Vascular diseases
Stroke
Emergencies in vascular neurosurgery
In 84% of cases, a stroke results from a circulatory disorder of the brain. In 16% of cases, it results from cranial haemorrhaging.
A circulatory disorder of a brain area is caused by a blood clot that blocks one or more cranial vessels. The brain area no longer supplied by blood is thus damaged. Cerebral or vascular haemorrhaging is the result of a blood vessel rupture.
As a result of the escaping blood, part of the brain is destroyed and compressed because the skull prevents diversion. The compressed areas of the brain no longer function and often suffer serious damage.
The Hirslanden Clinic features a modern stroke unit. Patients experiencing all kinds of neurovascular emergencies are admitted so that diagnosis and treatment can be carried out without delay. The immediate care plays a central role in stroke therapy because the affected brain centres must be rescued as quickly as possible. If a circulatory disorder is addressed promptly, blood clots can be dissolved with medication or removed from the vessels using a micro-catheter. If the cerebral haemorrhage is large and compresses the healthy brain, it can be surgically removed.
The neurovascular focus our clinic offers a comprehensive range of the most advanced diagnostic and therapy using high-quality minimally-invasive techniques. The focus is a multidisciplinary collaboration between neurologists, neuro-radiologists, and neurosurgeons.
Aneurysms
Cerebral aneurysms are vesicular sacs of cerebral arteries that develop at the bifurcations of vessels. Aneurysms are common. Approximately five percent of people suffer from cranial aneurysm. However, aneurysms “do not hurt” and rarely reach a size that causes symptoms because of space-occupying lesions. Often, an aneurysm is only diagnosed when it bursts and causes life-threatening haemorrhaging. If subarachnoid haemorrhaging is suspected, patients should immediately present themselves at our stroke unit in order to prevent fatal consequences.
Special techniques implemented at our centre
At our clinic, the surgical and interventional procedures are performed by our highly-skilled team. Regardless of whether the aneurysm has haemorrhaged, the most appropriate treatment method for the respective patient is determined in a course of a multidisciplinary meeting. The collegial collaboration between neurosurgeons, neuro-radiologists, and neurologists is one of the strengths of our vascular team. If the patient requires surgery, we use the most modern techniques in our operating room. The optimal keyhole incision is planned with reference to the individual anatomy of the aneurysm. The safest and gentlest minimally-invasive route is then selected. The complete elimination of the aneurysm is controlled using endoscopic techniques and intra-operative ICG angiography. The use of ICG fluorescence angiography (ICG: indocyanine green) affords a simple and risk-free way to monitor the results of a vascular operation during surgery (without X-rays) and to make immediate corrections, if required.
Conventional angiography can also be performed to eliminate complex aneurysms during surgery. In our hybrid operating room, the clip location and the conservation of adjacent vessels is controlled during the procedure. Even in particularly difficult cases, the optimal surgical result is ensured, thereby maximising patient safety.
In addition, all patients (even when asleep) are electrophysiologically monitored during the operation in order to detect a disturbance of the cerebral functions as early as possible and adjust the operative procedure accordingly.
Arteriovenous malformations
Arteriovenous malformations (AVM) consist of a bundle of arteries and veins interconnected by fistulae. Because of the lack of capillary bed, the arterial pressure is transferred into veins without restriction. Thus, the thin-walled veins become dilated. There is a risk of rupture.
Special techniques implemented at our centre
Our clinic features interdisciplinary cooperation. The cooperation is exemplified in our daily routine. Patients are briefed by the neurovascular team. The treatment steps are then cooperatively planned and implemented.
After the last embolisation step, the angioma is surgically removed in our neurovascular hybrid operating room. The procedure is performed by both the radiologist and the surgeon. The resection of the angioma is monitored angiographically in the open skull. The procedure is only completed when the AVM are completely resected. Of course, neuronavigation and endoscope-assisted techniques are also available. During the operation, all patients (even when asleep) are electrophysiologically monitored in order to detect any disturbance of the cerebral functions as early as possible and adjust the operative procedure accordingly. If AVM become evident through an epileptic seizure, an additional electrocorticography is performed to identify and, if possible, to remove the potentially epileptic areas.
Our hybrid operating room is the most modern neurovascular surgery suite in Switzerland and in Europe. It was built to provide our patients with the best and safest treatment modalities.
Dural fistula
Arteriovenous fistula (AV fistula) are rare vascular malformations consisting of shunts between the arteries and normal cerebral veins or the spinal cord and the meninges. The literature distinguishes between different forms of fistula formation. Typically, there is only one fistula point between the arterial and venous vascular system.
Special techniques implemented at our centre
In our clinic, of interdisciplinary team offers various treatment options. After an interdisciplinary meeting, each case is treated using the method best suited for the particular patient.
During the operation, all patients (even when asleep) are electrophysiologically monitored in order to detect any disturbance of the cerebral and/or spinal functions as early as possible and adjust the operative procedure accordingly.
Cavernomas
A cavernoma is a vascular malformation consisting of pathologically thin-walled and fibrotic blood capillaries. Unlike arteriovenous malformations, in a spongiform cavernoma, neither arterial nor venous differentiation can be detected. In the surroundings, there are often deposits of blood breakdown products. This haemosiderin border is interpreted as an indication of older micro-haemorrhages; larger space-occupying haemorrhaging is rare.
Special techniques implemented at our centre
Treating brain stem cavernomas
Brain stem cavernomas are associated with a high risk of bleeding. Because of the anatomical density of tracts and cranial nerve nuclei in this region, even small haemorrhages can cause severe symptoms. However, this complex anatomy can make surgical treatment risky. The operative indications should be individually made and only then if the cavernoma has reached the surface and the incision protects functionally relevant structures.
In these cases, the intervention and the surgical access are carefully planned. In the operating room, the location of the skull opening is controlled using neuronavigation. The goal is a small, minimally invasive access, which nevertheless guarantees surgical reliability.
The endoscopic-assisted micro-surgical technique has proven successful in such operations. Through the use of endoscopes, hidden areas of the surgical area can be inspected, thereby reducing the extent of access-related injury. Extensive and considerably traumatic skull openings can be avoided by using minimally invasive keyhole incisions.
Intra-operative monitoring is essential so that functions of the brain stem and cranial nerves can be controlled in the anaesthetised state.
Treating cerebral cavernomas
Compared with low-lying cavernomas, cerebral cavernomas are less likely to haemorrhage. However, the typical blood deposits around the cavernoma cause irritation of the brain surface with frequent seizures. If the seizures cannot easily be treated with medication, surgery is recommended.
In such cases, the aim of surgery is not only the resection of the cavernoma. With the removal of the haemosiderin border, anti-epileptic drugs can often be reduced and discontinued. In order to prevent permanent damage, neuromonitoring of cerebral functions is performed during this radical resection. If the cavernoma is in the immediate vicinity of speech areas, the operation is performed in the awake state.
