1
|
Zhang M, Gao K, Wu X, Wang X, Wang Z, Tong X. Open surgical treatment of basilar artery aneurysms in the interventional therapy era. Acta Neurochir (Wien) 2024; 166:275. [PMID: 38910196 DOI: 10.1007/s00701-024-06153-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 05/30/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE The purpose of this study was to describe the effectiveness and evaluation of open surgical treatment of basilar artery aneurysms in the context of interventional therapy era, including surgical clipping and blood reconstruction, by retrospectively analyzing the clinical data of basilar artery aneurysms in our center. METHODS Patients with basilar artery aneurysms who were treated at our center were retrospectively included according to the inclusion and exclusion criteria. The basic clinical data, surgical approach, clinical follow-up and prognosis of the enrolled patients were analyzed in detail. In this study, the mRS score was applied to assess the neurological prognosis of the patients, and the relevant data were statistically analyzed using SPSS. RESULTS A total of 104 eligible patients treated at our center from January 2010 to August 2023 were included in this study, of which 67 were treated by open surgery and 37 by bypass. For the 67 patients with open surgical clipping, the mean age was 60.0 (52.0, 65.0) years. The maximum diameter of the aneurysms ranged from 2.0 mm to 54.0 mm, with a mean of 13.9 (10.0, 19.0) mm. The mean follow-up time was 38 (20, 58) months. At the last follow-up, 61 (91.0%) completely obliterated aneurysms and 6 (9.0%) incompletely obliterated aneurysms were found. The prognosis was good in 59 (88.1%) patients and poor in 8 (11.9%). After surgical clipping, the difference between complete and incomplete postoperative aneurysm elimination was statistically significant between the favorable and poor prognosis groups (P < 0.001). For the 37 bypass group patients, the mean age was 52.0 (45.5, 59.0) years. The maximum diameter of the aneurysm ranged from 10.5 mm to 55.0 mm, with a mean of 28.55 ± 12.08 mm. Bypass combined with proximal occlusion was performed in 18 (48.6%) patients, and bypass only was performed in 19 (51.4%) patients. Clinical follow-up was 19.0 (10.5, 43.0) months. There were 19 (51.4%) patients with complete elimination of the aneurysm, 13 (35.1%) with incomplete elimination of the aneurysm, and 5 (13.5%) with aneurysm stabilization. The prognosis was good in 32 (86.5%) patients and poor in 5 (13.5%) patients. CONCLUSION Treatment of basilar artery aneurysms is challenging. In the context of the rapidly evolving interventional therapy era, open surgery including surgical clipping and bypass is an ideal option for complex basilar artery aneurysms not amenable to intervention.
Collapse
Affiliation(s)
- Meng Zhang
- School of Medicine, Nankai University, 94 Weijin Road, Tianjin, 300071, China
- Department of Neurosurgery, Huanhu Hospital Affiliated to Nankai University, Tianjin Huanhu Hospital, NO.6, Jizhao Road, Jinnan District, Tianjin, China
| | - Kaiming Gao
- Department of Neurosurgery, Huanhu Hospital Affiliated to Nankai University, Tianjin Huanhu Hospital, NO.6, Jizhao Road, Jinnan District, Tianjin, China
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Xiangchen Wu
- Department of Neurosurgery, Huanhu Hospital Affiliated to Nankai University, Tianjin Huanhu Hospital, NO.6, Jizhao Road, Jinnan District, Tianjin, China
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Xingdong Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Zhiqiang Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Xiaoguang Tong
- School of Medicine, Nankai University, 94 Weijin Road, Tianjin, 300071, China.
- Department of Neurosurgery, Huanhu Hospital Affiliated to Nankai University, Tianjin Huanhu Hospital, NO.6, Jizhao Road, Jinnan District, Tianjin, China.
