Carotid artery sacrifice for unclippable and uncoilable aneurysms: endovascular occlusion vs common carotid artery ligation

Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association

Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.

Proximal Internal Carotid Artery Occlusion and Extracranial-Intracranial Bypass for Treatment of Fusiform and Giant Internal Carotid Artery Aneurysms

OBJECTIVE

To discuss the treatment of intracranial fusiform and giant internal carotid artery (ICA) aneurysms via revascularization based on our institutional experience.

METHODS

An institutional review board-approved retrospective analysis was performed of patients with unruptured fusiform and giant intracranial ICA aneurysms treated from November 1991 to May 2020. All patients were evaluated for extracranial-intracranial (EC-IC) bypass and ICA occlusion.

RESULTS

Thirty-eight patients were identified. Initially, patients failing preoperative balloon test occlusion were treated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and concurrent proximal ICA ligation. We then treated them with STA-MCA bypass, followed by staged balloon test occlusion, and, if they passed, endovascular ICA coil occlusion. We treat all surgical medically uncomplicated patients with double-barrel STA-MCA bypass and concurrent proximal ICA ligation. The mean length of follow-up was 99 months. Symptom stability or improvement was noted in 85% of patients. Bypass graft patency was 92.1%, and all surviving patients had patent bypasses at their last angiogram. Aneurysm occlusion was complete in 90.9% of patients completing proximal ICA ligation. Three patients experienced ischemic complications and 4 patients experienced hemorrhagic complications.

CONCLUSIONS

Not all fusiform intracranial ICA aneurysms require intervention, except when life-threatening rupture risk is high or symptomatic management is necessary to preserve function and quality of life. EC-IC bypass can augment the safety of proximal ICA occlusion. The rate of complete aneurysm occlusion with this treatment is 90.9%, and long-term bypass graft-related complications are rare. Perioperative stroke is a major risk, and continued evolution of treatment is required.

Cefaléia e disfunção de nervos cranianos secundários a aneurisma de artéria carótida: relato de dois casos e revisão da literatura

O seio cavernoso é um plexo venoso localizado na base do crânio. Várias patologias, como processos inflamatórios, aneurismáticos ou metastáticos, podem afetar esse plexo. A síndrome do seio cavernoso ocorre quando os nervos estão envolvidos nessa região (nervos cranianos III, IV, VI e divisões do V). Essas relações anatômicas explicam que a diplopia e a dor são os sintomas iniciais mais comuns nesses pacientes. Os aneurismas carotídeos cavernosos (CCAs) representam 2% a 9% dos aneurismas. Relatamos dois pacientes que apresentaram síndrome do seio cavernoso decorrente de aneurismas da artéria carótida. O reconhecimento da etiologia desse quadro clínico diferenciado é fundamental para evitar complicações e direcionar a melhor conduta para cada paciente.

Combined standard bypass and parent artery occlusion for management of giant and complex internal carotid artery aneurysms

BACKGROUND

Complex aneurysms do not have a standard protocol for treatment. In this study, we investigate the safety and efficacy of microsurgical revascularization combined with parent artery occlusion (PAO) in giant and complex internal carotid artery (ICA) aneurysms.

METHODS

Between 1998 and 2017, 41 patients with 47 giant and complex ICA aneurysms were treated by an a priori planned combined treatment strategy. Clinical and radiological outcomes were stratified according to mRS and Raymond classification. Bypass patency was assessed. Median follow-up time was 3.9 years.

RESULTS

After successful STA-MCA bypass, staged endovascular (n=37) or surgical (n=1) PAO was executed in 38 patients following a negative balloon occlusion test. Intolerance to PAO led to stent/coil treatments in two patients. Perioperative bypass patency was confirmed in 100% of completed STA-MCA bypass procedures. Long-term overall bypass patency rate was 99%. Raymond 1 occlusion and good outcome were achieved in 95% and 97% (mRS 0-2) of cases, respectively. No procedure-related mortality was encountered. Eighty-four percent of patients with preoperative cranial nerve compression syndromes improved during follow-up.

CONCLUSIONS

The combined approach of STA-MCA bypass surgery followed by parent artery occlusion achieves high aneurysm occlusion and low morbidity rates in the management of giant and complex ICA aneurysms. This combined indirect approach represents a viable alternative to flow diversion in patients with cranial nerve compression syndromes or matricidal aneurysms, and may serve as a backup strategy in cases of peri-interventional complications or lack of suitable endovascular access.

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.

Comaneci device-assisted embolization of wide-necked carotid aneurysms with an unfavorable ratio

Background

Endovascular treatment is the technique of choice for most intracranial aneurysms. However, the treatment of morphologically complex wide-necked aneurysms with an unfavorable anatomy is still a therapeutic challenge.

