Surgical treatment of brain tumor coexisted with intracranial aneurysm—case series and review of the literature

Co-occurrence of Meningioma and Intracranial Aneurysm: A Systematic Review

A complete understanding of the rare neurosurgical phenomenon of co-occurring meningioma and intracranial aneurysm is important to improve the quality of life and decrease future complications in these patients. In this review, we searched the literature for cases of this rare phenomenon to highlight the most important historical, investigation, and treatment-related factors to improve the accuracy of intraoperative procedural decisions. We searched the PubMed database for case reports on this neurological rare phenomenon to create organized data for our review. Then, we extracted information from these cases and organized it in a table. We identified 19 cases in the literature. In the published studies, there was a predominance of the female sex (73.68%). The mean age of the patients was 54.11 years, with the cases relatively evenly distributed among patients in their 30s, 40s, 50s, 60s, and 70s. Posterior communicating artery aneurysm was the most common among the 19 cases. For meningioma, the frontal lobe and clinoid were the two most affected locations, and the meningothelial histopathology was the most common. Complete tumor resection and aneurysmal clipping were done for the majority of the cases (57.8%) unless there was a complication that deferred simultaneous intervention. Fortunately, most patients (78.95%) recovered completely after surgery. The coexistence of meningioma and intracranial aneurysm has a very high cure rate, postoperative symptom resolution, and a very low recurrence rate. For most cases, neuroimaging investigations are recommended for simultaneous management. This imaging can also highlight other potentially suspicious findings.

Disappearance of a Ruptured Feeding Artery Fusiform Aneurysm After the Resection of a Large Subependymoma: A Case Report

Aneurysm formation on the tumor-feeding artery is rare, and its treatment strategies are not yet settled. We herein report the case of a 49-year-old female with a large subependymoma in the left lateral ventricle presenting remote intracerebral hemorrhage at the left posterior cingulate gyrus. Digital subtraction angiography (DSA) revealed the presence of a 5.5 mm fusiform tumor-feeding artery aneurysm on the left parieto-occipital branch of the posterior cerebral artery, considered to be the source of the hemorrhage. Three months after total tumor resection, the aneurysm subsequently disappeared on the follow-up angiography. Subependymomas are generally known as tumors with low vascularity and seldom present with symptoms such as intracerebral hemorrhage. From the subsequent disappearance of the aneurysm after the complete tumor resection, the pathophysiological cause of the aneurysm formation is assumed to be flow-related hemodynamic vessel wall stress of the feeding artery. Tumor resection alone may be a favorable first treatment strategy to avoid unnecessary brain damage since subsequent disappearance of the aneurysm can be expected. The coexistence of feeding artery aneurysms should be kept in mind, especially in cases with remote hemorrhage.

Middle Meningeal Artery Aneurysm in a Giant Meningioma

Nontraumatic perilesional aneurysms are thought to occur because of high-flow demands of feeding arteries and neoangiogenesis of hypervascular lesions, most commonly in vascular malformations, but they can rarely be associated with tumors as well. Most of these perilesional aneurysms are from intracranial vasculature associated with branches off the internal carotid artery. We report the unique case of a middle meningeal artery aneurysm associated with a giant convexity meningioma seen on a preoperative angiogram.

The coexistence of anterior communicating artery aneurysm and meningioma: A literature review and illustrative case

Background

Anterior communicating artery (Acom) aneurysm has an association with many types of intracranial lesions. However, its association with meningioma can be challenging, which is not well addressed in the literature. Herein, we described a literature review focused on the association between Acom aneurysm and meningioma, explicitly highlighting the spatial presence between these two pathologies. We analyzed the literature according to that association with particular emphasis on location-based challenges. Furthermore, we present an illustrative case of surgically treating both lesions in one surgery utilizing the same approach.

Methods

A Medline database search was conducted by the following combined formula: (Meningioma [Title/ Abstract]) AND (Aneurysm [Title/Abstract]) AND (((Anterior communicating artery [Title/Abstract]) OR (Acom [Title/Abstract])) OR Acomm [Title/Abstract]))). Additional resources were added after screening the references of the included papers.

