Table Of Content166 Giant Basilar Trunk Aneurysms
Table 11.4. Operative method and result of aneurysm Table 11.5. Timing of surgery and outcome in 22 patients
treatment in 59 patients with giant basilar trunk aneu- with ruptured giant basilar trunk aneurysms
rysms
Timing of Excel- Good Poor Dead Total
Operative Total Resid- Resid- No Not Total surgery lent
method obliter- ual ual oblit- known
ation neck fundus eration 0-1 day 1 1
4-6 day 2 2 4
Neck
7-10 day 3 1 4
clipping 6 1 7
11-30 day 5 1 6
Silk
31-365 day 4 3 7
ligature 1 1
Wrapping 1- 1 Total 12 5 2 3 22
Hunterian
ligation 28 1 9 1 39
Basilar a. 22b 1 5 1 2
1 Verte-
bral 1 2
2 Verte-
brals 4 1 2 7
Trapping 7 7
V-P shunt 1 1
Explora-
tion only 3 3
Total 41 1 11 5 1 59
a Thrombosed later spontaneously totally.
bI n one case tourniquet not closed.
c.
G. Drake
S. J. Peerless
J. A. Hernesniemi
Surgery of
Vertebrobasilar Aneurysms
London, Ontario Experience
on 1767 Patients
Foreword by M. G. Ya§argil
SpringerW ienN ewY ork
Charles G. Drake, OC, MD., FRCSC
University Hospital, London, Ontario, Canada
Sydney J. Peerless, MD., FRCSC
MERCY Neuroscience Institute, Miami, Florida, U.S.A.
Juha A. Hernesniemi, M.D., Ph.D.
Department of Neurosurgery, University Hospital, Kuopio, Finland
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© 1996 Springer-Verlag/Wien
Softcover reprint of the hardcover 1st edition 1996
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Printed on acid-free and chlorine free bleached paper
With 180 Figures in 554 Single Illustrations and 201 Tables
Library of Congress Cataloging-in-Publication Data
Drake, Charles C.
Surgery of vertebrobasilar aneurysms: London, Ontario, experience
on 1,767 patients / c. G. Drake, S. J. Peerless, J. A. Hernesniemi;
foreword by M. C. Ya;;argil.
p. cm.
Includes bibliographical references and index.
ISBN-13:978-3-7091-9411-9
1. Vertebrobasilar aneurysms - Surgery. I. Peerless, S. J. (Sydney
John) II. Hernesniemi, J. III. Title.
[DNLM: 1. Cerebral Aneurysm - surgery. 2. Vertebral Artery -
- surgery. 3. Vertebral Artery - physiopathology. 4. Basilar Artery -
- physiopathology. 5. Basilar Artery - surgery. WL 355 D761s 1995]
RD594.2.D73 1995
617.4'81 - dc20
DNLM/DLC
for Library of Congress 95-10940
clr
ISBN-13:978-3-7091-9411-9 e-ISBN-13:978-3-7091-9409-6
DOl: 10.1007/978-3-7091-9409-6
Every man owes it as a debt to his profession to put on record whatever he has
done that might be of use to others.
Francis Bacon (1561-1626)
Foreword
It is a great privilege to write the foreword for this classical work of Professor Charles
Drake. There is no doubt that intracranial aneurysms have existed since the beginning
of time. This terrifying disease of the brain arteries, with its dramatic consequences for
the patient, has surely been observed in all human collectives, although clear definition
and description in the literature began only 300 years ago. During the last century,
clinical signs and symptoms have been carefully observed and analyzed, and 100 years
ago, the first attempts were made for surgical treatment, such as the ligature of external
and internal carotid and vertebral arteries.
With the introduction of angiography, an entirely new dimension of diagnosis and
differential diagnosis of the vascular diseases of CNS, was accomplished. In the years
between 1945 and 1970, the neurosurgeon was increasingly stimulated to directly
eliminate intracranial aneurysms. The most respected and avoided location, the
aneurysms at the bifurcation of the basilar artery, remained as a "dark corner." Several
pioneers of neurosurgery attempted to explore the interpeduncular fossa, but finally
retreated. Not so Charles Drake. His vision must have been stronger than his anxiety,
after experiences of initial fatalities, to persevere more decisively in this desperate fight
instead of to yield. Such steadfastness requires enormous courage. But what distin
guishes courage! Surgical courage is not just a fearless or unscrupulous action. Courage
depends on the well calculated decision between the possible risks and the possible
success of a planned action. The courageous action requires, further on, a constant
balance between impeccable vision and an immaculate concept, continuously judging
the applicability of each single manipulation. Finally, courage implicates the wisdom to
know the right time, the right place, the right proportion, and the right significance of
surgical application. Charles Drake would stay this unique, gigantic fight on 1767
cases, establishing the principles of the surgical treatment of vertebrobasilar aneu
rysms. In this publication, he courageously presents his experiences and unique
results. His achievements are beyond any analytic and critical judgments. He illumi
nated the "dark corner" within the CNS, and provided a guiding light. It is evident
that others are indeed following. This monumental work will remain a milestone in
neuroscience.
