ica bifurcation aneurysms: assessment of clinical profile
TRANSCRIPT
INTERNAL CAROTID ARTERY BIFURCATION ANEURYSMS,
ASSESSMENT OF CLINICAL PROFILE AND OUTCOME OF
SURGICAL TREATMENT: A RETROSPECTIVE STUDY
THESIS
SUBMITTED IN PARTIAL FULFILLMENT FOR DEGREE OF
M.Ch NEUROSURGERY
(2015 - 2017)
OF THE
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY,
TRIVANDRUM, INDIA
DR. PANKAJ SHIVHARE
DEPARTMENT OF NEUROSURGERY
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY
TRIVANDRUM, INDIA
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND
TECHNOLOGY
TRIVANDRUM, INDIA
CERTIFICATE This is to certify that the work incorporated in this thesis titled
“Internal Carotid Artery Bifurcation Aneurysms, Assessment Of Clinical Profile And
Outcome Of Surgical Treatment: A Retrospective Study”
for the degree of
M.Ch NEUROSURGERY
has been carried out by Dr. Pankaj Shivhare under my supervision and guidance.
The work done in connection with this thesis has been carried out by the
candidate himself and is genuine.
Dr. Mathew Abraham
Professor& Head
Principal Guide
Department of Neurosurgery, SCTIMST, Trivandrum.
DECLARATION
I hereby declare that this thesis titled “Internal Carotid Artery Bifurcation
Aneurysms, Assessment Of Clinical Profile And Outcome Of Surgical Treatment: A
Retrospective Study” is a consolidated report based on a bonafide study during
the period 1st January 2011 to 31st December 2015 has been prepared by me
under the supervision and guidance of Prof Mathew Abraham, Prof and Head,
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences
and Technology, Thiruvananthapuram.
The thesis is submitted to SCTIMST in a partial fulfilment of rules and regulations
of M.Ch Neurosurgery examination
Date: 6/10/2017 Dr Pankaj Shivhare
Place: Thiruvananthapuram
ACKNOWLEDGEMENT
I am indebted to guidance of Prof. Mathew Abraham, Professor and Head of the
Department of Neurosurgery, has been invaluable and I am extremely grateful and
indebted for his contributions and suggestions, which were of invaluable help during the
entire work. He will always be a constant source of inspiration to me.
I owe a deep sense of gratitude to Prof. Suresh P Nair, former Head, Department of
Neurosurgery for his invaluable advice, encouragement and guidance, without which this
work would not have been possible. His critical remarks, suggestions, helped me in
achieving a high standard of work.
I am deeply indebted to Dr. Easwer H. V., Dr. Krishnakumar K., Dr. George Vilanilam,
DrJayanandSudhir, Dr. Prakash Nair and Dr. Tobin George and I thank them for their constant
encouragement and support.
I am grateful for my colleagues, Drs. Shashank, Gopikrishnan and Bimal as well as
my juniors and seniors who have made this work possible.
I owe a thanks to Dr. Savith Kumar and Dr. Ritu Garg for the significant amount of
the labor and support during the writing of this work.
I am blessed to have a supportive wife and family who encouraged and actively
supported throughout the long day working on this project.
Last but not the least, I owe a deep sense of gratitude to all the patients who put
their faith in us and without whom this work would not have been possible.
INDEX
Section Page No.
Introduction 1
Aims And Objectives 4
Materials And Methods 6
Review Of Literature 11
Results 35
Discussion 51
Conclusions 62
Bibliography 64
Annexures 74
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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INTRODUCTION
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INTRODUCTION
Internal carotid artery (ICA) bifurcation aneurysms are not very
common. The incidence among the adults accounts up-to 5% of all
intracranial aneurysms. (1–3) ICA bifurcation aneurysms represent more,
almost 40% of all intracranial aneurysms in patients less than 20 years (4,5)
and also have an increased ultimate chance of a bleed. (6,7) These
aneurysms tend to be more common in male in comparison to the other
aneurysms of the ICA. (7,8) Surgical management of these aneurysms are
likely to be more difficult compared to other types of ICA aneurysms,
because of the multiple perforators originating from the anterior cerebral
artery (ACA), middle cerebral artery (MCA), anterior choroidal artery, and
posterior communicating artery (PcomA) (9–11) which can come in the way
and can become problematic during microdissection of the aneurysm
(3,12)
The first neurosurgeon to treat an ICA aneurysm by direct surgery,
(wrapping it with a piece of muscle) in 1933 was Dott. (13) This was also
the first surgical attempt to treat an intracranial aneurysms. (14) Since
then, despite the advances in the field of micro-neurosurgery, aneurysms
at this location have remained difficult to treat. The micro-neurosurgical
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exposure and clipping of ICA bifurcation aneurysms can be demanding due
to: (a) the need for deep retraction to achieve exposure, (15) (b) high
position with respect to the skull base, (c) attachment of the dome to the
surrounding brain parenchyma, (d) large number of perforators
surrounding the base and/or the dome, and (e) the relatively high risk of
intraoperative rupture. The orientation of the aneurysm dome affects the
clipping, with the posterior orientation being the most difficult. Precise
dissection in the 3D anatomy of ICA bifurcation and the surrounding
perforators requires not only experience and microsurgical skill but also
the patience to work on the aneurysm base under the repeated protection
of temporary and pilot clips. (16)
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AIMS & OBJECTIVES
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AIMS AND OBJECTIVES
To study the
• Clinical profile
• Imaging features
• Intra-operative findings
• Post-operative outcome in patients who underwent surgery for
angiographic evidence of ICA bifurcation aneurysm followed upto
minimum period of 6 months.
• The primary outcome studied would be of quality of life and
independence achieved at 6 months. Which would be assessed using
the modified Rankin score.
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METHODS
&
MATERIALS
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METHODS AND MATERIALS
Study design and pateints:
Present study is a retrospective analysis of patients who underwent
surgery for ICA bifurcation aneurysmal SAH. The study recruited subjects
who were admitted with aneurysm (bled or un-bled) and identified those
aneurysm which were located in the termination of ICA between the period
of 1st January 2011 to 31st December 2015, at Sree Chitra Tirunal Institute
for Medical Sciences and Technology (SCTIMST), Trivandrum. This study
compromised of 32 cases, whose diagnostic preoperative cerebral
angiographic films were retrieved from our data base system for detailed
review.
The primary outcome studied was quality of life and independence
achieved at discharge and at 6 months. This was measured using modified
Rankin score.
Inclusion criteria:
• Sub arachnoid haemorrhage with ICA bifurcation segment aneurysm
as evidenced by CT, CT Angiography, DSA, MR Angiogram and then
underwent surgical treatment during the period of 1st January 2011
to 31st December 2015.
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Exclusion criteria
• Subjects who do not have follow up for minimum period of 6 months.
No gender, class, caste, ethnic or racial considerations will be used as
inclusion or exclusion criteria.
All patient underwent standard pterional craniotomy and clipping of the
aneurysm.
Study Analysis:
General information
Anonymized patient id:
Age, sex, family history
Clinical details
GCS on admission:
Fisher grade of bleed:
Intra-parenchymal/ intra-ventricular bleed:
Hydrocephalus:
Size of aneurysm:
Direction of the fundus of the aneurysm:
Time since bleed:
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Intraoperative events
Clipping and or wrapping:
Intra-operative rupture:
Intra-operative clipping:
Duration of temporary clipping:
Post-operative events
Vasospasm:
Infract early:
Re-exploration / decompression
Duration of the ventilator support:
Duration of icu stay:
Duration of post-op hospital stay:
GCS on pod 5
Status on discharge
GCS
Motor and speech status
Any other deficit
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Status on follow up on 6 months
GCS
Motor and speech status
Any other deficit
mRs score
Out-come parameter: Rankin score at discharge and follow up at 6
months was primary outcome parameter. Factors predicting the outcome
were studied. Rankin score 0, 1 and 2 was considered as good functional
outcome, 3 and more as poor functional outcome
Statistical analysis:
Pre-operative, intra operative and post-operative variables were
compared between the groups based on outcome variables. For analysis
of categorical outcomes variables, Fisher-Freeman-Halton Exact Test was
used. A p value of 0.05 or less was considered statistically significant. All
statistical calculations were made with widely available SPSS software
(SPSS 22.0).
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REVIEW
OF
LITERATURE
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REVIEW OF LITERATURE
Embryology
As per Charles Raybaud (17) there are 7 steps or stages in the
development of the brain arteries, from an early undifferentiated pattern
to the essentially adult pattern.
At stage 1, the primitive carotid artery supplies the forebrain as well
as the hindbrain through the transient carotid-vertebrobasilar connections
(4–5 mm, 28–29-day embryo). The ICA can already be recognized at this
stage. The ICA supplies all three vesicles, forebrain, midbrain, and
hindbrain. Rostrally when reaching the forebrain, it divides into an anterior
olfactory branch (future anterior cerebral artery ACA) and a posterior
branch that resolves into a plexus around the midbrain without reaching
the hindbrain. The ICA also connects with the contralateral ICA behind the
Rathke’s pouch, so forming the posterior segment of the future circle of
Willis. By stage 3 the forebrain arteries can be recognized; the trunk of ACA
develops rostrally around the neck of the growing hemispheric vesicle, and
the early stem of the future middle cerebral artery (MCA) extends laterally
from it. (fig 1)
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Figure 1: oa – olfactory artery, ma – mesenchephalic artery, mca – middle cerebral artery, ica – internal cerebral artery
Classification of ICA
The first classification of segments was given by Fischer, (18) which
was based on angiography, he divided ICA into 5 different segments: (a)
cervical, (b) petrous, (c) cavernous, (d) clinoid, and (e) supraclinoid; the
supraclinoid portion begins where the artery enters the subarachnoid
space and terminates at the bifurcation into the ACA and MCA. The more
recent classification by Bouthillier et al. (19) divided the ICA into seven
segments (figure 2) and was a modification of the Fischer’s classification -
Cervical segment (Cl), Petrous segment (C2), Lacerum segment (C3),
Cavernous segment (C4), Clinoid segment (C5), Ophthalmic segment (C6),
Communicating segment (C7). The other classification was proposed by SI
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Abdul Rauf in which he divided ICA into 7 segments (figure 3) Cervical
segment, Cochlear segment, Petrous segment, Gasserian segment, Sellar
segment, Sphenoid segment, Ring segment and Cisternal segments. (20)
Figure 2. Segments: Red – Cervical, Blue – petrous, Green – Laceral, Orange – Cavernous, Pink – Clinoid, Yellow– Ophthalmic, Brown- Communicating
Figure 3: Abdulrauf SI, voung P, Ashour MA, Marvin E, Coppens J,Kang B, Nery B et al. Propoed clinical internal carotid artery classification system. J Craniovertebr Junction Spine. 2016;127:161-70
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Micro-surgical anatomy
The supra-clinoid segment of ICA enters the intradural space and
carotid cistern inferomedially to the anterior clinoid process. Relation of
the anterior clinoid process with the proximal part of intradural ICA varies
and depends on its size and pneumatization of the bone and the length of
intradural ICA. The proximal part of the artery and occasionally its proximal
branches (ophthalmic artery (OphtA) and PCoA) may be covered by the
anterior clinoid process. The supra-clinoid ICA then travels in an upward
and posterolateral direction. Because the intradural approach toward the
ICA is pointed parallel to the sphenoid ridge and/or orbital roof toward the
anterior clinoid process, it is of utmost importance to disclose the relation
of skull base and the anterior clinoid process to the vessel in preoperative
imaging studies.