Results

Nine patients with coexistence of Acom aneurysm and meningioma were found in the literature. The coexistence of both pathologies was found in seven females and two males. The presence of an aneurysm was found to be solitary in 66.67% (n = 6/9). Furthermore, meningioma was found to be an isolated lesion in all included cases, and in 22.2% (n = 2/9), they were located ipsilaterally. The location of the meningioma to the aneurysm seems to be in proximity.

Conclusion

Acom aneurysm can coexist with intracranial meningioma; this association can be spatially related intracranially. Such coexistence entails a variety of nuances and challenges that neurosurgeons encounter during the management of these complex lesions.

Coexistence of neurovascular compression syndrome and unruptured cerebral aneurysm

Unruptured cerebral aneurysms (UCAs) are usually asymptomatic and detected incidentally by intracranial examinations. The coexistence of neurovascular compression syndrome (NVCS) and UCAs has not been well described. The aim of this study was to clarify the characteristics of UCAs with the NVCS. A total of 103 cases that underwent microvascular decompression (MVD) for trigeminal neuralgia (TN) or hemifacial spasm (HFS) were assigned to the NVCS group. The prevalence of UCAs in the NVCS group was compared retrospectively to that in 110 control cases (a control group) by neuro-imaging. Overall treatment courses for NVCS and UCAs were investigated in the NVCS group. Sixteen (15.3%; TN 11 cases, HFS 5 cases) of 103 MVD cases had 19 UCAs, a significantly higher prevalence than the 3.6% in the control group. Binomial logistic regression showed that NVCS is a significant factor for predicting the presence of UCAs, with an odds ratio of 4.80. In the NVCS group, 18 UCAs (94.7%) were supratentorial aneurysms, and 17 UCAs (89.5%) were less than 5 mm in size. Nine UCAs were surgically treated with clipping or coiling. Of the surgical cases, 2 UCAs were treated before MVD for NVCS, whereas the other 7 UCAs were treated after MVD. No aneurysms ruptured during the treatment course. The NVCS occurred with UCAs at a significantly higher rate than in the control group. Most UCAs with the NVCS were supratentorial, small aneurysms that did not affect the surgical treatment of NVCS.

Intraoperative rupture of intracerebral aneurysm immediately after meningioma resection: a case report

Background

Meningiomas and unruptured cerebral aneurysms (UCAs) rarely coexist. However, the treatment strategy remains to be fully elucidated. This report is a first report that UCA related to the tumor feeder intraoperatively ruptured when the meningioma was resected.

Case presentation

Herein, we present a case of meningioma coexisting with contralateral UCA related to a tumor feeder. Immediately after the meningioma was resected, intraoperative acute brain swelling due to rupture of the contralateral aneurysm appeared. The swollen brain protruding into the epidural space was resected, following contralateral ruptured aneurysm was performed by endovascular surgery. Intensive neurological treatment was administered and the patient gradually recovered.

Conclusion

This report highlights the possibility of intraoperative UCA rupture related to the tumor feeder when the meningioma is resected.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02664-8.

Magnetic resonance imaging finding of coexistence of bilateral paraclinoid aneurysms in a patient with a nonfunctioning macroadenoma, simultaneous resection, and clipping: illustrative case

BACKGROUND

Unruptured incidental intracranial aneurysm can coexist with pituitary adenoma, however, the occurrence is extremely rare. Timely diagnosis of asymptomatic intracranial aneurysms with pituitary adenoma may lead to planning a tailored surgical strategy to deal with both pathologies simultaneously. A case of a patient who underwent transcranial resection of a pituitary adenoma with clipping of two mirror aneurysms is reported.

OBSERVATIONS

A 55-year-old female presented with deterioration of visual acuity that progressed over 1 year, as well as presence of right eyelid ptosis. Magnetic resonance imaging of the head showed the presence of an intrasellar pituitary macroadenoma. Bilateral paraclinoid aneurysms were documented to be in contact with the pituitary tumor. The patient underwent surgery with simultaneous aneurysm clipping and tumor resection through a standard pterional approach with intradural clinoidectomy. The aneurysms were successfully clipped after the tumoral debulking. After clipping, the pseudocapsule was fully resected.

LESSONS

Various treatment options are available. Although endovascular securing of the aneurysms prior to the tumor resection would be ideal, in cases in which this resource is not readily available at all times, the surgeon must be prepared to solve pathologies with an elevated level of complexity.

