Responsibilities during Open Surgery for Cerebral Aneurysms

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  • Nakayama Naoki
    Advanced Cerebrovascular Center, Kashiwaba Neurosurgical Hospital
  • Ito Yasuhiro
    Advanced Cerebrovascular Center, Kashiwaba Neurosurgical Hospital
  • Sugiyama Taku
    Department of Neurosurgery, Hokkaido University Faculty of Medicine
  • Gekka Masayuki
    Department of Neurosurgery, Hokkaido University Faculty of Medicine
  • Maruichi Katsuhiko
    Advanced Cerebrovascular Center, Kashiwaba Neurosurgical Hospital

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Other Title
  • 脳動脈瘤開頭手術の責務
  • ノウ ドウミャクリュウカイトウ シュジュツ ノ セキム

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Abstract

<p>  Open surgery for cerebral aneurysms has reached a state of maturity, owing to the accumulation of experience and efforts made by our forerunners over the years. Ordinary clipping has become quite sophisticated and widespread in terms of its approach and dissection methods. Even internal carotid artery aneurysms that interfere with the tent or oculomotor nerve are not problematic if proper procedures are followed. If the shape of the aneurysm at the tip of the basilar artery is clippable, there is no problem with the approach itself if proper fissure dissection techniques are used. Large aneurysms can also be treated with reliable low/high flow bypass techniques, and parasellar aneurysms can be treated reliably if one has mastered cranial base techniques.</p><p>  However, a large or giant aneurysm that contains a critical perforating branch is difficult to be treated by craniotomy and will have to rely on further development of the flow diverter. However, these cases are few and far between. Almost all aneurysms can be treated with open surgery.</p><p>  On the other hand, endovascular treatment is becoming increasingly applicable with the development of ever-advancing devices. Even though recurrence is possible and hemorrhagic complications tend to be serious, but the rate of endovascular treatment is likely to increase in the future. What are the responsibilities during invasive open surgery in the current situation? The answer lies in safety, certainty, and curability. In other words, any surgery that cannot guarantee these qualities will lose its value.</p><p>  Simple clipping also requires the pursuit of a closure line, which requires wide craniotomy and sufficient fissure dissection and mobilization of the vessel. The interhemispheric approach must also be able to expand widely from the corpus callosum without being overwhelmed. The bypass also needs to be a routine and reliable technique for all areas, and the skull base technique needs to be mastered with anterior clinoid process removal, petrous bone removal, and condyle removal. These methodologies have already been well developed.</p><p>  The problem that remains is how to pass on the knowledge of an open surgery to the next generation in the future, when the learning curve of craniotomy is slow and the number of cases to be treated by craniotomy is decreasing. In view of the fact that the number of difficult cases and recurrent cases will increase, this is an issue that needs to be considered seriously.</p>

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