Combined endovascular and microsurgical management of complex cerebral aneurysms

Efficacy and Safety of Extracranial-Intracranial Bypass Surgery for Posterior Circulation Aneurysms: A Systematic Review and Single-Arm Meta-Analysis

OBJECTIVE

Treating complex posterior circulation aneurysms poses challenges, and extracranial to intracranial (EC-IC) bypass techniques are potential therapeutic options. However, the safety and efficacy of this approach for posterior circulation aneurysms remain unclear. The study's objective was to assess the safety and efficacy of EC-IC bypass in these aneurysms.

METHODS

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review on EC-IC revascularization for posterior circulation aneurysms. Included studies had at least 4 patients and reported data on mortality, patency, complications, or clinical outcomes. Favorable clinical outcomes were defined as modified Rankin Scale below 3 or Glasgow Outcome Scale above 3, and complications were any issues related to the bypass procedure.

RESULTS

From 3036 articles reviewed, 22 studies involving 196 patients who underwent 210 EC-IC bypass procedures for posterior circulation aneurysms were selected. The median follow-up period of 14 studies was 31.66 months (6-61 months). Final follow-up indicated a high bypass patency rate of 96% [95% confidence interval [CI]: 91%-100%; I2 = 12%], with a mortality rate of 5% [95% CI: 1%-9%; I2 = 0%]. Additionally, 83% [95% CI: 70%-96%; I2 = 77%] of patients showed good outcomes at the last follow-up. Complications were observed in 40% [95% CI: 26%-55%; I2 = 80%]. Heterogeneity was associated with specific studies.

CONCLUSIONS

EC-IC bypass procedures are a viable treatment option for posterior circulation aneurysms, with high bypass patency rates and favorable clinical outcomes. However, complications, especially neurological deficits, exist. Open revascularization remains essential for neurovascular surgeons dealing with complex aneurysms.

Outcomes following surgical and endovascular treatment of extracranial vertebral artery aneurysms (VAA): a systematic evaluation of the literature

Extracranial vertebral artery aneurysms are rare complications resulting from trauma and multiple different diseases. However, the difference between clinical and surgical profiles is well understood. To investigate the clinical and interventional outcomes following extracranial vertebral artery aneurysms (VAA) treatment through a systematic review of the literature to date, an electronic database search for full-text English articles was conducted following PRISMA guidelines. The search yielded results on clinical and surgical outcomes for extracranial VAAs. These results included patient-specific risk factors, indications, and techniques. Our literature search resulted in 561 articles, of which 36 studies were qualified to be included in the analysis. A total of 55 patients with multiple various extracranial VAA incidents were included. The mean age of subjects was 42 years (ranging from 13.0 to 76.0 years), and the majority of patients were males (71%, n =39). Blunt trauma was the most frequent risk factor for extracranial VAA formation (35%, n = 19). The majority of aneurysms (60%) were dissected in nature. The most common form of treatment for extracranial VAAs was the use of a flow diverter (24%, n=13). Overall, five (9%) patients had long-term adverse neurological complications following intervention with 5% (n=3) mortality, 2% (n=1) resulting in unilateral vocal cord paralysis, and 2% (n=1) resulted in a positive Romberg sign. The mortality rate is 15.7% in the surgical group, whereas the endovascular treatment did not result in any mortality. The endovascular approach is a safe and effective treatment of extracranial VAAs due to its relatively low overall complication rate and lack of resulting mortality. This is in contrast to the surgical approach which results in a higher rate of complications, recurrence, and mortality outcomes. An understanding of the factors and clinical outcomes associated with the incidence of extracranial VAAs is essential for the future improvement of patient outcomes.

A cases series of endovascular and microsurgical combined treatment of intracranial aneurysms

OBJECTIVE

Our scientific paper is aimed at describing multimodal treatment of intracranial aneurysms represented by microsurgery and endovascular therapy.

PATIENTS, MATERIALS AND METHODS

We report four cases of intracranial aneurysms treated in our Department of Neurosurgery by microsurgery (clipping) and endovascular treatment (coiling), through the joint efforts of a team of highly skilled neurosurgeons.

RESULTS

Mixed treatment has been imposed by the complications we were presented with, resulting from either of the two surgical methods employed.

CONCLUSIONS

Although endovascular surgery is considered a newer treatment method, favored by many practitioners, and preferred by patients, there are situations where open surgery is still required. There are certain situations were using one of the surgical methods fails and a complementary procedure is required for a secure and successful treatment. The cases reported here will demonstrate the utility of combining the two procedures.

