1. Surgical Treatment of Aneurysms of the Anterior Wall of the
Internal Carotid Artery
崔源生
台中榮民總醫院神經外科

2. Anatomy: ICA:5 segments: Cervical Petrous Cavernous Clinoidal
Supraclinoid

3. Morphology:

4. Pathology: No internal elastic lamina and media
The gap was covered with thin adventitia and fibrinous tissue, not composed of thick adventitia or collagenous tissue as ordinarily seen in an berry aneurysm wall

5. Pathology:

6. Pathogenesis: Atherosclerosis: Dissecting:
(Stehbens,et al:The pathology of intracranial arterial aneurysms and their complications, Intracranial Aneursyms, 1983, Vol 1)
Dissecting:

7. Anterior Wall Aneurysm
Dorsal type, Blister-like aneurysm
Low incidence
Small size
Thin wall
No neck
High intraoperative bleeding rate
High morbidity & mortality

8. Diagnosis:
It’s difficult to detect anterior wall aneurysm on angiograms, in large part because of their small size and unusual location.(Shigeta et al, 6 (30%) negative in 20 pts)
It’s of great importance to evaluate collateral circulation because ICA sacrifice at surgery is relative common with these aneurysms.

9. Case 1: angiogram (AP+Lat)

10. Case 1: angiogram (oblique)

11. Case 2: angiogram

12. Case 2:

13. Case 2: CTA

14. OP Findings:Video

15. Textbook-Management of Cerebral Aneurysms (2004)

16. Poor outcome of Anterior Wall ICA Aneurysms:

17. Aneurysm protruding from the dorsal wall of internal carotid artery Fukuo Nakagawa, et al. J of Neurosurgery 65: , 1986
5 year period, 8 cases/460 ANs

18. Blood blisterlike aneurysms of the internal carotid artery Masamitsu Abe, et al. J of Neurosurgery 89: ,1998
, 6 cases/488 ANs

19. Abe series: Clipping on wrapping

20. Aneurysms at nonbranching sites in the supraclinoid portion of the internal carotid artery:Internal carotid artery trunk aneurysms Akira Ogawa, et al. Neurosurgery 47: , 2000
5 year period, 48 cases/7408 ANs

21. Ogawa series-outcome:

22. New method for obliterative treatment of an anterior wall aneurysm in the internal carotid artery: Encircling silicone sheet clip procedure-Technical case report Yasutaka Kurokawa, et al. Neurosurgery 49: , 2001

23. Techinical note:

24. Surgical management: Possible trapping of parent artery
Exposure of cervical ICA for proximal control
Wide open of Sylvian fissure
Little frontal lobe traction
Clip placement parallel to the ICA axis
Necessary to catch the adjacent carotid artery wall with the neck
Temporary clipping to reduce aneurysm turgor
Clipping on wrapping
Endovascular may be an alternative option

25. Thank you