Long-term follow-up study of patients with cavernous sinus aneurysm treated by proximal occlusion

Destructive strategies in treating cerebrovascular pathology: Review and treatment algorithm

The goal of cerebrovascular pathology treatment is most often to angiographically eradicate a lesion with the lowest probability of morbidity. Destructive strategies using parent vessel occlusion are less commonly considered in the modern era. We review principles of parent vessel occlusion for treatment of cerebrovascular pathology and select cases to demonstrate these principles. Many common cerebrovascular conditions have been safely and effectively treated with destructive strategies including intracranial aneurysms, traumatic craniocervical vascular injuries, and oncologic indications such as carotid blowout. Avoiding procedural morbidity in these procedures involves assessment of collaterals distal to a planned parent vessel occlusion, determination of this arterial segment's eloquence, prevention of distal migration of endovascular devices or thrombus, and prevention of stump emboli. An algorithm for case selection and method of destructive technique versus a reconstructive approach can be used. Destructive strategies for treating cerebrovascular pathology are still relevant and can be applied safely in appropriately selected cases.

Cerebrovascular bypass for ruptured aneurysms: A case series

In patients with aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular or traditional open surgical techniques, surgical revascularization strategies comprise one of remaining limited options. There is nonetheless a paucity of data on the safety and efficacy of bypass in aSAH. In this study, we aimed to investigate complications and outcomes in a cohort of patients with aSAH treated with bypass. A prospective single-surgeon database of consecutive patients treated for aSAH between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge were recorded and analyzed for the patients that underwent bypass surgery. Forty patients with aSAH were treated with bypass surgery (23 extracranial-intracranial; 17 intracranial-intracranial). All-cause perioperative mortality was 13% (6 patients). At discharge and at mean 14-month follow up, respectively, 16/40 (40%) and 16/25 (64%) of patients achieved a Glasgow Outcome Score of 4-5. All-cause, in-hospital complications occurred in 28 patients (70%), of which any ischemic complication occurred in 20 patients (50%), 7 (18%) being open surgical complications. This work represents the largest modern series of bypass for aSAH to date. In cases of aSAH unfavorable for endovascular intervention or traditional open surgical techniques, bypass remains a viable option in this complex group of patients.

Opening of unusual vascular collaterals leads to early recanalization of a giant intracavernous carotid artery aneurysm following common carotid artery occlusion: A Case report and literature review

Background:

Parent artery occlusion (PAO) with or without bypass surgery is a feasible treatment for large intracavernous carotid artery (ICCA) aneurysms. The ideal occlusion site (internal or common carotid artery [CCA]) and ischemic complications after PAO have received special attention since the description of the technique. Unfrequently, some patients can also develop unusual external carotid artery-internal carotid artery collateral pathways distal to the ligation site that can explain the failure to aneurysm size reduction.

Case Description:

We describe a rare case of delayed refilling of a large ICCA aneurysm partially thrombosed which early recanalized after surgical ligation of the cervical CCA through an unusual collateral pathway.

Conclusion:

Based on our experience, we recommend periodic long-term follow-up neuroimaging, especially in those cases where potential collateral branches have not been clearly identified in the preoperative studies.

Bypass and Deconstructive Technique for Hunt and Hess Grade 3-5 Aneurysmal Subarachnoid Hemorrhage Deemed Unfavorable for Endovascular Treatment: Case Series of Outcomes and Comparison with Clipping

BACKGROUND

Intracranial bypass to treat ruptured aneurysms has been well described in the literature but is largely deferred in patients with higher Hunt and Hess (H & H) grades due to complexity and length of surgery, risk of inducing vasospasm, and poor prognosis. However, there is a paucity of data and no direct comparison with more traditional open surgical techniques. This study investigated outcomes in patients with H & H grade 3-5 aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for stand-alone endovascular treatment managed with bypass compared with direct surgical clipping.

METHODS

A prospective database of patients treated for aSAH with H & H grade 3-5 between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge and latest follow-up were compared between patients who underwent bypass surgery versus direct clipping.

RESULTS

Twenty-three patients underwent revascularization, and 60 underwent clipping alone. There were no significant differences in all-cause 30-day mortality (15% vs. 16%; P = 0.97) or Glasgow Outcome Scale and modified Rankin Scale at discharge or median 8-month follow-up (P > 0.67). There was a higher overall stroke rate with revascularization (P = 0.004), specifically endovascular treatment-related stroke (P = 0.049), with no difference in surgical (P = 0.47) or vasospasm-related stroke (P = 0.53). There were no differences in overall complications, medical complications, seizures, reruptures, hydrocephalus, or perioperative death (P > 0.05).

CONCLUSIONS

Bypass is a viable option for patients presenting with higher H & H grade aSAH deemed unfavorable for stand-alone endovascular therapy. Despite obvious differences in aneurysm complexity and a higher risk of stroke, functional outcomes with revascularization can be comparable with clipping in this high-risk patient cohort.

[Proximal clipping of a large fusiform aneurysm of the A2 segment of the left anterior cerebral artery with awakening of the patient (a case report and literature review)]

Arterial aneurysms of the A2 segment are very rare (<1%) peripheral aneurysms of the anterior cerebral artery (ACA) territory. Usually, these are saccular aneurysms; there are single reports of fusiform aneurysms of this location. Surgical treatment of these aneurysms involves both microsurgical and endovascular interventions. In the presented case, we used deconstructive surgery (proximal clipping of the aneurysm) with intraoperative awakening of the patient, which verified sufficient collateral blood flow. In the case of focal deficit development, we planned to simultaneously perform an interarterial anastomosis between the A3 segments of the right and left ACAs.