Safety and effect of pipeline flex embolization device for complex unruptured intracranial aneurysms

To investigate the safety and short-term effect of Pipeline Flex devices in the treatment of complex unruptured intracranial aneurysms, a retrospective study was performed for patients with complex unruptured intracranial aneurysms who were treated with the Pipeline Flex embolization device (PED Flex device) combined with or without coiling. The clinical, endovascular, and follow-up data were analyzed. One hundred and thirty-one patients with 159 complex unruptured cerebral aneurysms were treated with the PED Flex device, with 144 Flex devices deployed. Periprocedural complications occurred in four patients, resulting in the complication rate of 3.1%, including ischemic complications in three patients (2.3%) and hemorrhagic complication in one (0.8%). At discharge, the mRS was 0 in 101 (77.1%) patients, 1 in 25 (19.1%), 2 in four (3.1%), and 4 in one (0.8%), with the good prognosis rate (mRS 0-2) of 99.2%. Clinical follow-up was carried out in 87 (66.4%) patients 3-42 months after the procedure, with the mRS of 0 in 78 (89.7%), 1 in five (5.7%), 2 in three (3.4%), and 4 in one (1.1%). No significant (P = 0.16) difference existed in the mRS at discharge compared with that at clinical follow-up. Angiographic follow-up was performed in 61 (46.7%) patients with 80 (50.3%) aneurysms at 3-40 months, with the OKM grade of D in 57 (71.3%) aneurysms, C in eight (10%), and B in 15 (18.8%). Asymptomatic instent stenosis occurred in four patients (6.6%). In conclusion: The treatment of complex intracranial aneurysms with the Pipeline Flex embolization device may be safe and effective, with a high complete occlusion rate, a decreased complication rate, and a good prognosis rate at medium follow-up.

Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series

Background and purpose

The treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk.

Materials and methods

Retrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization/occlusion for complex intracranial aneurysms from 1/2016 to 6/2022.

Results

Ten patients (4 male [40%]; mean age 51.9 ± 8.7 years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9/10 (90%), were ruptured and 8/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7/10 [70%]) and extracranial-to-intracranial (EC-IC; 3/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm/vessel sacrifice in 9/10 patients) were performed early after surgery (0.7 ± 1.5 days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4-72 months). Good outcomes (defined as a Glasgow Outcomes Scale ≥4 and modified Rankin Scale ≤2) occurred in 6/10 patients (60%).

Conclusion

A variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.

Unsuccessful bypass and trapping of a giant dolichoectatic thrombotic basilar trunk aneurysm. What went wrong?

Aneurysms of the basilar trunk represent an exceptional challenge to the neurosurgeon, due to high mortality and surgical morbidity. We present a 69-year-old man with a giant dolichoectatic thrombotic basilar trunk aneurysm (BTA), who underwent right orbitozygomatic craniotomy, posterior cerebral artery (PCA) to right middle cerebral artery (MCA) bypass and trapping of the BTA. Unfortunately, patient died after surgery due to multiple foci of intraparenchymal haemorrhage and thrombosis of a short segment proximal to aneurysm trapped and his body was donated to the hospital, giving us the unique opportunity to compare intraoperative details with anatomical dissection findings, according to our previously published cadaveric neurosurgical research. The great and unique opportunity of this reported case, to learn by watching and watching again what has been done during surgery, to observe small vessels and brainstem perforators and to look at stiches of the bypass, SVG and the position of the clips, permits to refine the theoretical and practical skills for the treatment of complex aneurysms such as that one reported.

[Mathematical modeling of high-flow extra-intracranial bypass in the treatment of a complex cerebral aneurysm]

BACKGROUND

Intracranial aneurysms (IAs) pose a high risk of spontaneous subarachnoid hemorrhage. In the most complex cases, the only way to exclude the aneurysm from the circulation is to perform a high-flow extracranial-to-intracranial bypass, thus creating a new bloodstream. This avoids severe ischemic complications; however, it requires careful consideration of individual anatomy and hemodynamic parameters. Computational fluid dynamics (CFD) can be of great help in planning such a surgery by creating 3D patient-specific models of cerebral circulation.

OBJECTIVE

Assessment of the perspectivity of high-flow extracranial-to-intracranial bypass planning using computational modeling.

