Obliteration of a giant carotid aneurysm after extracranial-to-intracranial bypass surgery: case report

Tailored Communicating Bypass for the Management of Complex Anterior Communicating Artery Aneurysms: "Flow-Counteraction" In Situ Bypass and Interposition Bypass Using Contralateral A2 Orifice as Donor Site

BACKGROUND

The use of bypass surgery for anterior communicating artery (ACOM) aneurysms is technically challenging. Communicating bypass (COMB), such as pericallosal artery side-to-side anastomosis, is the most frequently used and anatomically directed reconstruction option. However, in many complex cases, this technique may not afford a sufficient blood supply or necessitate sacrificing the ACOM and the eloquent perforators arising from it.

OBJECTIVE

To evaluate tailored COMB and propose a practical algorithm for the management of complex ACOM aneurysms.

METHODS

For 1 patient with an aneurysm incorporating the entire ACOM, conventional in Situ A3-A3 bypass was performed as the sole treatment in order to create competing flow for aneurysm obliteration, sparing the sacrifice of eloquent perforators. In situations in which A2s were asymmetric in the other case, the contralateral A2 orifice was selected as the donor site to provide adequate blood flow by employing a short segment of the interposition graft.

RESULTS

The aneurysm was not visualized in patients with in Situ A3-A3 bypass because of the "flow-counteraction" strategy. The second patient, who underwent implementation of the contralateral A2 orifice for ipsilateral A3 interposition bypass, demonstrated sufficient bypass patency and complete obliteration of the aneurysm.

CONCLUSION

The feasibility of conventional COMB combined with complete trapping may only be constrained to selected ideal cases for the treatment of complex ACOM aneurysms. Innovative modifications should be designed in order to create individualized strategies for each patient because of the complexity of hemodynamics and the vascular architecture. Flow-counteraction in Situ bypass and interposition bypass using the contralateral A2 orifice as the donor site are 2 novel modalities for optimizing the advantages and broadening the applications of COMB for the treatment of complex ACOM aneurysms.

"Flow Reversal" and Cure in a Case of Giant Intracranial Aneurysm: A Case Report

We describe the case of an 11-year-old girl having a giant anterior circulation aneurysm. The ipsilateral internal carotid artery was entirely blocked and the aneurysm was supplied by posterior circulation. Following a high-flow bypass that connected the external carotid artery to the middle cerebral artery, the giant aneurysm thrombosed spontaneously. We discuss several relatively rare and unique features of the case.

Complex Aneurysm: The Unpredictable Pathological Entity

BACKGROUND

Surgical treatment of complex aneurysms often requires the execution of a revascularization procedure. Even if avoiding the concomitant trapping of the aneurysm during the bypass procedure (waiting for the subsequent endovascular or spontaneous closure) permits one to verify the graft's patency and patient's adaptation to increased flow, the hemodynamic changes induced by the bypass may cause the aneurysmal rupture. Whether or not to perform the concomitant trapping of the aneurysm still remains a dilemma. Here we illustrate our management protocol through the critical analysis of some illustrative cases of our series.

MATERIALS AND METHODS

Between 1990 and 2016, 48 of 157 patients affected by complex aneurysms underwent a revascularization procedure. In 19 cases (1990-1997) only a bypass procedure was performed. Spontaneous or endovascular closure was obtained within the first postoperative week once the graft patency had been verified (staged revascularization strategy). In the remaining 29 cases. The total amount of cases is 48. 19 cases staged revascularization strategy. 29 cases single stage revascularization strategy.

RESULTS

In the staged revascularization era, one patient died because of the rupture of the aneurysm before its closure.In the single-stage era no further cases of rebleeding were observed. Neurologic status of this group was unvaried or improved.

CONCLUSIONS

Given the unpredictable response of complex aneurysms to the hemodynamic changes induced by the revascularization, in our opinion it is always preferable to perform complete or at least incomplete trapping of the aneurysm during the bypass procedure.

Surgical Flow Alteration for the Treatment of Intracranial Aneurysms That Are Unclippable, Untrappable, and Uncoilable

OBJECTIVE

The treatment of complex intracranial aneurysms remains challenging. One approach is the application of surgical flow alteration to treat aneurysms that are neither clippable, trappable, or coilable. The efficacy and limitations of surgical flow alteration have not yet been established.