| |
Collapse
|
2
|
Huang LT, Zhang M, Tong X. Cerebral revascularization for complex vertebrobasilar artery dissecting aneurysms. Neurosurg Rev 2024; 47:138. [PMID: 38578572 DOI: 10.1007/s10143-024-02365-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/20/2024] [Accepted: 03/16/2024] [Indexed: 04/06/2024]
Abstract
Vertebrobasilar artery dissecting aneurysms (VBDAs) are the most surgically challenging type of aneurysm. Cerebral revascularization is the ultimate treatment for complex VBDAs. We retrospectively analysed the characteristics, surgical outcomes and follow-up data of 21 patients who underwent cerebral revascularization to treat complex VBDAs from 2015 to 2022. According to the location of the aneurysm and the anatomic relationship between the VBDA and the PICA, VBDA patients were classified into four groups: aneurysms located at the VA with PICA involvement (10 patients), aneurysms located at the VA without PICA involvement (1 patient), aneurysms located at the basilar apex segment (1 patient) and aneurysms located at the basilar trunk segment (9 patients). A surgical algorithm for complex VBDAs was determined primarily by the location of the aneurysm, the status of the aneurysm and the ability of retrograde blood flow to reach the proximal vertebrobasilar artery. Surgical modalities for patients with aneurysms in the VA with PICA involvement included low-flow (OA-PICA) bypasses with aneurysm trapping, aneurysm excision or reconstructive clip in 8 patients and STA-PCA bypass combined with PICA preservation and aneurysm trapping in 2 patients. In patients with aneurysms in the VA without PICA involvement, aneurysm excision was performed without cerebral bypass. In patients with aneurysms in the basilar apex segment, high-flow bypass (ECA-RA-P2) with aneurysm trapping was performed. In patients with aneurysms in the basilar trunk segment, surgical modalities included high-flow bypasses (ECA-RA-P2 and LVA-RA-P2) with aneurysm trapping or proximal occlusion in 6 patients, ECA-RA-P2 bypass with partial proximal occlusion in 1 patient, ECA-RA-P2 bypass alone in 1 patient, and STA-PCA bypass with R-VA narrowing in 1 patient. Of the 21 patients, 20 experienced clinical improvement or no change, and 17 of 21 patients achieved favourable functional outcomes (mRS ≤ 2). However, one patient died of infarction and respiratory failure postoperatively. Aneurysms were completely obliterated in 13 patients, shrank in 5 patients and stabilized in 2 patients. The median follow-up period was 32.5 months. During the follow-up period, all bypasses were patent, and further clinical improvement was observed in 11 patients. Cerebral revascularization appears to be safe and effective for the treatment of complex VBDAs, and cerebral revascularization could act as a complementary treatment strategy.
Collapse
Affiliation(s)
- Li-Tian Huang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Meng Zhang
- The school of medicine, Nankai University, 94 Weijin Road, Tianjin, 300071, China
| | - Xiaoguang Tong
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China.
| |
Collapse
|
3
|
Wang X, Tong X. Vascular reconstruction related to the extracranial vertebral artery: the presentation of the concept and the basis for the establishment of the bypass system. Front Neurol 2023; 14:1202257. [PMID: 37388550 PMCID: PMC10301721 DOI: 10.3389/fneur.2023.1202257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/02/2023] [Indexed: 07/01/2023] Open
Abstract
The intracranial vertebrobasilar artery system has a unique hemodynamic pattern (vessel trunk converged bilateral flow with three groups of perforators directly arising from it), is embedded within intense osseous constraints, and is located far from conventional donor vessels. Two major traditional modalities of posterior circulation revascularization encompass the superficial temporal artery to the superior cerebellar artery and the occipital artery to the posteroinferior cerebellar artery anastomosis, which are extracranial-intracranial low-flow bypass with donor arteries belonging to the anterior circulation and mainly supply focal perforators and distal vascular territories. As our understanding of flow hemodynamics has improved, the extracranial vertebral artery-related bypass has further evolved to improve the cerebral revascularization system. In this article, we propose the concept of "vascular reconstruction related to the extracranial vertebral artery" and review the design philosophy of the available innovative modalities in the respective segments. V1 transposition overcomes the issue of high rates of in-stent restenosis and provides a durable complementary alternative to endovascular treatment. V2 bypass serves as an extracranial communication pathway between the anterior and posterior circulation, providing the advantages of high-flow, short interposition grafts, orthograde flow in the vertebrobasilar system, and avoiding complex skull base manipulation. V3 bypass is characterized by profound and simultaneous vascular reconstruction of the posterior circulation, which is achieved by intracranial-intracranial or multiple bypasses in conjunction with skull base techniques. These posterior circulation vessels not only play a pivotal role in the bypass modalities designed for vertebrobasilar lesions but can also be implemented to revascularize the anterior circulation, thereby becoming a systematic methodology.