MATERIAL AND METHODS

In this research work, we have applied the CFD methods to a patient with a giant thrombosed IA of the internal carotid artery (ICA). Preoperative CTA images and Gamma Multivox workstation were used to create a 3D model with current geometry and three additional models: Normal anatomy (no IA), Occlusion (with ligated ICA), Virtual bypass (with bypass and ligated ICA). The postoperative data were also available. Boundary conditions were based on PC-MRI measurements. Calculation of hemodynamics was conducted with a finite element package ANSYS Workbench 19.

RESULTS

The results demonstrated an increase in the blood flow on the affected side by more than 70% after the virtual surgery and uniformity of flow distribution between the affected and contralateral sides, indicating that the treatment is likely to be efficient. Later, postoperative data confirmed that.

CONCLUSION

The study showed that virtual preoperative CFD modeling could significantly simplify and improve surgical planning.

Third Nerve Palsy Due to Intracranial Aneurysms and Recovery after Endovascular Coiling

INTRODUCTION

The modality of treatment of third nerve palsy (TNP) associated with intracranial aneurysms remains controversial. While treatment varies with the location of the aneurysm, microsurgical clipping of PComm aneurysms has generally been the traditional choice, with endovascular coiling emerging as a reasonable alternative.

METHODS

Patients with TNP due to an intracranial aneurysm who subsequently underwent treatment at a mid-sized Canadian neurosurgical center over a 15-year period (2003-2018) were examined.

RESULTS

A total of 616 intracranial aneurysms in 538 patients were treated; the majority underwent endovascular coiling with only 24 patients treated with surgical clipping. Only 37 patients (6.9%) presented with either a partial or complete TNP and underwent endovascular embolization; of these, 17 presented with a SAH secondary to intracranial aneurysm rupture. Aneurysms associated with TNP included PComm (64.9%), terminal ICA (29.7%), proximal MCA (2.7%), and basilar tip (2.7%) aneurysms. In general, smaller aneurysms and earlier treatment were provided for patients for ruptured aneurysms with a shorter mean interval to TNP recovery. In the endovascularly treated cohort initially presenting with TNP, seven presented with a complete TNP and the remaining were partial TNPs. TNP resolved completely in 20 patients (55.1%) and partially in 10 patients (27.0%). Neither time to coiling nor SAH at presentation were significantly associated with the recovery status of TNP.

CONCLUSION

Endovascular coil embolization is a viable treatment modality for patients presenting with an associated cranial nerve palsy.

The evolution of intracranial aneurysm treatment techniques and future directions

Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.

HYBRID MICROSURGICAL AND ENDOVASCULAR APPROACH IN THE TREATMENT OF MULTIPLE CEREBRAL ANEURYSMS: AN ILLUSTRATIVE CASE SERIES IN CORRELATION WITH LITERATURE DATA

Contemporary cerebral aneurysm treatment has advanced due to the expansion of microsurgical and endovascular techniques having different advantages and restraints. However, some aneurysms cannot be effectively treated by a single method alone due to their specific anatomy, location, complexity, and/or multiplicity. Subsequently, multiple aneurysms sometimes necessitate a hybrid strategy integrating both methods. The study aims were to discuss indications, possibilities, and challenges of a hybrid strategy in the decision making and treatment of multiple intracranial aneurysms. A single-institution illustrative case series of multiple intracranial aneurysm patients treated by a hybrid approach was analyzed and management outcome discussed and correlated with literature data. Following the treatment, both patients from our case series recovered well, having complete and stable aneurysmal occlusion with no relapse and no postoperative procedure-related complications or long-lasting neurological symptoms. In conclusion, a hybrid approach is advised as a treatment option for multiple cerebral aneurysms when a single modality is insufficient to bring satisfactory results. It may be a suitable and safe addition to an assortment of treatments pledging clinical improvement and enabling positive management outcome in patients with ruptured and non-ruptured multiple cerebral aneurysms.

Anterior Temporal Approach for Clipping Posterior-Projecting Supraclinoid Carotid Artery Aneurysms: A More Lateral Corridor to Better Visualize the Aneurysm Neck and Related Branches

BACKGROUND

Direct visualization of the aneurysm neck and its related branches during microsurgical clipping of supraclinoid internal carotid artery (SICA) aneurysms using a standard pterional approach may be difficult, especially when aneurysms are posteriorly projected. We evaluated the efficacy and safety of an anterior temporal approach for clipping posterior-projecting SICA aneurysms.

