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Aboukais R, Devalckeneer A, Boussemart P, Bourgeois P, Menovsky T, Bretzner M, Karnoub MA, Lejeune JP. Giant unruptured middle cerebral artery aneurysm revealed by intracranial hypertension: is a systematic decompressive hemicraniotomy mandatory? Neurosurg Rev 2024; 47:414. [PMID: 39117892 PMCID: PMC11310238 DOI: 10.1007/s10143-024-02662-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/30/2024] [Accepted: 08/05/2024] [Indexed: 08/10/2024]
Abstract
Our study aimed to evaluate the postoperative outcome of patients with unruptured giant middle cerebral artery (MCA) aneurysm revealed by intracranial hypertension associated to midline brain shift. From 2012 to 2022, among the 954 patients treated by a microsurgical procedure for an intracranial aneurysm, our study included 9 consecutive patients with giant MCA aneurysm associated to intracranial hypertension with a midline brain shift. Deep hypothermic circulatory flow reduction (DHCFR) with vascular reconstruction was performed in 4 patients and cerebral revascularization with aneurysm trapping was the therapeutic strategy in 5 patients. Early (< 7 days) and long term clinical and radiological monitoring was done. Good functional outcome was considered as mRS score ≤ 2 at 3 months. The mean age at treatment was 44 yo (ranged from 17 to 70 yo). The mean maximal diameter of the aneurysm was 49 mm (ranged from 33 to 70 mm). The mean midline brain shift was 8.6 mm (ranged from 5 to 13 mm). Distal MCA territory hypoperfusion was noted in 6 patients. Diffuse postoperative cerebral edema occurred in the 9 patients with a mean delay of 59 h and conducted to a postoperative neurological deterioration in 7 of them. Postoperative death was noted in 3 patients. Among the 6 survivors, early postoperative decompressive hemicraniotomy was required in 4 patients. Good functional outcome was noted in 4 patients. Complete aneurysm occlusion was noted in each patient at last follow-up. We suggest to discuss a systematic decompressive hemicraniotomy at the end of the surgical procedure and/or a partial temporal lobe resection at its beginning to reduce the consequences of the edema reaction and to improve the postoperative outcome of this specific subgroup of patients. A better intraoperative assessment of the blood flow might also reduce the occurrence of the reperfusion syndrome.
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Affiliation(s)
- Rabih Aboukais
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, Lille cedex, 59037, France.
- University Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, F-59000, France.
| | - Antoine Devalckeneer
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, Lille cedex, 59037, France
- University Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, F-59000, France
| | - Pierre Boussemart
- Neurosurgical Intensive Care Department, Lille University Hospital, Lille, France
| | - Philippe Bourgeois
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, Lille cedex, 59037, France
| | - Tomas Menovsky
- Department of Neurosurgery, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Martin Bretzner
- Department of Neuroradiology, Lille University Hospital, Lille, France
| | - Mélodie-Anne Karnoub
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, Lille cedex, 59037, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, Lille cedex, 59037, France
- University Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, F-59000, France
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Kraehling H, Akkurt BH, Elsharkawy M, Ayad A, Ergawy M, Celik E, Chapot R, Schwindt W, Stracke CP. A Giant Stent for Giant Cerebral Aneurysms-The Accero ®-Rex-Stent. J Clin Med 2024; 13:388. [PMID: 38256521 PMCID: PMC10816579 DOI: 10.3390/jcm13020388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/14/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE Until now, giant intracranial aneurysms (GIAs) have in many cases been a vascular disease that was difficult or impossible to treat, not least due to the lack of availability of a large-format stent. In this multicentre study, we report on the first five clinical applications of the Accero®-Rex-Stents (Acandis, Pforzheim, Germany) in the successful treatment of fusiform cerebral giant aneurysms. MATERIAL AND METHODS The Accero®-Rex-Stents are self-expanding, braided, fully radiopaque Nitinol stents designed for aneurysm treatment. The stent is available in three different sizes (diameter 7-10 mm, length 30-60 mm) and intended for endovascular implantation in vessels with diameters of 5.5-10 mm. RESULTS Five patients (all male, age 54.4 ± 8.1 years) with large fusiform aneurysms of the posterior circulation were treated endovascularly using the Accero®-Rex-Stents. There were no technical complications. One major ischemic complication occurred. A significant remodeling and reduction in the size of the stent-covered aneurysms was already seen in the short-term post-interventional course. CONCLUSIONS The Accero®-Rex-Stents were successfully and safely implanted in all five patients with fusiform giant aneurysms, showing technical feasibility with promising initial results and significant aneurysm size reduction in already available follow-up imaging. KEY POINT With the Accero-Rex-Stents, a new device is available that offers another treatment option for rare cerebral fusiform giant aneurysms with very large parent vessels.
