ICA Bifurcation Aneurysms: Assessment of Clinical Profile

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

Page | 1

INTRODUCTION


Page | 2

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)


Page | 4

AIMS & OBJECTIVES


Page | 5

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.


Page | 6

METHODS

&

MATERIALS


Page | 7

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).


Page | 11

REVIEW

OF

LITERATURE


Page | 12

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


Page | 14

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


Page | 15

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


Page | 16

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


Page | 17

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


Page | 18

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)


Page | 19

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


Page | 20

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


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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.


Page | 29

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


Page | 30

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


Page | 31

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


Page | 32

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


Page | 33

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


Page | 34

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.


Page | 35

RESULTS


Page | 36

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.


Page | 37


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.


TIME SINCE BLEED

< 3 days 10 41.6

> 3 days 14 58.33

Table 3: Patients categorized by Time since bleed.


Page | 38

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


Page | 39

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


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


Page | 40

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.


Multiple Aneurysm

Present 11 34.37

Absent 21 65.62

Neck

Narrow 23 71.87

Wide 09 28.12

Table 5


Page | 41

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


Page | 42

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.


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


Page | 43

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.


Page | 44

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%)


Page | 45

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).


Page | 46

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.


Page | 47

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


Page | 48

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


Page | 49

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


Page | 50

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


Page | 51

DISCUSSION


Page | 52

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


Page | 53

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


Page | 54

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) -


Page | 55

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


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.


Page | 57

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.


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.


Page | 59

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


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


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.


Page | 62

CONCLUSION


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.


Page | 64

BIBLIOGRAPHY


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.


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.


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.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994148/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994148/


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


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.


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.


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.


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


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.


Page | 74

ANNEXURES


Page | 75

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


Page | 76

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.


Page | 77

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


Page | 78

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


Page | 79

IEC CLEARANCE


Page | 80


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


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


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Internal Carotid Artery Bifurcation Aneurysms, Assessment Of

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0% - https://www.scribd.com/doc/247163743/AAO


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