Bilateral aneurysms, one of which is embedded in a meningioma: a rare case report and literature review

BACKGROUND

Although the coexistence of primary brain neoplasms with intracranial aneurysms is rare, this phenomenon has become more recognized. Meningioma is the most frequently occurring type of tumor associated with an aneurysm. However, meningiomas encasing aneurysms are extremely rare, posing a diagnostic and therapeutic challenge to healthcare providers.

CASE DESCRIPTION

We report a case of a 46-year-old female patient admitted to our hospital with headache and dizziness for ten years. Enhanced magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) indicated a mass in the right sphenoid ridge, surrounding a posterior communicating artery aneurysm of the right internal carotid artery. Digital subtraction angiography (DSA) revealed left ophthalmic segment aneurysm and right posterior communicating artery aneurysm. We first clipped the aneurysm and then removed intracranial tumor during the same operation. The postoperative pathological diagnosis of tumor was meningioma (World Health Organization grade I). The patient's postoperative course was uneventful, with only a mild reduction in lateral vision of both eyes.

CONCLUSIONS

We reported a rare case in which an intracranial aneurysm was encased in a meningioma and could be safely treated during the same operation. Notably, embolizing or clipping aneurysm first and then removing intracranial tumor appears to enhance the safety of patients. This is the best treatment option if the aneurysm and meningioma can be treated concurrently in the hybrid operating room. Additionally, it may be necessary to carefully evaluate preoperative MRA or computed tomography angiography (CTA), and it is critical to confirm the existence of any vascular lesions in patients with brain tumors using MRA or CTA.

[Combination of pituitary adenomas and intracranial aneurysms]

The combination of intracranial tumors and asymptomatic brain aneurysms is an urgent problem, since it can significantly affect surgical intervention. Aneurysms are common in patients with meningioma, glioma and pituitary adenoma. According to certain authors, combination of aneurysms with pituitary adenomas is 7 times more common than with other tumors. In these cases, a comprehensive examination of the patient and decision-making on surgical strategy are required. This review is devoted to epidemiology, diagnosis and treatment of patients with a combination of pituitary adenomas and intracranial aneurysms detected intraoperatively or at the preoperative stage. The manuscript is illustrated by cases observed at the Burdenko Neurosurgery Center.

Multiple Tumor-Associated Intracranial Aneurysms Adjacent to a Suprasellar Germ Cell Tumor: Case Report and Review of Literature

INTRODUCTION

Tumor-associated intracranial aneurysms are rare and not well understood.

CASE PRESENTATION

We describe a 4-year-old female with multiple intracranial aneurysms intimately associated with a suprasellar germ cell tumor (GCT). We provide the clinical history, medical, and surgical treatment course, as well as a comprehensive and concise synthesis of the literature on tumor-associated aneurysms.

DISCUSSION

We discuss mechanisms for aneurysm formation with relevance to the current case, including cellular and paracrine signaling pertinent to suprasellar GCTs and possible molecular pathways involved. We review the complex multidisciplinary treatment required for complex tumor and cerebrovascular interactions.

Higher Prevalence and Age Susceptibility of Intracranial Aneurysm in Patients With Acoustic Neuroma

Introduction: The purpose of this study was to verify whether the prevalence of intracranial aneurysm (IA) in patients with acoustic neuroma is greater than that in age- and sex-matched controls and to evaluate the independent risk factors related to the occurrence of IA. Methods: We retrospectively analyzed 231 patients diagnosed with acoustic neuroma at our institute between 2015 and 2019 and 489 controls from the medical examination center. Cerebrovascular angiography was acquired from all subjects to assess the presence of IA or not. The prevalence of IA and risk factors associated with a higher IA occurrence were compared, respectively. Results: Cerebral aneurysms were detected in 23 patients (10.0%) and 11 controls (2.2%). The prevalence of IA was significantly different between patients with acoustic neuroma and controls (p < 0.001), and the difference was mainly reflected in the age of 50 and above. In the subgroup analysis, there were distinct differences in several clinical features including age, hypertension, and tumor volume, and cystic change between patients coexisted with IA or not. However, age was a unique independent risk factor for coexistence of IA in patients with acoustic neuroma after multivariate logistic regression (OR 1.050, 95% CI 1.008-1.093, p = 0.019). Conclusions: Our results demonstrate that patients with acoustic neuroma have a higher prevalence of IA than the general population. Older age is correlated with greater occurrence of IA in these patients.

