Changes and Innovations for the surgical management of intracranial aneurysms

335 Pages·2015·4.28 MB·English

by  Leon Lai

Changes and Innovations For The Surgical
Management of Intracranial Aneurysms

Leon Tat Lai, MBBS

A thesis submitted to fulfill the requirements for the degree of
Doctor of Philosophy in the Australian School of Advanced Medicine,
Faculty of Human Sciences, Macquarie University

January 2014
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TABLE OF CONTENTS

Abstract ................................................................................................................................ 15
Statement of Originality ....................................................................................................... 17
Acknowledgements ............................................................................................................. 19
Author‟s publications and book chapters written during the period of candidature ............ 21
Published/accepted manuscripts related to this thesis .................................................. 21
Published book chapters related to this thesis .............................................................. 24
Published/accepted manuscripts not related to this thesis ............................................ 24
Author‟s conference proceedings and presentations at scientific meetings during the period
of candidature ....................................................................................................................... 25
Oral presentations at scientific meetings related to this thesis ..................................... 25
Invited lectures at scientific meetings and courses related to this thesis ...................... 27
Poster presentations at scientific meetings related to this thesis .................................. 27
List of tables and figures ...................................................................................................... 29
Abbreviations and definitions .............................................................................................. 35

CHAPTER 1. ................... 39
Preface to Chapter 1 ......................................................................................................... 39
Author‟s contribution ....................................................................................................... 39
Abstract ............................................................................................................................ 40
Introduction ...................................................................................................................... 41
The Hunterian principle of carotid artery ligation ............................................................. 41
Extending the Hunterian principle intracranially ............................................................. 42
The beginning of direct surgery on intracranial aneurysms ............................................. 43
The birth of Surgical clip ligation of intracranial aneurysms ........................................... 44
The microsurgical era of aneurysm treatment ................................................................... 45
The development of cranial base approaches to intracranial aneurysms ........................ 46
The refinement of aneurysm clip designs ......................................................................... 47
Continuing microsurgical innovations for intracranial aneurysm surgery ...................... 48
Endoscopic endonasal approach and surgical treatment of intracranial aneurysms ....... 48
Conclusion ........................................................................................................................ 50
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Declaration of interest and acknowledgements ................................................................ 50

CHAPTER 2.
............................................................................... 53
Preface to Chapter 2 ......................................................................................................... 53
Author‟s contribution ....................................................................................................... 53
Abstract ............................................................................................................................ 54
Introduction ...................................................................................................................... 55
Methods ............................................................................................................................ 56
Data source ................................................................................................................... 56
Inclusion and exclusion criteria .................................................................................... 57
Statistical analysis ........................................................................................................ 58
Results .............................................................................................................................. 58
Discussion ........................................................................................................................ 59
Limitations of Study ......................................................................................................... 64
Conclusion ........................................................................................................................ 64
Declaration of interest and acknowledgements ................................................................ 64

CHAPTER 3.
............................................................................................. 65
Preface to Chapter 3 ......................................................................................................... 65
Author‟s contribution ....................................................................................................... 65
Abstract ............................................................................................................................ 66
Introduction ...................................................................................................................... 67
Methods ............................................................................................................................ 68
Data source ................................................................................................................... 68
Inclusion and exclusion criteria .................................................................................... 69
Statistical analysis ........................................................................................................ 69
Results .............................................................................................................................. 71
Overall incidences ........................................................................................................ 71
Gender .......................................................................................................................... 71
Age ............................................................................................................................... 71
Aneurysm location ....................................................................................................... 72
Discussion ........................................................................................................................ 77
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Limitations of Study ......................................................................................................... 79
Conclusion ........................................................................................................................ 80
Declaration of interest and acknowledgements ................................................................ 80

CHAPTER 4.
.................................................................................. 81
Preface to Chapter 4 ......................................................................................................... 81
Author‟s contribution ....................................................................................................... 81
Abstract ............................................................................................................................ 82
Introduction ...................................................................................................................... 83
Methods ............................................................................................................................ 83
Data source, selection criteria and definition of endpoints ........................................... 83
Admission status risk factors ......................................................................................... 84
Ruptured aneurysm locations ........................................................................................ 84
In-hospital related variables........................................................................................... 85
Statistical analysis ......................................................................................................... 85
Results .............................................................................................................................. 86
Admission status risk factors ........................................................................................ 86
Ruptured aneurysm locations ....................................................................................... 86
In-hospital related variables .......................................................................................... 87
Multivariate logistic regression Analysis ..................................................................... 87
Discussion ........................................................................................................................ 89
Limitations of Study ......................................................................................................... 91
Conclusion ........................................................................................................................ 92
Declaration of interest and acknowledgements ................................................................ 92