Giant and Very Large Intracranial Aneurysms: Surgical Strategies and Special Issues

Giant intracranial aneurysms (GIAs) and very large intracranial aneurysms (VLAs) have a poor natural history because of a high incidence of bleeding and strokes. These lesions always represent a great challenge for neurosurgeons and interventional neuroradiologists because of some peculiar intrinsic features such as size, angioarchitecture, wide neck, mass effect, intraluminal thrombosis, atherosclerotic changes, involvement of branches and perforators, and a frequent need to perform revascularization procedures. The results of a cumulative surgical series of 75 VLAs and GIAs are reported. Thirty-three aneurysms were unruptured. Sixty aneurysms underwent direct surgical treatment consisting of 56 direct clippings, 3 trappings w/o revascularization, and 1 wrapping. Fifteen aneurysms were treated by means of extracranial to intracranial (EC-IC) high-flow bypass. An mRS score ranging between 0 and 2 was observed in 54 patients, whereas an mRS of 3 was seen in 5 patients. Four patients had a severe disability (mRS 4-5) and six patients died. Aneurysm's fragmentation, with stacking and seating clips, thrombectomy, and aneurysmorrhaphy were the techniques most frequently employed. Revascularization options involving EC-IC high-flow bypass were used in cases not amenable for direct treatment. Some technical tips and special issues related to the surgical management of these complex lesions are discussed.

High-flow bypass with radial artery graft followed by internal carotid artery ligation for large or giant aneurysms of cavernous or cervical portion: clinical results and cognitive performance

High-flow bypass followed by ligation of the internal carotid artery (ICA) is an effective treatment, but the impact of abrupt occlusion of the ICA is unpredictable, especially on postoperative cognitive function. The present study evaluated the clinical results as well as cognitive performances after high-flow bypass using radial artery graft (RAG) with supportive superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, followed by ICA ligation. Ten consecutive patients underwent high-flow bypass surgery for large or giant ICA aneurysms of cavernous or cervical portion. Demographics, clinical information, magnetic resonance (MR) imaging, computed tomography, digital subtraction angiography (DSA), intraoperative somatosensory evoked potentials, neuropsychological examinations including the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R), and follow-up data were analyzed. The aneurysm was located on the cavernous segment in eight cases and cervical segment in two cases, and mean aneurysm size was 27.9 mm. Postoperative DSA demonstrated robust bypass flow from the external carotid artery to MCA via the RAG, and no anterograde flow into the aneurysm. No patient showed new symptoms after the operation. Follow-up clinical study and MR imaging were performed in nine patients and showed no additional ischemic lesion compared with preoperative imaging. Seven patients completed neuropsychological examinations before and after surgery. All postoperative scores except WMS-R composite memory score slightly improved. High-flow bypass followed by ICA ligation can achieve good clinical outcomes. Successful high-flow bypass using RAG with supportive STA-MCA bypass and ICA ligation does not adversely affect postoperative cognitive function.

Intraoperative Computed Tomography (CT) for Treating Giant Carotid Intracavernous Aneurysms

Background

Giant carotid intracavernous aneurysm refers to those lesions larger than 2.5 cm and derived from a cavernous segment, accounting for about 30% of all intracranial tumors. Dynamic CT perfusion imaging (PCT) is a common method recently employed to evaluate cerebral perfusion. This study investigated the efficacy and clinical application of intraoperative CT in the surgery for giant symptomatic carotid intracavernous aneurysm.

Material/Methods

A retrospective analysis was performed on 23 cases with giant symptomatic carotid intracavernous aneurysm. BTO testing was performed before surgery. Differential treatments were performed based on the condition of aneurysm, and some patients received intraoperative PCT. Postoperative anti-coagulation was given with DSA or CTA follow-up examinations at 3–6 months, 1 year, and 2 years after surgery.

Results

A total of 17 patients received aneurysm isolation coupled with high-flow bypass surgery. Among those, 9 developed early-onset neurological function after surgery, with gradual recover within 6 months. One coma patient died 25 months after discharge. One patient had aneurysm isolation with clapping of anterior communicating artery, and the other 5 cases received artery clapping only. In those patients, 4 had improvement at early phase, while 1 patient had numbness of the oculomotor nerve. Six patients received surgery in the CT room, including 5 cases with single proximal ligation of the internal carotid artery plus 1 aneurysm isolation combined with high-flow bypass surgery.

Conclusions

Intraoperative PCT can provide objective evidence and effective evaluation of cerebral perfusion.

Rationale for graft selection in patients with complex internal carotid artery aneurysms treated with extracranial to intracranial high-flow bypass and therapeutic internal carotid artery occlusion