Branches and segments of the supra-clinoid ICA: The supra-clinoid
ICA bifurcates into its 2 terminal branches: (a) the proximal M1 segment of
the MCA and (b) the proximal A1 segment of the ACA just below the
anterior perforating substance. Other main branches arising from the pre-
bifurcational supra-clinoid ICA are (a) OphtA, (b) several small superior
hypophyseal arteries, (c) the PCoA, (d) anterior choroidal artery (ACHA),
(e) the 2 to 3 small branches to the uncus, and (f) the artery to the dura of
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anterior clinoid process. (21) Besides these major branches, an average of
8 (3-12) small perforating arteries originate from the trunk of supra-clinoid
ICA. The supra-clinoid portion of the ICA is divided into 3 segments based
on the origin of its major branches: (a) the ophthalmic segment, the longest
segment of the C4 portion, extending from the origin of the OphtA to the
origin of the PCoA; (b) the communicating segment, extending from the
origin of the PCoA to the origin of the ACHA; and (c) the choroid segment,
extending from the origin of the ACHA to ICA bifurcation. (22)
1) Ophthalmic artery
The Ophthalmic artery is the single major branch of the ICA that runs
medially. It usually arises from the medial (78%) or the middle (22%) one-
third of the superior surface of the supra-clinoid ICA below the optic nerve
and above the dura of the cavernous sinus. It may arise from the cavernous
segment (up to 8%) of the ICA, and is very rarely absent altogether. The
ophthalmic artery runs anterolaterally below and attached to the under-
surface of the optic nerve to enter the optic canal. The intradural segment
of the ophthalmic artery is usually short, but it is often possible to visualize
the origin and the proximal segment of the ophthalmic artery with or
without minor retraction of the optic nerve. (23)
2) Superior hypophyseal arteries
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The superior hypophyseal arteries are a complex group of small
vessels (average, 2; range, 1-5) with a diameter of 0.1 to 0.5 mm. They arise
from the posteromedial, medial, or posterior aspect of the ophthalmic
segment of the ICA in the midway between the origin of the OphtA and
PcomA. The superior hypophyseal arteries run medially under the optic
chiasm to terminate in the tuber cinereum, anterior lobe of the pituitary,
and the inferior surface of the optic nerve and the chiasm. As the superior
hypophyseal arteries may provide major blood supply to the optic nerve
and the chiasm, their preservation during dissection is of vital importance.
(24)
3) Posterior communicating artery
The posterior communicating artery arises from the posteromedial,
posterior, or rarely from the medial wall of the supra-clinoid ICA, 2 to 8 mm
after its origin (22) and rarely may have origin from the OphtA. (25) The
PcomA runs backward and medially, above the sella turcica, slightly above
and medial to the oculomotor nerve, and below the tuber cinereum to join
the Posterior cerebral artery (PCA) in the interpeduncular cistern. Inside
the carotid cistern, an arachnoid sleeve similar and adherent to that of the
oculomotor nerve covers the PCoA. The distal part of the PCoA may be in
close relation to the dura of the posterior clinoid process or might even lie
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inside the groove within the process. (22) The PCoA can be absent
altogether in up to 14% of cases. (21)
4) Anterior choroid artery
The anterior choroid artery is the first posterolateral branch distal to
the PCoA. In most cases, it arises closer to the origin of the PCoA (2-5 mm)
than to the ICA bifurcation. The ACHA is nearly always present, but it can
sometimes originate also from other arteries such as the PCoA or the MCA
in up to 23% of cases. The diameter of the ACHA ranges from 0.5 to 2.0
mm, and the pattern of origin of the artery may also be highly variable. (26)
The ACHA may arise as a single trunk or multiple vessels from the
posterolateral wall of ICA. To identify and preserve the ACHA during
different steps of dissection toward ICA bifurcation aneurysms or
temporary clipping one should be aware of these possible anatomic
variations and the course of the ACHA. (27) After its origin in the carotid
cistern, the ACHA enters the crural cistern with a posteromedial direction
and is often found behind the ICA bifurcation. The artery courses lateral
and inferior to the optic tract, passes through the wing of the ambient
cistern, to enter the choroidal fissure. (21,26)
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5) Uncal arteries
The uncal arteries usually originate distal to the ACHA or from the
very proximal part of the MCA. (21)
6) Artery to the dura of the anterior clinoid process
The dural branch of the ICA is a small branch usually originating from
the anterior wall of the ICA 3 to 5 mm proximal to its bifurcation or rarely
from the proximal A1 segment. It moves toward the dura of the anterior
clinoid process.
7) Perforating branches of the supra-clinoid ICA
Each segment of the supra-clinoid ICA gives off a series of
perforating branches with a relatively constant site of termination. The
perforating branches arising from the ophthalmic segment (average, 4;
range, 1-7) arise from the posterior or medial wall of the ICA and pass
medially to (a) the optic nerve and the chiasm, (b) the infundibulum, and
(c) the floor of the third ventricle. (22) The perforating branches arising
from the communicating segment are rare. Infrequently, up to 3 small
perforators arise from the posterior side of the ICA wall and pass to (a)
optic tract, (b) pre-mamillary part of the floor of the third ventricle, (c) optic
chiasm, and (d) infundibulum. They rarely enter the anterior or posterior
perforating substances. (22) The perforating branches of the choroidal
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segment (average, 4; range, 1-9) arise from the posterior half of the ICA
wall, pass upward and terminate in (a) the anterior perforating substance,
(b) the optic tract, and (c) the uncus. Some of these perforators may also
arise from the ICA bifurcation. (26,28)
8) Perforating branches around the ICA bifurcation
There are a large number of perforating branches with their course
behind the ICA bifurcation. These perforators arise from (a) the choroidal
segment of the ICA, (b) ACHA, (c) recurrent artery of Heubner (RAH), (d)
medial lenticulostriate artery, and (e) lateral lenticulostriate artery
(21,28,29) .These vessels may be stretched to varying degrees by the ICA
bifurcation aneurysms or have their origins involved in the base of an
aneurysm. They should be identified and if possible protected during
dissection or clipping by, for example, a small cottonoid.
Anatomical variants of ICA, M1, and A1
Several variants of the supra-clinoid ICA are known which may affect
intraoperative orientation during dissection of ICA bifurcation aneurysms
such as: (a) hypoplastic ICA, (b) absent ICA, (c) ICA trifurcation, (d) or
persistence of fetal remnants. (30,31) A hypoplastic ICA diminishes in
caliber shortly distal to its origin. In these cases, the petrous and sellar
segments are also frequently also absent. The exact incidence of
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hypoplasia or aplasia of the ICA is not known but seems to be less than
0.01% (31) and is rare. Three major patterns of collateral circulation have
been described for hypoplasia/absence of the ICA by de Medonca et al.
(30) The ICA trifurcation is rare and results from the anomalies of the
terminal part of the ICA itself, from accessory origins of the ACHA and from
the absent M1. (32) Fetal remnants of anastomosis between the carotid
arteries and the vertebral system can persist. (30)
Cisternal anatomy of supra-clinoid ICA
Based on the height of the ICA bifurcation and the size and
projection of the ICA bifurcation aneurysms, a different combination of
several cisterns such as: (a) the carotid cistern, (b) the olfactory cistern, (c)
the lamina terminalis cistern, and (d) the sylvian cistern, may surround the
aneurysm. Strict attention to these cisternal boundaries is mandatory for
orientation to proper dissection planes. (33) The carotid cistern is limited
superiorly by the dura of the anterior clinoid process and the orbitofrontal
lobe; it shares the medial wall with the chiasmatic cistern; the tentorial
edge and mesial temporal lobe limit it laterally; the inferior limit is the
cavernous sinus; and posteriorly, it is limited by the crural cistern. The
supra-clinoid ICA, origins of its branches and the fronto-orbital veins
draining into the spheno-parietal sinus are all within the carotid cistern.
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The supra-clinoid ICA travels entirely inside the carotid cistern in a superior-
anterior direction with a variable degree of lateral bend toward the ICA
bifurcation. The relation of the ICA and the optic nerve can vary from a
parallel course of the artery and the nerve to a concave or convex curve of
the artery compared to the nerve. The chiasmatic cistern or optic cistern
contains the optic nerves, pituitary stalk, branches from the supra-clinoid
ICA to these structures and the OphtA. The lamina terminalis cistern
located in front of the lamina terminalis is limited by the rostrum of the
corpus callosum superiorly and the optic chiasm inferiorly. The lamina
terminalis cistern contains the A1 segment, the medial lenticulostriate
artery, the RAH, ACOM complex, the origins of A2 segments of the ACA,
the orbitofrontal and rarely, the frontopolar arteries, and the anterior
cerebral veins. (21)
The A1 arises from the ICA in the carotid cistern with a medial and
somewhat anterior course and enters the lamina terminalis cistern. A
group of thick arachnoid bands extending from the olfactory triangle to the
lateral side of optic nerve encase the A1 segment at this point. (21,34) The
M1 segment of the MCA begins at the carotid bifurcation, lateral to the
optic chiasm and enters the sylvian cistern. The M1 then runs laterally and
posteriorly until it reaches the level of the limen insula. (11,29)
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Venous structures
The superficial and deep venous structures of the ICA bifurcation
region are complex and vary a lot. Superficial middle and anterior cerebral
veins run over or under the ICA bifurcation to reach the spheno-parietal or
cavernous sinus. The deep venous system, including the anterior and deep
middle cerebral veins and the basal vein of Rosenthal, may be found near
the inferior aspect of the ICA bifurcation. (21,35)
Classification of ICA bifurcation aneurysms according to the dome projection
ICA bifurcation aneurysms are classified according to the dome
projection because it is important for the microsurgical approach and
strategy. ICA bifurcation aneurysms can be classified as (a) anteriorly, (b)
superiorly, and (c) posteriorly projecting. The anteriorly projecting ICA
bifurcation aneurysms originate from the anterior aspect of the ICA
bifurcation with their dome projecting into the lateral fronto-orbital gyrus
or the base of the olfactory tract. The superiorly projecting ICA bifurcation
aneurysms originate from the superior aspect of the ICA bifurcation with
their dome projecting into the anterior perforated substance, the lateral
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portion of the lamina terminalis cistern, or the sylvian cistern. The
posteriorly projecting ICA bifurcation aneurysms originate from the
posterior aspect of the ICA bifurcation with their dome projecting into the
carotid and interpeduncular or even the ambient and crural cisterns.