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Affiliation(s)
- Hermann Kraehling
- University Clinic for Radiology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- University Clinic for Radiology, Department for Interventional Neuroradiology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Burak Han Akkurt
- University Clinic for Radiology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Mohamed Elsharkawy
- University Clinic for Radiology, Department for Interventional Neuroradiology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- Department of Neuroradiology, Alfried-Krupp-Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany (R.C.)
| | - Ahmed Ayad
- Department of Neuroradiology, Alfried-Krupp-Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany (R.C.)
| | - Mostafa Ergawy
- University Clinic for Radiology, Department for Interventional Neuroradiology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Ekin Celik
- Department of Radiology and Neuroradiology, Ludmillenstift Hospital, Ludmillenstrasse 4-6, 49716 Meppen, Germany
| | - René Chapot
- Department of Neuroradiology, Alfried-Krupp-Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany (R.C.)
| | - Wolfram Schwindt
- University Clinic for Radiology, Department for Interventional Neuroradiology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Christian Paul Stracke
- University Clinic for Radiology, Department for Interventional Neuroradiology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- Clinic and Policlinic for Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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Muacevic A, Adler JR. Giant Vertebrobasilar Aneurysm: The Rule of Decompressive Craniectomy Previous to Endovascular Treatment. Cureus 2022; 14:e30187. [PMID: 36397908 PMCID: PMC9648616 DOI: 10.7759/cureus.30187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 01/25/2023] Open
Abstract
Giant vertebral-basilar aneurysms are rare and represent 1% of intracranial aneurysms. Natural history and treatment are associated with severe clinical manifestations, such as ischemia, mass effect, hydrocephalus, and subarachnoid hemorrhage, leading to high mortality and morbidity. In this case, a 51-year-old male with no relevant medical history presented to the emergency department with severe pulsatile right temporo-occipital headache, radiating to the territory of the maxillary branch of the trigeminal nerve. Investigation revealed a giant unruptured vertebrobasilar aneurysm partially thrombosed. As treatment strategy, a suboccipital craniectomy was initially performed, and a week later, as a second stage, the patient underwent a stent placement from the V3 segment of the vertebral artery to the distal segment of the basilar trunk. Very few cases of this entity have been reported, and the endovascular treatment of this type of aneurysm is complex, with a high risk of mortality or morbidity, caused by thrombosis or by the inflammatory response secondary to the treatment, with compression of the brainstem. Decompressive craniectomy prior to endovascular treatment may play an important role in preventing life-threatening complications.
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Guo Y, Song Y, Hou K, Yu J. Intracranial Fusiform and Circumferential Aneurysms of the Main Trunk: Therapeutic Dilemmas and Prospects. Front Neurol 2021; 12:679134. [PMID: 34305790 PMCID: PMC8299836 DOI: 10.3389/fneur.2021.679134] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Intracranial fusiform and circumferential aneurysms (IFCAs), especially those located on the main trunk, are uncommon and difficult to manage. Currently, literature focused on IFCAs on the main trunk of cerebral arteries is lacking. The treatment of IFCAs is still under debate. Therefore, in this review, we further explore the treatment of this complicated entity. In addition, we also present some interesting cases. Based on the literature review and our experience, we found that IFCAs are often located in the vertebrobasilar system and that ruptured or large symptomatic IFCAs are associated with increased mortality and higher rebleeding rates. The treatment strategies for IFCAs can be classified as deconstructive and reconstructive methods via open surgery and/or endovascular treatment (EVT). Currently, EVT is a popular method and the main therapeutic choice. In particular, flow diversion has revolutionized the treatment of IFCAs. Parent artery occlusion (PAO) with or without revascularization may still be considered a suitable choice. Complex IFCAs that cannot be resolved by EVT can also be treated via open surgery with or without extracranial–intracranial bypass. Targeted embolization for the weak points of IFCAs is a temporary or palliative choice that is rarely used. In summary, despite complications, both surgical treatment and EVT are effective options for appropriately selected cases. Due to the development of endovascular implants, EVT will have better prospects in the future.
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Affiliation(s)
- Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Ying Song
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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Wang L, Lu S, Qian H, Shi X. Internal Maxillary Artery Bypass with Radial Artery Graft Treatment of Giant Intracranial Aneurysms. World Neurosurg 2017; 105:568-584. [DOI: 10.1016/j.wneu.2017.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/01/2017] [Accepted: 06/02/2017] [Indexed: 11/24/2022]
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