OBJECTIVE After internal carotid artery (ICA) sacrifice without revascularization for complex aneurysms, ischemic complications can occur. In addition, hemodynamic alterations in the circle of Willis create conditions conducive to the formation of de novo aneurysms or the enlargement of existing untreated aneurysms. Therefore, the revascularization technique remains indispensable. Because vessel sizes and the development of collateral circulation are different in each patient, the ideal graft size to prevent low flow-related ischemic complications (LRICs) in external carotid artery (ECA)-middle cerebral artery (MCA) bypass with therapeutic ICA occlusion (ICAO) has not been well established. Authors of this study hypothesized that the adequate graft size could be calculated from the size of the sacrificed ICA and the values of MCA pressure (MCAP) and undertook an investigation in patients with complex ICA aneurysms treated with ECA-graft-MCA bypass and therapeutic ICAO. METHODS In the period between July 2006 and January 2016, 80 patients with complex ICA aneurysms were treated with ECA-MCA bypass and therapeutic ICAO. Preoperative balloon test occlusion (BTO) was performed, and the BTO pressure ratio was defined as the mean stump pressure/mean preocclusion pressure. Low flow-related ischemic complications were defined as new postoperative neurological deficits and ipsilateral cerebral blood flow reduction. Initial MCAP (iMCAP), MCAP after clamping the ICA (cMCAP), and MCAP after releasing the graft (gMCAP) were intraoperatively monitored. The MCAP ratio was defined as gMCAP/iMCAP. Based on the Hagen-Poiseuille law, the expected MCAP ratio ([expected gMCAP]/iMCAP) was hypothesized as follows: (1 - cMCAP/iMCAP)(graft radius/ICA radius)² + (cMCAP/iMCAP). Correlations between the BTO pressure ratio and cMCAP/iMCAP, and between the actual and expected MCAP ratios, were evaluated. Risk factors for LRICs were also evaluated. RESULTS The mean BTO pressure ratio was significantly correlated with the mean cMCAP/iMCAP (r = 0.68, p < 0.0001). The actual MCAP ratio correlated with the expected MCAP ratio (r = 0.43, p < 0.0001). If the expected MCAP ratio was set up using the BTO pressure ratio instead of cMCAP/iMCAP (BTO-expected MCAP ratio), the mean BTO-expected MCAP ratio significantly correlated with the expected MCAP ratio (r = 0.95, p < 0.0001). During a median follow-up period of 26.1 months, LRICs were observed in 9 patients (11%). An actual MCAP ratio < 0.80 (p = 0.003), expected MCAP ratio < 0.80 (p = 0.001), and (M₂ radius/graft radius)² < 0.49 (p = 0.002) were related to LRICs according to the Cox proportional-hazards model. CONCLUSIONS Data in the present study indicated that it was important to use an adequate graft to achieve a sufficient MCAP ratio in order to avoid LRICs and that the adequate graft size could be evaluated based on a formula in patients with complex ICA aneurysms treated with ICAO.

Surgical treatment of large and giant cavernous carotid aneurysms

Cavernous carotid aneurysms (CCAs) are uncommon pathologic entities. Extradural place and the skull base location make this type of an aneurysm different in clinical features and treatment techniques. Direct aneurysm clipping is technically difficult and results in a significant postoperative neurological deficit. Therefore, several techniques of indirect surgical treatment were developed with different surgical outcomes, such as proximal occlusion of internal carotid artery (ICA) or trapping with or without bypass (superficial temporal artery-middle cerebral artery bypass or high-flow bypass). High-flow bypass with proximal ICA occlusion seems to be the most appropriate surgical treatment for CCA because of the high rate of symptom improvement, aneurysm thrombosis, and minimal postoperative complications. However, in cases of CCA presented with direct carotid-cavernous fistula, the appropriate surgical treatment is high-flow bypass with aneurysm trapping, which the fistula can be obliterated immediately after surgery.

Tailored flow sequestration treatment using high-flow and low-flow bypass for partially thrombosed giant internal carotid artery aneurysm-a technical case report

Direct clipping of giant partially thrombosed intracranial internal carotid artery (ICA) aneurysms is challenging, especially when important perforating arteries are involved. Proximal occlusion with bypass represents a possible alternative approach. An 80-year-old female presented with worsening visual acuity and severe headache caused by partially thrombosed giant (38 mm in diameter) aneurysms of the right ICA, suggestive of impending rupture. Direct clipping in conjunction with temporary occlusion of the lesion involving the anterior choroidal artery (AChA) was considered too risky. Thus, we sequestrated the ipsilateral ICA flow into a low-flow and a high-flow system using two external carotid artery (ECA)-ICA bypasses and one in situ bypass with cervical ICA ligation. As a result, the low-flow system by the superficial temporal artery-middle cerebral artery (MCA) bypass perfused mainly the proximal MCA lesions and aneurysm, whereas the high-flow system by ECA-radial artery-M2 bypass exclusively supplied the residual distal MCA area. This tailored flow sequestration successfully interrupted intra-aneurysmal flow and accelerated near-complete thrombosis of the aneurysm while preserving the AChA and avoiding any significant neurological deterioration. We conclude that this method is effective for the management of giant partially thrombosed aneurysms of the ICA, especially when direct clipping is difficult.

De novo giant A2 aneurysm following anterior communicating artery occlusion

BACKGROUND

De novo intracranial aneurysms are reported to occur with varying incidence after intracranial aneurysm treatment. They are purported to be observed, however, with increased incidence after Hunterian ligation; particularly in cases of carotid artery occlusion for giant or complex aneurysms deemed unclippable.

CASE DESCRIPTION

We report a case of right-sided de novo giant A2 aneurysm 6 years after an anterior communicating artery (ACoA) aneurysm clipping. We believe this de novo aneurysm developed in part due to patient-specific risk factors but also a significant change in cerebral hemodynamics. The ACoA became occluded after surgery that likely altered the cerebral hemodynamics and contributed to the de novo aneurysm. We believe this to be the first reported case of a giant de novo aneurysm in this location. Following parent vessel occlusion (mostly of the carotid artery), there are no reports of any de novo aneurysms in the pericallosal arteries let alone a giant one. The patient had a dominant right A1 and the sudden increase in A2 blood flow likely resulted in increased wall shear stress, particularly in the medial wall of the A2 where the aneurysm occurred 2 mm distal to the A1-2 junction.