Stent-Assisted Coil Embolization of a Basilar Artery Dissecting Aneurysm Involved in Skull Base Chordoma Before Endoscopic Transsphenoidal Transclival Resection

BACKGROUND

Skull base chordomas will occasionally penetrate the clival dura mater and extend into the prepontine cistern, involving the basilar artery. Few reports have described cases of skull base chordoma accompanying a dissecting aneurysm of the basilar artery, and the treatment strategies have remained largely unknown.

CASE DESCRIPTION

A 28-year-old man was referred to our hospital with a complaint of severe headache. A skull base chordoma involving a basilar artery dissecting aneurysm was diagnosed. We initially performed endovascular surgery for the dissecting aneurysm after dual antiplatelet therapy before surgical resection of the tumor, which was successfully achieved without complications. Follow-up angiography 3 months after endovascular surgery disclosed obliteration of the dissecting aneurysm. We then stopped the dual antiplatelet therapy, and performed judicious resection using an endoscopic transclival approach. The residual tumor was treated with radiosurgery. At the last follow-up examination, the patient was stable, and the tumor remained sufficiently controlled.

CONCLUSIONS

We have reported a case of a dissecting aneurysm of the basilar artery with clival chordoma. Our findings suggest that chordoma with intradural vascular encasement has the potential to invade the vessel wall. To avoid rupture of those critical vascular structures, treatment strategies that minimize stress on the involved arteries and offer safe and sufficient surgical resection should be considered.

Association between intracranial aneurysm and meningiomas: An integrative survival Analysis with identification of prognostic factors

OBJECTIVE

To analyze prognostic factors in clinical association between intracranial aneurysm (IA) and meningioma. Prognostic factors on overall survival (OS) were evaluated.

METHODS

We selected articles, published from January 1944 to December 2018 on the Medical databases (Web of Sciences, Medline and EMBASE) and included case series and reports. Clinical information was obtained and variables associated with the primary outcome of 27-mo survival were identified through Cox regression models.

RESULTS

The study evaluated 77 patients. Female represented 76.6 % (n = 59), a ratio of 3.27 female: 1 male. The age range was 7-84 years old, with an average of 54.74 (SD: 14.30). Age and sex were not significant statistically different between the two groups for overall survival (OS) (log-rank P = 0.806), (log-rank P = 0.983) respectively. 77.9 % (n = 60) were ipsilateral, the same side was 4 times more common in univariate analysis (P = 0.052; 95 % CI, 0.924-17.319). Most aneurysms were detected in the internal carotid artery, 29.87 %. In Clinical data, 62.33 % (n = 48) had exclusive tumor symptoms, while 25.97 % (n = 20) presented exclusively subarachnoid hemorrhage (SAH). In multivariate analysis, although there is an independent protective factor for those who did not have SAH (HR; 0.099; CI; 0.010-0.986; P = 0.049) and the treatment is an independent predictor for OS (HR, 42.096; CI, 4.270-415.056; P = 0.01).

CONCLUSION

This is the first study to approach this association. This is not just an occasional finding, but it seems to have a shared pathophysiology. Unruptured aneurysms and treatment modality were protective independent factors for OS. Prospective studies are warranted to provide definitive answers.

Feeding artery aneurysms associated with large meningiomas: case report and review of the literature

Though brain tumors and intracranial aneurysms co-exist, the occurrence of feeding artery aneurysms with meningiomas are unusual. We describe here a large falcine meningioma that was associated with three feeding artery aneurysms of the anterior circulation. These aneurysms can be treated either by pre-operative endovascular therapy or during the meningioma surgery. The management strategy for these patients will depend on the clinical presentation, morphology and localization of these aneurysms with respect to the tumor.

Follow-Up and Treatment of Patients with Coexisting Brain Tumor and Intracranial Aneurysm

OBJECTIVE

The association of primary brain tumors with coexisting unruptured intracranial aneurysms (UIAs) has been debated, and treatment strategies have not yet been established. We evaluated the flow association between brain tumors and coexisting UIAs and the outcomes of patients with brain tumor who did not receive treatment of coexisting UIAs.