Collapse
Affiliation(s)
- Xuan Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| | - Xiaoguang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| |
Collapse
|
4
|
Wang X, Tong X, Liu J, Shi M, Shang Y, Wang H. Petrous Carotid to Upper Posterior Circulation Bypass for the Treatment of Basilar Trunk Aneurysm: A Novel High-Flow Intracranial-Intracranial Skull Base Bypass for Posterior Circulation. Oper Neurosurg (Hagerstown) 2023; 24:301-309. [PMID: 36729820 DOI: 10.1227/ons.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/11/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Basilar trunk aneurysms are the most surgically challenging, and the spectrum covers small fusiform to dolichoectatic aneurysms and may lead to rupture, brain ischemia, or direct brainstem compression. The current strategy remains cerebral revascularization coupled with aneurysm trapping. Available bypass options for upper posterior circulation (UPC) are based on (1) different flow volumes from diverse blood supplies and (2) distinct modulation purposes for cerebral revascularization; however, the potential compromise of eloquent perforators of the basilar trunk and the occurrence of fatal brainstem infarcts remain unacceptable. OBJECTIVE To innovate a high-flow intracranial-intracranial skull base bypass for posterior circulation to afford robust retrograde flow and shorten the graft length. METHODS We retrospectively reviewed our experience in the treatment of a patient with basilar trunk aneurysm and reported a novel bypass alternative supplied by petrous internal carotid artery to augment blood flow to the UPC by a pretemporal approach. RESULTS The postoperative course was uneventful, and there was no pons or midbrain ischemia or other complications. Postoperative computed tomography angiogram revealed the patency of bypass. There was no further development or rerupture observed during follow-up. CONCLUSION Petrous internal carotid artery as a donor site is a reliable bypass modality for UPC. This approach provides the utmost retrograde flow to alleviate the development of dissecting aneurysms, preserves eloquent perforators of the basilar trunk, maintains bypass patency, and shortens the graft course. Therefore, this novel therapeutic alternative could be beneficial for improving the prognosis of basilar trunk aneurysms.
Collapse
Affiliation(s)
- Xuan Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| | - Xiaoguang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| | - Jie Liu
- Department of Neurosurgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Minggang Shi
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Yanguo Shang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Hu Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| |
Collapse
|
5
|
Kim MJ, Chung J, Park KY, Kim YB, Kim DJ, Kim BM, Lee JW. Endovascular treatment for large (> 10 mm) basilar tip aneurysms: a retrospective case series. Acta Neurochir (Wien) 2022; 164:1239-1245. [PMID: 35262793 DOI: 10.1007/s00701-022-05175-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/23/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To report the long-term clinical and angiographic outcomes of the endovascular treatment of large/giant basilar tip aneurysms (BTAs) in our institutions. METHODS We retrospectively reviewed cases of BTA larger than 10 mm that received endovascular treatment between January 2009 and December 2019. Data on the demographic and clinical characteristics and radiologic severity were obtained from the patients' medical records. The collected clinical follow-up data included neurological evaluation. Magnetic resonance angiography (MRA) was performed 6 to 12 months after the procedure, followed by once every 1 to 2 years as needed. RESULTS A total of 12 patients with BTA were included in this study. The median age was 60.08 years (27-80 years), and the mean clinical follow-up was 66.78 months (19.00-142.87 months). Almost half of the patients presented with unruptured BTAs (58.33%, n = 7). The median maximum aneurysm diameter was 13.00 mm (10.46-20.90 mm) and the mean neck size was 8.34 mm (4.82-13.04 mm). A Modified Raymond Roy Classification (MRRC1) of 1 or 2 was observed in 66.67% of the patients (n = 8) immediately after the first procedure. Procedural morbidity and mortality were 33.33% and 8.33%, respectively. Major recanalization occurred in two patients, one of whom underwent additional coiling with the other being merely observed due to older age. CONCLUSION It is very difficult to cure a large BTA completely at once and recanalization occurred often after endovascular treatment. Conducting long-term follow-up studies at short intervals is warranted, as well as improving existing treatment methods and developing new approaches.