CONCLUSION

ACoA preservation is a key element of aneurysm surgery in this location. Suspected occlusion of this vessel may warrant closer radiographic follow-up in patients with other risk factors for aneurysm development.

Bilateral Cavernous Carotid Aneurysms: The Growth Potential of a Contralateral Aneurysm after Therapeutic Unilateral Internal Carotid Artery Occlusion

BACKGROUND

Although the introduction of flow-diverter stents has been recognized as a major revolution in the treatment of cavernous carotid aneurysms (CCAs), therapeutic internal carotid artery occlusion (TICAO) remains a reliable procedure for alleviating symptoms caused by CCAs. However, TICAO has the potential risk of the enlargement of coexisting aneurysms that are frequently detected in CCA patients. The purpose of this study is to assess the occurrence of the enlargement of aneurysms coexisting with CCAs after TICAO.

METHODS

We reviewed medical charts of CCA patients who were managed using unilateral TICAO. Coexisting aneurysms were identified using angiograms obtained before TICAO, and imaging data in long follow-up periods were retrospectively examined to determine the extent of the enlargement after TICAO.

RESULTS

Of 12 patients with CCAs, 10 had 12 coexisting aneurysms; 5 of the coexisting aneurysms (41.7%) showed enlargement during a mean follow-up period of 8.1 years, and all enlarged aneurysms were smaller of the bilateral CCAs; the larger CCA had been managed by TICAO. Five of 6 (83.3%) patients with bilateral CCAs showed enlargement of the contralateral aneurysm after TICAO. Two contralateral CCAs showed marked enlargement after TICAO and were subsequently treated with stent-assisted coil embolization.

CONCLUSIONS

Contralateral, smaller aneurysms frequently enlarge after unilateral TICAO in patients with bilateral CCAs. The findings emphasize the importance of long-term observation after TICAO and appropriate interventions against enlarging contralateral aneurysms.

SILK flow diverter for complex intracranial aneurysms: a Canadian registry

INTRODUCTION

The SILK flow diverter (SFD) is used for the treatment of complex intracranial aneurysms. Small case series have been reported in the literature but few studies with a large number of patients have been published. We present our experience with the SFD for the treatment of intracranial aneurysms in Canada.

METHODS

Centers across Canada using SFDs were contacted to fill out a case report form for patients treated with an SFD in their center. Individual centers were responsible for approval from their ethics committee. Image analysis was performed by individual operators. The case report forms were collected and the final analysis was performed.

RESULTS

A total of 92 patients were treated with SFDs in eight centers in Canada between January 2009 and August 2013. The aneurysms were located in the posterior circulation in 16 patients and in the anterior circulation in 76 patients. Most aneurysms (75%) were saccular in shape; 22% were fusiform and 3% were blister aneurysms. The size of the aneurysms varied from 2 to 60 mm with the neck varying from 2 to 60 mm. Perioperative morbidity and mortality were 8.7% and 2.2%, respectively. At the last available follow-up, 83.1% of the aneurysms were either completely or near-completely occluded. The rate of complications was higher for fusiform aneurysms (p<0.001).

CONCLUSIONS

The SFD appears to be an important tool for the treatment of complex intracranial aneurysms. Treatment outcomes and complication rates remain a problem, but should be considered in the context of available alternative interventions. Ongoing analysis of flow-diverting stents for radiographic and clinical performance is required.

Cavernous carotid aneurysms in the era of flow diversion: a need to revisit treatment paradigms

BACKGROUND AND PURPOSE

Recent techniques of endoluminal reconstruction with flow-diverting stents have not been incorporated into treatment algorithms for cavernous carotid aneurysms. This study examines the authors' institutional experience and a systematic review of the literature for outcomes and complications using the Pipeline Embolization Device in unruptured cavernous carotid aneurysms.

MATERIALS AND METHODS

A retrospective search for cavernous carotid aneurysms from a prospectively collected data base of aneurysms treated with the Pipeline Embolization Device at our institution was performed. Baseline demographic, clinical, and laboratory values; intrainterventional data; and data at all follow-up visits were collected. A systematic review of the literature for complication data was performed with inquiries sent when clarification of data was needed.

RESULTS

Forty-three cavernous carotid aneurysms were included in the study. Our mean radiographic follow-up was 2.05 years. On last follow-up, 88.4% of the aneurysms treated had complete or near-complete occlusion. Aneurysm complete or near-complete occlusion rates at 6 months, 12 months, and 36 months were 81.4%, 89.7%, and 100%, respectively. Of patients with neuro-ophthalmologic deficits on presentation, 84.2% had improvement in their visual symptoms. Overall, we had a 0% mortality rate and a 2.3% major neurologic complication rate. Our systematic review of the literature yielded 227 cavernous carotid aneurysms treated with the Pipeline Embolization Device with mortality and morbidity rates of 0.4% and 3.1%, respectively.

CONCLUSIONS

Endoluminal reconstruction with flow diversion for large unruptured cavernous carotid aneurysms can yield high efficacy with low complications. Further long-term data will be helpful in assessing the durability of the cure; however, we advocate a revisiting of current management paradigms for cavernous carotid aneurysms.

Urgent treatment of severe symptomatic direct carotid cavernous fistula caused by ruptured cavernous internal carotid artery aneurysm using high-flow bypass, proximal ligation, and direct distal clipping: Technical case report

Background:

Direct carotid cavernous fistula (CCF) secondary to ruptured carotid cavernous aneurysms (CCAs) is rare, but patients with this condition who develop acutely worsening and severe neuro-ophthalmic symptoms require urgent treatment. Endovascular methods are the first-line option, but this modality may not be available on an urgent basis.