METHODS

The medical records of patients with coexisting UIAs and brain tumors who had undergone surgical tumor resection were retrospectively analyzed to evaluate the incidence of UIAs according to tumor type, association of arterial feeder vessels and coexisting UIAs, and the occurrence of subarachnoid hemorrhage during the follow-up period for patients who had not receive treatment for the UIAs.

RESULTS

Of the 55 patients, 21 (38.9%) had undergone treatment of UIAs and 33 (61.1%) had received regular follow-up examinations without UIA treatment. Two patients (6.1%) developed subarachnoid hemorrhage. Of the 33 patients with astrocytic or oligodendroglial tumors who had not undergone treatment of UIAs, 2 had experienced an interval increase. Flow-related UIAs were found to be significantly more common in patients with astrocytic or oligodendroglial tumors than in those with tumors of other histological types (P = 0.01).

CONCLUSIONS

The incidence of UIAs among patients with primary brain tumors appears to be greater than that in the general population. An interval increase in aneurysm size and aneurysmal rupture was observed in 2 patients with astrocytic or oligodendroglial tumors. We would recommend perioperative treatment of flow-related UIAs in patients with astrocytic or oligodendroglial tumors and noninvasive evaluations such as magnetic resonance angiography if coexisting UIAs remain untreated.

Coexistence of intracranial solitary fibrous tumor/hemangiopericytoma and right middle cerebral artery aneurysm

Intracranial solitary fibrous tumors are rare mesenchymal neoplasms originating in the meninges and constitute a heterogeneous group of rare spindle cell tumors that include benign and malignant neoplasms of which hemangiopericytoma is nowadays considered a cellular phenotypic variant. From literatures, the incidence of coexistence of brain tumors and intracranial aneurysms is ~0.7-5.4%. Meningioma is the most frequent tumor coexisted with intracranial aneurysms, followed by pituitary adenoma, neuroepithelial tumor, and metastatic tumor. We would like to report a case of 74-year-old man harboring a rare intracranial solitary fibrous tumor/hemangiopericytoma and an unruptured aneurysm of the right middle cerebral artery which probably the first report of these combinations in the English literature. Both lesions were treated surgically in one session with favorable outcome. Magnetic resonance angiography should be performed in patients with brain tumor preoperatively not only to visualize neoplastic vascularization but also to pick up incidental aneurysm.

Cerebellopontine Angle Tumors Are Associated with a Greater Incidence of Unruptured Intracranial Aneurysms

OBJECTIVE

We tested the hypothesis that cerebellopontine angle (CPA) tumors are associated with a greater incidence of unruptured intracranial aneurysms (IAs).

METHODS

Patients with intracranial tumors (ITs) undergoing computed tomography angiography and magnetic resonance imaging were enrolled in an observational cohort study that prospectively collected age, sex, hypertension, diabetes, cerebral arteriosclerosis, tumor type, tumor location, hydrocephalus, smoking, alcohol intake, CPA tumor size, cerebral aneurysms, and cerebral arteriosclerosis. Patients with the coexistence of IA and ITwere classified as group II, whereas the others with IT as group I.

RESULTS

We included 1218 patients with IT for analysis. The incidence of IA was 7.1% (86/1218). A total of 31% of patients with aneurysms had CPA tumors. In a multivariate logistic regression model, a greater incidence of IA was found in female patients (odds ratio [OR] 1.726, 95% confidence interval [CI] 1.050-2.836, P=0.031) and in patients with CPA tumors (OR 3.002, 95% CI 1.822-4.947, P=0.000) after adjustment for tumor type, cerebral arteriosclerosis, and age. In female patients, CPA tumors were a unique independent risk factor of a greater incidence of IA (OR 2.270, 95% CI 1.194-4.317, P=0.012). Furthermore, cerebral arteriosclerosis was a unique independent risk factor of IA in patients with CPA tumors (OR 7.626, 95% CI 2.928-19.860, P=0.000).

CONCLUSIONS

These data support the hypothesis that CPA tumors are associated with a greater incidence of unruptured IAs, especially in female patients. Cerebral arteriosclerosis contributed to elevated risk of IA in patients with CPA tumors.