METHODS

Cases of complex aneurysms treated with surgical flow alteration (proximal occlusion with or without bypass, distal occlusion with or without bypass and bypass only) were included in this retrospective study.

RESULTS

Among a total of 16 cases, there were 7 giant aneurysms (≥25 mm diameter) and 9 large aneurysms (>10 mm diameter); 15 of 16 aneurysms were unruptured. There were 8 aneurysms located in the anterior circulation, while the other 8 were in the posterior circulation. Aneurysms were treated with proximal occlusion in 10 cases and distal occlusion in 5 cases; in 1 case, the aneurysm occluded spontaneously after bypass without parent artery occlusion. All but 2 cases underwent prior or concurrent bypass surgery. Complete obliteration of the aneurysm at the latest imaging follow-up was shown in 12 of 16 cases (75.0%). Bypass patency was confirmed in 13 of 15 cases (86.7%). Surgery-related morbidity developed in 3 cases (18.8%, Glasgow outcome scale of 4) and all were perforator infarctions. There were no mortalities.

CONCLUSION

Surgical flow alteration resulted in a high rate of aneurysmal obliteration with acceptable morbidity. Although several limitations remained, it could represent an alternative method for treating complex aneurysms.

EC-IC bypass for cavernous carotid aneurysms: An initial experience with twelve patients

AIMS

Need for performing a bypass procedure prior to parent artery occlusion in patients with good cerebral vascular reserve is controversial. We analyze our experience of 12 giant internal carotid artery aneurysms treated with extracranial-intracranial (EC-IC) bypass and proximal artery occlusion.

MATERIALS AND METHODS

Retrospective analysis of the case records of all complex carotid aneurysms operated in our institute since January 2009.

RESULTS

The study included eleven cavernous carotid aneurysms and one large fusiform cervical carotid aneurysm reaching the skull base. Preoperative assessment of cerebral vascular reserve was limited to Balloon test occlusion with hypotensive challenge. Eleven patients who successfully completed a Balloon test occlusion (BTO) underwent low flow superficial temporal artery to middle cerebral artery (STA-MCA) bypass, while one patient with a failed BTO underwent a high flow bypass using a saphenous vein graft. Parent artery ligation was performed in all patients following the bypass procedure. Check angiogram revealed thrombosis of the aneurysm in all patients with a graft patency rate of 81.8%. We had one operative mortality, probably related to a leak from the anastomotic site. The only patient who had a high flow bypass developed contralateral hemispheric infarcts and remained vegetative. All the other patients had a good recovery and with a Glasgow outcome score of 5 at last follow-up.

CONCLUSION

We feel that combining EC-IC bypass prior to parent vessel occlusion helps in reducing the risk of post operative ischemic complications especially in situations where a complete mandated cerebral blood flow studies are not feasible.

Carotid artery occlusion for the treatment of symptomatic giant carotid aneurysms: a proposal of classification and surgical protocol

Giant intracranial aneurysms are rare disorders that represent only 5% of all intracranial aneurysms; they have a wide variety of presentations including rupture, embolic effects, and mass effect symptoms that can mislead the diagnosis to tumors rather than aneurysms. Their treatment is difficult and carries higher morbidity and mortality than usual aneurysms due to their complex nature. This study involved retrospective analysis of data of 28 patients, managed between 2006 and 2012, suffering from giant internal carotid artery (ICA) aneurysms with various presenting symptoms, none of which was hemorrhage. They were all evaluated by BOT prior to any intervention; they were subjected to various treatment strategies including selective coiling, parent artery occlusion with or without bypass, aneurysm trapping with or without bypass, and patients were followed for a period ranging from 6 months to 5 years. Out of 26 patients with giant aneurysms with mass effects, 16 patients showed full recovery (61.5 %), 5 showed partial improvement (19.2 %), and 5 showed no change in mass effect symptoms (19.2 %). One patient died (3.5 %). Symptoms such as TIA or epistaxis showed complete recovery. This study shows that a well-designed protocol aiming at parent artery sacrifice will yield good to excellent results in managing ICA giant aneurysms, and it also shows that parent artery sacrifice is superior to other forms of treatment of these lesions regarding recurrence rates, morbidity, and mortality.