Case Description:

In this article, we report a 45-year-old female with severe direct CCF due to rupture of the CCA. She presented with intractable headache and acute worsening of double vision and visual acuity. Emergent radiographic study revealed high-flow fistula tracked from the CCA toward the contralateral cavernous sinus and drained into the engorged left superior orbital vein. To prevent permanent devastating neuro-ophthalmic damages, urgent high-flow bypass with placement of a radial artery graft was performed followed by right cervical internal carotid artery (ICA) ligation and the clipping of the ICA at the C3 portion, proximal to the ophthalmic artery. In the immediate postoperative period, her symptoms resolved and angiography confirmed patency of the high-flow bypass and complete occlusion of the CCF.

Conclusion:

With due consideration of strategy and techniques to secure safety, open surgical intervention with trapping and bypass is a good treatment option for direct severe CCF when the endovascular method is not available, not possible, or is unsuccessful.

Evolution of management strategies for cavernous carotid aneurysms: a review

OBJECTIVE

Cavernous carotid aneurysms are considered benign lesions with indolent natural history. Apart from idiopathic aneurysms, traumatic, iatrogenic, and mycotic aneurysms are common in the cavernous segment of the carotid artery. With rapid advances in endovascular therapy, management of cavernous carotid aneurysms has evolved. Our aim was to review the management options available for cavernous carotid aneurysms.

METHODS

The English literature was searched for various studies describing the management of cavernous carotid aneurysms and the evolution of various treatments was studied.

RESULTS

Numerous treatment options are available such as conservative management, Hunterian ligation, surgical clipping, and endovascular therapy. The introduction of flow-diverting stents has revolutionized the management of these lesions. The evolution of various treatment strategies are described.

CONCLUSIONS

A thorough knowledge of all the options is paramount to individualize therapy. We discuss the indications of treatment, various management options for cavernous carotid aneurysms and their outcomes.

Development of medical devices for neurointerventional procedures: special focus on aneurysm treatment

Since the introduction of the Guglielmi detachable coil in 1990, the role of endovascular treatment for intracranial aneurysm has changed significantly. However, this endovascular modality has intrinsic technical limitations in wide-neck and large (11-25 mm) or giant (>25 mm) aneurysms. Long-term anatomic outcomes for these aneurysms include an approximate 25% recanalization rate. Since the aneurysm recanalization is related to morphologic, hemodynamic and biologic factors associated with aneurysm healing, improvement of these factors has elicited several technical modifications of the original technique. This review will describe new endovascular devices that have been manufactured to improve the technical limitations inherited by the Guglielmi detachable coil technique, as well as the historic background of endovascular treatment for cerebral aneurysms.

Clinical and angiographic outcome of endovascular and conservative treatment for giant cavernous carotid artery aneurysms

This study evaluated the outcome of endovascular and conservative treatment for giant cavernous carotid artery aneurysms (CCAAs). We retrospectively reviewed a series of 35 consecutive giant CCAAs treated with endovascular and conservative treatment. All patients were evaluated by balloon occlusion test (BOT) before treatment. Patients who could tolerate BOT were treated by parent artery occlusion (PAO), those who could not tolerate BOT were treated by stent/coil or conservative methods. Eight patients were treated conservatively, symptoms were worsened in four patients (50%), unchanged in three, and improved in one at 33.6±19.9 months (6~65 months) follow-up. In 27 aneurysms treated with endovascular methods, 17 aneurysms were treated by PAO, eight aneurysms were treated with stent-assisted coil embolization, and two aneurysms were embolized with coils. The initial post-procedure angiogram revealed complete occlusion, neck remnant, and incomplete occlusion in 81.5 %, 11.1 %, and 7.4 %, respectively. Procedure-related mortality and morbidity were 0 and 7.4 %, respectively. At 33.1±17.4 months (4~71 months) follow-up, a good clinical outcome (mRS 0-1) was observed in 25 (92.6%) patients, symptoms were resolved or improved in 20 (74.1%). Statistical analysis showed that risk factors for poor clinical outcome included age of 60 years and older (P=0.006), and conservative treatments (P=0.038). Risk factors for poor clinical outcome of giant CCAAs included conservative treatment and age older than 60 years. A symptomatic giant cavernous carotid aneurysm should be treated. The outcome of endovascular treatment of giant CCAAs is promising.

Treatment of cavernous sinus aneurysms with flow diversion: results in 44 patients

BACKGROUND AND PURPOSE

Aneurysms of the cavernous segment of the ICA are difficult to treat with standard endovascular techniques, and ICA sacrifice achieves a high rate of occlusion but carries an elevated level of surgical complications and risk of de novo aneurysm formation. We report rates of occlusion and treatment-related data in 44 patients with cavernous sinus aneurysms treated with flow diversion.

MATERIALS AND METHODS

Patients with cavernous segment aneurysms treated with flow diversion were selected from a prospectively maintained data base of patients from 2009 to the present. Demographic information, treatment indications, number/type of flow diverters placed, outcome, complications (technical or clinical), and clinical/imaging follow-up data were analyzed.