An Integrative Survival Analysis with Identification of Prognostic Factors in the Patients with Coexisting Glioma and Intracranial Aneurysm

OBJECTIVE

This study aimed to perform an integrative clinical and survival analysis for patients with coexisting glioma and intracranial aneurysm and to assess the influence of prognostic factors on overall survival (OS).

METHODS

A systematic literature search on PubMed and Web of Science was performed for literature in English published from 1951 to August 2017. Detailed information including clinical characteristics, treatments, critical events, and time to events for survival analysis was extracted from the included articles. Clinical characteristics of included patients were reviewed, and survival analysis was performed to identify prognostic factors of OS.

RESULTS

A total of 56 cases from 38 articles published in English-language journals were included in this study, and relative details were selected for integrative analysis. Univariate analysis demonstrated that age (<47/≥47 years), ruptured aneurysm (yes/no), glioma type (glioblastoma multiforme [GBM]/no GBM), World Health Organization (WHO) grade (low/high), and radiotherapy (yes/no) had a statistically significant correlation with OS (log-rank P = 0.004, P = 0.037, P = 0.004, P < 0.001, and P < 0.001, respectively). Further, multivariate analysis revealed that WHO grade (hazard ratio [HR], 22.383; 95% confidence interval [CI], 1.795-279.151; P = 0.016) and receiving radiotherapy (HR, 0.054; 95% CI, 0.009-0.333; P = 0.002) were the independent prognostic factors for OS.

CONCLUSIONS

This integrative survival analysis revealed that WHO grade and receiving radiotherapy were independent prognostic factors for OS, and patients with low-grade glioma and receiving radiotherapy had longer survival than counter groups. Nevertheless, similar clinical studies which should be larger samples, multicenter, and collaborative are needed further.

Preoperative Coiling of Coexisting Intracranial Aneurysm and Subsequent Brain Tumor Surgery

Objective

Few studies have investigated treatment strategies for brain tumor with a coexisting unruptured intracranial aneurysm (cUIA). The purpose of this study was to evaluate the safety and efficacy of preoperative coiling for cUIA, and subsequent brain tumor surgery.

Materials and Methods

A total of 19 patients (mean age, 55.2 years; M:F = 4:15) underwent preoperative coiling for 23 cUIAs and subsequent brain tumor surgery. Primary brain tumors were meningiomas (n = 7, 36.8%), pituitary adenomas (n = 7, 36.8%), gliomas (n = 3, 15.8%), vestibular schwannoma (n = 1, 5.3%), and Rathke's cleft cyst (n = 1, 5.3%). cUIAs were located at the distal internal carotid artery (n = 9, 39.1%), anterior cerebral artery (n = 8, 34.8%), middle cerebral artery (n = 4, 17.4%), basilar artery top (n = 1, 4.3%), and posterior cerebral artery, P1 segment (n = 1, 4.3%). The outcomes of preoperative coiling of cUIA and subsequent brain tumor surgery were retrospectively evaluated.

Results

Single-microcatheter technique was used in 13 cases (56.5%), balloon-assisted in 4 cases (17.4%), double-microcatheter in 4 cases (17.4%), and stent-assisted in 2 cases (8.7%). Complete cUIA occlusion was achieved in 18 cases (78.3%), while residual neck occurred in 5 cases (21.7%). The only coiling-related complication was 1 transient ischemic attack (5.3%). Neurological deterioration did not occur in any patient during the period between coiling and tumor surgery. At the latest clinical follow-up (mean, 29 months; range, 2–120 months), 15 patients (78.9%) had favorable outcomes (modified Rankin Scale, 0–2), while 4 patients (21.1%) had unfavorable outcomes due to consequences of brain tumor surgery.

Conclusion

Preoperative coiling and subsequent tumor surgery was safe and effective, making it a reasonable treatment option for patients with brain tumor and cUIA.