(16,36–38)
S. Sakamoto et al. used DSA to measure the angle between the ICA
and the A1 segment of the ACA on the ipsilateral side which was defined as
the I-A angle. The angle between the ICA and the M1 segment of the MCA
on the ipsilateral side was defined as the I-M angle. Author classified ICA
bifurcation aneurysms by type as follows. When the aneurysmal neck was
located on a line extending from the midline of the ICA, the aneurysm was
defined as an IC-Bi aneurysm (Figs. 3A and 4). Otherwise, the aneurysm was
defined as an ICA-ACA or ICA-MCA bifurcation (IC-A-Bi or IC-M-Bi)
aneurysm according to the daughter artery (ACA or MCA) involved (39)
Imaging of ICA bifurcation aneurysms
Digital subtraction angiography is the present “gold standard” for
imaging the ICA bifurcation aneurysms. (16,40–42) Multi-slice helical CTA
is the primary modality for imaging of IA’s in many centres for several
reasons such as: (a) the virtual independence from the hemodynamic
situation; (b) the non-invasive and quick imaging technique; (c) the
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comparable sensitivity and specificity to DSA in aneurysms larger than 2
mm; (16) (d) the disclosure of calcifications in the walls of arteries and the
aneurysm; and (e) the quick reconstruction of 3D images that, for example,
show the surgeon's view of the ICA bifurcation. Some ICA bifurcation
aneurysms may be difficult to visualize by routine 3D CTA, (16,43) usually
due to very small size. Hence, subsequent rotational 3D DSA is required.
Occasionally, ICA bifurcation aneurysms may be difficult to visualize by
routine DSA or CTA, mostly small ones or those projecting backward, that’s
why subsequent oblique projections or rotational images are needed. (16)
Micro-neurosurgical strategy with ICA bifurcation aneurysms
The ICA bifurcation aneurysms are challenging to approach. These
aneurysms are located at the highest point of the ICA, overlaid by the
frontal lobe and surrounded by perforators. The surgical trajectory should
provide optimal visualization of the whole ICA bifurcation and the ICA
bifurcation aneurysm with the least possible brain retraction. The aim of
the micro-neurosurgical clipping is the total occlusion of the aneurysmsal
sac with preservation of flow in the main branches and the perforating
arteries surrounding the aneurysm dome. The perforators in the ICA
bifurcation region are- RAH, medial and lateral lenticulostriate artery,
anterior choroid artery, posterior communicating artery. These perforators
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may be adherent to the dome and may be severed during (a) retraction,
(b) dissection, (c) coagulation, (d) kinking, (e) compression for hemostasis,
(f) temporary occlusion, or (g) final clipping.
Intracerebral hematoma (ICH)
Ruptured ICA bifurcation aneurysms are sometime associated with
ICH. In Kuopio series the incidence of hematoma was 19%. The ICH is
usually located in the frontal lobe. The relatively close proximity of ICA
bifurcation aneurysms to the ventricular system predisposes to intra-
ventricular hemorrhage (IVH), which is an independent risk factor for poor
outcome in aneurysmal SAH. (44)
Approach and craniotomy
Exposure of the ICA bifurcation aneurysms surgery depends on
several factors: (a) deviation of the ICA bifurcation aneurysms base with
respect to the A1 and M1 segments, (b) presence of ICH and/or IVH, (c) the
length of the supra-clinoid ICA and the height of ICA tip from the skull base,
(d) lateral or medial deviation of the ICA bifurcation with respect to the
optic nerve and the oculomotor nerve, (e) size and orientation of the ICA
bifurcation aneurysms dome, (f) presence and extent of atherosclerotic
plaques in the parent artery and the aneurysm base, (g) presence of
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associated aneurysms, (h) pre-existing neurological deficits, and (i) possible
earlier operations.
ICA bifurcation aneurysms are approached from the ipsilateral side,
especially if ruptured and associated with ICH. Unruptured ICA bifurcation
aneurysms with the dome projecting anteriorly or superiorly can also be
approached from the contralateral side over the midline, provided that the
ICA tip is not too high. In all the posteriorly projecting ICA bifurcation
aneurysms and large superiorly projecting ICA bifurcation aneurysms,
proper visualization of the perforators attached to the posterior wall of an
aneurysm would be very difficult from the contralateral side and would
lead to injury. The standard pterional approach was introduced by Yaşargil
et al. (33,36) has been widely used for ICA bifurcation aneurysms by many
authors. (8,45,46)
Lehecka M et al. (16) used the lateral supraorbital approach for the
ICA bifurcation aneurysms. Lateral supraorbital approach craniotomy is a
more sub-frontal and less invasive modification of the pterional approach
for the anterior circulation aneurysms. (47)
Briefly, the head fixed to the head frame is: (a) elevated clearly above
the cardiac level, (b) rotated toward the opposite side according to the
projection of the ICA bifurcation aneurysm dome, (c) tilted somewhat
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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laterally to visualize the ICA bifurcation complex, and (d) extended. The
goal is to have the very proximal part of the Sylvian fissure almost vertical.
Because ICA bifurcation aneurysms are located higher than other ICA
aneurysms, the head has to be extended more than other locations.
Dissection towards ICA bifurcation aneurysms
The first and most important precaution when approaching the ICA
bifurcation aneurysms, it is to prepare a site for proximal control of the ICA,
usually just above the origin of the ACHA.
Dissection of carotid and optic cisterns at the very early steps of
surgery is continued with the identification of proper place for the
temporary clips on the proximal ICA. In addition to the proximal control, it
is advisable to have distal control of both the M1 and A1 segments as well.
The next step is the dissection of the proximal one-third of the
sylvian fissure. Dissection of the sylvian fissure is more difficult in acute SAH
with swollen brain or due to adhesions from previous SAH or microsurgery.
It is very important not to retract the frontal lobe because the dome of an
aneurysm is usually buried in the sub-frontal cortex. Once the proximal part
of the MCA (M1 segment) is identified, the dissection should continue
along its lateral surface to identify the anterolateral wall of the ICA.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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Dissection along the carotid cistern and the optic cistern, helps to identify
the lateral branches of the ICA: ACHA and PCoA.
At this stage of dissection, a proper place for temporary clip
application should be prepared, distal to the origin of the ACHA in a
perforator free zone. During the exposure of the ICA, the M1 and the A1,
the goal is to locate the point of origin and trajectory of all the perforators,
which may be adherent to the posterior wall of an aneurysm. Use of
temporary clippings both during the dissection and clipping of the ICA
bifurcation aneurysms, reduces intraluminal pressure and facilitates sharp
dissection of both an aneurysm and the adjacent arteries. Temporary clip,
usually a small one, curved or straight, is applied proximal to an aneurysm
on the ICA. The second small straight temporary clip is applied on the M1
trunk avoiding the lateral lenticulostriate artery. The third clip is placed on
the A1 without involving the Recurrent artery of Huebner or the
perforators. The dissection continues around the aneurysm base to
prepare the site for the pilot clip. All the perforators should be freed from
the base, most of them will be on the posterior aspect of an aneurysm.
Temporary clips should be removed in distal-proximal order.
Clipping of the ICA bifurcation Aneurysm base
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A proper selection of clips with different shapes and lengths of
blades and applicators, suiting the imaged ICA bifurcation aneurysm
anatomy. The blade of a single occluding clip should be one and a half times
the width of the base as suggested by Drake. The clip is generally best
introduced across the neck of the aneurysm along M1 trunk. As the clip is
slowly closed, the surrounding arteries and perforators are inspected for
kinking, twisting and compromised flow. The clip blades should completely
close the neck of the aneurysm. If the first clip slides, exposing some of the
neck, another clip may be applied proximal to the first one for final closure
(double clipping).
ICA bifurcation aneurysm rupture before clipping
The ICA bifurcation aneurysm may rupture during any step of the
approach or the dissection. The 2 most common causes of intraoperative
rupture are lifting of the frontal lobe and dislocation of the ICA while the
aneurysm dome is still adherent to the frontal lobe. The risk is highest for
the anteriorly projecting ICA bifurcation aneurysms. In case of rupture,
control should be first attempted via suction and compression of the
bleeding site with cottonoids. Short and sudden hypotension by cardiac
arrest, induced by intravenous adenosine, (48) can be used to facilitate
quick dissection and application of a pilot clip in case of uncontrolled
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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bleeding. Temporary clips must be applied to the parent vessels proximally
and distally and the aneurysm is prepared for pilot clipping under local flow
arrest.
Very small ICA bifurcation aneurysms
Very small (2-3 mm) ICA bifurcation aneurysms may be difficult to
identify preoperatively and intraoperatively due to superimposition of the
ICA and its branches. In some patients, surgical clipping is technically
impossible. In such cases, it is necessary to protect against aneurysmal
rupture with external wrapping with an available material like, muslin
gauze, surgicel, muscle, bio-bond adhesive and histoacryl adhesive. In
some cases, partial clipping before wrapping was done on the weak or
ruptured point and if there was room for partial clipping - Clip-wrap
technique. This method is more protective than the wrapping only method.
(49)
Considerations for individual ICA bifurcation Aneurysm dome projections
1. Anteriorly projecting ICA bifurcation aneurysm
The anteriorly or forward projecting ICA bifurcation aneurysms
originate from the anterior aspect of the ICA bifurcation. They are generally
easier to visualize during dissection and they are less involved with
perforators than other ICA bifurcation aneurysms. The anteriorly
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projecting ICA bifurcation aneurysms are often embedded in the fronto-
orbital gyrus, so even slight retraction and elevation of the frontal lobe can
cause intraoperative rupture. Therefore, in the ruptured anteriorly
projecting ICA bifurcation aneurysms, it is preferred not to approach the
chiasm and the lamina terminalis until the aneurysm dome has been
dissected free. Unruptured anterior projecting ICA bifurcation aneurysms
may be approached from the contralateral side.
2. Superiorly projecting ICA bifurcation aneurysm
The superiorly or upward projecting ICA bifurcation aneurysms
originate from the superior aspect of the ICA bifurcation. Because of their
vertical dome orientation, they are located higher than other ICA
bifurcation aneurysms such that complete dissection of the dome requires
slightly more elevation of the frontal lobe. The posterior and lateral walls
are often involved with perforators, which have to be identified and
separated before clipping. Because of the dome orientation, the base can
be approached relatively safely and controlled before dissecting the entire
dome free. Unruptured superiorly projecting ICA bifurcation aneurysms
can also be approached from the contralateral side, but then, the
visualization of the perforators may be more tedious. The superiorly
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projecting ICA bifurcation aneurysms are occasionally present with a
frontal ICH but no blood in the subarachnoid space.
3. Posteriorly projecting ICA bifurcation aneuryms
The posteriorly or backward projecting ICA bifurcation aneurysms
originate from the superior and posterior aspect of the ICA bifurcation.
They are usually the most challenging ICA bifurcation aneurysms but
fortunately are also the least frequent ones. They are heavily involved with
the perforators, posing the greatest risk for perforator injury. The dome is
partially obstructed by the ICA such that proper visualization of the
perforators, even if the aneurysm dome is small, is particularly difficult.
While clipping, an aneurysm remnant is easily left unnoticed at the dead
angle behind the ICA trunk. The contralateral approach to the posteriorly
projecting ICA bifurcation aneurysms is not advisable because it is
extremely difficult to get a proper visualization of the perforators that
envelope major part of the aneurysm dome.
Associated aneurysms
The ICA bifurcation aneurysms are often associated with other intra-
cranial aneurysms (IA). In the Kuopio series, 43% of all ICA bifurcation
aneurysms patients and 26% of those with a ruptured ICA bifurcation
aneurysms had at least 1 additional IA. (16) Bilateral ICA bifurcation
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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aneurysms were seen in 6%. It is advisable to clip the ruptured IA first and
if this succeeds without particular difficulties, additional IAs can be treated
in the same session.