RESULTS

We identified 44 patients (37 females, 7 males) who had a flow diverter placed for treatment of a cavernous ICA aneurysm (mean age, 57.2; mean aneurysm size, 20.9 mm). The mean number of devices placed per patient was 2.2. At final angiographic follow-up (mean, 10.9 months), 71% had complete occlusion, and of those with incomplete occlusion, 40% had minimal remnants (<3 mm). In symptomatic patients, complete resolution or significant improvement in symptoms was noted in 90% at follow-up. Technical complications (which included, among others, vessel perforation in 4 patients, groin hematoma in 2, and asymptomatic carotid occlusion in 1) occurred in approximately 36% of patients but did not result in any clinical sequelae immediately or at follow-up.

CONCLUSIONS

Our series of flow-diversion treatments achieved markedly greater rates of complete occlusion than coiling, with a safety profile that compares favorably with that of carotid sacrifice.

De novo large fusiform posterior circulation intracranial aneurysm presenting with subarachnoid hemorrhage 7 years after therapeutic internal carotid artery occlusion: case report and review of the literature

BACKGROUND AND IMPORTANCE

Although the use of proximal artery occlusion, or hunterian ligation, for the treatment of intracranial aneurysms has decreased greatly over the past decades, this approach still finds use for certain giant and complex aneurysms. The main risks of artery sacrifice are ischemic complications but also, although rare, de novo aneurysm formation. We present here a case of de novo formation of a large fusiform basilar artery aneurysm 7 years after internal carotid artery occlusion.

CLINICAL PRESENTATION

A 17-year-old male patient with a history of a giant right cavernous aneurysm treated 7 years earlier with right-sided endovascular internal carotid artery occlusion presented to our institution with a thunderclap headache. At the time of initial evaluation, the patient was neurologically intact and imaging revealed a 22 × 10-mm fusiform aneurysm of the distal basilar artery with mass effect on the adjacent pons as well as a small amount of subarachnoid and intraventricular blood. Complete occlusion of the right internal carotid artery was demonstrated with retrograde filling of the right middle cerebral artery from the enlarged right posterior communicating artery. The patient was subsequently treated with hunterian occlusion of the basilar artery below anterior inferior cerebellar arteries. A superficial temporal artery to middle cerebral artery bypass was performed on the right side before this occlusion.

CONCLUSION

Further studies on the epidemiology of de novo aneurysms after carotid artery occlusion are warranted. Patients at higher risk of the development of intracranial aneurysms should be followed aggressively after hunterian ligation, and the possibility of an extracranial-intracranial bypass should be discussed.

Giant extracranial aneurysm of the internal carotid artery in neurofibromatosis type 1. A case report and review of the literature

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by cutaneous pigmentations, neurofibromas, Lisch nodules and neuroectodermal tumors. Supra-aortic vessel aneurysms may affect patients with NF-1 and can be associated with rupture, ischemic complications and compression symptoms. We describe a 48-year-old woman with NF-1 and an extracranial 3×5 cm right internal carotid artery aneurysm. After balloon test occlusion the patient was treated with parent artery sacrifice which led to significant shrinkage on follow-up MR and reduction of compression symptoms. The literature concerning internal carotid artery aneurysms associated with NF-1 is reviewed evaluating the possible therapeutic options.

Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results

BACKGROUND AND PURPOSE

Flow-diverting devices now offer a new treatment alternative for cerebral aneurysms. We present the results of a large single-center series of patients treated with the PED, including long-term follow-up.

MATERIALS AND METHODS

Between November 2008 and September 2011, sidewall aneurysms with a wide neck (≥4 mm) or unfavorable dome-neck ratio (≤1.5); large/giant, fusiform, dissecting, blister-like, and recurrent sidewall aneurysms; aneurysms at difficult angles; and aneurysms in which a branch was originating directly from the sac were treated with the PED. Patients were premedicated with dual antiplatelet medications. Data, including demographics, aneurysm features, clinical presentation, complications, results, and follow-up information, for up to 2 years are presented.

RESULTS

Two hundred fifty-one aneurysms in 191 patients were treated. Of these, 96 (38.3%) were large or giant (≥10 mm). In 34/251 (13.5%), PEDs were used for retreatment. Adjunctive coiling was performed in 11 aneurysms (2.1%). The mean number of devices per aneurysm was 1.3. One aneurysm ruptured in the fourth month posttreatment (0.5%), and symptomatic in-construct stenosis was detected in 1 patient (0.5%) treated with percutaneous transarterial angioplasty. Any event rate was 27/191 (14.1%), with a permanent morbidity of 1% and mortality of 0.5%. Control angiography was available in 182 (95.3%) patients with 239 (95.2%) aneurysms. In 121 aneurysms (48.2%), 1- to 2-year control angiography was available. The aneurysm occlusion rate was 91.2% in 6 months, increasing to 94.6%.

CONCLUSIONS

Use of the PED is safe, efficacious, and durable in cerebral aneurysm treatment, with low morbidity-mortality and high occlusion rates as confirmed with mid- to long-term control angiography.

Canadian experience with the pipeline embolization device for repair of unruptured intracranial aneurysms

BACKGROUND AND PURPOSE

Flow-diverting stents, such as the PED, have emerged as a novel means of treating complex intracranial aneurysms. This retrospective analysis of the initial Canadian experience provides insight into technical challenges, clinical and radiographic outcomes, and complication rates after the use of flow-diverting stents for unruptured aneurysms.

MATERIALS AND METHODS

Cases were compiled from 7 Canadian centers between July 2008 and December 2010. Each center prospectively tracked their initial experience; these data were retrospectively updated and pooled for analysis.

