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García-Pérez D, Panero I, Eiriz C, Moreno LM, Munarriz PM, Paredes I, Lagares A, Alén JF. Delayed extensive brain edema caused by the growth of a giant basilar apex aneurysm treated with basilar artery obliteration: a case report. BMC Neurol 2020; 20:232. [PMID: 32505180 PMCID: PMC7275367 DOI: 10.1186/s12883-020-01819-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Partially thrombosed giant aneurysms at the basilar apex (BA) artery are challenging lesions with a poor prognosis if left untreated. Here we describe a rare case of extensive brain edema after growth of a surgically treated and thrombosed giant basilar apex aneurysm. Case presentation We performed a proximal surgical basilar artery occlusion on a 64-year-old female with a partially thrombosed giant BA aneurysm. MRI showed no ischemic lesions but showed marked edema adjacent to the aneurysm. She had a good recovery, but 3 months after surgical occlusion, her gait deteriorated together with urinary incontinence and worsening right hemiparesis. MRI showed that the aneurysm had grown and developed intramural hemorrhage, which caused extensive brain edema and obstructive hydrocephalus. She was treated by a ventriculoperitoneal shunt placement. Follow-up MRI showed progressive brain edema resolution, complete thrombosis of the lumen and shrinkage of the aneurysm. At 5 years follow-up the patient had an excellent functional outcome. Conclusions Delayed growth of a surgically treated and thrombosed giant aneurysm from wall dissection demonstrates that discontinuity with the initial parent artery does not always prevent progressive enlargement. The development of transmural vascular connections between the intraluminal thrombus and adventitial neovascularization by the vasa vasorum on the apex of the BA seems to be a key event in delayed aneurysm growth. Extensive brain edema might translate an inflammatory edematous reaction to an abrupt enlargement of the aneurysm.
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Affiliation(s)
- Daniel García-Pérez
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain.
| | - Irene Panero
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Carla Eiriz
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Luis Miguel Moreno
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - José F Alén
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
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Uchino A, Maurer P, Brara H, Numaguchi Y. Balloon Migration into a Giant Carotid Aneurysm after Parent Artery Occlusion Using Detachable Balloons. Interv Neuroradiol 2016; 4:323-8. [DOI: 10.1177/159101999800400410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/1998] [Accepted: 09/20/1998] [Indexed: 11/15/2022] Open
Abstract
We treated a 70-year-old man with a giant paraophthalmic region aneurysm of the right internal carotid artery using the parent artery occlusion technique with three detachable balloons. Initially, the patient did well, but migration of the distal balloon into the aneurysm was detected seven months later. This report suggests that initial parent artery occlusion using balloons will not always induce permanent thrombosis of a large aneurysm, because the occlusion and thrombosis is strictly dependant on the position of the balloons that are used, and adjunct use of coils may be indicated.
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Affiliation(s)
| | - P.K. Maurer
- Dept. of Neurosurgery, University of Rochester Medical Center; Rochester, NY
| | - H.S. Brara
- Dept. of Neurosurgery, University of Rochester Medical Center; Rochester, NY
| | - Y. Numaguchi
- Dept. of Diagnostic Radiology, University of Rochester Medical Center; Rochester, NY
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Raychev R, Tateshima S, Vinuela F, Sayre J, Jahan R, Gonzalez N, Szeder V, Duckwiler G. Predictors of thrombotic complications and mass effect exacerbation after pipeline embolization: The significance of adenosine diphosphate inhibition, fluoroscopy time, and aneurysm size. Interv Neuroradiol 2015; 22:34-41. [PMID: 26537850 DOI: 10.1177/1591019915609125] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/03/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The mechanisms leading to delayed rupture, distal emboli and intraparenchymal hemorrhage in relation to pipeline embolization device (PED) placement remain debatable and poorly understood. The aim of this study was to identify clinical and procedural predictors of these perioperative complications. METHODS We conducted a retrospective review of consecutive patients who underwent PED placement. We utilized a non-commercial platelet aggregation method measuring adenosine diphosphate (ADP)% inhibition for evaluation of clopidogrel response. To our knowledge, this is the first study to test ADP in neurovascular procedures. Multivariable regression analysis was used to identify the strongest predictor of three separate outcomes: (1) thrombotic complications, (2) hemorrhagic complications, and (3) aneurysm mass effect exacerbation RESULTS Permanent complication-related morbidity and mortality at 3 months was 6% (3/48). No specific predictors of hemorrhagic complications were identified. In the univariate analysis, the strongest predictors of thrombotic complications were: ADP% inhibition<49 (p=0.01), aneurysm size (p=0.04) and fluoroscopy time (p=0.002). In the final multivariate analysis, among all baseline variables, fluoroscopy time exceeding 52 min was the only factor associated with thrombotic complications (p=0.007). Aneurysm size≥18 mm was the single predictor of mass effect exacerbation (p=0.039). CONCLUSIONS Procedural complexity, reflected by fluoroscopy time, is the strongest predictor of thrombotic complications in this study. ADP% inhibition is a reliable method of testing clopidogrel response in neurovascular procedures and values of <50% may predict thrombotic complications. Interval mass effect exacerbation after PED placement may be anticipated in large aneurysms exceeding 18 mm.