Collapse
Affiliation(s)
- Min Jeoung Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Keun Young Park
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Joon Kim
- Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Whan Lee
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| |
Collapse
|
6
|
Liu K, Liu X, Song H, Gao X, Zhang M, Qi Y. The assessment of the frequency and arrangement of the subsegmental branches of V3 using computed tomography angiography. Quant Imaging Med Surg 2021; 11:1284-1291. [PMID: 33816167 DOI: 10.21037/qims-20-725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The frequency and arrangement of the subsegmental branches of the third portion of the vertebral artery (V3) have been assessed in small samples by autopsy, but they have not been assessed by computed tomography angiography (CTA). To determine the frequency and arrangement of subsegmental branches of V3 by CTA and to analyze the interrelationships among frequency, arrangement, sex, and side-to-side. Methods First, the radiology records of 668 consecutive patients who underwent cervical or craniocervical CTA scans from October 1, 2017 to October 31, 2019 were retrospectively retrieved. Second, the four demarcation points were ascertained to define the three subsegments by reviewing the resource images, namely, the vertical portion of V3(V3v), horizontal portion of V3(V3h), and extradural portion of V3(V3e). Then, the numerical value and the location of the bifurcating branch in each subsegment of V3 were recorded. Third, the frequency and arrangement of the branches was assessed, and the relationships between sex, laterality and frequency and arrangement were analyzed as well as the interobserver performance. Results On the left, 25%, 20.21%, and 6.59% were the frequencies of one branch in the V3v, V3h, and V3e, and 1.05%, 0.00%, and 0.45% were the frequencies of two branches, respectively. On the right, 25.04%, 17.07%, and 6.44% were the frequencies of one branch in the V3v, V3h, and V3e, and 1.04%, 0.3%, and 0.15% were the frequencies of two branches, respectively. There were no differences between the side-to-side and numerical values of the branches according to the t-test (P=0.4341, P=0.7968), and there were no differences between the side-to-side variable, sex variable and number of branches according to the t-test (P=0.4474, P=0.3593). There were no differences between the side-to-side and eight arrangements (permutation of 000; 100; 110; 111; 010; 011; 001; 101) by using the two-sample KS test (P=0.942), and there were no differences between sex and the eight arrangements according to the two-sample KS test (P=0.9973, P=0.8519). The interobserver reliability was excellent (Spearman's ranked correlation: 0.9927). Conclusions The frequency and arrangement of V3 subsegmental branches could be displayed by source imaging with CTA, and there were no significant differences according to the sex or side of the individual. It was imperative to acquaint the subsegmental branches before the operation involving V3 in the craniocervical junction to determine the surgical approach and reduce bleeding during the surgical procedures.
Collapse
Affiliation(s)
- Kai Liu
- Department of Medical Imaging, Ganzhou People's Hospital, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Xinli Liu
- Department of Radiology, The Forth People's Hospital of Jinan, Jinan, China
| | - Huixiao Song
- Department of Traditional Chinese Medicine, Ganzhou People's Hospital, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Xiujuan Gao
- Department of Cardiology, Ji'nan Jigang Hospital, Jinan, China
| | - Menglong Zhang
- Department of Minimally Invasive Intervention, Ganzhou People's Hospital, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Yuangang Qi
- Department of Radiology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| |
Collapse
|
7
|
Lawton MT, Abla AA, Rutledge WC, Benet A, Zador Z, Rayz V, Saloner D, Halbach V. Bypass Surgery for the Treatment of Dolichoectatic Basilar Trunk Aneurysms: A Work in Progress. Neurosurgery 2016; 79:83-99. [PMID: 26671632 PMCID: PMC4956413 DOI: 10.1227/neu.0000000000001175] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The treatment of dolichoectatic basilar trunk aneurysms has been ineffectual or morbid due to nonsaccular morphology, deep location, and involvement of brainstem perforators. Treatment with bypass surgery has been advocated to eliminate malignant hemodynamics and to stabilize aneurysm growth. OBJECTIVE To validate that flow alteration with bypass and parent artery occlusion favorably impacts aneurysm progression. METHODS Surgical management evolved in 3 phases, each with different hemodynamic alterations. RESULTS During a 17-year period, 37 patients with dolichoectatic basilar trunk aneurysms were retrospectively identified, of whom 21 patients were observed, 12 treated immediately, and 4 selected for treatment after clinical progression. In phase 1, flow reversal was overly thrombogenic, despite heparin (N = 5, final mortality, 100%). In phase 2, flow reduction with intracranial-to-intracranial bypass was safer than flow reversal, but did not prevent progressive aneurysm enlargement (N = 3, final mortality 67%). In phase 3, distal clip occlusion of the basilar trunk aneurysm preserved anterograde flow in the aneurysm without rupture, but reduced flow threatened perforator patency, despite treatment with clopidogrel (N = 8, final mortality 62%). CONCLUSION Shifting treatment strategy for dolichoectatic basilar trunk aneurysms improved surgical (80% to 50%) and final mortalities (100% to 62%), with stabilization of aneurysms in the phase 3 survivors. Good outcomes are determined by perforator preservation and mitigating aneurysm thrombosis. Occlusion techniques with increased distal run-off seem to benefit perforators. The treatment of dolichoectatic basilar trunk aneurysms can advance through concentrated management in dedicated centers, concerted efforts to study morphology and hemodynamics with computational methods, and widespread collection of registry data. ABBREVIATIONS 4D PC-MRI, time-resolved phase-contrast MRIAICA, anterior inferior cerebellar arteryCE-MRA, high-resolution contrast-enhanced MR angiographyEC-IC, extracranial-to-intracranial bypassMCA, middle cerebral arteryMR, magnetic resonancemRS, modified Rankin ScalePCA, posterior cerebral arteryPICA, posterior inferior cerebellar arterySCA, superior cerebellar arterySTA, superficial temporal arteryVA, vertebral artery.