RESULTS

During the defined study period, 97 cases of unruptured aneurysm were treated with the PED, with successful stent deployment in 94 cases. The overall complete or near-complete occlusion rate was 83%, with a median follow-up at 1.25 years (range 0.25-2.5 years). Progressive occlusion was witnessed over time, with complete or near-complete occlusion in 65% of aneurysms followed through 6 months, and 90% of aneurysms followed through 1 year. Multivariate analysis found previous aneurysm treatment and female sex predictive of persistent aneurysm filling. Most patients were stable or improved (88%), with the most favorable outcomes observed in patients with cavernous carotid aneurysms. The overall mortality rate was 6%. Postprocedural aneurysm hemorrhage occurred in 3 patients (3%), while ipsilateral distal territory hemorrhage was observed in 4 patients (3.4%).

CONCLUSIONS

Flow-diverting stents represent an important tool in the treatment of complex intracranial aneurysms. The relative efficacy and morbidity of this treatment must be considered in the context of available alternate interventions.

De novo aneurysm formation after carotid artery occlusion for cerebral aneurysms

Therapeutic parent artery occlusion has been routinely utilized for management of some intracranial aneurysms. One possible long-term complication of this procedure is "de novo" formation of aneurysms. The purpose of this paper is to estimate the incidence of de novo aneurysm formation, the time period between occlusion and formation, and the most common sites of formation. A PubMed search was performed for all articles between 1970 and 2008 reporting cases of both therapeutic carotid occlusion and de novo cerebral aneurysms. The 20 papers reviewed reported 187 patients having undergone therapeutic carotid occlusion. Of the 163 patients reported in complete-case series, seven developed new aneurysms (4.3%). Thirty-six total new aneurysms were reported, ranging from 1 to 5 per patient. The average time period between occlusion and detection of de novo aneurysm was 9.1 years (range: 2 to 20 years). These aneurysms occurred mostly in the anterior circulation, predominately the anterior communicating artery and posterior communicating artery, and frequently occurred contralateral to the site of occlusion. Therapeutic parent artery occlusion is a likely risk factor for de novo aneurysm formation. Noninvasive follow-up studies should be performed, especially between 2 and 10 years after occlusion.

Angiographic pitfall: duplicated tapered A1 segment of the anterior cerebral artery mimicking an anterior communicating artery aneurysm

We describe a misleading case of a partially occluded A1 segment duplication that mimicked an ACoA aneurysm on computed tomography angiography and conventional angiography and led to surgical intervention. The location of such an anomaly at the ACoA on the side of least hemodynamic stress may provide a clue to recognizing this variant.

De Novo Aneurysm: Case Reports and Literature Review

BACKGROUND AND IMPORTANCE:

Formation of cerebral de novo aneurysms (CDNAs) is rare, and the pathogenesis remains obscure. We analyzed factors involved in formation of CDNAs and suggest guidelines for follow-up of patients.

CLINICAL PRESENTATION:

We retrospectively reviewed intracranial aneurysms at our institute and published reports from 1964 to 2008. Eleven patients were found with CDNAs, and 138 patients were collected from the published literature. We assessed the clinical characteristics, such as sex, size, and site of CDNA, past history, and time to occurrence of CDNAs. Of 11 patients, 10 were female and 1 was male; the mean age of the first onset was 53 years (range, 25-69 years). The mean time between first aneurysms and CDNAs was 10.6 years (range, 3-29 years). The most common site of occurrence was anterior circulation. One patient experienced contralateral occurrence, and 2 patients changed from anterior to posterior circulation CDNAs. Six (54.5%) patients had a history of arterial hypertension. Results from analysis of the whole series from the literature revealed that the risk of rupture increased with a previous history of hemorrhage. Contralateral occurrence of CDNAs was related to previous location, and multiplicity, whereas the occurrence of anterior to posterior changes of CDNAs and shorter interval only correlated with an older age group.

CONCLUSION:

Although the formation of CDNAs is rare, several factors may contribute to its occurrence. Female patients with a history of arterial hypertension were at a higher risk for CDNA occurrence. We recommend follow-up imaging studies within 10 years after the initial aneurysms; therefore, at least 50% of CDNAs can be found before rupture.

Surgical treatment for aneurysms in the cavernous-petrous portion of the internal carotid artery

BACKGROUND

As direct surgery to treat aneurysms in the cavernous-petrous portion of the ICA is difficult, proximal ligation of the ICA with or without bypass surgery is still the conventional treatment. Some patients have an ECA-ICA collateral pathway distal to the ligation site. This is related to the recanalization of the aneurysm. We describe the treatment strategy of these aneurysms and the surgical pitfalls of the treatment.

METHODS

We analyzed 30 cases of symptomatic aneurysms in the cavernous-petrous portion of the ICA. In all cases, proximal ligation of the ICA was performed with bypass surgery followed by BTO.

RESULTS

In 21 patients who could tolerate BTO, we performed a low-flow bypass. In nine patients who could not tolerate BTO, we performed a high-flow bypass. In four patients with ECA-ICA collateral pathways distal to the ligation site, we performed endovascular parent artery occlusion using detachable coils. In four patients without endovascular parent artery occlusion, we experienced recanalization of the aneurysm.

CONCLUSION

Based on our experience and in view of the late recanalization of aneurysms that have an ECA-ICA collateral pathway, we recommend that intraoperative angiography should be performed to detect the ECA-ICA collateral pathway in proximal ligation of the ICA.

Cavernous carotid aneurysms: to treat or not to treat?