Spontaneous regression of an unruptured and non-giant intracranial aneurysm

It is well known that spontaneous thrombosis in giant cerebral aneurysm is common. However, spontaneous obliteration of a non-giant and unruptured cerebral aneurysm has been reported to be rare and its pathogenic mechanism is not clear. We describe a case with rare vascular phenomenon and review the relevant literatures.

Spontaneous thrombosis of a giant fusiform aneurysm following extracranial-intracranial bypass surgery

The authors describe the cases of 2 patients who underwent extracranial-intracranial bypass surgery for a giant fusiform aneurysm but in whom further surgery was then not necessary because the aneurysm spontaneously thrombosed. The authors hypothesize that this thrombosis was caused by alterations in aneurysm's hemodynamics, leading to a decreased rate of blood flow in the aneurysm. In the older of the 2 cases, more than 10 years after surgery the patient has not required further surgical intervention. Spontaneous thrombosis of a giant fusiform aneurysm is a rare occurrence during extracranial-intracranial bypass, and although continual monitoring is recommended, these patients can remain stable long term.

Surgical Treatment of Giant Intracranial Aneurysms: Current Viewpoint

Objective:

Despite new endovascular techniques and technological advances in microsurgery, the treatment of giant intracranial aneurysms is still a daunting neurosurgical task. Many of these aneurysms have a large, calcified neck, directly involve parent and collateral branches, and are partly thrombosed. In this retrospective review, we focused our analysis on the indications for high-flow, extracranial-intracranial (EC-IC) bypass surgery using a saphenous vein graft.

Methods:

A series of 130 patients were treated between 1990 and 2004; 31 patients were managed endovascularly, and 99 patients were treated microsurgically (surgical clipping in 58 patients and high-flow EC-IC bypass followed by aneurysm trapping in 41 patients). We examined the patients’ clinical records and pre- and postoperative case notes for cerebral angiographic examinations. Graft patency was verified with cerebral angiography, computed tomographic angiography, Doppler ultrasound, or graft palpation.

Results:

The high-flow EC-IC bypass was used for all surgically treated prepetrous aneurysms (3 patients), intracavernous aneurysms (1 patient), intracavernous aneurysms with subarachnoid extension (23 patients), as well as for some supraclinoid aneurysms (12 of the 32 patients). It was also used for 1 of the 9 aneurysms located in the carotid bifurcation and 2 of 5 vertebrobasilar circulation aneurysms. Of the 58 patients managed by surgical clipping, 4 (6.9%) died, and 51 (94.4%) improved. Of the 41 patients managed with high-flow EC-IC bypass, 4 (9.8%) died and 34 (91.9%) improved. Graft patency at the follow-up examination was 92.7%.

Conclusion:

The “gold standard” for the treatment of giant aneurysms remains surgical clipping. When direct surgical clipping or endovascular repair is contraindicated, the high-flow EC-IC bypass is a viable surgical option.

Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization

OBJECT

Certain intracranial aneurysms, because of their fusiform or complex wide-necked structure, giant size, or involvement with critical perforating or branch vessels. are unamenable to direct surgical clipping or endovascular coil treatment. Management of such lesions requires alternative or novel treatment strategies. Proximal and distal occlusion (trapping) is the most effective strategy. In lesions that cannot be trapped, alteration in blood flow to the "inflow zone," the site most vulnerable to aneurysm growth and rupture, is used.