METHODS

Between December 2017 and March 2020, 26 patients with posterior-projecting SICA aneurysms who received microsurgical clipping via an anterior temporal approach were retrospectively reviewed. The percentage of complete aneurysm obliteration, intraoperative visualization, and preservation of related branches were evaluated.

RESULTS

Aneurysm locations were the posterior communicating artery (PCoA) (internal carotid artery [ICA]-PCoA) in 22 patients (84.6%), the anterior choroidal artery (AChA) (ICA-AChA) in 3 patients (11.5%), and both locations in 1 patient (3.9%). Complete aneurysm obliteration was achieved in all patients. For ICA-PCoA aneurysms in which the PCoA was preoperatively identified, the artery was intraoperatively identified in all cases and preserved 100% after surgery. For ICA-AChA aneurysms, AChAs were intraoperatively identified and preserved in all cases after surgery. Procedural-related infarction was 8.7% for ICA-PCoA aneurysms and 7.7% for all SICA aneurysms. Transient oculomotor nerve palsy was found in 2 patients (7.7%). No postoperative temporal contusion was detected. A good outcome at 3 months after surgery was achieved in 90% of patients for good clinical-grade subarachnoid hemorrhage and unruptured cases.

CONCLUSIONS

The anterior temporal approach is safe and effective for clipping SICA aneurysms with posterior projection, with a high preservation rate of the related branches.

Usefulness of Hybrid Surgery Combining CEA and CAS for Carotid Artery Stenosis with a Large Amount of Vulnerable Plaque

Objective

For carotid artery stenosis with a large amount of vulnerable plaque in a wide range, we performed a hybrid surgery combining carotid endarterectomy (CEA) and carotid artery stenting (CAS), and report the results of treatment.

Methods

Surgical treatment for carotid artery stenosis in 216 patients was performed between January 2016 and June 2018. Of these, 15 patients were treated in a hybrid operating room because both CEA and CAS were judged to be risky. We treated these patients with preparation of stenting for remote lesions far from the CEA arterial incision. The perioperative treatment results were retrospectively examined.

Results

Of the 15 patients treated in a hybrid operating room, 10 were stented after CEA. All these cases were treated by retrograde stent placement in the proximal common carotid artery (CCA). Treatment was completed in all patients, and no cerebral infarction, myocardial infarction, or death was observed in the perioperative period. There were no cases of additional neurological events during the follow-up period, but asymptomatic restenosis was observed in one patient.

Conclusion

Hybrid surgery combining CEA and CAS was considered to be an effective treatment for carotid artery stenosis with a large amount of vulnerable plaque.

Application of hybrid operating rooms for clipping large or giant intracranial carotid-ophthalmic aneurysms

BACKGROUND

A hybrid operating room (Hybrid-OR) is a surgical theatre that combines a conventional operating room with advanced medical imaging devices. There are still plenty of limitations when endovascular treatment or microsurgical treatment is used individually to treat large or giant carotid-ophthalmic aneurysms.

AIM

To explore and summarize the technical features and effectiveness of the application of a Hybrid-OR in managing major intracranial carotid-ophthalmic aneurysms.

METHODS

The Department of Neurosurgery treated 12 cases of large or giant intracranial carotid-ophthalmic aneurysms between March 2013 and December 2019 in a Hybrid-OR. All cases were treated with clipping and parent vessel reconstruction.

RESULTS

With the assistance of the Hybrid-OR, the rate of incomplete intraoperative aneurysm clipping decreased from 25% (3/12) to 0%, while the rate of vessel stenosis decreased from 16.7% (2/12) to 8.35% (1/12). In terms of thromboembolic events, ischemic infarction complication occurred in only one patient, and none of the patients experienced embolic infarction complications. All 12 patients were followed for an average of 3 years, and no aneurysms recurred. The postoperative recovery was evaluated with the modified Rankin Scale (mRS): 11 patients showed no symptoms (mRS = 0), 1 patient showed slight disability (mRS 1-2), and none of the patients had severe disability (mRS = 5) or died (mRS = 6).

CONCLUSION

The Hybrid-OR provides new ideas for the surgical clipping of large or giant intracranial carotid-ophthalmic aneurysms and decreases the rate of intraoperative vessel stenosis and unsuccessful clipping.