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RESULTS
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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RESULTS
Patients demography:
During the study period of 5 years (1st January 2011 to 31st December
2015) total of 28 patients were included in the study out of which 4 had
bilateral ICA bifurcation aneurysms, of which 12 were present on the right
side and 20 on the left side. There were total of 32 individual aneurysms,
amongst which 24 (75%) presented as a rupture, of which two were
rupture of other associated aneurysms. Among ruptured aneurysms, 23
(95.8%) were in grade I and 1 (4.16%) was in grade III. The good percentage
of preoperative good grade on admission is due to probably because of the
referral bias. 29 aneurysms underwent surgical procedure (24 were
ruptured), 3 aneurysms were left alone.
FREQUENCY PERCENTAGE
Bled 24 75
Un-bled 8 25
Side of the aneurysm
Left 20 62.5
Right 12 37.5
Table 1: No. of patients categorized by CT findings correlation.
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FREQUENCY PERCENTAGE
WFNS Grade
Grade I 23 95.8
Grade II - -
Grade III 1 4.16
Table 2: Patients categorized by WFNS grade
Mean age was 44.15 (age range 14-65) years, with 43.75% of patient
were less than 40yrs. 15 patients (53.57%) were male and 13 patients
(46.42%) were female. Among the bled aneurysm 10 patients presented
within 3 days of bleed. All patient presented with headache. The other
initial presentations include altered sensorium 13 patients (40.62%), limb
weakness 2 patients (6.25%), memory loss in 2 (6.25%) patients.
FREQUENCY PERCENTAGE
TIME SINCE BLEED
< 3 days 10 41.6
> 3 days 14 58.33
Table 3: Patients categorized by Time since bleed.
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Graph 1
CT Findings: For all ruptured aneurysms extent of the hemorrhage was
determined by Fisher grading. Out of 24 cases of ruptured aneurysms,
Fisher grade was grade I in 2 (6.25%) grade II in 10 (31.25%), grade III in 6
(18.75%), grade IV in 6 (18.75%). Intraparenchymal bleed was present in 5
patients (15.62%), and hydrocephalous was seen in 8 (25%) patients.
12.5%
31.25%
18.7%15.6%
21.8%
0
5
10
15
20
25
30
35
<30 30-39 40-49 50-59 >60
AGE DISTRIBUTION
PERCENTAGE
54%46%
SEXMALE FEMALE
Graph 2
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0
10
20
30
40
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4
25
6.25
31.25
18.75 18.75
Modified Fischer's Grade
Percent
FREQUENCY PERCENTAGE
Modified Fischer Grade
Grade 0 08 25
Grade 1 02 6.25
Grade 2 10 31.25
Grade 3 06 18.75
Grade 4 06 18.75
Intra-parenchymal bleed
Present 05 15.62
Absent 27 84.37
Hydrocephalous
Present 08 25
Absent 24
75
Table 4
Graph 3
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Angiographic findings
4 (14.28%) had bilateral ICA bifurcation aneurysms, and 11 (34.37%)
patients had multiple aneurysms, ICA-PCom junction 2 cases (6.25%), 3
cases (9.37%) of ICA-Ophth junction, 1 case (3.1%) of ICA-Superior
hypophyseal junction, BA-Superior cerebellar artery each, 4 cases (12.5%)
of MCA bifurcation and 1 case (3.1%) of Acom-ACA junction aneurysm. 14
(44.75%) patients had small, 15 (46.87%) patients had medium, and 1
patient (3.1%) had large and giant size aneurysm was present in 2 patients
(6.2%). Most common projection of the dome was superior in 27 (84%)
patients and posterior projection was far less common, seen only in 5 (16%)
patients.
FREQUENCY PERCENTAGE
Multiple Aneurysm
Present 11 34.37
Absent 21 65.62
Neck
Narrow 23 71.87
Wide 09 28.12
Table 5
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Graph 4
44%47%
3%6%
0
5
10
15
20
25
30
35
40
45
50
SMALL MEDIUM LARGE GIANT
SIZE OF THE ANEURYSM
PERCENTAGE
81%
16%
DIRECTION OF THE DOME OF ANEURYSM
SUPERIOR POSTERIOR
Graph 5
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Procedure done and Intra-Operative findings
24 (75%) aneurysms were clipped, 5 (15.62%) aneurysm clipping
along with wrapping was done, and 3 (9.3%) aneurysms no procedure was
done. Of the 28 patient who underwent surgery for ICA bifurcation
aneurysms 6 (21.42%) patients had intra-operative rupture, and in 16
(57.14%) patients temporary clipping was applied during aneurysm
dissection. Mean duration of temporary clipping was 3mins 2 seconds.
FREQUENCY PERCENTAGE
Clipping 24 75
Clipping + Wrapping 5 15.62
None 03 9.3
Table 6: Operative procedures.
Graph 6
0
5
10
15
20
25
INTRA-OPERATIVE RUPTURE TEMPORARY CLIPPING
6%
16%
23%
13%
INTRA-OPERATIVE FINDINGS
YES NO
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Post-Operative findings
28 patient who underwent surgery, early CT scan (done within 24hrs)
showed infract in 10 (31.25%) patients and vasospasm was seen in 6
(18.75%) patients among which 4 (12.5%) patients underwent chemical
angioplasty. 1 (3.1%) patient underwent decompressive hemicraniectomy
for post-operative infract, and another one (3.1%) patient underwent re-
exploration and mastoid waxing foe CSF rhinorrhea. Average stay in the
hospital was 8 days (3-38 days). Post-operative period 7 (21.87%) patients
had motor deficit.
POST-OPERATIVE PARAMETER FREQUENCY
PERCENTAGE
Vasospasm
Present 6 18.75
Early Infarct
Present 10 31.25
ENDOVASCULAR PROCEDURE
YES 4 12.5
MOTOR DEFICIT
YES 7 21.87 Table 7: Post-operative parameters and outcomes.
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OUTCOME Assessment
1 (3.1%) patient died, vegetative state was seen in one (3.1%)
patient, and good outcome was seen among 75% of patient (24 patient),
at 6 weeks also 75% (24 patient) showed good outcome with 3 patients lost
to follow up, and at 6 months follow up 22 of 26 (84.6%) patients. Six
patients were lost to follow-up and were hence not included in the analysis.
The relationship between outcomes and age, clinical grades, size of
the aneurysm, multiplicity, use of temporary clipping, and aneurysmal
projection.
Outcome at discharge
Good outcome was achieved:
• 6 (75%) out of 8 patients in the un-bled category,
• All the 2 (100%) patients in grade I,
• 8 (80%%) out of 10 patients in grade II,
• 5 (83.3%) out of 6 patients in grade III,
• 3 (50%) out of 6 patients in grade IV,
However, these differences were not statistically significant (p-
0.494). Favourable out-come was seen in 10 (75%) of 14 patients with small
size aneurysm, 14 (93.3%) of 15 patients in medium size aneurysm, none
of the patient with large aneurysm had good outcome, and only 1(50%)
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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patient of 2 patient with giant aneurysm had good outcome. The outcome
among this group was statistically significant (p <0.05). favourable outcome
was seen 7 (63.6%) of patient with multiple aneurysm, but these findings
were not statistically significant (p- 0.197). favourable outcome was seen
in 19 (70%) out of 27 patients with superior projection, in all 5 (100%)
patients with posterior projection, these findings were not statistically
significant (p- 0.296). Good out-come was seen in 12 (75%) out of 16
patients who underwent temporary clipping (p- 1.000) and 4 (66.7%) out 6
patients who had intra-operative rupture (p- 0.590), but these differences
were also not statistically significant.
Outcome at 6 months follow up.
Good outcome was achieved:
• 6 (85.7%) out of 7 patients in the un-bled category
• All the 2 (100%) patients in grade I
• 8 (88.9%) out of 9 patients in grade II
• 4 (80%) out of 5 patients in grade III
• 2 (66.7%) out of 3 patients in grade IV
However, these differences were not statistically significant (p-
0.928).
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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Favourable outcome at 6 months was seen in 9 (75%) of 12 patients
with small size aneurysm, all 12 (100%) patients in medium size aneurysm,
none of the patient with large aneurysm had a good outcome, and only 1
(100%) patient with giant aneurysm had good outcome. The outcome
among this group was statistically significant (p – 0.042). Favourable
outcome was seen in 7 patients (77.8%) with multiple aneurysms, but these
findings were not statistically significant (p- 0.58). Favourable outcome
was seen in 17 (80.9%) out of 21 patients with superior projecting
aneurysm, in all 5 (100%) patients with posterior projection, but these
findings are not statistically significant (p- 0.428). Good outcome was seen
in 9 (81%) out of 12 patients who underwent temporary clipping (p- 1.000)
and 2 (66.7%) out of 3 patients who had intra-operative rupture (p- 0.395),
both these differences were not statistically significant.
mRs At Discharge At 6 Months
GRADE FREQUENCY % FREQUENCY %
0 17 53.12 22 84.6
I 4 12.5 0 0
II 3 9.37 0 0
III 1 3.1 0 0
IV 5 15.62 4 18
V 1 3.1 0 0
VI 1 3.1 0 0
TOTAL 32 100 32 100.0 NO FOLLOW
UP
0
0 6 18.75
Table 8: mRS grade at discharge and 6 months.