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Sekhar LN, Tariq F, Mai JC, Kim LJ, Ghodke B, Hallam DK, Bulsara KR. Unyielding Progress. Neurosurgery 2012; 59:6-21. [DOI: 10.1227/neu.0b013e3182698b75] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Miyamoto S, Funaki T, Iihara K, Takahashi JC. Successful obliteration and shrinkage of giant partially thrombosed basilar artery aneurysms through a tailored flow reduction strategy with bypass surgery. J Neurosurg 2011; 114:1028-36. [DOI: 10.3171/2010.9.jns10448] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors evaluated the efficacy of a new flow reduction strategy for giant partially thrombosed upper basilar artery (BA) aneurysms, for which proximal parent artery occlusion is not always effective.
Methods
Eight consecutive patients with severely symptomatic, partially thrombosed, giant upper BA aneurysms were treated with a tailored flow reduction strategy, or received conservative therapies. The flow reduction strategy comprised isolation of several branches from the upper BA at their origins with bypasses in addition to parent artery occlusion.
Results
The median follow-up period of all 8 patients was 15.0 months (range 4–31 months). In 6 patients treated with flow reduction, the mean decrease in residual blood lumen was −10.7 mm (95% CI −19.7 to −1.7 mm; p = 0.029) and the mean decrease in diameter of the aneurysms was −11.5 mm (95% CI −25.1 to 2.1 mm; p = 0.082). Complete or virtually complete thrombosis was achieved in all but 1 aneurysm (83%) and shrinkage was observed in 4 (67%). In those in whom complete or virtually complete thrombosis was achieved, significant shrinkage of the aneurysm was observed (mean decrease in diameter −14.8 mm; 95% CI −28.8 to −0.8 mm; p = 0.043). Improvement or stabilization of symptoms occurred in 67% of the patients who received flow reduction treatment. Both patients who received conservative treatment had unfavorable outcomes.
Conclusions
The flow reduction strategy is effective at promoting complete thrombosis of the aneurysm. This strategy can also induce shrinkage of the aneurysm if successful thrombosis is achieved. Although the neurological outcome of the treatment appears favorable considering its intractable nature, further study of the treatment is necessary to confirm its clinical efficacy and safety.
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Affiliation(s)
- Susumu Miyamoto
- 1Departments of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, and
| | | | - Koji Iihara
- 2National Cardiovascular Center, Suita, Osaka, Japan
| | - Jun C. Takahashi
- 1Departments of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, and
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Clarençon F, Bonneville F, Boch AL, Lejean L, Biondi A. Parent artery occlusion is not obsolete in giant aneurysms of the ICA. Experience with very-long-term follow-up. Neuroradiology 2010; 53:973-82. [PMID: 21152912 DOI: 10.1007/s00234-010-0800-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 11/03/2010] [Indexed: 11/29/2022]
Affiliation(s)
- Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Paris VI University, 47 Bd de l'Hôpital, 75013, Paris, France.