Perioperative Ischemic Stroke in Unruptured Intracranial Aneurysm Surgical or Endovascular Therapy

Background: Ischemic stroke among hospitalized patients who underwent surgical or endovascular therapies for unruptured intracranial aneurysms (IAs) has not been previously examined in nationally representative samples.

Objectives: The purpose of this study is to compare the occurrence and in-hospital outcomes (nonroutine discharge, length of stay) of perioperative ischemic stroke among hospitalized patients diagnosed with unruptured IA across treatment selection [surgical clipping, endovascular coiling, stent- or balloon-assisted coiling (SAC or BAC), combined clipping and coiling].

Methods: A cross-sectional study was conducted using 23,053 hospital discharge records from the 2002-2012 Nationwide Inpatient Sample (NIS). Rates, β coefficients, and odds ratios (ORs) with their 95% confidence intervals (CIs) were calculated accounting for survey design complexity, patient- and hospital-level confounders.

Results: Ischemic stroke rate was 6.9% [surgical clipping (4.3%), endovascular coiling (8.1%), BAC or SAC (1.9%), and combined techniques (4.2%)]. Multivariable logistic regression models suggested that compared to patients undergoing surgical clipping alone, those undergoing SAC or BAC were less likely to be diagnosed with ischemic stroke (adjusted OR=0.34, 95% CI: 0.14, 0.85). Compared to clipping, endovascular techniques resulted in fewer nonroutine dispositions and shorter hospitalizations, whereas combined techniques resulted in longer hospitalizations. Differences in hospitalization outcomes between treatment types were only affected by ischemic stroke when comparing coiling to clipping.

Conclusions: Perioperative ischemic stroke rate among patients with unruptured IA may be less among those undergoing SAC or BAC as compared to those undergoing surgical clipping alone. Improved in-hospital outcomes among coiling versus clipping recipients may depend on ischemic stroke diagnosis.

Multiple ruptured cerebral aneurysms at the National Hospital of the Kyrgyz Republic between 2008 and 2014: a departmental summary

Despite the rapid progress of vascular neurosurgery with the development of microsurgical and endovascular techniques, the optimal strategy for surgical treatment of multiple cerebral aneurysms has not yet been developed. The indications for choosing one-stage or multi-stage surgery remain unsolved. This is a summary of the departmental routine reports at the Clinic of Neurosurgery, National Hospital of the Kyrgyz Republic. Subjects were 235 patients (124 males and 111 females) with ruptured multiple cerebral aneurysms admitted to the hospital. Their ages ranged from 18 to 72 years (average and standard deviation: 44.3 ± 9.7 years) and 48.1% of patients had 3 or more aneurysms. Among aneurysms that ruptured, 20.4% were a giant aneurysm (>25 mm) and 43.0% of patients had grade IV or V according to the Hunt-Hess Scale. Among 228 patients who were operated on, 147 were treated by single-stage surgery and 81 by multi-stage surgery. Microsurgical operations with clipping of the aneurysm neck were performed in 141 (61.8%) patients (97 single-stage and 44 multi-stage), while 40 (17.5%) patients (16 single-stage and 24 multi-stage) were operated using the endovascular technique. The number of palliative surgeries (trapping, ligation of the internal carotid artery, and reinforcement of the aneurysm wall) was significantly less (p=0.011) with multi-stage surgery (9 out of 81 cases, 11.1%) than with single-stage surgery (38 out of 147 cases, 25.9%). Among 600 aneurysms, 583 (97.2%) were treated by either single-stage surgery (n=296) or multi-stage surgery (n=287). There were no differences in prognosis at discharge between single-stage and multi-stage surgery.

[Successful combination treatment of giant bicameral fusiform partially thrombosed vertebral artery aneurysm at 12-year-old patient (practical case and literature review)]

Giant cerebral aneurysms are diagnosed more often in children than in adults. Treatment of giant aneurysms is carried out both by endovascular and microsurgical methods. Literature information on combination of microsurgical and endovascular operations of cerebral aneurysms at children is little. A clinical case of the combined treatment of a giant bicameral fusiform partially thrombosed aneurysm of the right vertebral artery at a 12-year-old patient and a literature review on this topic are presented. The patient underwent several complex neurosurgical interventions during two operations: 1) microsurgery including revascularization of the right posterior lower cerebellar artery, thrombectomy and trapping of the larger chamber of fusiform aneurysm of the right vertebral artery, and 2) endovascular, which consists in the installation of redirecting stent from the left vertebral artery to main artery. The uniqueness of the case which we presented lies in the fact that the tactics of stage combined treatment for a complex aneurysm at child was originally planned and successfully implemented. The treatment allowed to ensure a complete shutdown of aneurysm and to exclude postoperative cerebral complications.