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Graph 7
ASSOCIATION BETWEEN FISCHER’S GRADE AND OUTCOME
Modified Fischer’s
grade
mRS at discharge
Fisher-Freeman-
Halton Exact Test
mRS at 6 months
Fisher-Freeman-
Halton Exact Test
0-2 n (%)
>2 n (%)
p-value
0-2 n (%)
>2 n (%)
p-value
Gr 0 6 (75) 2 (25)
0.494
6 (85.7) 1 (14.3)
0.928 Gr I 2 (100) 0 2 (100) 0
Gr II 8 (80) 2 (20) 8 (88.9) 1 (11.1)
Gr III 5 (83.3) 1 (16.7) 4 (80) 1 (20)
Gr IV 3 (50) 3 (50) 2 (66.7) 1 (33.3)
Total 24 (75) 8 (25) 22 (84.61) 4 (15.38)
Table 9
ASSOCIATION BETWEEN SIZE OF THE ANEURYSM AND OUTCOME
Size of the aneurysm
mRS at discharge Fisher-
Freeman-Halton
Exact Test
mRS at 6 months Fisher-
Freeman-Halton
Exact Test 0-2
n (%) >2
n (%)
p-value
0-2 n (%)
>2 n (%)
p-value
<5mm 10 (71.4) 4 (28.6)
0.05
9 (75) 3 (25)
0.042 5-15mm 14 (93.3) 1 (6.7) 12 (100) 0
15-25mm 0 1 (100) 0 1 (100)
>25mm 1 (50) 1 (50) 1 (100) 0
Total 25 (78.1) 7 (21.9) 22 (84.6) 4 (15.4)
Table 10
0
20
40
60
80
100
AT DISCHARGE AT 6 MONTHS
53%
84%
12% 9%3%
16% 18%
3% 3%
Modified Rankin Score
GR 0 GR I GR II GR III GR IV GR V GR VI
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ASSOCIATION BETWEEN DIRECTION OF DOME OF ANEURYSM AND OUTCOME
Direction
of dome of aneurysm
mRS at discharge
Fisher-Freeman-Halton Exact
Test
Fisher-Freeman-Halton Exact Test
Fisher-Freeman-
Halton Exact Test
0-2 n (%)
>2 n (%)
p-value
0-2 n (%)
>2 n (%)
p-value
0.296
0.428 Superior 19 (60%) 8(25) 17 (81%) 4(19%)
Posterior 5 (15) 0 5 (15%) 0
Total 24(75%) 8(25) 22(84.6) 4 (15.4%)
Table 11
ASSOCIATION BETWEEN MULTIPLE ANEURYSM AND OUTCOME
MULTIPLE
ANEURYSM
mRS at discharge
Fisher-Freeman-
Halton Exact Test
mRS at 6 months
Fisher-Freeman-
Halton Exact Test
0-2 n (%)
>2 n (%)
p-value
0-2 n (%)
>2 n (%)
p-value
YES 7 (77.8) 2 (22.2) 0.574
7 (77.8) 2 (22.2) 0.582 NO 17 (89.5) 2 (10.5) 15 (88.2) 2 (11.1)
TOTAL 24 (85.7) 4 (14.3) 22 (84.6) 4 (15.4)
Table 12
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ASSOCIATION BETWEEN TEMPORARY CLIPPING AND INTRA-OP RUPTURE WITH
OUTCOME
mRS at discharge
Fisher-Freeman-
Halton Exact Test
mRS at 6 months
Fisher-Freeman-
Halton Exact Test
0-2 n (%)
>2 n (%)
p-value
0-2 n (%)
>2 n (%)
p-value
Temporary clipping
1.000
1.000 Yes 12 (75) 4 (25) 9 (81) 2 (19)
No 13 (81.2) 3 (18.8) 13 (86.7) 2 (13.3)
Intra-op rupture
0.590
0.395 Yes 4 (66.7) 2 (33.3) 2 (66.7) 1 (33.3)
No 21 (80.8) 5 (19.2) 20 (90.9) 3 (9.1)
Table 13
No association was found between temporary clipping and post-
operative infract, as well as age and outcome.
ASSOCIATION BETWEEN TEMPORARY CLIP V/S INFARCT
TEMPORARY CLIPPING
INFARCT
Total
Fisher-Freeman-
Halton Exact Test
YES n (%)
NO n (%)
p-value
YES 7 (43.8) 9 (56.2) 16 (100) 0.111
NO 3 (18.8) 13 (81.2) 16 (100)
TOTAL 10 (31.2) 22 (68.8) 32 (100)
Table 14
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ASSOCIATION BETWEEN AGE AND OUTCOME
AGE RANGE
mRS AT DISCHARGE Fisher-Freeman-Halton Exact Test
0-2 n (%)
>2 n (%)
p-value
<30 4 (100) 0
0.340 30-39 9 (90) 1 (10)
40-49 5 (83.3) 1 (16.7)
50-59 3 (60) 2 (40)
>60 4 (57.1) 3 (42.9)
TOTAL 25 (78.1) 7 (21.9)
Table 15
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DISCUSSION
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DISCUSSION
Since Dott first successfully coated an ICA bifurcation aneurysm with
a muscle patch in a 53-year-old male patient in 1933, (13) ICA bifurcation
aneurysms have been treated by many neurosurgeons without (Table) or
with the operating microscope (Table). More than forty series have been
reported since1933. (15)
Author Year Total number
Number of operations
Dott NM (13) 1933 1 1 Poppen JL (50) 1951 12 12
Falconer MA (51) 1951 8 8 Norlen G and Olivecrona H
(52) 1953 2 2
Walsh (53) 1957 30 15
Sengupta et al. (14) 1975 9 9 Kodama et al. (54) 1979 29 29
Lassman LP. (6) 1979 20 20
Pian RD et al. (8) 1980 21 21 Yasargil (21) 1984 55 55
Weir (3) 1987 1 1 Ojemann et al (12) 1988 16 16
Hattori T and Kobayashi H et al. (45)
1992 1 1
Spetzler et al. (55) 1996 17 17
Kwon TH et al. (56) 1999 17 17
Miyazawa N et al. (15) 2002 26 25
Kim JW et al. (57) 2003 22 22
Gupta SK (38) 2006 89 89
Konczalla L et al (58) 2016 23 23 Table 16
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Present study the age range of the patients were between 14 – 65, the
mean age of patient with ICA bifurcation aneurysm was 43.075 years. 18
(45%) patients were aged <40 years, out of which 6 (15%) patients were
less than 30 years of age. As per the literature the mean age of
presentation of patient with ruptured ICA bifurcation aneurysm is 41 years.
(14,56,57) Average age of 31.5 was observed in SK Gupta series and
ascending trend was seen in other studies. (15,58)
Young population are more likely to present with ICA bifurcation
aneurysm, compared to other aneurysms, and also have increased
tendency to bleed.
In our study male to female to ratio was 1:1.05, this finding is similar
to Miyazawa N et al. (15) The present study finding was in contrast to
previous studies in which few reported male dominance (8,23,54,59) and
some studies reported female dominance (38,46,56,58)
Presence of ICA bifurcation aneurysms are not indicated by any
specific clinical signs or symptoms (15). The most common presentation in
our study was headache. Limb weakness was seen in one patient having
small and other having medium size aneurysm. Yasargil in his study
reported hemiparesis and seizure only in cases of giant aneurysm (33). In
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our study, however none of the patient with giant aneurysm presented
with seizure.
The incidence of bilateral aneurysm 14.28%, whereas the incidence
of multiple aneurysm was 34.37%. There was no clinically significant
association between the outcome and multiple aneurysm. (p <0.574)
Miyazawa et al (15) in their series of 25 cases reported bilateral ICA
bifurcation aneurysms in 3 cases (12%) almost same as present study,
whereas SK Gupta reported incidence of only 2.9% (38). As per the
literature the incidence of the multiple aneurysms in the case of ICA
bifurcation aneurysm is 30%, which is higher compared to other site of the
aneurysms (15) . Similar incidence of multiple aneurysms was seen in few
studies. (15,57) In contrast, Suzuki et al (60) reported no multiple
aneurysms in their ICA bifurcation aneurysm series, lower incidence was
reported in few series (8,38,46) and higher incidence 53% was reported in
Taek HK et al. series. (56) In our study the outcome was not affected by the
multiplicity of the aneurysm at discharge as well as at 6 months. Previous
studies did not corelate between the multiplicity and outcome.
Mulitiple classification are given in the literature for ICA bifurcation
aneurysms (8,23,50,54) Present study we classified ICA bifurcation
aneurysms, based on the classification followed by miyazawa et al (15) -
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Superior projection (projecting upward), anterior, and posterior (projecting
downward backward). In present series, superiorly projecting aneurysm
were most common, followed by posteriorly projecting aneurysm.
Figure 4: Angiogram image showing superior projection of ICA bifurcation aneurysm.
Figure 5: Angiogram image showing posterior projection of ICA bifurcation aneurysm
As the study was a retrospective analysis, we had to depend a on the
radiological report for the direction of the aneurysm especially when the
images were not available, as well as there was lot of ambiguity of the
report and intra-operative finding, we divided the aneurysmal dome
direction into superior and posterior. As per the literature also superior
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Page | 56
projecting aneurysms are most common 54.4% and the least common is
anteriorly projected aneurysm only 5.3%. (6,8,9,14,54,59,61) SK gupta
series (38) had 67.3 aneurysm projecting superiorly 20% projecting
anteriorly, where as in Miyazawa et al series, 48% had superior projecting,
where as 28% had anterior projecting. (15) From the surgical strategy point
to know the projection of the aneurysm prior to surgery is important.
(8,12,46) Posteriorly projecting aneurysm are most challenging ICA
bifurcation aneurysms. The perforator density is high, hence an increased
risk for perforator injury. Dome of the aneurysm is partially obstructed by
the ICA, which obstructs the proper visualization of the perforators. While
clipping, an aneurysm remnant may be easily missed at the dead angle
behind the ICA trunk.
Present study 75% aneurysms were clipped, whereas 15.62%
aneurysms underwent clipping along with wrapping. In 1979, Kodama et
al. series (54) of 29 (79%) cases underwent clipping and clipping with
aneurysmal neck ligation. In 1984, Yasargil reported a series of 55 cases,
90% underwent clipping and 10% underwent carotid ligation using the
operating microscope (33). As per the literature, before microscope was
introduced, 41% was managed with carotid ligation and 23% with clipping
but since then 97% were treated by clipping and 2% with carotid ligation.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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In the present study, 28 patients underwent surgery for 32 ICA
bifurcation aneurysm, of which 6 of 32 (19%) of patients had intra-
operative rupture, and 50% patients temporary clipping was applied during
aneurysm dissection. There was no significant difference in the outcome
between the two groups where temporary clip was used and not used (p
1.000). Miyazawa et al (15) in their series of 25 patients also did not
observe any significant correlation between outcome and application of
the temporary clip.
Taek HK et al series, (56) intraoperative aneurysmal rupture
occurred in 5.8% of cases, and temporary clipping was used in 41.17% of
cases, whereas González-Darder et al. series, (58) all patient underwent
temporary clipping with mean duration of 5.4min, with no intraoperative
complications. The above two authors did not study the relation between
the temporary clipping and outcome.
Temporary clipping is applied in cases of premature rupture and
difficult aneurysmal dissection. Pian et al. (8) considered that there was no
need to place temporary clips on the parent vessel under deep
hypotension, and Reynier et al. (61) commented that hypotension was
useful even for large aneurysms with no need for temporary clipping. In
our series deep hypotension was not done for any patients.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 58
Incidence of vasospasm in present study vasospasm was seen in 6
patients (18.75%) among which 4 patients underwent chemical
angioplasty. SK gupta et al, (38) in their series reported vasospasm in 24
patients (43.6%), and there was no statistically significant correlation
between the vasospasm and out-come.
Main causative factor of unfavourable outcomes was considered to
be vasospasm. As per literature six series have shown that vasospasm is the
main cause for poor outcome, (7,8,12,54,59,61) where as 3 series
concluded perforator damage was also the causative factors of poor
outcome. (7,46,59) Kodama et al. reported post-operative deterioration
and poor outcome in four cases (13%), due to vasospasm and concluded
that since the incidence of pre- and postoperative vasospasm exceeded
60%, control of vasospasm is imperative for the management of these
aneurysms (54). In contrast, Yasargil et al. in his study found no correlation
between vasospasm, neurological deficit, and the surgical results (36) and
he concluded that outcome in patients was related to the clinical grade.
(33) In our series, unfavourable outcomes were due to poor clinical grade
and vasospasm. Vasospasm was associated with increased morbidity,
prolonged ICU stay.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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In present study, clinical grade IV was seen in 6 of 32 patients
(18.75%) of patients, among which 3 patients had poor outcome, with
vegetative state and mortality in 3.1% each (1 patient). Though the clinical
grade was not found to be statistically significant with regard to outcome.
