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Anterior perforated substance region aneurysms: review of a series treated with microsurgical technique

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Abstract

Aneurysms arising from the distal carotid, proximal A1, and proximal M1 that project posteriorly and superiorly toward the anterior perforated substance (APS) are rare. Their open surgical treatment is particularly difficult due to poorly visualized origin of the aneurysm and the abundance of surrounding perforators. We sought to analyze the anatomical and clinical characteristics of APS aneurysms and discuss surgical nuances that can optimize visualization, complete neck clip obliteration, and preservation of adjacent perforators. Thirty-two patients with 36 APS aneurysms were surgically treated between November 2000 and September 2017. Patients were prospectively enrolled in a cerebral aneurysm database and their clinical, imaging, and surgical records were retrospectively reviewed. Twenty-seven aneurysms originated from the distal ICA, 7 from the proximal A1, and 2 from the proximal M1; 15 patients presented with subarachnoid hemorrhage. Careful intraoperative dissection revealed 4 aneurysms originating at the takeoff of a perforator; another 25 had at least 1 adherent perforator. All aneurysms were clipped except for one that was trapped. Postoperatively, 3 patients had radiographic infarctions in perforator territory with only 1 developing delayed clinical hemiparesis. Good outcome (modified Rankin Scale, 0–2) was achieved in 28 patients (88%). APS aneurysms present a challenging subset of aneurysms due to their complex anatomical relationship with surrounding perforators. These should be identified on preoperative imaging based on location and projection. Successful microsurgical clipping relies on optimization of the surgical view, meticulous clip reconstruction, preservation of all perforators, and electrophysiological monitoring to minimize ischemic complication.

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Our materials are maintained at the Arkansas Neuroscience Institute database.

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Acknowledgements

The authors wish to thank Nathan E. Moore for technical and artistic editing and Andrew J. Gienapp (Neuroscience Institute, Le Bonheur Children’s Hospital and Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA) for copyediting, formatting the manuscript for publishing, and publication assistance.

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Authors and Affiliations

  1. Arkansas Neuroscience Institute, CHI Saint Vincent Infirmary, Little Rock, AR, USA

    Jaafar Basma, Hassan Saad, Tarek Abuelem, Khaled Krisht, Li Cai, Svetlana Pravdenkova & Ali F. Krisht

  2. Department of Neurosurgery, The University of Tennessee Health Science Center, 847 Monroe Avenue, Suite 427, Memphis, TN, 38163, USA

    Jaafar Basma

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  1. Jaafar Basma
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  2. Hassan Saad
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  7. Ali F. Krisht
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Contributions

Jaafar Basma was involved in the conception, data collection, and manuscript writing. Hassan Saad participated in the data collection. Tarek Abuelem contributed to the conception, literature review, and manuscript writing. Khaled Krisht helped with manuscript editing. Li Cai worked on the manuscript’s figures. Svetlana Pravdenkova contributed to data collection and analysis. Ali Krisht, as the senior surgeon performing the reported operations, conceptualized the project, aneurysm classification, and surgical techniques, and contributed to data analysis and manuscript writing.

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Correspondence to Jaafar Basma.

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The IRB approval was waived as the study is a retrospective review with de-identified patient information. The study was conducted in line with the ethical principles of the Saint Vincent Hospital.

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Basma, J., Saad, H., Abuelem, T. et al. Anterior perforated substance region aneurysms: review of a series treated with microsurgical technique. Neurosurg Rev 44, 2991–2999 (2021). https://doi.org/10.1007/s10143-021-01485-6

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