Mid A1 blister aneurysm presenting with subarachnoid hemorrhage: Case report and review

Blister aneurysms are uncommon and difficult-to-treat lesions. They are a substantial cause of morbidity and mortality when encountered. Here, we report a blister aneurysm of the mid A1 segment of the anterior cerebral artery presenting with diffuse basal subarachnoid hemorrhage (SAH). The aneurysm was treated by surgical clipping of the parent vessel. Postoperatively, there was no filling of the parent vessel or aneurysm. A treatment algorithm including direct surgical repair and flow diversion for ruptured blister aneurysms is described. A high level of suspicion should be maintained in the setting of angiographic-negative SAH with an asymmetrically diffuse pattern.

Surgical Reconstruction to Allow Endovascular Access for Flow Diversion of Giant Cavernous Aneurysm: A Combined Approach

Giant cavernous aneurysms of the internal carotid artery (ICA) are challenging lesions associated with high surgical morbidity. Prior to the past several years, these were treated by surgical reconstruction, proximal ligation, or stent-assisted coiling techniques. Flow diversion has become the standard of care for these lesions, providing a high rate of obliteration with a much better safety profile. However, flow diverters rely upon a navigable vasculature and, usually, a tri-axial support system. Cases in which such access is difficult require unique approaches to combine the strengths of both surgical and endovascular therapy. A woman with a giant cavernous ICA aneurysm and an ophthalmic artery aneurysm presented for treatment, but access was challenging due to cervical ICA tortuosity and pseudoaneurysms. We elected a staged, combined approach with surgical reconstruction of the cervical ICA followed by flow diverter placement for the intracranial aneurysms. Our case features an “outside-the-box” approach that synergistically applied both microsurgical and endovascular techniques to treat a challenging pathology. Classic microsurgical techniques remain important in cases that are refractory or not amenable to endovascular therapy alone.

Microsurgical Clipping of a Giant Middle Cerebral Artery Aneurysm with Successful Postoperative Endovascular Mechanical Thrombectomy for Emergent Treatment of Large Vessel Occlusion

BACKGROUND

Giant intracranial aneurysms (>25 mm) are uncommon. These lesions typically manifest clinically due to mass effect, acute hemorrhage, or thromboembolic events. To minimize the risk of poor clinical outcome, detailed operative planning and a consideration of all neurosurgical and endovascular techniques are essential before proceeding with microsurgical clipping of ruptured giant aneurysms.

CASE DESCRIPTION

We describe a case involving a 15-year-old male with a ruptured giant middle cerebral artery aneurysm treated with microsurgical clipping. After clip application, poor distal flow was demonstrated intraoperatively, and emergent angiography demonstrated an M1 occlusion with thrombus. A salvage procedure using endovascular mechanical thrombectomy reestablished distal flow resulting in a good neurologic outcome.

CONCLUSIONS

To our knowledge, this is the first case report to describe microsurgical clipping of an aneurysm followed by successful postoperative endovascular mechanical thrombectomy.

Vertebral artery-posterior inferior cerebellar artery convergence aneurysms treated by endovascular or surgical treatment: Mid- and long-term outcome

INTRODUCTION

Management of vertebral artery-posterior inferior cerebellar artery convergence (VA-PICA) saccular aneurysms requires a specialized neurovascular team. The objective is to preserve the functional outcome while performing a complete and reliable long-term exclusion of the aneurysm.

OBJECTIVE

The aim of our study was to evaluate the outcome of patients with VA-PICA saccular aneurysms after treatment.

MATERIALS AND METHODS

This was a retrospective series of 21 consecutive patients with a VA-PICA saccular aneurysm treated between 2000 and 2012 at our institution. Treatment option (endovascular or microsurgical) was decided for each patient following a multidisciplinary discussion.

RESULTS

Twenty-one patients were treated for a VA-PICA saccular aneurysm including 16 for a ruptured aneurysm and 5 for an asymptomatic aneurysm. Among all patients, 11 underwent endovascular treatment and 10 had microsurgical treatment. Our results showed a major aneurysm recurrence after endovascular treatment in 3 patients that required a further endovascular treatment in 2 cases. These 3 major recurrences occurred after treatment of a ruptured aneurysm when the initial angiography demonstrated the origin of the PICA at the neck of the aneurysm. After microsurgery, angiography showed a remnant neck in 2 patients including 1 treated by further endovascular procedure.