Pian et al. (8) in his series of 21 cases, reported mortality in 1 (4.76%)
patient, due to vasospasm and good recovery in one (4.76%) patient in
Grade IV. Yasargil in his study reported good outcome in patient with
clinical Grades III and IV, and only two (3.6%) mortalities within the same
group. (33) Kodama et al. (54) and Ohno et al. (7) also reported good
results in patients with clinical grade IV. Kashiwagi et al. (59) reported poor
outcome in three (17.64%) patient with clinical Grade IV among their 17
patients. Miyazawa et al in their series of 25 patients, 71.1% (five) patient
among the poor clinical grade (grade IV) had unfavourable outcomes, with
a significant difference in favourable outcomes between patients in Grades
I and II and those in Grades III and IV. High clinical grade is a factor of
unfavourable outcome. (15)
Mortality in our series was seen in one patient (3.12%), was probably
due to poor clinical grade, primary brain injury due to SAH as well as
vasospasm. As per the literature mortality rate for carotid ligation was 41%,
and that of conservative therapy was 43%. (62) Until 1968, treatment of
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 60
choice was carotid ligation for ICA bifurcation aneurysm, although further
bleeding following the carotid ligation was observed and the mortality
remained high. (50,51,62) Before microsurgery was introduced, mean
mortality rate was 26.7%, (15) and few studies reaching as high as 30-40%
(23,62), but since then mortality rate has been around 3-5%. (8,33,54)
Contrary to the literature SK Gupta series reported a high mortality rate,
which was approximately about 11.4% mortality rate was due to poor
clinical grade and early intra-operative rupture. (38) The main cause for
mortality seem to be vasospasm, and poor clinical grade.
At discharge, good outcome was achieved in 75% of 32 patients,
whereas poor outcome 25% of patients. At six months follow up, good
outcome was seen in 84.6% of 26 patients whereas poor outcome was seen
in 15.4%. The clinical grade improved by 9.6% patients in 6 months follow
up. The outcome at discharge and at 6 months in present study was not
significant statistically with regard to Fischer’s grade, direction of the dome
of the aneurysm, multiple aneurysm, temporary clipping, or intra-operative
rupture of aneurysm. Only statistically significant finding was seen between
size of the aneurysm and outcome at discharge and 6 months. To validate
this finding, larger prospective study must confirm the same. Our finding
of good outcome was similar to various study, (38,56) contrary to our
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 61
finding over all poor outcome was seen in patient with ICA bifurcation
aneurysms who underwent surgery in Kim JW et al series. (57)
Study limitation:
The present study is a retrospective study and is limited by its
inherent drawbacks. Another drawback of the study is the small sample
size. Over all we are comfortable with the reliability of the information that
we were able to extract from the medical records, and took care to note
when specific data were insufficient. Probably there was also an element
of referral bias. Only large prospective study can overcome these
weaknesses.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 62
CONCLUSION
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 63
CONCLUSION
1. ICA bifurcation aneurysms are more common in young population
and hence has increased tendency to bleed among these group of
population during the life time
2. ICA bifurcation aneurysms are technically more difficult to operate,
mainly the posterior directed due large number of perforators.
3. Direction of the dome of aneurysm and temporary clipping donot
seem to affect the outcome.
4. Size of the aneurysm seem to affect the outcome, but larger
studies will be required to validate the results.
5. They have excellent outcome in both rupture and incidentally
detected aneurysms with microsurgical technique and aggressive
management of vasospasm.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 64
BIBLIOGRAPHY
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 65
Bibliography
1. Bull JW. Contribution of Radiology to the Study of Intracranial
Aneurysms. Br Med J. 1962;2:1701–8.
2. Flamm ES. Other aneurysms of the internal carotid artery. In: Wilkins
RH, Rengachary SS, editors. Neurosurgery.1996;2301–10.
3. Weir B. Carotid bifurcation artery aneurysms. Aneurysms affecting
the nervous system. Baltimore, Williams and Wilkins. 1987;456–60.
4. Huang J, McGirt MJ, Gailloud P, Tamargo RJ. Intracranial aneurysms
in the pediatric population: case series and literature review. Surg
Neurol. 2005;63:424–32.
5. Krishna H, Wani AA, Behari S, Banerji D, Chhabra DK, Jain VK.
Intracranial aneurysms in patients 18 years of age or under, are they
different from aneurysms in adult population? Acta Neurochir.
2005;147:469–76.
6. Lassman LP. Internal carotid artery bifurcation aneurysms. In: Pia
HW, Langmaid C, Zierski J, editors. Cerebral aneurysms, advances
in diagnosis and therapy. Berlin: Springer,1979:96– 106.
7. Ohno K, Komatsu K, Aoyagi M, Takada Y, Wakabayashi S. Aneurysms
of the internal carotid bifurcation. surgery for cerebral stroke.
1996;5–10.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 66
8. Da Pian R, Pasqualin A, Scienza R. Direct microsurgical approach to
aneurysms of the internal carotid bifurcation. Surg Neurol.
1980;13:27–37.
9. Gibo H, Lenkey C, Rhoton AL. Microsurgical anatomy of the
supraclinoid portion of the internal carotid artery. J Neurosurg.
1981;55:560–74.
10. Grand W. Microsurgical Anatomy of the Proximal Middle Cerebral
Artery and the Internal Carotid Artery Bifurcation. Neurosurgery.
1980;7:215–8.
11. Umansky F, Gomes FB, Dujovny M, Diaz FG, Ausman JI, Mirchandani
HG, et al. The perforating branches of the middle cerebral artery. J
Neurosurg. 1985;62:261–8.
12. Ojemann RG CR. Internal carotid artery aneurysms. Surgical
Management of cwewbrovascular disease.Williams and Wilkins.
1988. 179–98.
13. Dott NM. Intracranial aneurysms: cerebral arterioradiography:
surgical treatment. Edinb Med J. 1933;40:219–40.
14. Sengupta RP, Lassman LP, de Moraes A a, Garvan N. Treatment of
internal carotid bifurcation aneurysms by direct surgery. J Neurosurg.
1975;43:343–51.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 67
15. Miyazawa N, Nukui H, Horikoshi T, Yagishita T, Sugita M, Kanemaru K.
Surgical management of aneurysms of the bifurcation of the internal
carotid artery. Clin Neurol Neurosurg. 2002;104:103–14.
16. Lehecka M, Dashti R, Romani R, Çelik Ö, Navratil O, Kivipelto L, et al.
Microneurosurgical management of internal carotid artery
bifurcation aneurysms. Surg Neurol. 2009;71:649–67.
17. Raybaud C. Normal and Abnormal Embryology and Development of
the Intracranial Vascular System. Neurosurg Clin N Am. 2010;21:399–
426.
18. Fischer, E. Die Lagenweichungen der vorderen Hirnarteie im
Gefassbild. Zentralbl Neurochir. 1938;3:300–12.
19. Bouthillier A, van Loveren HR, Keller JT. Segments of the internal
carotid artery: A new classification. Neurosurgery. 1996;38:425–32
20. Abdulrauf SI, Marvin E, Ashour AM, Coppens J, Nery B, Kang B et al.
Proposed clinical internal carotid artery classification. J Craniovertebr
Junction Spine. 2016;7:161–70.
21. Yasargil MG. Operative anatomy In: Yasargil MG, editor.
Microneurosurgery, vol 1. Stuttgart: Georg Thieme Verlag. 1984;5–
168.
22. Rhoton Jr AL. The supratentorial arteries. Neurosurgery.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 68
2002;51:S53-S120.
23. L. Perria, C. Rivano, G.F. Rossi GV. Aneurysms of the bifurcation of the
internal carotid artery. Acta neurochirugica. 1968;51–68.
24. Krisht AF, Barrow DL, Barnett DW, Bonner GD, Shengalaia G. The
microsurgical anatomy of the superior hypophyseal artery.
Neurosurgery. 1994;35:899–903; discussion 903.
25. Bisaria KK. Anomalies of the posterior communicating artery and
their potential clinical significance. J Neurosurg. 1984;60:572–6.
26. Rhoton AL, Fujii K, Fradd B. Microsurgical anatomy of the anterior
choroidal artery. Surg Neurol. 1979;12:171–87.
27. Yasargil MG, Yonas H, Gasser JC. Anterior choroidal artery aneurysms:
their anatomy and surgical significance. Surg Neurol. 1978;9:129–38.
28. Marinković SV, Milisavljević MM, Karinković MS, Stevic ZD. The
perforating branches of the internal carotid artery: the microsurgical
anatomy of their extracerebral segments. Neurosurgery.
1990;26:472-8-9.
29. Türe U, Yaşargil MG, Al-Mefty O. Arteries of the insula. J Neurosurg.
2000;92:676–87.
30. de Mendonça JL, Viana SL, Freitas FMO, Matos V de L, Viana MA de
CB, Faria e Silva R, et al. Unilateral dysgenesis of the internal carotid
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 69
artery: spectrum of imaging findings. Can Assoc Radiol J. 2008;59:61–
9.
31. Taşar M, Yetişer S, Taşar A, Uğurel S, Gönül E, Sağlam M. Congenital
absence or hypoplasia of the carotid artery: radioclinical issues. Am J
Otolaryngol. 25:339–49.
32. Kaliaperumal C, Jain N, McKinstry CS, Choudhari KA. Carotid
“Trifurcation” aneurysm: Surgical anatomy and management. Clin
Neurol Neurosurg. 2007;109:538–40.
33. Yasargil MG. Aneurysms of internal carotid artery bifurcation (ICBi-
aneurysms). Microneurosurgery. 1984;2:109-22.
34. Rosner SS, Rhoton Jr AL, Ono M, Barry M. Microsurgical anatomy of
the anterior perforating arteries. J Neurosurg. 1984;61:468–85.
35. Rhoton Jr AL. The cerebral veins. Neurosurgery. 2002;51:S159-205.
36. Yaşargil MG, Boehm WB, Ho REM. Microsurgical treatment of
cerebral aneurysms at the bifurcation of the internal carotid artery.
Acta Neurochir. 1978;41:61–72.
37. Kyoshima K, Kobayashi S, Nitta J, Osawa M, Shigeta H, Nakagawa F.
Clinical analysis of internal carotid artery aneurysms with reference
to classification and clipping techniques. Acta Neurochir.
1998;140:933–42.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 70
38. Gupta SK, Khosla VK, Chhabra R, Mohindra S, Bapuraj JR, Khandelwal
N, et al. Internal carotid artery bifurcation aneurysms: surgical
experience. Neurol Med Chir (Tokyo). 2007;47:153-7-8.
39. Sakamoto S, Ohba S, Shibukawa M, Kiura Y, Okazaki T, Arita K, et al.
Characteristics of aneurysms of the internal carotid artery
bifurcation. Acta Neurochir. 2006;148:139–43.
40. Kangasniemi M, Makela T, Koskinen S, Porras M, Poussa K,
Hernesniemi J. Detection of intracranial aneurysms with two-
dimensional and three-dimensional multislice helical computed
tomographic angiography. Neurosurgery. 2004;54:336-401.
41. Siablis D, Kagadis GC, Karamessini MT, Konstantinou D, Karnabatidis
D, Petsas T, et al. Intracranial aneurysms: reproduction of the surgical
view using 3D-CT angiography. Eur J Radiol. 2005;55:92–5.