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Dehdashti AR, Thines L, Willinsky RA, Tymianski M. Symptomatic enlargement of an occluded giant carotido-ophthalmic aneurysm after endovascular treatment: the vasa vasorum theory. Acta Neurochir (Wien) 2009; 151:1153-8. [PMID: 19343269 DOI: 10.1007/s00701-009-0270-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2008] [Accepted: 12/12/2008] [Indexed: 11/28/2022]
Abstract
We describe a patient with a symptomatic left giant carotido-ophthalmic aneurysm who initially underwent coil embolization with subtotal obliteration. The patient's symptoms were initially stable, but 1 year later, she presented with a rapidly progressive contralateral visual deficit. Although angiogram showed a stable neck remnant, MR confirmed aneurysm growth and showed a new peripheral hematoma in the wall of the thrombosed aneurysm. Surgical exploration was undertaken, and even after trapping and intra-aneurysmal thrombectomy, constant bleeding was observed from the wall of the thrombosed aneurysm consistent with the vasa vasorum. Bleeding stopped after cauterization and partial resection of the aneurysm dome, and the aneurysm was clipped. The patient's recent visual deficit markedly improved, and the angiogram did not reveal any residue. Giant aneurysms may continue to grow due to a hypertrophic vasa vasorum and subadventitial hemorrhages. Surgery should be considered if complete thrombosis of the aneurysm does not alleviate patient's symptoms.
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MESH Headings
- Carotid Artery, Internal/diagnostic imaging
- Carotid Artery, Internal/pathology
- Carotid Artery, Internal/surgery
- Carotid Artery, Internal, Dissection/diagnostic imaging
- Carotid Artery, Internal, Dissection/pathology
- Carotid Artery, Internal, Dissection/therapy
- Cerebral Angiography
- Disease Progression
- Embolization, Therapeutic/adverse effects
- Female
- Hematoma/diagnostic imaging
- Hematoma/pathology
- Hematoma/therapy
- Humans
- Intracranial Aneurysm/diagnostic imaging
- Intracranial Aneurysm/pathology
- Intracranial Aneurysm/therapy
- Middle Aged
- Ophthalmic Artery/diagnostic imaging
- Ophthalmic Artery/pathology
- Ophthalmic Artery/physiopathology
- Postoperative Complications/etiology
- Postoperative Complications/pathology
- Postoperative Complications/physiopathology
- Reoperation
- Secondary Prevention
- Surgical Instruments
- Treatment Outcome
- Vasa Vasorum/pathology
- Vasa Vasorum/physiopathology
- Vision, Low/etiology
- Vision, Low/physiopathology
- Vision, Low/therapy
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Affiliation(s)
- Amir R Dehdashti
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada.
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Takahashi JC, Murao K, Iihara K, Nonaka Y, Taki J, Nagata I, Miyamoto S. Successful “blind-alley” formation with bypass surgery for a partially thrombosed giant basilar artery tip aneurysm refractory to upper basilar artery obliteration. J Neurosurg 2007; 106:484-7. [PMID: 17367074 DOI: 10.3171/jns.2007.106.3.484] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓Partially thrombosed giant aneurysms that are located at the basilar artery (BA) bifurcation and are not amenable to clip application are among the most challenging lesions for neurosurgeons. They compress vital structures such as the brainstem and the thalamus, and the prognosis is extremely poor when they are left untreated. Although obliteration of the upper BA is a promising approach for these aneurysms, some lesions are refractory to this treatment, and effective additional strategies have not been clearly established. The authors report a case treated by placement of clips in the unilateral posterior cerebral artery (PCA) and posterior communicating artery as well as by superficial temporal artery–PCA bypass after unsuccessful upper BA obliteration. Complete thrombosis and dramatic shrinkage of the aneurysm were obtained.
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Affiliation(s)
- Jun C Takahashi
- Department of Neurosurgery, National Cardiovascular Center, Suita-City, Osaka, Japan.
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Gonzalez NR, Duckwiler G, Jahan R, Murayama Y, Viñuela F. Challenges in the Endovascular Treatment of Giant Intracranial Aneurysms. Neurosurgery 2006; 59:S113-24; discussion S3-13. [PMID: 17053594 DOI: 10.1227/01.neu.0000237559.93852.f1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Giant intracranial aneurysms present unique therapeutic intricacies. The purpose of this study was to evaluate the anatomic and hemodynamic characteristics of these lesions and the current endovascular and combined surgical and endovascular techniques available for their treatment.
METHODS:
A review of the literature and the personal experiences of the authors with endovascular treatment of giant aneurysms are presented. This review included anatomic and hemodynamic features and analysis of the diverse endovascular techniques that have been reported for the management of these aneurysms.
