Download Approaches To Intracranial Aneurysms Iraj Bemana, M.D.,PhD Razi

In The Name Allah
Approaches To Intracranial
Aneurysms
Iraj Bemana, M.D.,PhD
Razi Hospital ,Qazvin
Approaches to Intracranial Aneurysms
•
•
•
•
•
Intracranial aneurysms can be occluded using:
Direct surgical techniques
Endovascular approaches,
Combined surgical and endovascular strategies,
Or indirect techniques such as revascularization
procedures and Parent vessel occlusion.
Approaches to Intracranial Aneurysms
• The optimal treatment strategy is best handled
by a team of neurovascular and endovascular
surgeons to select an occlusion strategy that is
suited to the patient and the aneurysm.
Approaches To Intracranial Aneurysms
• There are several techniques that are common
to all aneurysms, including patient selection and
diagnostic studies, anesthetic techniques
positioning, neuroimaging, and brain relaxation
that should be considered before surgery.
Approaches to Intracranial Aneurysms
• Craniotomy Selection:
• Selection of the correct approach enhances the safety
and efficacy of aneurysm occlusion. The type and size
of the craniotomy chosen for a specific aneurysm is
influenced by four factors:
• The aneurysm type(location and size)
• Aneurysm configuration and anatomy of associated
vessels and neural structures.
• The patient's clinical status
• Surgeon preference.
Anterior Circulation Aneurysms
• Pterional Craniotomy
• Most anterior circulation aneurysms can be
approached through a pterional craniotomy,
including aneurysms of ICA, PcomA, AcomA,
and MCA.
Anterior Circulation Aneurysms
• The AcomA is the most common location cerebral
aneurysms.
• Twenty-five percent of intracranial aneurysms arise
from the ICA at the PcomA origin, making this site the
second most common location after AcomA
aneurysms.
• The MCA is the third most common location of
ruptured aneurysms(about 20%) arise from M1/M2
junction.
Modification of the Pterional Approach
• In some cases, the traditional pterional craniotomy can
be modified to improve the surgical technique:
• The orbitozygomatic approach:
• Specifically removing the orbital rim and superior and
lateral orbital wall, can expand the operative corridor.
• An extended orbital -zygomatic approah in wich a
subtemporal decompression is performed. It increase
the inferior exposure.
The Frontal Parasagittal Approach
• This approach is used for distal anterior
cerebral artery(ACA), specifically pericallosal
and callosal marginal aneurysms, which
comprise about 2% to 3% of intracranial
aneurysms.
Posterior Circulation Aneurysms
• About 10% to 15% of intracranial aneurysms are
located in the posterior circulation where they
occur most often at the basilar bifurcation,
followed by the origins of the superior crebellar
artery (SCA) and posterior inferior cerebllar
artery(PICA).
• Dissection and fusiform aneurysms are more
common in the posterior than in the anterior
circulation.
Approaches To The Posterior
Circulation Aneurysms
• Subtemporal approach:
• The subtemporal approach proceeds from a
lateral trajectory under the temporal lobe and
along the middle fossa floor.. The area behind
the aneurysm, including the perforators, whose
preservation is essential, usually is seen best
from this approach. This approach is also may
be suitable for some distal basilar artery(BA),
SCA, and PCA aneurysms.
Surgical Approaches to
Posterior Circulation
Aneurysms
•
•
•
•
•
•
•
Subtemporal approach
Pterional-transsylvian approach
Orbitozygomatic-pterional approach
Retrosigmoid approach
Transpetrosal approaches: Retrolabyrinthin
Translabyrinthin
Transcochlear
Surgical Approaches to Posterior
Circulation Aneurysms
•
•
•
•
Combined supra- and infratentorial approach
Extended middle fossa approach
Far-lateral approach
Extended far-lateral approaches
Surgical Approaches To The Basilar
Apex Aneurysms
•
•
•
•
1. Subtemporal approach
2. Pterional-Transsylvian approach
Orbitoxygomatic-Pterional approach
Extended Orbitozygomatic approach
• Like Sirens that lure mariners at sea, posterior
circulation aneurysms have engaged
neurosurgery's technical innovators in a
treacherous seduction
Endovascular Treatment of
Aneurysms
• Endovascular therapy of intracranial
aneurysms is generally aimed toward
occlusion or thrombosis of the aneurysm sac.
• The approaches can be classified into two
broad categories:
• Deconstructive approaches: Involve occlusion
of parent vessel, with the aim of
thrombosing both the parent vessel and its
aneurysm.
• Reconstructive approaches involve selective
occlusion of the aneurysm lumen, with
sparing of the parent artery.
Thank You For
Your Attention