42. Wintermark M, Ko NU, Smith WS, Liu S, Higashida RT, Dillon WP.
Vasospasm after subarachnoid hemorrhage: utility of perfusion CT
and CT angiography on diagnosis and management. Am J
Neuroradiol. 2006;27:26–34.
43. Schuknecht B. High-concentration contrast media (HCCM) in CT
angiography of the carotid system: impact on therapeutic decision
making. Neuroradiology. 2007;49:S15–S26.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 71
44. Rinne J, Hernesniemi J, Niskanen M, Vapalahti M. Analysis of 561
patients with 690 middle cerebral artery aneurysms: anatomic and
clinical features as correlated to management outcome.
Neurosurgery. 1996;38:2–11.
45. Hattori T, Kobayashi H. Fenestration of the supraclinoid internal
carotid artery associated with carotid bifurcation aneurysm. Surg
Neurol. 1992;37:284–8.
46. Laranjeira M, Sadasivan B, Ausman JI. Direct surgery for carotid
bifurcation artery aneurysms. Surg Neurol. 1990;34:250–4.
47. Hernesniemi J, Ishii K, Niemelä M, Smrcka M, Kivipelto L, Fujiki M,
Shen H. Lateral supraorbital approach as an alternative to the
classical pterional approach. Acta Neurochir Suppl. 2005;94:17–21.
48. Randell T, Niemelä M, Kyttä J, Tanskanen P, Määttänen M, Karatas A,
Ishii K, Dashti R HJ. Principles of neuroanesthesia in aneurysmal SAH:
the Helsinki experience. Surger neurol. 2006;66:382–388.
49. Suh SJ, Kim SC, Kang DG, Ryu, Lee HG, Cho JHC. Clinical and
angiographic results after treatment with combined clipping and
wrapping technique for intracranial aneurysm. J. Korean Neurosurg.
2008;44: 190–5.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 72
50. Poppen JL. Specific Treatment of Intracranial Aneurysms:Experiencs
with 143 surgicallytreated patients. J Neurosurg. 1951;8:75–102.
51. Falconer MA. The surgical treatment of bleeding intracranial
aneurysms. J Neurol Neurosurg Psychiatry. 1951;14:153–86.
52. Norlen G, Olivecrona H. The Treatment of Aneurysms of the Circle of
Willis. J Neurosurg. 1953;10:404–15.
53. Walsh LA. Results of treatment of spontaneous subarachnoid
hemorrhage. Mod Trends Neurol. 1957;2:119–29.
54. Kodama N. Surgical treatment of internal carotid bifurcation
aneurysms. cerebral aneurysms. 1979;261–7.
55. Spetzler RF, Koo WT, Richling B, Lang J. Aneurysms of the brain. 1996.
Color atlas of microneurosurgery. 1996;2:169–18.
56. Kwon TH, Cho TH, Park YK, Chung YG, Chung HS, Lee HK, et al. ICA
Bifurcation Aneurysm:Clinical Features and Surgical Outcome. J
Korean Neurosurg Soc. 1999;28:1624–8.
57. Kim JW, Lee SH, Lee KS, Ghang CG, Chung UW PS. Clinical Features
and Surgical Results of ICA Bifurcation Aneurysms. 2003. p. 33–8.
58. Gonzalez-Darder JM, Botella-Maciá, Gonzalez-Lopez. Microsurgical
treatment of aneurysms of the internal carotid bifurcation
aneurysms. Neurocirugia. 2010;21;205-10
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 73
59. Kashiwagi S, Yamashita K, Kato S, Akimura T, Ito H, Harada K, Ihara K.
Surgical treatment of the internal carotid bifurcation aneurysm. surg.
cereb stroke. 1997;25;428–33.
60. Suzuki J:Cerebral Aneurysm. Tokyo:Neuron. 1979; 263–7.
61. Reynier Y, Lena G, Vincentelli F, Vigouroux RP. Aneurysm of the
internal carotid artery bifurcation. Technical reflections apropos of a
series of 10 cases. Neurochirurgie. 1989;35:242–5.
62. McKissock W, Paine KW, Walsh LS. An Analysis of the Results of
Treatment of Ruptured Intracranial Aneurysms:report of 772
consecutive cases. J Neurosurg. 1960;17:762–76.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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ANNEXURES
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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ANNEXURE 1
Proforma:
Demographic data:
1. Name
2. Hospital registration number
3. Age:
4. Sex
Preoperative parameters
1. Location of aneurysm, side of the aneurysm, bled or un-bled aneurysm
2. Pre-operative GCS, presenting symptoms, clinical grade, Time since
bleed
3. Pre-op associated parenchymal or ventricular bleed
4. Fischer’s grade
5. Preoperative hydrocephalus
6. Aneurysm size, direction of the dome of the aneurysm, size of the neck
7. Multiplicity of aneurysm
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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Intraoperative parameters
1. Method used for securing the aneurysm: Clipping or wrapping or
clipping+ wrapping
2. Intraoperative rupture of aneurysm
3. Intraoperative temporary clipping
Postoperative parameters
1. Postoperative vasospasm
2. Postoperative early infarct
3. Postoperative re-exploration or decompression
4. Deficit on discharge – motor, speech, any other deficit
Follow-up parameters
1. mRs score at 6 weeks follow up
2. mRs score at 6 months follow up.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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MODIFIED RANKIN SCALE (mRs)
Score Description
0 No symptoms at all
1 No significant disability despite symptoms; able to carry out all usual
duties and activities
2 Slight disability; unable to carry out all previous activities, but able to
look after own affairs without assistance
3 Moderate disability; requiring some help, but able to walk without
assistance
4 Moderately severe disability; unable to walk without assistance and
unable to attend to own bodily needs without assistance
5 Severe disability; bedridden, incontinent and requiring constant nursing
care and attention
6 Dead
TOTAL (0–6): _______
References
Rankin J. “Cerebral vascular accidents in patients over the age of 60.”
Scott Med J 1957;2:200-15
Bonita R, Beaglehole R. “Modification of Rankin Scale: Recovery of motor
function after stroke.” Stroke 1988 Dec;19(12):1497-1500
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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ANNEXURE 2
MASTERCHART ABBREVIATIONS:
AGE < 30 :1, 30-39:2, 40-49: 3, 50-59: 4, 61-70: 5, > 70: 6
SEX: M= 1 F= 2
PRE-OPERATIVE GCS;
PRE-OP ASSOCIATED ICH (PARENCHYMAL) OR HYDROCEPHALOUS: YES 1,
NO 2
PRE-OP FISCHERS GRADE: 1 , 2, 3, 4
PRE-OP ANEURYSM Size </= 5mm: 1; 5-15mm:2; 15-25:3; >25mm =4
PRE OP Time since bleed < 3DAYS : 1, >3 DAYS : 2
INTRAOPERATIVE CLIP/WRAP: CLIPPING = 1, WRAPPING = 2, clipping +
wrapping =3
INTRAOP- RUPTURE: Y=1, N=2
INTRAOP TEMPORARY CLIPPING: Y=1, N=2
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
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IEC CLEARANCE
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 80
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 1
MASTERCHART
Patient ID Hospital
No.
Age Age
<30 1
30-39 2
40-49 3
50-59 4
>60 5
Sex Female
1 Male 2
NA 3
clipped
ICA
Right 1
left 2
B/L 3
Side of
aneurysm
right - 1 left
- 2,
Bled 1
Unbled 2
Assos
aneur
ysm
Locati
on
Como
rbiditi
es
No 0
HTN
1
DM 2
CAD 3
HTN +
Family
history
yes 1
No 2
Time
since
bleed in
(days)
NA 0,
<3 days -1
>3 days -2
Time
since
blee
d in
(days
) NA
0,
Headache
yes 1
No 2
Lim
b
wea
kne
ss
yes
1
no 2
Seizu
re
yes 1
no 2
Other
presentations
None 0
LOC 1
altered
sensorium 3
Memory loss 4
decreased
vesion ®5
GCS on
admission
WFNS
GRADE AS
PER
NUMBER
NA - 0
Modified
Fischers grade
- GRADE AS
PER NUMBER
NA - 0
Intraparen
chymal
bleed Yes
1 No 2
INFRA
CT
Yes 1
No 2
HCP Yes
1 No 2
CTA
Yes 1
No 2
DSA
Yes 1
No 2
Assos
aneurysm
Location
Multilple
aneurysm
Yes 1 NO
2 B/L
ICA 3
Size of aneurysm
in mm
1small 5
2medium 5- 15
3large
15 X 25
4giant 25 mm
Direction of
dome Superior-
-1 Posterior --2
Neck
Narro
w 1
Wide 2
1 325214 40 3 1 1 1 1 1 2 1 2 1 2 2 0 15/15 1 2 2 2 1 1 2 2 1 2 1
2 325497 42 3 1 1 1 1 0 2 1 2 1 2 2 0 15/15 1 2 2 2 2 1 2 2 2 1 1
3 327076 34 2 2 2 1 2 0 2 0 2 2 2 5 15/15 1 0 2 2 2 2 1 2 2 2 1
4 329956 37 2 1 2 2 1 Right para PCOM aneurysm0 2 2 5 1 2 2 1 15/15 1 2 2 2 1 1 1 Right para PCOM aneurysm1 1 1 1
5 338646 52 4 2 2 2 1 1 2 2 10 1 2 2 1 15/15 1 2 2 2 2 2 1 2 1 2 1
6 52 4 1 2 2 0 0 1 2 2 3 15/15 0 0 2 2 2 2 1 1 1
6 347211 52 4 3 1 1 1 0 2 2 4 1 2 2 3 15/15 1 2 2 2 2 1 2 1 2 1 1