CHAPTER 5.
................................... 93
Preface to Chapter 5 ......................................................................................................... 93
Author‟s contribution ....................................................................................................... 93
Abstract ............................................................................................................................ 94
Introduction ...................................................................................................................... 95
Methods ............................................................................................................................ 95
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Data source, selection criteria and definition of endpoints ........................................... 95
Defining the risk of seizures based on treatment modalities ........................................ 96
Defining predictive factors for seizures ........................................................................ 96
Establishing a difference in complication rates for clipping and coiling ...................... 97
Statistical analysis ......................................................................................................... 97
Results .............................................................................................................................. 97
Risk of seizures following surgical clipping or endovascular coiling of UIAs ............ 97
Predictors of in-hospital seizures ................................................................................. 98
Complications associated with surgical clipping and endovascular coiling of UIAs . 99
Discussion ........................................................................................................................ 99
Limitations of Study ....................................................................................................... 101
Conclusion ...................................................................................................................... 102
Declaration of interest and acknowledgements .............................................................. 102

CHAPTER 6.
............................................................................................................. 105
Preface to Chapter 6 ....................................................................................................... 105
Author‟s contribution ..................................................................................................... 105
Abstract .......................................................................................................................... 106
Introduction .................................................................................................................... 106
Methods .......................................................................................................................... 107
Clinical material .......................................................................................................... 107
Technical consideration .............................................................................................. 108
Outcome assessment .................................................................................................... 109
Statistical analysis ....................................................................................................... 109
Results ............................................................................................................................ 109
Surgical procedures ..................................................................................................... 111
Intraoperative complications ....................................................................................... 111
Transient morbidity ..................................................................................................... 111
Permanent morbidity and mortality ............................................................................. 113
Visual outcomes .......................................................................................................... 113
Angiographic and clinical outcomes ........................................................................... 114
Prognostic predictors of surgical outcomes ................................................................. 114
Age ............................................................................................................................. 114
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Size ............................................................................................................................. 114
Calcification, thrombus and irregularities of the aneurysms on CT ........................... 116
Surgical procedures .................................................................................................... 117
Temporary clipping .................................................................................................... 117
Specific subgroup of patients with surgical complications ........................................ 117
Logistic regression analysis of prognostic factors ...................................................... 118
Discussion ...................................................................................................................... 118
Limitations of Study ....................................................................................................... 121
Conclusion ...................................................................................................................... 121
Declaration of interest and acknowledgements .............................................................. 122

CHAPTER 7.
............................................................................................................. 123
Preface to Chapter 7 ....................................................................................................... 123
Author‟s contribution ..................................................................................................... 123
Abstract .......................................................................................................................... 124
Introduction .................................................................................................................... 125
Methods .......................................................................................................................... 125
Clinical material .......................................................................................................... 125
Technical consideration .............................................................................................. 126
Outcome assessment .................................................................................................... 126
Statistical analysis ........................................................................................................... 127
Results ............................................................................................................................ 127
Surgical procedures ..................................................................................................... 127
Morbidity ..................................................................................................................... 128
Angiographic and clinical outcomes ........................................................................... 129
Specific subgroup of patients with surgical complications ........................................ 130
Prognostic predictors of surgical outcomes ................................................................ 131
Discussion ...................................................................................................................... 131
Limitations of Study ....................................................................................................... 132
Conclusion ...................................................................................................................... 133
Declaration of interest and acknowledgements .............................................................. 134

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CHAPTER 8.