Pure Endoscopic Endonasal Clipping of an Incidental Anterior Communicating Artery Aneurysm

Anterior communicating artery (AcoA) aneurysm is the most common form of intracranial aneurysm. It occurs rarely together with other intracranial lesion. Today, microsurgical techniques and endovascular methods are used in the treatment of these aneurysms. Endoscopic endonasal approach is a useful technique for midline lesions of the skull base and is underpinned with extensive experience. In this article, we present a 72-year-old female patient who underwent endoscopic endonasal transplanum-transtubercular surgery for tuberculum sellae meningioma followed by clipping of the incidental AcoA aneurysm. After complete removal of a tuberculum sellae meningioma via an endoscopic endonasal approach, an anterior and superior projected saccular AcoA aneurysm in the gyrus rectus area was totally clipped successfully via pure endoscopic endonasal transplanum-transtubercular approach, without any damage to parent arteries. The patient was discharged from the hospital within a short period of time without any postoperative complication. Endoscopic endonasal approach is a new paradigm in the treatment of aneurysm. Although this technique cannot be routinely used due to lack of experience, it is an effective and safe method in selected and anatomically appropriate cases. We believe that increased knowledge and experience will create successful results in this approach, and it can offer an alternative method for selected aneurysm cases.

Intraoperative Combined Use of Somatosensory Evoked Potential, Microvascular Doppler Sonography, and Indocyanine Green Angiography in Clipping of Intracranial Aneurysm

Background

The aim of this study was to evaluate the effect of combining application of somatosensory evoked potential (SEP), microvascular Doppler sonography (MDS), and indocyanine green angiography (ICGA) in intracranial aneurysm clipping surgery.

Material/Methods

A total of 158 patients undergoing an intracranial aneurysm clipping operation were recruited. All patients were evaluated with intraoperative SEP and MDS monitoring, and 28 of them were evaluated with intraoperative combined monitoring of SEP, MDS, and ICGA.

Results

The SEP waves dropped during temporary occlusion of arteries in 19 cases (12.0%), and returned to normal after the clips were repositioned. After aneurysms were clipped, the vortex flow signals were detected by MDS in 6 cases. The aneurysm neck remnants were detected by ICGA in 2 cases of olfactory artery (OA) and in 1 case of middle cerebral artery (MCA), which disappeared after the clips were repositioned. Postoperative CTA or DSA showed that aneurysms were clipped completely and parent arteries and perforating vessels were patent. GOS at 1 month after the surgery was good in 111 cases (70.3%), mild disability in 22 cases (13.9%), severe disability in 14 cases (8.9%), vegetative state in 5 cases (3.2%), and death in 6 cases (3.8%).

Conclusions

Intraoperative combining application of SEP, MDS, and ICGA can reduce brain tissue ischemia and damage and disability and mortality rate after effective clipping of intracranial aneurysms, thereby improving surgical outcomes.

The role of preoperative angiography in the management of giant meningiomas associated to vascular malformation

Background:

The role of preoperative digital subtraction angiography (DSA) in meningiomas is currently under discussion because of the introduction of noninvasive magnetic resonance imaging (MRI) angiography to study vascular anatomy associated to the tumor. Preoperative DSA is mainly performed to obtain embolization of the lesion, although a number of complications have been reported after this procedure. Nonetheless, the coexistence of meningiomas with vascular malformations has previously been reported and it has been evidenced that this event could be underestimated because of neglect of preoperative DSA. Here, we report on two challenging cases of giant meningiomas associated to vascular malformations and we discuss the pertinent literature.

Case Descriptions:

In the first case: A large right temporal meningioma with erosion of the sphenoid greater wing and extension toward infratemporal fossa and right orbit - a large pseudoaneurysm of right middle cerebral artery branch was found end embolized during DSA. In the second case: A giant parieto-temporal meningioma - DSA permitted the full visualization of an abnormal drainage of superior sagittal sinus like a “sinus pericranii” that was respected during the following surgery.

Conclusion:

We think that MRI angiography is the exam of choice to study vascular anatomy in meningiomas. Nonetheless, DSA remains a useful tool in giant meningiomas not only to embolizate the lesion but also to treat tumor associated vascular malformation and to achieve the full knowledge of vascular anatomy. We think that a wide communication between interventionalist and surgeon is essential for the optimal management of these patients.

Clinoidal meningioma associated with an internal carotid artery aneurysm

Coexistence of primary brain neoplasms with intracranial aneurysms is rare but presents a diagnostic and therapeutic challenge to healthcare providers. We describe the case of a 60-year-old woman who had a left internal carotid artery aneurysm with a small ipsilateral clinoidal meningioma. The meningioma was an unexpected finding encountered during the surgery for aneurysmal clipping. Both the lesions were dealt with simultaneously.