7 354677 14 1 2 2 2 1 0 2 1 3 1 2 2 1 15/15 1 4 2 2 2 1 2 2 1 1 1
8 65 5 2 2 2 4 0 1 2 2 0 15/15 0 0 2 2 2 2 1 1 1
8 354920 65 5 3 1 1 1
rt
supra 4 2 2 4 1 2 2 0 15/15 1 4 1 2 1 1 2
rt
supraclinoi 1 4 2 2
9 359896 40 3 1 2 1
right
ophth 1 2 2 9 1 2 2 0 15/15 1 2 2 2 2 1 1
right
ophthalmic 1 1 1 1
10 361881 27 1 1 2 2 1 0 2 1 1 1 2 2 0 15/15 1 3 2 2 2 1 2 2 2 1 1
11 363689 49 3 1 1 1 1 0 2 2 14 1 2 2 1 15/15 1 2 2 2 2 1 2 2 1 1 1
12 366343 62 5 1 1 2 1 1 2 1 3 1 2 2 1 15/15 1 2 2 2 2 2 2 1 2
13 366829 36 2 2 2 2 1 0 2 2 30 1 2 2 0 15/15 1 2 2 2 2 1 1 2 1 1 1
14 369159 39 2 2 1 1 2 0 2 0 2 2 2 0 15/15 0 0 2 2 2 1 2 2 2 1 2
15 371660 28 1 1 2 2 1 2 2 2 4 1 2 2 1 15/15 1 3 1 2 2 1 2 2 2 1 1
16 375540 55 5 1 2 2 2 1 2 0 1 2 2 0 15/15 0 0 2 2 2 1 2 2 2 1 2
17 375844 42 3 2 2 2 2 right ophthalmic and cavernous aneurysms0 2 0 1 2 2 0 15/15 0 0 2 2 2 2 1 right ophthalmic and cavernous aneurysms1 1 1 1
18 55 4 2 2 2 0 0 1 2 2 0 15/15 0 0 2 2 2 2 1 1 1
18 377302 55 4 3 1 1 1 left para pcom0 2 2 9 1 2 2 0 15/15 1 3 1 2 2 1 2 left para pcom 1 3 1 2
19 381025 62 5 1 2 2 1 L MCA 1 2 2 17 1 2 2 1 15/15 1 4 1 2 1 1 1 L MCA 1 2 1 1
20 381613 63 5 2 1 1 2 0 2 0 2 2 2 0 15/15 0 0 0 2 2 1 1 2 4 1 2
21 382727 22 1 2 2 2 1 0 2 2 7 1 2 2 1 15/15 1 3 2 2 1 2 1 2 2 1 1
22 385870 61 5 2 1 1 1
ACO
M 3 2 2 23 1 1 2 0 15/15 3 4 1 2 1 2 1 ACOM 1 1 1 2
23 398653 37 2 2 2 2 1 2 2 1 1 1 2 2 1 15/15 1 4 2 2 1 1 1 2 1 1 2
24 401448 32 2 2 2 2 1 right supraclinoid ICA0 2 1 1 1 2 2 0 15/15 1 3 2 2 2 1 2 2 2 1 1
25 401622 49 3 1 1 1 1 RMCA 0 2 1 3 1 2 2 1 15/15 1 3 2 2 2 1 2 RMCA 1 2 1 2
26 404044 37 2 1 2 2 1 0 2 2 6 1 2 2 1 15/15 1 4 2 2 1 1 1 2 2 1 1
27 405158 36 2 2 3 2 1 0 2 1 1 2 2 2 4 15/15 1 1 2 2 2 1 2 1 2 1 1
27 36 2 3 1 2 0 0 2 2 2 4 15/15 1 1 2 2 2 2 1 1 1
28 397108 37 2 2 1 1 1
Right
M1 0 2 2 19 1 1 2 0 15/15 1 1 2 2 2 1 2
Right M1
MCA, left 1 2 2 1
Preoperative parameters
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 1
L Functional status
Patient ID
Date of
surgery
Direc
tion
of
fundu
s
intra-
op
Clipping 1
wrapping 2
both 3 coiling
4 NONE 5
Intraopera
tive
rupture
Yes 1 No
2 NA 3
Intraopera
tive
temporary
clipping
Yes 1 No
2 NA 3
Durati
on of
Tempo
rary
clippin
g NA 3
Temporary
clipping Yes
1 No 2 NA 3
Vasospasm
Yes 1 No 2
Blood in
post op
CT
(within
24 hrs)
Yes 1
No 2
I/L
ACA
AND
MCA
Yes 1
No 2
C/L ACA
AND MCA
Yes 1
No 2
Re-
exploration/
Decompress
ion Yes 1
No 2
ENDOVAS
CULAR
PROCEDU
RE POST
OPERATIV
E Yes 1
No 2
Ventilator
y support
duration
(days)
GCS on
POD5
Stay in
hospital in
days
Motor
deficit
Yes 1 No
2
mRscore
at
discharge
mRscore
at
discharge
1 <= 2
2 >2
mRscore at 6
weeks GRADE AS
PER NUMBER
NO F/UP - 7
mRscore at 6
weeks
1 0-2
2 >2
3 NA
mRs at 6
months
GRADE AS
PER
NUMBER
NO F/UP - 7
mRscore
at 6
months 1
0-2 2
>2 3
NA
1 17-03-2011 PM 1 2 2 0 2 2 2 2 2 2 2 0 15/15 11 2 0 1 0 1 0 1
2 23-03-2011 1 2 2 0 2 2 NA 1 2 2 2 0 15/15 8 2 0 1 0 1 0 1
3 14-07-2011 SM 1 2 1 5'30 1 1 2 1 2 2 2 0 15/15 7 1 1 1 1 1 0 1
4 05-07-2011 3 2 2 0 2 2 2 2 2 2 2 0 15/15 6 2 1 1 0 1 0 1
5 09-01-2012 P 3 2 2 0 2 2 2 2 2 2 2 0 15/15 9 2 0 1 0 1 0 1
6 5 3 3 0 2 2 2 2 2 2 0 15/15 2 0 1 0 1 0 1
6 05-07-2012 S 1 2 1 5'10 1 2 2 2 2 2 2 0 15/15 8 2 0 1 0 1 0 1
7 14-12-2012 SL 3 1 1 8'30 1 2 2 2 2 2 2 0 15/15 6 2 1 1 0 1 7 3
8 5 3 3 0 2 2 2 2 2 2 0 15/15 2 0 1 0 1 0 1
8 20-12-2012 PL 1 2 2 0 2 2 2 2 2 2 2 0 15/15 7 2 0 1 0 1 0 1
9 11-04-2013 PL 1 1 1 29' 1 1 2 1 2 2 1 1 15/15 12 1 4 2 4 2 4 2
10 21-05-2013 PS 1 2 2 0 2 2 2 2 2 2 2 0 15/15 13 2 1 1 0 1 0 1
11 26-06-2013 PM 1 2 1 3'18 1 2 2 2 2 2 2 0 15/15 7 2 0 1 0 1 0 1
12 23-08-2013 SL 3 1 1 3'16 1 2 2 2 2 2 2 0 15/15 10 2 0 1 0 1 0 1
13 07-10-2013 NA 1 2 2 0 2 2 2 2 2 2 2 0 15/15 8 2 2 1 0 1 0 1
14 07-11-2013 S 1 2 2 0 2 2 2 2 2 2 2 0 15/15 6 2 0 1 0 1 0 1
15 10-12-2013 AS 1 2 1 2'30" 1 2 2 2 2 2 2 0 15/15 6 2 0 1 0 1 0 1
16 02-07-2014 AS 1 1 1 4'40 1 1 1 1 2 2 1 1 15/15 7 2 2 1 0 1 0 1
17 14-04-2014 PL 1 2 2 0 2 2 2 2 2 2 2 0 15/15 7 2 0 1 0 1 0 1
18 5 3 3 0 2 2 2 2 2 2 0 15/15 1 4 2 4 2 4 2
18 11-04-2014 S 1 2 1 3'38 1 2 2 2 2 2 2 0 15/15 10 1 4 2 4 2 4 2
19 27-06-2014 NA 1 1 1 11' 59" 1 2 2 2 2 2 2 0 15/15 5 2 6 2 7 3 7 3
20 08-08-2014 1 2 1 0 2 2 2 2 2 2 0 15/15 17 1 4 2 4 2 7 3
21 02-08-2014 NA 3 1 1 19'25 1 1 2 1 2 2 2 0 15/15 5 2 2 1 7 3 7 3
22 11-10-2014 S 1 2 1 1'50 1 2 2 2 2 2 2 26 E4M1VT 2 5 2 7 3 7 3
23 26-06-2015 S 1 2 2 0 2 1 2 1 2 1 1 0 15/15 38 1 4 2 4 2 4 2
24 24-08-2015 SP 1 2 1 5'30 1 2 2 2 2 2 2 0 15/15 3 2 0 1 0 1 0 1
25 29-08-2015 ANT 1 2 1 7'30 1 1 2 1 2 2 1 0 15/15 11 1 3 2 0 1 0 1
26 17-10-2015 SUP 1 2 1 3'45 1 2 2 2 2 2 2 0 15/15 9 2 0 1 0 1 0 1
27 26-11-2015 AS 1 2 1 8'28 1 2 2 2 2 2 2 0 15/15 5 2 0 1 0 1 0 1
27 1 2 2 0 2 2 2 2 2 2 0 15/15 2 0 1 0 1 0 1
28 28-05-2015 INFERIORLY 1 2 2 0 2 2 2 2 2 2 2 0 15/15 12 2 0 1 0 1 0 1
Intra-operative findings Postoperative events Status at Discharge Status at follow up
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 1
Plagiarism Checker X Originality
Report
Internal Carotid Artery Bifurcation Aneurysms, Assessment Of
Clinical Profile And Outcome Of Surgical Treatment: A Retrospective
Study
Similarity Found: 11%
Date: Thursday, October 05, 2017
Statistics: 247 words Plagiarized / 2214 Total words
Remarks: Low Plagiarism Detected.
ICA Bifurcation Aneurysms: Assessment of Clinical Profile and Surgical Outcomes
Page | 2
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0% - https://de.scribd.com/doc/104895462/sesa
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0% - https://clinicalgate.com/microsurgery-of
0% - https://www.diepflap.com/pdfs/MRI-butt.p
2% - http://www.sciencedirect.com/science/art
0% - https://www.scribd.com/document/28095908
5% - http://www.sciencedirect.com/science/art
5% - http://www.sciencedirect.com/science/art
5% - http://www.sciencedirect.com/science/art
0% - http://www.ajnr.org/content/26/9/2328
0% - https://link.springer.com/content/pdf/10
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0% - https://link.springer.com/article/10.100
0% - http://thejns.org/doi/10.3171/jns.2003.9
0% - https://www.researchgate.net/profile/Lji
0% - http://thejns.org/doi/10.3171/jns.1997.8
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0% - http://thejns.org/doi/full/10.3171/2017.
5% - http://www.sciencedirect.com/science/art
5% - http://www.sciencedirect.com/science/art
0% - http://thejns.org/doi/10.3171/jns.1997.8
0% - http://casereports.bmj.com/content/2014/
0% - https://link.springer.com/content/pdf/10
0% - https://www.researchgate.net/publication
0% - https://link.springer.com/content/pdf/10
5% - http://www.sciencedirect.com/science/art
5% - http://www.sciencedirect.com/science/art
0% - http://www.sciencedirect.com/science/art
0% - https://link.springer.com/article/10.100
0% - http://stroke.ahajournals.org/content/37
0% - https://emcrit.org/wp-content/uploads/20
0% - https://link.springer.com/article/10.100
0% - http://thejns.org/doi/10.3171/jns.1981.5
0% - https://www.scribd.com/doc/247163743/AAO
5% - http://www.sciencedirect.com/science/art
0% - https://bmccancer.biomedcentral.com/arti
0% - https://link.springer.com/chapter/10.100
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0% - https://link.springer.com/article/10.100
0% - https://www.researchgate.net/profile/Rog
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5% - http://www.sciencedirect.com/science/art
0% - http://www.berkeleywellness.com/fitness/
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0% - https://rd.springer.com/content/pdf/10.1
0% - http://www.neurologyindia.com/text.asp?2
0% - https://springerplus.springeropen.com/ar
0% - https://link.springer.com/article/10.118
0% - https://www.ncbi.nlm.nih.gov/pubmed/1827
0% - https://www.thefreelibrary.com/Grading+s
0% - http://www.gfmer.ch/Books/Reproductive_h
0% - http://www.sciencedirect.com/science/art
0% - https://josr-online.biomedcentral.com/ar
1% - https://www.coursehero.com/file/p1o8io0/