Surgical management of giant aneurysms

Predictors of the Effects of Flow Diversion in Very Large and Giant Aneurysms

BACKGROUND AND PURPOSE

The treatment paradigm for very large and giant aneurysms has recently changed to flow diversion, in light of the results of the Pipeline for Uncoilable or Failed Aneurysms trial. However, the effects of flow diversion were definitely unknown. We explored this topic and identified the predictors of such effects.

MATERIALS AND METHODS

We retrospectively reviewed 51 patients with unruptured aneurysms admitted to our institution for flow diversion between February 2014 and August 2019. Patients were categorized into an effect group (no filling or remnant entry) and a no-effect group (subtotal or total filling). We evaluated the aneurysm size and shape, incorporation vessel, parent artery stenosis and curvature, stagnation of contrast medium within the aneurysm, use of balloon angioplasty, and intra-aneurysm thrombus as potential predictors of the effects of flow diversion.

RESULTS

The effect group comprised 34 patients (66.7%, 34/51; no filling, 35.3%, 18/51; and remnant entry, 31.4%, 16/51). The no-effect group comprised 17 patients (33.3%, 17/51; subtotal filling, 29.4%, 15/51; and total filling, 3.9%, 2/51). An incorporation vessel and balloon angioplasty were independent risk factors for the no-effect group in multivariate logistic regression analyses (OR = 0.13 and 0.05; 95% confidence intervals, 0.02-0.62 and 0.00-0.32; P values, .021 and .004, respectively).

CONCLUSIONS

Flow diversion is effective for very large and giant aneurysms, but the outcomes require further improvement. The results of this study show that an incorporated vessel and excessive balloon angioplasty might compromise flow diversion. This finding can help improve the outcomes of flow diversion.

Early and long-term outcome of surgically treated giant internal carotid artery aneurysms--comparison with smaller aneurysms

BACKGROUND

Internal carotid artery (ICA) is predominant localization of giant intracranial aneurysms (GIAs). The rupture of GIA is supposed to be related to higher risk of poor clinical outcome. Although endovascular techniques are still being developed, they seem to be unsatisfactory in the mean of GIAs.

METHODS

Included in the retrospective analysis were 78 giant and 250 smaller surgically treated ICA aneurysms. Exclusion criteria were multiple and blood blister-like aneurysms. Neurological deficit on admission, clinical and radiological presentation, gender, age, segment of ICA, surgical methods, accessory techniques and complications were analyzed. Death rate and short- and long-term outcome of giant aneurysms were compared with smaller aneurysms and risk factors for mortality, unfavorable short- and long-term outcome were determined.

RESULTS

There was no difference in general and surgical complications between ICA aneurysm size groups, as well as in occurrence of newly diagnosed neurological deficit after the operation. There were similar mortality rates, proportion of unfavorable outcome, and low health related quality of life for giant and smaller aneurysms. A 12.2% death rate for all ICA aneurysms was achieved. Trapping method as well as Fisher grades 3 and 4 increased mortality risk in the smaller aneurysm group. No significant factors were related to an unfavorable outcome in the ruptured giant aneurysm group. Patients older than 65, Hunt-Hess grades 4 and 5, Fisher grade 4, and newly diagnosed deficit after operation were connected with unfavorable outcome in the ruptured smaller aneurysm group. Newly diagnosed neurological deficit was also an unfavorable outcome risk factor in both giant and smaller ICA unruptured aneurysms. No difference was noted in long-term health-related quality of life between the giant and smaller ICA groups. Higher age and presence of concomitant disease were independent factors affecting quality of life, although obtained data were incomplete.

CONCLUSIONS

The study breaks the stereotype of unfavorable giant ICA aneurysms treatment results. Mortality rate, short- and long-term outcome after the operation of giant and smaller ICA aneurysms are similar. Higher age, patients' condition at admission, and the amount of extravasated blood and trapping method are poor prognostic factors in patients with smaller ICA aneurysm.

Endovascular treatment for complex intracranial aneurysms: lessons learnt in five patients

We describe our experience in five cases of endovascular treatment for complex intracranial aneurysms. The senior author (ZW) has clinical experience with more than 6000 cases of brain aneurysms treated with endovascular techniques. Multiple endovascular therapies, such as treatment with Onyx, parent vessel occlusion, stent-assisted coiling, covered stent, can be used in an attempt to provide a solution to various clinical dilemmas associated with the management of these difficult lesions. Here, we focus on the latest five patients and lessons learnt in endovascular techniques for complex intracranial aneurysms.On the basis of the knowledge obtained over the years, multimodality endovascular techniques should be re-evaluated to improve patient outcomes.

Surgical treatment of complex intracranial aneurysms

Complex intracranial aneurysms include not only giant aneurysms (classically larger than 25 mm in diameter) but also smaller aneurysms in difficult locations of the human brain and cranial base. Such lesions are associated with a high risk of subarachnoid hemorrhage and progressive neurological deterioration or death caused by mass effect or stroke. In the past 30 years, the understanding and treatment of these lesions have progressed considerably. Nonetheless, a deep understanding of these lesions, including the nuances of blood flow dynamics, natural history, and potential therapeutic options, is necessary when one is managing such aneurysms. The senior author's (RFS) clinical experience with more than 5000 brain aneurysms was reviewed. We also reviewed recent literature on the surgical management of giant cerebral aneurysms, focusing on the most up-to-date microsurgical techniques. Combinations of therapies can be used in an attempt to provide a solution to various clinical dilemmas associated with the management of these difficult lesions. The synergistic association between microsurgery and endovascular modalities is also illustrated. On the basis of the knowledge obtained over the years, indirect and multimodality approaches are becoming more common as neurosurgeons strive to improve patient outcomes.