M. Gazi Ya~argil
Preface
Until recently I have resisted writing a book on aneurysms or arteriovenous malforma
tions since most of our experience has been published where it could be seen promptly
and widely in neurosurgical journals. Having contributed many chapters in multi
authored books, I became concerned that by the time the galley proofs arrived much of
what I had written was out of date or needed major change - and these were even
moreso when the volume was finally published a year or so later.
But I have been persuaded by many neurosurgeons that because our experience
with posterior circulation aneurysms is so large and unique and unlikely to be
repeated, that it deserves summation in a book, if for no other than historical reasons.
I can only hope that it will also be of value to those younger neurosurgeons who are
pursuing these aneurysms to their final solution.
The operative illustrations have been updated from those featured in Clinical
Neurosurgery, Volume 26, 1979. A new inclusion is the transmastoid-transpetrosal
approach, an old technique used for clival tumors, which has been very useful for
certain mid-and lower basilar aneurysms. Persuant to long felt convictions, the results
have been amplified with description and discussion of the poor outcomes.
That the patient profiles and outcomes are in some detail is only because of
Juha Hernesniemi, M.D., Ph.D., who took more than a year out of his life in Miami to
put one hundred or so features of each patient into a computer data base.
The book is dedicated to these patients who with their families allowed us to
approach their aneurysms under and in front of their brain stems. If only we could have
back again many of those who were lost or badly hurt, for a second chance in the
operating room with what we have learned.
Charles G. Drake, OC, MD., FRCSC
C. G. Drake and S. J. Peerless J. A. Hernesniemi
Acknowledgements
The clinical material to be discussed constitutes mostly a personal series of the two
senior authors who operated upon 95% of the patients. We are grateful to Drs. J. P.
Girvin, G. G. Ferguson, H. R. Reichmann and S. P. Lownie to have their cases included
in the series, and for their continuing and most important help in the clinical work
through the years.
The referring doctors, mainly from the USA and Canada, but also from many
different countries in Europe, South America, Australia, Asia and Africa, made this
unique series of 1767 patients with vertebral-basilar aneurysms possible. The patients
were operated upon at the teaching hospitals of the University of Western Ontario in
London, Canada; at Victoria Hospital 1959-72, at University Hospital 1973-1992, and at
the University of Miami/Jackson Memorial Hospital in Miami, Florida 1991-1992.
Many patients were operated upon by the senior authors at other university clinics
around the world as visiting surgeons and their staffs' kind hospitality remains fresh in
our memories.
The work could only be done because of the team. Our neuroanesthesia was
exceptional under Drs. R. Aitken, G. Varkey, A. Gelb and P. H. Manninen especially
and we must acknowledge their skills in providing us with slack brains and their
thoughtful originality in blood pressure control and brain protection and ceaseless
vigilance over countless hours. The excellence of neuroradiology unders Drs. J.
Allcock, A. Fox and their staff was a major factor in what we were able to accomplish.
Not only did they insure superb imaging and expert interpretation, they were early
into the endovascular story when in 1978 Dr. G. Debrun brought the latest techniques
to our unit and with Dr. F. Vinuela and the rest achieved remarkable innovations over
the years. We were fortunate to have neuroradiologists and anesthesiologists who
thought beyond their specialty and contributed many fresh ideas to management of
these complex patients.
We thank the nurses on the floor and the operating theater staff whose skills and
efficiency have supported our patients, and us, day and night through the years. The
medical staff, physiotherapists, occupational therapists and dieticians in the different
hospitals have always given excellent pre-and postoperative care. The contribution of
these many dedicated professionals to our results can never be measured, but it has
been the cornerstone for the recovery of our patients.
The help of countless neurosurgeons and residents, who were educated at the
teaching hospitals of the University of Western Ontario in London, Canada, is grateful
ly acknowledged. Many new ideas were tested, and even born, in discussions with
them and with many foreign visitors. We are proud of these young people, many of
whom now have leadership roles in universities around the world. That posterior
circulation aneurysms are now operated upon worldwide in major neurosurgical units
is in large part the result of their efforts and teaching.
