Combined Microsurgical, Endovascular, and Endoscopic Approach to the Treatment of a Giant Vertebrobasilar Aneurysm

Combined Transcranial and Endonasal Approach for Clipping of a Partially Thrombosed Giant Aneurysm of the Lower Basilar Artery

The conventional transcranial approach for treating lower basilar artery aneurysms is challenging because the deep and narrow surgical field limits surgical maneuvering for clipping. We report a case of a 77-year-old female who presented with right hemiparesis caused by a partially thrombosed giant aneurysm in her lower basilar artery. We performed neck clipping and thrombus debulking using a combined transcranial and endonasal approach. This approach enabled us to secure the parent artery from the endonasal side, which is difficult to achieve with the transcranial approach alone. It also allowed for early thrombus removal, thereby widening the surgical field on the transcranial side. Additionally it compensated for the transcranial blind spot by observing the clip tip from the endonasal side. After surgery, the patient required 3 months of rehabilitation for residual right hemiparesis before being discharged. Follow-up imaging revealed a reduction in the size of the partially thrombosed aneurysm. To our knowledge, this is the first report of a combined transcranial and endonasal approach for the treatment of a basilar artery aneurysm. For lower basilar artery aneurysms, this combined approach may offer advantages in achieving safe parent artery control, thrombus debulking, and neck clipping.

Additive Manufacturing for Personalized Skull Base Reconstruction in Endoscopic Transclival Surgery: A Proof-of-Concept Study

BACKGROUND

Endoscopic transnasal transclival intradural surgery is limited by a high postoperative cerebrospinal fluid leak rate. The aim of this study was to investigate the role of three-dimensional printing to create a personalized, rigid scaffold for clival reconstruction.

METHODS

Two different types of clivectomy were performed in 5 specimens with the aid of neuronavigation, and 11 clival reconstructions were simulated. They were repaired with polylactide, three-dimensional-printed scaffolds that were manually designed in a computer-aided environment based either on the real or on the predicted defect. Scaffolds were printed with a fused filament fabrication technique and different offsets. They were positioned and fixed either following the gasket seal technique or with screws. Postdissection radiological evaluation of scaffold position was performed in all cases. In 3 specimens, the cerebrospinal fluid leak pressure point was measured immediately after reconstruction.

RESULTS

The production process took approximately 30 hours. The designed scaffolds were satisfactory when no offset was added. Wings were added during the design to allow for screw positioning, but broke in 30% of cases. Radiological assessment documented maximal accuracy of scaffold positioning when the scaffold was created on the real defect; accuracy was satisfactory when the predicted clivectomy was performed under neuronavigation guidance. The cerebrospinal fluid leak pressure point was significantly higher when the scaffold was fixed with screws compared with the gasket technique.

CONCLUSIONS

In this preclinical setting, additive manufacturing allows the creation of customized scaffolds that are effective in reconstructing even large and geometrically complex clival defects.

Intracranial Fusiform and Circumferential Aneurysms of the Main Trunk: Therapeutic Dilemmas and Prospects

Intracranial fusiform and circumferential aneurysms (IFCAs), especially those located on the main trunk, are uncommon and difficult to manage. Currently, literature focused on IFCAs on the main trunk of cerebral arteries is lacking. The treatment of IFCAs is still under debate. Therefore, in this review, we further explore the treatment of this complicated entity. In addition, we also present some interesting cases. Based on the literature review and our experience, we found that IFCAs are often located in the vertebrobasilar system and that ruptured or large symptomatic IFCAs are associated with increased mortality and higher rebleeding rates. The treatment strategies for IFCAs can be classified as deconstructive and reconstructive methods via open surgery and/or endovascular treatment (EVT). Currently, EVT is a popular method and the main therapeutic choice. In particular, flow diversion has revolutionized the treatment of IFCAs. Parent artery occlusion (PAO) with or without revascularization may still be considered a suitable choice. Complex IFCAs that cannot be resolved by EVT can also be treated via open surgery with or without extracranial–intracranial bypass. Targeted embolization for the weak points of IFCAs is a temporary or palliative choice that is rarely used. In summary, despite complications, both surgical treatment and EVT are effective options for appropriately selected cases. Due to the development of endovascular implants, EVT will have better prospects in the future.