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.

T- configuration stent assisted coiling treatment of a complex wide-necked basilar tip aneurysm

The advancement of intracranial stent technology and techniques has extended the applications of endovascular coiling methods for complex intracranial aneurysms. Coiling of wide-necked and complex bifurcation aneurysms usually requires double stent implantation. Different configurations for double stent-assisted coil embolization have been described. The T-configuration stent-assisted coiling procedure was recently described as a feasible, effective, and relatively safe endovascular technique used to treat wide-necked complex bifurcation aneurysms. In this article, we present the successful management of a complex wide-neck basilar tip aneurysm using a slightly modified T-configuration stent-assisted coiling technique.

Particular management strategy for intraprocedural coil migration during endovascular treatment of intracranial aneurysm

Migration of coils represents one of the most challenging complications of endovascular management of cerebral aneurysms with a potentially catastrophic result. In this article, we present the successful management of a coil migration during the endovascular occlusion of an anterior communicating artery aneurysm. A stent fixation technique was used with good vascular repermeabilisation. The reported frequency, risk factors and management strategies are also discussed.

The stent-assisted coil-jailing technique for very small intracranial aneurysm treatment

The stent-assisted coil-jailing technique was initially introduced as an effective and secure method in the treatment of large wide-necked intracranial aneurysms. Later on, this technique has proved its efficiency in the safety and optimal treatment of very small aneurysms. In this article, we will present the successful treatment of a very small middle cerebral artery aneurysm using the stent-assisted coil-jailing technique and review the current trends in this type of treatment.

Management of a double basilar tip aneurysm

Complex basilar tip aneurysms are still challenging to secure with coils or stent-assisted coiling. Double aneurysms at the basilar bifurcation and the basilar artery-superior cerebellar artery are a rare particular situation that usually requires more appropriate treatment. This case reports details of our experience with a double basilar tip aneurysm treated in two steps by coiling repair and stent-assisted coiling.

The 3D printed models technology for the management of intracranial aneurysms

Management of intracranial aneurysms is still a therapeutic challenge, especially in cases of complex lesions. Thus, the improvement of the study and intervention planning possibilities correlated with the access to continuous professional training based on simulation and clinical diversity represent optimal conditions for the efficient solution of this pathology. The development of three-dimensional printing technology offers a new opportunity in the modern treatment of intracranial aneurysms. The aim of this study is to present some aspects related to the materials and methods of manufacturing simulation models of individual 3D printed aneurysms and their influence in the optimal management of these lesions.

Mechanical thrombectomy techniques for acute ischemic stroke

Mechanical thrombectomy technique was introduced as an effective and secure method in acute ischemic stroke patients suffering from intracranial large vessel occlusion (LVO). In this article, we will review the main mechanical thrombectomy techniques and current trends in this type of treatment for acute ischemic stroke.

Current applications of 3d printing in neurosurgery

Medical implications of 3-dimensional (3D) printing technology have progressed with increasingly used especially in surgical fields. 3D printing techniques are practical and anatomically accurate methods of producing patient specific models for medical education, surgical planning, training and simulation, and implants production for the assessment and treatment of neurosurgical diseases. This article presents the main directions of 3D printing models application in neurosurgery.

Preliminary study of thrombogenicity induced by the nanoparticle surface coating of intracranial stents

Endovascular treatment of intracranial aneurysms with intracranial stents was proven to be clinically safe and effective, but is still associated with a risk of thromboembolic complications. Stent thrombosis could be a sever complication associated with specific stent surface coatings and designs. Standardized in vitro tests for investigation of thrombogenicity induced by different nanomaterials were used as the basic method in carrying out the present study. Therefore, the aim of this study was to evaluate the thrombogenicity of three different nanomaterials (ZnO, TiO2 si Fe3O4) possible used as surface coating for intracranial stents. This study is based on a procedure for in vitro analyses of plasma coagulation time. To measure the plasma coagulation time, platelet-poor plasma from human whole blood was in vitro exposed to nanoparticles and analysed in prothrombin (PT) and activated partial thromboplastin (APTT).

Our experience with a single stage bilateral approach for treatment of bilateral middle cerebral artery aneurysms

Surgical management of bilateral middle cerebral artery (MCA) aneurysms is particular challenging clinical situation. For these patients various options of surgical treatment are available as unilateral approach, single stage bilateral craniotomy or two stage bilateral craniotomy. We report our experience with a case of bilateral MCA aneurysm which was managed by single stage bilateral pterional craniotomy.

Endovascular management of recurrent anterior communicating aneurysm previously embolized. Case presentation

Although endovascular coiling treatment has been widely accepted as the method of choice for intracranial aneurysms, concerns about its durability are still discussed. Attention was largely focused on aneurysm recurrence after coil occlusion with possible unfavourable evolution to a new bleeding episode. We present our experience of a patient with a ruptured anterior communicating artery aneurysm previously treated by endovascular coil embolization that presented over a 4-year period for aneurysm recurrence.