............................................................................................................................................ 139
Preface to Chapter 8 ....................................................................................................... 139
Author‟s contribution ..................................................................................................... 139
Abstract .......................................................................................................................... 140
Introduction .................................................................................................................... 141
Methods .......................................................................................................................... 141
Clinical material ......................................................................................................... 141
Technical consideration .............................................................................................. 142
Outcome assessment ................................................................................................... 142
Statistical analysis ...................................................................................................... 143
Results ............................................................................................................................ 143
Surgical procedures .................................................................................................... 144
Morbidity .................................................................................................................... 144
Oculomotor nerve palsy ............................................................................................. 145
Angiographic and long-term outcomes ...................................................................... 145
Specific subgroup of patients with surgical complications ........................................ 145
Discussion ...................................................................................................................... 146
Limitations of Study ....................................................................................................... 148
Conclusion ...................................................................................................................... 148
Declaration of interest and acknowledgements .............................................................. 149

CHAPTER 9. ............... 155
Preface to Chapter 9 ....................................................................................................... 155
Author‟s contribution ..................................................................................................... 155
Abstract .......................................................................................................................... 156
Introduction .................................................................................................................... 157
Methods .......................................................................................................................... 157
Literature review ........................................................................................................ 157
Patient population ....................................................................................................... 158
Statistical analysis ...................................................................................................... 159
Results ............................................................................................................................ 160
Literature review of de novo aneurysm detection ....................................................... 160
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Clinical case series....................................................................................................... 160
Discussion ...................................................................................................................... 161
Limitations of Study ....................................................................................................... 163
Conclusion ...................................................................................................................... 163
Declaration of interest and acknowledgements .............................................................. 163

CHAPTER 10.
..................................... 169
Preface to Chapter 10 ..................................................................................................... 169
Author‟s contribution ..................................................................................................... 169
Abstract .......................................................................................................................... 170
Introduction .................................................................................................................... 171
Methods .......................................................................................................................... 171
Clinical material .......................................................................................................... 171
Outcome assessment ................................................................................................... 172
Surgical management .................................................................................................. 172
Principles of ICG videoangiography .......................................................................... 173
Statistical analysis ....................................................................................................... 173
Results ............................................................................................................................ 174
Discussion ...................................................................................................................... 177
Limitations of Study ....................................................................................................... 179
Conclusion ...................................................................................................................... 180
Declaration of interest and acknowledgements .............................................................. 180

CHAPTER 11.
.............................................................................................................. 185
Preface to Chapter 11 ..................................................................................................... 185
Author‟s contribution ..................................................................................................... 185
Abstract .......................................................................................................................... 186
Introduction .................................................................................................................... 187
Methods .......................................................................................................................... 187
Specimens .................................................................................................................. 188
Surgical dissection ..................................................................................................... 188
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Dimensions of the surgical field and craniotomy ...................................................... 189
Exposure of the posterior circulation arteries ............................................................. 189
Instrument access and clip application ...................................................................... 189
Statistical analysis ...................................................................................................... 190
Results ............................................................................................................................ 190
Dimensions of the surgical field and craniotomy ...................................................... 190
Exposure of the posterior circulation arteries ............................................................ 190
Instrument access and clip application ...................................................................... 191
Discussion ...................................................................................................................... 192
Conclusion ...................................................................................................................... 197
Declaration of interest and acknowledgements .............................................................. 197

CHAPTER 12.
.......................................................................... 199
Preface to Chapter 12 ..................................................................................................... 199
Author‟s contribution ..................................................................................................... 199
Abstract .......................................................................................................................... 200
Introduction .................................................................................................................... 201
Methods .......................................................................................................................... 201
Specimens .................................................................................................................. 202
Surgical dissection ..................................................................................................... 202
Dimensions of the surgical field, craniotomy, and the infra-chiasmal window ......... 202
Exposure of the clinoidal ICA segment and proximal vascular control .................... 203
Exposure of the paraclinoid region vasculature ......................................................... 204
Instrument access and clip application ...................................................................... 204
Predictors of surgical access and vascular clip placement ........................................ 204
Statistical analysis ...................................................................................................... 204
Results ............................................................................................................................ 205
Dimensions of the surgical field, craniotomy, and the infra-chiasmal window ........ 205
Exposure of the clinoid ICA segment for proximal vascular control ........................ 205
Exposure of the paraclinoid region vasculature ......................................................... 205
Instrument access and clip application ...................................................................... 206
Predictors of surgical access and vascular clip placement ........................................ 207
Discussion ...................................................................................................................... 207
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