The manuscript was only made possible with the personal and secretarial assist
ance of Ms. Heather Carter, whose skills are too numerous to be listed here. Further,
the authors wish to thank Mrs. Deborah Bisnaire, Mrs. Dorothy McManus and Mrs.
Lynda McMillan for their secretarial help and data collection, and to Dr. F. Gutman,
XII Acknowledgements
Mr. M. Peerless, Ms. A. Hanks and Mr. M. Halmu for their assistance in developing
the database. This research was supported in part by grants to Dr. Hernesniemi from
UH of Kuopio, Maire Taponen Foundation, Families Hernesniemi, Kuopio and
Ruovesi, FIN, Family Ketola, Lantana, FL, and Jac~son Memorial Hospital Founda
tion.
Springer-Verlag, and especially Mag. Elisabeth Hunger and Mr. Raimund Petri
Wieder, deserve special recognition for their generous help, patience and outstanding
production work.
London,Canada Charles C. Drake, OC, M.D., FRCSC
Sydney J. Peerless, M.D., FRCSC
Juha A. Hernesniemi, M.D., Ph.D.
.
,
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The admitting office used a pin for each case - where they come from in North America and around
the world
Contents
Authors' Addresses XVII
Abbreviations XIX
List of Operative Drawings XX
1. Historical Notes 1
2. Clinical Material 7
3. Small Aneurysms at the Bifurcation of the Basilar Artery: 493 Patients 17
Clinical Features 17
Early Surgical Experience 17
Anatomical Features 18
The Subtemporal Approach 21
Induced Intraoperative Hypotension 27
The Transsylvian (Pterional) Approach 28
Other Approaches 29
Upward Projecting Basilar Bifurcation Aneurysms 30
High Basilar Bifurcation 36
Low Basilar Bifurcations 36
Forward Projecting Aneurysms 37
Backward Projecting Aneurysms 37
Results 38
4. Large (or Bulbous) Basilar Bifurcation Aneurysms (12.5-25 mm): 265 Patients 42
Clinical Features 42
Results 51
5. Analysis of Operative Morbidity in Basilar Bifurcation Aneurysms: Small and
Large (Non-Giant): 758 Patients 55
Perforator Injury or Occlusion 55
Final Comments on Non-Giant Basilar Bifurcation Aneurysms 65
6. Giant Basilar Artery Bifurcation Aneurysms: 137 Cases 68
Anatomical Features of Giant Basilar Bifurcation Aneurysms 68
Clinical Features 68
Treatment 69
Explored Only 69
Intra-AneurysmalOcclusion 69
Neck Clipping 75
Vertebral Artery Occlusion 80
Basilar Artery Occlusion 81
7. Non-Giant (Small and Large) Basilar Superior Cerebellar Artery Aneurysms:
210 Patients 95
Anatomical Features 95
Clinical Features 95
Treatment 96
XIV Contents
8. Giant Basilar-Superior Cerebellar Artery Aneurysms: 56 Patients 110
Anatomical Features 110
Clinical Features 110
Explored Only 110
Neck Clipping 112
Basilar Artery Occlusion 112
9. Midbasilar Trunk Aneurysms: 44 Patients 119
Anatomical Features 119
Clinical Features 121
Approach 121
Results 128
10. Basilar-Anterior Inferior Cerebellar Artery Aneurysms: 41 Patients 133
Anatomical Features . 133
Clinical Features 133
Approaches 135
Results 141
11. Giant Basilar Trunk Aneurysms: 59 Patients 143
Anatomical Features 143
Clinical Features 143
Treatment 143
Neck Clipping 145
Parent Artery Occlusion 145
Trapping 162
12. Vertebral-Basilar Junction Aneurysms: 77 Patients 167
Anatomical Features 167
Clinical Features 167
Approach 167
Results 174
13. Giant Vertebrobasilar Junction Aneurysms: 39 Patients 177
Treatment 177
Vertebral Artery Occlusion 180
Unilateral Vertebral Occlusion 180
Bilateral Vertebral Occlusion 180
Trapping and Evacuation 192
14. Non-Giant Aneurysms of the Vertebral Artery: 181 Patients 195
Anatomical Features 195
Classification 195
Clinical Features 197
Approaches 201
Results 203
15. Giant Vertebral Aneurysms: 40 Patients 207
Anatomical Features 207
Clinical Features 207
Treatment 207
Description:It is a great privilege to write the foreword for this classical work of Professor Charles Drake. There is no doubt that intracranial aneurysms have existed since the beginning of time. This terrifying disease of the brain arteries, with its dramatic consequences for the patient, has surely been obs