Collapse
Affiliation(s)
- Michael T. Lawton
- Department of Neurological Surgery, University of California, San
Francisco, San Francisco, California
| | - Adib A. Abla
- Department of Neurological Surgery, University of California, San
Francisco, San Francisco, California
| | - W. Caleb Rutledge
- Department of Neurological Surgery, University of California, San
Francisco, San Francisco, California
| | - Arnau Benet
- Department of Neurological Surgery, University of California, San
Francisco, San Francisco, California
| | - Zsolt Zador
- Department of Neurological Surgery, University of California, San
Francisco, San Francisco, California
| | - Vitaliy Rayz
- Department of Radiology and Biomedical Imaging, University of
California, San Francisco, San Francisco, California
| | - David Saloner
- Department of Radiology and Biomedical Imaging, University of
California, San Francisco, San Francisco, California
| | - Van Halbach
- Department of Neuroradiology, University of California, San
Francisco, San Francisco, California
| |
Collapse
|
8
|
Lee SH, Ahn JS, Kwun BD, Park W, Park JC, Roh SW. Surgical Flow Alteration for the Treatment of Intracranial Aneurysms That Are Unclippable, Untrappable, and Uncoilable. J Korean Neurosurg Soc 2015; 58:518-27. [PMID: 26819686 PMCID: PMC4728089 DOI: 10.3340/jkns.2015.58.6.518] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/14/2015] [Accepted: 09/15/2015] [Indexed: 11/27/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sung Ho Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.; Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Woo Roh
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
9
|
Ruptured Basilar Tip Aneurysm in a Patient with Bilateral Internal Carotid Artery Occlusion Successfully Treated with Bilateral Superficial Temporal Artery-Middle Cerebral Artery Anastomoses: Case Report. World Neurosurg 2015; 86:512.e5-8. [PMID: 26459704 DOI: 10.1016/j.wneu.2015.09.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 09/27/2015] [Accepted: 09/28/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Some ruptured intracranial aneurysms concomitant with major artery occlusion may not be amenable for standard clipping or coiling due to the specific hemodynamic conditions. The long-term effect of flow reduction therapy for such aneurysms is largely unknown. CASE PRESENTATION A 45-year-old woman presented with subarachnoid hemorrhage due to a ruptured basilar tip aneurysm. Angiography revealed that the bilateral internal carotid arteries were hypoplastic and that the anterior circulation was fed by the collateral flow through the bilateral posterior communicating arteries and the posterior choroidal arteries. Endovascular treatment failed because it was extremely difficult to secure the catheter at the neck of the aneurysm and insert the coil safely because it was a small aneurysm with a wide neck. In addition, direct clipping was risky due to the location and projection of the aneurysm. We therefore adopted the 2-stage bilateral superficial temporal artery-middle cerebral artery bypass to alleviate the vascular demand on the anterior circulation, with the aim of reducing the hemodynamic stress to the basilar bifurcation. The patient had no rebleeding for 4 years after surgery, with gradual shrinkage of the aneurysm. CONCLUSION All the possible treatment options should be carefully assessed because the long-term effect of the flow alternation method to prevent rebleeding has not been proved. However, our case suggests that the strategy of reducing the hemodynamic stress at the parent artery may be effective even in selected cases of ruptured aneurysms for which standard clipping or coiling is not feasible.
Collapse
|