Most cavernous carotid aneurysms (CCAs) are considered benign lesions, most often asymptomatic, and to have a natural history with a low risk of life-threatening complications. However, several conditions may exist in which treatment of these aneurysms should be considered. Several options are currently available regarding the management of CCAs with resultant good outcomes, namely expectant management, luminal preservation strategies with or without addressing the aneurysm directly, and Hunterian strategies with or without revascularization procedures. In this article, we discuss the sometimes difficult decision regarding whether to treat CCAs. We consider the natural history of several types of CCAs, the clinical presentation, the current modalities of CCA management and their outcomes to aid in the management of this heterogeneous group of cerebral aneurysms.

Revascularization for complex intracranial aneurysms

The modern management of intracranial aneurysms includes both constructive and deconstructive strategies to eliminate the aneurysm from the circulation. Both microsurgical and endovascular techniques are used to achieve this goal. Although most aneurysms can be eliminated from the circulation with simple clip reconstruction and/or coil insertion, some require revascularization techniques to enhance tolerance of temporary arterial occlusion during clipping of the aneurysm neck or to enable proximal occlusion or trapping. In fact, the importance of revascularization techniques has grown because of the need for complex reconstructions when endovascular therapies fail. Moreover, the safety and feasibility of bypass have progressed due to advances in neuroanesthesia, technological innovations, and ~ 5 decades of accumulating wisdom by bypass practitioners. Cerebral revascularization strategies become necessary in select patients who possess challenging vascular aneurysms due to size, shape, location, intramural thrombus, atherosclerotic plaques, aneurysm type (for example, dissecting aneurysms), vessels arising from the dome, or poor collateral vascularization when parent artery or branch occlusion is required. These techniques are used to prevent cerebral ischemia and subsequent clinical sequelae. Bypass techniques should be considered in cases in which balloon test occlusion demonstrates inadequate cerebral blood flow and in which there is a need for Hunterian ligation, trapping, or prolonged temporary occlusion. This review article will focus on decision making in bypass surgery for complex aneurysms. Specifically, the authors will review graft options, the utility of balloon test occlusion in decision making, and bypass strategies for various aneurysm types.

Endovascular Management of a Patient after SAH

Treatment of acute aneurysmal subarachnoid hemorrhages consists of occluding the aneurysm to prevent rebleed, attempting to prevent vasospasm, and maintaining blood flow to the brain through vessels in vasospasm. Endovascular treatment has been shown to be as safe as, or safer, than surgical clipping for patients with SAH. Engineering solutions to our clinical problems continue to improve endovascular outcomes. This article reviews the current state of endovascular therapy.

An unusual complication of septorhinoplasty: massive subarachnoid hemorrhage

Septorhinoplasty is a very common operation in the practice of plastic surgery and otolaryngology. We report a case with massive subarachnoid hemorrhage originating from carotid artery injury, following corrective septorhinoplasty. The carotid rupture is a very rare but life-threatening, major complication of nasal surgery. Therefore, surgeons performing surgery in this area should be very careful and aware of this entity. According to our knowledge, this is the fourth case report of a carotid artery injury following septorhinoplasty, but it is the first bilateral and lethal one in the literature.

Imaging of parasellar lesions

The sellar and parasellar region is an anatomically complex area that represents a crucial crossroad of important adjacent structures, e.g. orbits, cavernous sinus and its content, polygon of Willis, hypothalamus through the pituitary stalk and dural reflections forming the diaphragm sellae and the walls of the cavernous sinuses. Although the cavernous sinus represents the most relevant parasellar structure, from the practical and clinical point of view all the structures that surround the sella turcica can be included in the parasellar region. CT and, mainly, MRI are the imaging modalities to study and characterise the normal anatomy and the majority of processes in this region. We present a practical short review of the most relevant CT and MRI characteristics, such as location, nature of contrast enhancement and presence of cystic components, together with clinical findings, which permit differentiation of the most frequent and less common lesions found in the parasellar region.

LEARNING OBJECTIVES

-A short review of the anatomy and clinical symptoms related to the parasellar region. -Radiological characterisation, mainly by MRI, of the many lesions that alter the structure and function of sellar and parasellar anatomy. -Description of the MRI features that permit differentiation among less common lesions.

Long term visual and neurological prognosis in patients with treated and untreated cavernous sinus aneurysms

OBJECTIVE

To determine the long term visual and neurological outcome of patients diagnosed with cavernous sinus aneurysms (CCAs).

METHODS

Prospective follow up for at least five years or until death of 31 retrospectively recruited patients (27 women, 4 men) with treated and untreated CCAs.

RESULTS

There were 40 aneurysms in all. Mean age at diagnosis was 60.4 years (range 25 to 86; median 64). The most common symptoms were diplopia (61%), headache (53%), and facial or orbital pain (32%). Fifteen patients (48%) were diagnosed after they developed cranial nerve pareses, four (13%) after they developed carotid-cavernous sinus fistulas (CCFs), and 12 (39%) by neuroimaging studies done for unrelated symptoms. Twenty one patients (68%) had treatment to exclude the aneurysm from circulation, 10 shortly after diagnosis and 11 after worsening symptoms. Immediate complications of treatment occurred in six patients and included neurological impairment, acute ophthalmoparesis, and visual loss. Ten patients (32%) were observed without intervention. Over a mean (SD) follow up period of 11.8 (7.7) years, eight had improvement in symptoms, five remained stable, and eight deteriorated. Among the 10 patients followed without intervention, none improved spontaneously, three remained stable, and seven worsened.

CONCLUSIONS

Most treated patients in this series improved or remained stable after treatment, but none improved without treatment. The long term prognosis for treated cases is relatively good, with most complications occurring immediately after the procedure. Endovascular surgery has decreased the morbidity and mortality of treatment so should be considered for any patient with a CCA.