3 Vascular Neurosurgery
3.1 Aneurysms
3.1.1 Nonruptured Aneurysms (Table 3.1a)
3.1.2 Ruptured Aneurysms: Spontaneous Subarachnoid Hemorrhage (Table 3.1d)
SAH grades (Table 3.1f)
Glasgow outcome scale
9 (Table 3.1g)
Score | Definition |
5 | Good recovery |
4 | Moderate disability (disabled but independent) |
3 | Severe disability (conscious but disabled/dependent) |
2 | Persistent vegetative state |
1 | Death |
SAH Grades versus Glasgow outcome scale (Table 3.1h)
Rebleed rates (if not treated)
10 (Table 3.1i)
0–24 h | 4% |
0–2 wk | 20% |
0–6 mo | 50% |
> 6 mo | 3% |
Note: Rebleed mortality is higher than 50%. |
3.1.3 Vascular Spasm
Triple-H therapy (Table 3.1n)
Consider ICP Monitoring + Baseline CT | ||
Triple-H therapy | Targets | Medication |
Hypervolemia | CVP: 10 cm H2O Pwedge: 18 mm Hg | Crystalloids |
Hemodilution | Hct:30% | |
Hypertension | SBP: up to 220 mm Hg | Dobutamine (5μg/kg/min) add phenylephrine (2 μg/kg/min) |
Note:
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3.1.4 Clipping versus Coiling
ISAT (International Subarachnoid Aneurysm Trial)
15 (Table 3.1o)
Primary outcome | Modified Rankin scale 3–6 at 1 year (= death or dependence) |
Dependent/Dead at 1 y | |
Coiling | 24% |
Clipping | 31% |
3.1.5 Aneurysm Surgery: General Recommendations
Surgical options for fusiform aneurysms (Table 3.1q)
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Attention to perforators! |
Intraoperative rupture (Table 3.1s)
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Five to 10% of aneurysm cases. |
Intraoperative papaverine for vessel in spasm (Table 3.1t)
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3.1.6 Aneurysm Surgery: Details per Location
PCom/anterior choroidal (Ach; supraclinoid) aneurysms (Table 3.1w)
ICA bifurcation aneurysms (Table 3.1x)
ACom aneurysms (Table 3.1y)
MCA aneurysms (Table 3.1z )
Pericallosal aneurysms (Table 3.1aa)
Basilar tip aneurysm (Table 3.1bb)
PICA aneurysms (Table 3.1cc)
Vertebrobasilar (VB) junction aneurysms (Table 3.1dd)
Head position/craniotomy |
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Proximal control | Both vertebrals proximally |
Distal control | Basilar
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General surgical pearls |
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Note: The most technically demanding. |