. Wrapping is used as a sole method of securing GIAs or combined with clipping clip-wrapping technique. The treatment of GIAs should not be aimed at wrapping, although long-term findings based on 63 cases indicated that it is safe and durable method Deshmukh, In our opinion, preventing rehaemorrhage from a GIA before further by-pass or coiling is the goal of wrapping.
Various materials can be used, including cotton, muscle, gauze, Teflon, adhesives fibrin glue and sealant or collagen-impregnated Dacron fabric. We prefer to use cotton because it causes an intermediate inflammatory response Herrera, The previous results suggested that wrapping ruptured aneurysms is less effective than clipping in preventing rehaemorrhage or regrowth Minakawa, ; Todd, The contemporary papers showed that wrapping of unclippable aneurysms mostly GIAs may be protective.
Furthermore, the risk of complications due to wrapping is low. Extracranial to intracranial bypass. A Saphenous vein graft filled with saline and heparin. C Temporary clips are being opened and the vein graft is filled with circulating blood.
Incorporation of parent vessels, giant dome, arteriosclerosis or dense calcification of the aneurysm dome and neck, or fusiform shape may prevent successful obliteration. However, BTO has several variations, technical nuances and interpretations Lesley, The adjunct of xenon cerebral blood flow measurement, single-photon-emission in computer tomography and transcranial Doppler ultrasonography increased the sensitivity of BTO Fraser, Bypass is an alternative method of securing from further rupture.
Since the first superficial temporal artery STA to MCA by-pass, the revascularisation methods have significantly developed.