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Trapping large thrombosed vertebral artery aneurysms

Hybrid OR setup - the optimum choice for complex vertebral aneurysm treatment

With an incidence rate of 3.2 - 4.9 %1, unruptured intracranial aneurysms are common, especially in women over the age of 502. However, most aneurysms are detected incidentally as they are often asymptomatic. In this case which presented at Jikei University, Japan, the vertebral artery aneurysm compressed adjacent brain structures and the 74-year-old female patient therefore presented with left hemiparesis. 

The decision regarding vertebral artery aneurysm treatment management is difficult, as treatment has a high rate of success, there is an inherent risk of complications, and nonoperative treatment comes with the risk of rupture. In this case the decision was made to watch and wait with operative treatment given the location of the aneurysm and its complex access, the fairly mild symptoms, and the aneurysm size of 27 mm (three dimensions: 27 x 21 x 24 mm). 

Unfortunately, 4 months later the symptoms worsened, and MRI imaging revealed a giant partially thrombosed aneurysm of the right vertebral artery with perifocal edema as well as a large mass effect.

"The literature reveals that aneurysmal growth tends to occur more with larger aneurysms. The likelihood of aneurysms of 12 mm growing is 12 times higher than with 8 mm aneurysms."


Strategic decision-making and thoughtful planning to facilitate maximum procedural success

Unruptured thrombosed aneurysms can be treated either microsurgically through clipping or by using endovascular techniques. The two techniques require different imaging solutions.
In this patient case, due to the location and anatomy of the aneurysm, the strategic decision was made to treat the woman in the Hybrid OR. There were two decisive factors - the first was the room and the second the anatomy of the aneurysm.

  1. Although the Neurosurgical Department at Jikei University in Tokyo, Japan, headed by Prof. Y. Murayama, has a dedicated angiography lab with a fixed biplane system, the surgeons decided to operate in the Hybrid OR with a robotic imaging system. 
    As clipping involves an open craniotomy, the procedure needed the highest level of hygiene for open access, which is a prerequisite of the room.
    This room also comprises a segmented tabletop equipped with a head clamp for stable access.
  2. Given the vessel anatomy of the aneurysm, it required two open accesses, not only to gain proximal vascular control but also to control the neck and adjacent branches. In addition, the obliteration of the vasa vasorum revealed the clipping treatment to be the best operating method when the aneurysm is located ventral to the brain stem. 
    ARTIS pheno provides confidence that there is no vessel leakage or bleeding, and there is sufficient perfusion of the brain tissue before the patient is transferred to the intensive care unit. 
    A high-quality 3D image was generated in four seconds. The physician used the image to evaluate the operative result while still in the operating room. This can be a decisive advantage. For example, in case of leakage, the surgeon is able to react immediately. This not only spares the patient the stress of a reoperation, but also helps save costs for the hospital. 
    The beauty of operating in the Hybrid OR is that you have ultimate intraoperative control within the same procedure.
Hybrid OR Imaging Solutions

Learn more about Hybrid OR imaging solutions with procedural intelligence

Discover the large thrombosed vertebral artery aneurysm trapping workflow

Image courtesy of Jikei University, Tokyo, Japan

    Find out what our customers are saying3

    “Although neurosurgery was the first to start using the first Hybrid OR at Jikei, the demand for the Hybrid OR has increased at our hospital. Today, we have a total of four Hybrid OR rooms at Jikei, but it can still be difficult to manage the schedule and to accommodate all the cases from all the specialties who want to use these rooms.”

    <p>Yuichi Murayama, MD</p>

    Yuichi Murayama, MD

    Professor and Chairman of Neurosurgery, The Jikei University School of Medicine

    “The beauty of working in a Hybrid OR using ARTIS pheno, as opposed to a purely endovascular approach, is that the aneurysm and thrombus can be completely removed without the possibility of further growth. Intraoperative DSA can show the entire vessel structure after the aneurysm trapping at a glance.”

    <p>Naoki Kato, MD</p>

    Naoki Kato, MD

    Associate Professor, Department of neurosurgery, The Jikei University School of Medicine

    “The ARTIS pheno hybrid OR provides us with real-time information on blood flow changes during surgery, which is especially important in cases of complex vascular disorders or tumor surgery. In this case, obtaining vascular information before waking the patient up from anesthesia was very reassuring because it confirmed that normal blood flow was maintained.”

    <p>Kentaro Watanabe, MD</p>

    Kentaro Watanabe, MD

    Associate Professor, Department of neurosurgery, The Jikei University School of Medicine

    See how patients can benefit

    The Hybrid OR provides confidence that there is no vessel leakage or bleeding, and there is sufficient perfusion of the brain tissue before the patient is transferred to the intensive care unit (ICU).

    The Hybrid OR provides confidence that there is no vessel leakage or bleeding, and there is sufficient perfusion of the brain tissue before the patient is transferred to the intensive care unit (ICU).

    Our Hybrid OR imaging systems

    1)
    Source: Incidence and risk factors of intracranial aneurysm: A national cohort study in Korea Tackeun Kim Heeyoung Lee Soyeon Ahn O-Ki Kwon Jae Seung Bang Gyojun Hwang Jeong Eun Kim Hyun-Seung Kang Young-Je Son5 Won-Sang Cho4 Chang Wan Oh International Journal of StrokeVolume 11, Issue 8, October 2016, Pages 917-927 https://doi.org/10.1177/1747493016660096
    2)
    Source: Incidence and risk factors of intracranial aneurysm: A national cohort study in Korea Tackeun Kim Heeyoung Lee Soyeon Ahn O-Ki Kwon Jae Seung Bang Gyojun Hwang Jeong Eun Kim Hyun-Seung Kang Young-Je Son5 Won-Sang Cho4 Chang Wan Oh International Journal of StrokeVolume 11, Issue 8, October 2016, Pages 917-927 https://doi.org/10.1177/1747493016660096
    3)
    The statements by Siemens Healthineers’ customers described herein are based on results that were achieved in the customer's unique setting. Because there is no “typical” hospital or laboratory and many variables exist (e.g., hospital size, samples mix, case mix, level of IT and/or automation adoption) there can be no guarantee that other customers will achieve the same results.