Management of spinal dural arteriovenouse fistula

Spinal dural arteriovenous fistulas are rare vascular lesions whose management is still at high interest between specialists. If microsurgical treatment is still considered as treatment of choice for SDAVFs, endovascular treatment is increasingly grow in interest with the development of endovascular techniques and new embolization materials. In this article we made a short discussion about the spinal dural arteriovenous fistulae on aspects related to anatomy, pathophysiology, diagnosis and treatment, with some general conclusions.

Angiography procedure and endovascular treatment Retrospective analysis in Neurosurgery Department of “Prof. Dr. N. Oblu” Clinic Emergency Hospital Iasi

A retrospective analysis of the cases admitted, investigated and treated in “Prof. Dr. N. Oblu” Clinic Emergency Hospital from the beginning of activity in the angiography laboratory from 2008 to June 2017.

Microsurgical clipping of giant thrombosed aneurysm

Treatment of giant thrombosed aneurysm is still a challenge for most of neurosurgeons. We present our experience of a patient with a thrombosed giant middle cerebral artery aneurysm manifesting as headache that developed over a 15-year period. Magnetic resonance (MR), computed tomographic angiography (CTA), and digital subtraction angiography (DSA) have clarified the vascular lesion and directed the therapeutic protocol. An open craniotomy with direct clipping and thrombectomy was performed successfully with an uneventful postoperative course.

Intra-arterial nimodipine for the treatment of vasospasm due to aneurysmal subarachnoid hemorrhage

The cerebral vasospasm is still considered the most devastating complication for the patients with aneurysmal subarachnoid haemorrhage. The aim of this study was to evaluate the efficiency of intra-arterial nimodipine administration in cerebral vasospasm diminutions and outcome of the patients.

Associated intracranial lesions: meningioma and anterior communicating aneurysm

Asymptomatic associated intracranial lesions are more frequently diagnosed with the utilization of high-resolution imaging. The occurrence of brain tumors together with intracranial aneurysms are a very rare situation. This coexistence is still a diagnostic and therapeutic challenge as no consensus concerning imaging that may cover both type of intracranial lesion was established. We report a case of a 62 years old patient with a meningioma and aneurysm treated in one session with good outcome.

The superior ophthalmic vein approach for the treatment of carotid-cavernous fistulas: our first experience

Complex cavernous sinus fistulae (CCF) are still a technical challenge to neurovascular team. The most commonly performed treatment consists in endovascular embolization of the lesion through an arterial or venous approach. Not always these conventional routes are feasible, requiring alternative routes. We report a case of a 44-year-old woman with a complex indirect (Barrow D) carotid cavernous sinus fistula treated by two interventional sessions that imposing a retrograde direct transvenous approach via the superior ophthalmic vein.

Extracranial internal carotid artery aneurysm treated by combined endovascular - microsurgical techniques

Extracranial internal carotid artery aneurysms are rare lesions that still represent a challenge from diagnosis and treatment point of view. Giant complex aneurysms of extracranial internal carotid artery are usually completely excluded by surgical approaches. We present a case of a patient with an extracranial internal carotid artery aneurysm treated by a combined treatment, along with a short review of this pathology.

Ruptured fusiform aneurysm of the proximal anterior cerebral artery in young patient - case report

A 16-year old male presented with a ruptured aneurysm of the proximal segment of the anterior cerebral artery, with symptoms like sudden headache. Paraclinical explorations revealed a fusiform aneurysm of the right A1 segment. The optimal treatment used was the microsurgical one via right pterional approach. The aneurysm was associated with a saccular pseudoneurysm at the proximal part. The saccular portion was clipped and the fusiform one was wrapped with muscle. The postoperative evolution was favorable, without neurological deficits.

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

Acute intracerebral haemorrhage complication after carotid artery stenting

Intracranial hemorrhage following carotid artery stenting is a recognized rare complication but with potentially devastating evolution. Reports of acute cerebral hemorrhage injury following internal carotid artery (ICA) angioplasty are few, and usually were discussed in correlation with hyperperfusion syndrome. In this article we present a patient who experienced a fatal ipsilateral basal ganglia hemorrhage within 10 minutes after carotid angioplasty and stent placement

Temporo-sylvian anastomosis and aneurysm clipping in a case of left M1 aneurysm with progressive evolution after initial embolization; Case report

A giant unrupted middle cerebral artery aneurysm partially thrombosed, previously endovascularly treated after a mild right hemiparesis remitted. After 12 months, in routine check we discovered a reperfusion of the aneurysm and decide ECIC bypass and clipping, with a good outcome