METHODS

From 1991 to 1999 the combined neurosurgical-neuroendovascular team at the Massachusetts General Hospital (MGH) managed 48 intracranial aneurysms that could not be clipped or occluded. Intracavernous internal carotid artery aneurysms were excluded from this analysis. By applying a previously described aneurysm rupture risk classification system (MGH Grades 0-5) based on the age of the patient, aneurysm size, Hunt and Hess grade, Fisher grade, and whether the aneurysm was a giant lesion located in the posterior circulation, the authors found that a significant number of patients were at moderate risk (MGH Grade 2; 31.3% of patients) and at high risk (MGH Grades 3 or 4; 22.9%) for treatment-related morbidity. The lesions were treated using a variety of strategies--surgical, endovascular, or a combination of modalities. Aneurysms that could not be trapped or occluded were treated using a paradigm of flow alteration, with flow redirected from either native collateral networks or from a surgically performed vascular bypass. Overall clinical outcomes were determined using the Glasgow Outcome Scale (GOS). A GOS score of 5 or 4 was achieved in 77.1%, a GOS score of 3 or 2 in 8.3%, and death (GOS 1) occurred in 14.6% of the patients. Procedure-related complications occurred in 27.1% of cases; the major morbidity rate was 6.3% and the mortality rate was 10.4%. Three patients experienced aneurysmal hemorrhage posttreatment; in two patients this event proved to be fatal. Aneurysms with MGH Grades 0, 1, 2, 3, and 4 were associated with favorable outcomes (GOS scores of 5 or 4) in 100%, 92.8%, 71.4%, 50%, and 0% of instances, respectively.

CONCLUSIONS

Despite a high incidence of transient complications, intracranial aneurysms that cannot be clipped or occluded require alternative surgical and endovascular treatment strategies. In those aneurysms that cannot safely be trapped or occluded, one approach is the treatment strategy of flow alteration.

[Saphenous vein graft bypass from the external carotid artery to the supraclinoid internal carotid artery to treat a giant aneurysm of the cavernous internal carotid: case report]

Alternative surgical procedures to treat unclippable aneurysms of the intracavernous carotid artery include proximal vessel occlusion and trapping. Those techniques, even in patients with rich collateral vessels, are associated with risk of hemodynamic compromise and ischemic complications. Therefore, a safe treatment requires revascularization to maintain blood flow to the involved territories. We report the case of a 47-year-old female, with ischemic signs and symptoms and a right third nerve palsy caused by a giant aneurysm, partially trombosed, of the intracavernous carotid artery. The patient was submitted to trapping after a saphenous vein graft bypass from the external carotid artery to the supraclinoid internal carotid artery. The surgical result was good without complications.

The formation and regression of a flow-related cerebral artery aneurysm

The authors report a patient with an aneurysm of the right cerebral posterior communicating artery (PCoA) developing after thrombotic pseudo-occlusion of the right internal carotid artery (ICA). The aneurysm regressed spontaneously subsequent to ipsilateral ICA endarterectomy and reversal of blood flow in the PCoA. The formation and regression of the aneurysm was well documented by repeat cerebral digital subtraction angiography studies, computed tomography and magnetic resonance imaging. The authors conclude that the formation and regression of this 'flow-related' aneurysm was associated with hemodynamic changes in blood flow of the right PCoA and the right ICA.

Extracranial carotid artery aneurysms: Texas Heart Institute experience

BACKGROUND AND PURPOSE

Aneurysms of the extracranial carotid artery (ECA) are rare. Large single-institution series are seldom reported and usually are not aneurysm type-specific. Thus, information about immediate and long-term results of surgical therapy is sparse. This review was conducted to elucidate etiology, presentation, and treatment for ECA aneurysms.

METHODS

We retrospectively reviewed the case records of the Texas Heart Institute/St Luke's Episcopal Hospital, Houston, and found 67 cases of ECA aneurysms treated surgically (the largest series to date) between 1960 and 1995: 38 pseudoaneurysms after previous carotid surgery and 29 atherosclerotic or traumatic aneurysms. All aneurysms were surgically explored, and all were repaired except two: a traumatic distal internal carotid artery aneurysm and an infected pseudoaneurysm in which the carotid artery was ligated.

RESULTS

Four deaths (three fatal strokes and one myocardial infarction) and two nonfatal strokes were directly attributed to a repaired ECA aneurysm (overall mortality/major stroke incidence, 9%); there was one minor stroke (incidence, 1.5%). The incidence of cranial nerve injury was 6% (four cases). During long-term follow-up (1.5 months-30 years; mean, 5.9 years), 19 patients died, mainly of cardiac causes (11 myocardial infarctions).

CONCLUSION

The potential risks of cerebral ischemia and rupture as well as the satisfactory long-term results achieved with surgery strongly argue in favor of surgical treatment of ECA aneurysms.