CONCLUSION

VA-PICA aneurysms are rare and require multidisciplinary management. Microsurgical treatment should be discussed when the PICA originates from the aneurysmal neck, particularly in patients with a ruptured small aneurysm, in order to obtain a reliable and long-term exclusion of the aneurysm.

Intraoperative Angiography Using Portable Fluoroscopy Unit in the Treatment of Vascular Malformation

Intraoperative angiography (IOA) is employed for the treatment of the complicated cases in neurological surgery. The IOA is usually performed with OEC portable digital subtraction angiography (DSA) unit. We are performing IOA with portable fluoroscopy unit with simple DSA function and report its usefulness on neurosurgical treatment. IOA or hybrid treatment with mobile fluoroscopy system was performed for 9 cases [cerebral arteriovenous malformation (AVM), 3; cranial dural arteriovenous fistula (AVF), 2; and spinal AVM/AVF, 4]. Thus, ex vivo analysis was performed comparing image quality of portable fluoroscopy unit and conventional DSA system. Although the resolution of portable fluoroscopy unit is not so high compared to conventional DSA system, the existence of the vascular lesions such as cerebral aneurysm, cerebral AVM, and spinal dural AVF were detected. The operation of portable fluoroscopy unit was simple and no special assistance was required. The complication related to the catheterization or IOA did not occur. IOA with portable fluoroscopy unit was useful for the identification of vascular lesion and has advantage on the cost benefit.

Combined treatment for complex intracranial aneurysm

Complex aneurysms often cannot be completely excluded by a single approaches. Today successful treatment of these lesions requires a combination between microsurgical and endovascular techniques. Planning of combined treatment require a very good understanding of aneurysm anatomy and a close collaboration between neurosurgeon and neuroendovascular interventionist. Endovascular coiling can usually be used as early treatment for a partially aneurysm occlusion including the ruptured area and followed by definitive clipping. On the other hand microsurgical clipping also can be used as first treatment for complex aneurysm neck reconstruction, allowing successful secondary placement of coils inside the remnant aneurysm sac

Endovascular and surgical options for ruptured middle cerebral artery aneurysms: review of the literature

Middle cerebral artery (MCA) aneurysms are common entities, and those of the bifurcation are the most frequently encountered sublocation of MCA aneurysm. MCA bifurcation (MBIF) aneurysms commonly present with subarachnoid hemorrhage (SAH), are devastating, and are often lethal. At the present time, the treatment of ruptured MBIF aneurysms entails either endovascular or open microneurosurgical methods to permanently secure the aneurysm(s). The purpose of this report is to review the current available data regarding the relative superiority of endovascular versus open microneurosurgical clipping for the treatment of ruptured middle cerebral artery bifurcation aneurysms.

Surgical outcome of primary clipping for anterior circulation aneurysms of size 2 centimeters or larger

BACKGROUND

Aneurysms of the anterior circulation larger than 2cm have a complex relationship to the anterior skull base, requiring a multi-modality management approach. This retrospective study of 54 patients with such aneurysms who underwent clipping between 2001 and 2012 analyzes clinical and surgical data, aneurysm characteristics and correlates them with respect to the Glasgow outcome score at follow-up and immediate post-operative clinical status.

METHODS

Patients with an outcome score of 5 or 4 were categorized as "good", while those with score 3-1 were "poor". Fisher's exact test and paired T-test (p<0.5) were used to test statistical significance for discrete and continuous variables respectively.

RESULTS

44 (81.4%) patients had a good outcome. Patients with non-ophthalmic/paraclinoid aneurysms had significantly lower incidence of adverse intra-operative events (p=0.035). Patients older than 50 years (p=0.045), with adverse intra-operative events (p=0.015) and post-operative infarction (p<0.001) had a poor outcome compared to those younger than 50 years age and those without adverse intra-operative events or infarctions. The grouped age variable had maximum influence on patient outcome. Location and size of aneurysm did not have an overall impact on surgical outcome. There were 4 mortalities.

CONCLUSIONS

Primary clipping of proximal non-cavernous aneurysms on the internal carotid artery is associated with adverse intra-operative events. A multi-modality treatment approach in these aneurysms should be individualized, more so in patients older than 50 years.