RESULTS:
Anatomic features that create particular challenges in the therapeutic approach of giant aneurysms include size, shape (saccular, fusiform, serpentine), neck dimensions, branch involvement, intraluminal thrombosis, and location. Hemodynamic characteristics that affect endovascular treatment are lateral or terminal aneurysm type of flow and embolic material placement (inflow versus outflow aneurysmal region). The current endovascular therapeutic approaches include parent artery occlusion, trapping, endosaccular embolization with or without adjunctive techniques such as balloon-assisted or stent placement, and combined surgical and endovascular approaches, mainly with surgical revascularization and endovascular occlusion.
CONCLUSION:
Although there are a wide variety of endovascular therapeutic options for the treatment of giant intracranial aneurysms, none of the current techniques is completely successful and free of complications in the management of these complex lesions. A detailed and individualized analysis of each case in conjunction with sufficient understanding of the anatomy and hemodynamics of a particular aneurysm should guide the therapeutic decision. Further research advances will assist in elucidating the factors predisposing to genesis, progression, and aggressive clinical manifestations of these giant lesions.
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Affiliation(s)
- Nestor R Gonzalez
- Division of Neurosurgery, University of California, Los Angeles Medical Center, Los Angeles, California 90095-7039, USA.
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KANO T, HIRAYAMA T, KATAYAMA Y. Unruptured Thrombosed Giant Aneurysm: Strategy for Treatment. ACTA ACUST UNITED AC 2003. [DOI: 10.2335/scs.31.344] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Piepgras DG, Khurana VG, Nichols DA. Occult rupture of a giant vertebral artery aneurysm following proximal occlusion and intrasaccular thrombosis. Case report. J Neurosurg 2001; 95:132-7. [PMID: 11453384 DOI: 10.3171/jns.2001.95.1.0132] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe a unique clinicopathological phenomenon in a patient who presented with an unruptured giant vertebral artery aneurysm and who underwent endovascular proximal occlusion of the parent artery followed, several days later, by surgical trapping of the aneurysm after delayed subarachnoid hemorrhage (SAH). The intraoperative finding of a thrombus extruding from the wall of the aneurysm at a site remote from the origin of the SAH underscores the possibility that occult rupture of an aneurysmal sac can occur in patients with thrombosed giant aneurysms.
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Affiliation(s)
- D G Piepgras
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Gewirtz RJ, Awad IA. Giant aneurysms of the anterior circle of Willis: management outcome of open microsurgical treatment. SURGICAL NEUROLOGY 1996; 45:409-20; discussion 420-1. [PMID: 8629240 DOI: 10.1016/0090-3019(95)00437-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is no uniform agreement to date regarding the optimal management of giant aneurysms (GAs) of the anterior circle of Willis. Endovascular therapeutic techniques have yielded unacceptable rates of aneurysm growth and recanalization (endosaccular) or high rates of complications (distal parent vessel occlusion). Despite size, frequent thrombosis and calcification (incollapsibility), and splaying of parent vessels, these aneurysms are readily amenable to direct surgical exposure and control of parent vessels intracranially. Published series have not considered these lesions separately and have often reflected a mixture of management strategies for these and other GAs. METHODS Thirty-eight consecutive patients with symptomatic GAs of the anterior circle of Willis were managed by the senior author over a 7-year period. Twenty-six of these patients (68%) presented with subarachnoid hemorrhage (SAH). Temporary occlusion was performed under a protocol to enhance brain protection. Direct clip reconstruction or trapping was used in all instances, with intraoperative angiographic control. Revascularization procedures and suture vascular reconstructions were not used in any case. RESULTS All patients were considered for direct microsurgical treatment. One patient refused surgery, and two patients were deemed a prohibitive medical risk. Thirty-five patients were treated surgically with complete obliteration of the aneurysm in 34 cases (97%), and patency of all parent arteries in 30 cases (86%). Overall mortality was 6% in the surgical cohort, with good or excellent clinical outcome in 71%. Mortality and poor outcome occurred exclusively in the setting of recent hemorrhage. CONCLUSIONS The results are compared to the natural history of these lesions and to outcome (safety and effectiveness) of currently available endovascular techniques. This experience supports direct microsurgical intervention as the primary therapeutic modality for these lesions.
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Affiliation(s)
- R J Gewirtz
- Department of Neurological Surgery, Cleveland Clinic Foundation, Ohio, USA
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Crecimiento rápido de un aneurisma encefálico sin cirugía previa. Neurocirugia (Astur) 1995. [DOI: 10.1016/s1130-1473(95)70773-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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