The purpose of the study is to describe the initial experience with the Comaneci embolization assist device for the treatment of wide-necked aneurysms with an unfavorable ratio for direct embolization.

Methods

We report a retrospective single-center analysis taken from a prospective database of consecutive aneurysms of the anterior circulation treated using the Comaneci device in the period from March 2017 to March 2019.

Results

Eighteen aneurysms were collected from 16 patients (9 women and 7 men) treated using the Comaneci device. The mean age was 48.4 years (range 36–81). Twelve patients had SAH, three were incidental aneurysms and one had compressive symptoms. A complete asymptomatic occlusion rate of 88.8% was obtained. The major complication rate was 5.55%.

Conclusion

The Comaneci embolization assist device is a safe, effective option for endovascular treatment of complex aneurysms with an unfavorable ratio.

Cavernous carotid artery large aneurysm treated with a new flow diverter – Xcalibur aneurysm occlusion device (AOD)

We report a case of an unruptured, symptomatic, large right cavernous internal carotid artery aneurysm successfully treated with a new balloon-expandable flow diverter – Xcalibur Aneurysm Occlusion Device (AOD). Follow up imaging performed at six months demonstrated complete exclusion of the aneurysm and regression in dimensions, resulting in resolution of mass effect and clinical improvement.

Parent Vessel Occlusion via the Balloon-Assisted, Dual Microcatheter Technique

Endovascular parent vessel sacrifice is an established technique used to treat vascular pathology and tumor infiltration of blood vessels. In high-flow vessels, such as the carotid artery or vertebral artery, distal coil migration and embolization are concerns. A method to mitigate this risk would improve the safety profile of the procedure. Five patients undergoing parent vessel sacrifice were retrospectively identified (from June 2018 to May 2019) for the purpose of illustrating this high-flow parent vessel occlusion technique. The technique utilizes a proximal dual-lumen balloon microcatheter inflated for blood flow arrest. The balloon-assisted, dual microcatheter technique is useful for occlusion of high-flow parent arteries. Because it utilizes both flow arrest and a tethered coil backstop, precise occlusion of a vessel can be achieved.

A Patient with a Large Aneurysm Complicated by Stenosis of the Internal Carotid Artery Distal to the Aneurysm in Whom Treatment Using a Pipeline Flex Was Performed

Objective

We report a case of in-stent stenosis as a complication at 6 months after the deployment of Pipeline Flex. This case necessitated retreatment for parent artery occlusion.

Case Presentation

A 55-year-old woman with right-side visual disorder was referred to our hospital for the deployment of Pipeline Flex. Cerebral digital subtraction angiography (DSA) demonstrated a large right-side paraclinoid aneurysm in combination with severe internal carotid artery (ICA) stenosis just beyond the aneurysm. We deployed Pipeline Flex under general anesthesia. After deployment, we performed angioplasty through the Pipeline. Six months after deployment, this patient exhibited exacerbation of visual disorder. Follow-up DSA revealed in-stent stenosis at 6 months after the deployment of Pipeline Flex. Therefore, we performed parent artery occlusion. Right-side visual disorder was improved in this patient.

Conclusion

If Pipeline is deployed for patients with ICA stenosis just beyond an aneurysm, we need to be aware of in-stent stenosis after deployment.

Opening of unusual vascular collaterals leads to early recanalization of a giant intracavernous carotid artery aneurysm following common carotid artery occlusion: A Case report and literature review

Background:

Parent artery occlusion (PAO) with or without bypass surgery is a feasible treatment for large intracavernous carotid artery (ICCA) aneurysms. The ideal occlusion site (internal or common carotid artery [CCA]) and ischemic complications after PAO have received special attention since the description of the technique. Unfrequently, some patients can also develop unusual external carotid artery-internal carotid artery collateral pathways distal to the ligation site that can explain the failure to aneurysm size reduction.

Case Description:

We describe a rare case of delayed refilling of a large ICCA aneurysm partially thrombosed which early recanalized after surgical ligation of the cervical CCA through an unusual collateral pathway.

Conclusion:

Based on our experience, we recommend periodic long-term follow-up neuroimaging, especially in those cases where potential collateral branches have not been clearly identified in the preoperative studies.

Blind-Alley Formation and Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for the Treatment of Unclippable Vertebral Artery Aneurysms with Posterior Inferior Cerebellar Artery Involvement

BACKGROUND AND IMPORTANCE

Unclippable vertebral artery aneurysms (UVAs) are difficult to treat with direct clipping, especially in cases involving the origin of the posterior inferior cerebellar artery (PICA). Bypass with trapping is the common procedure used for these conditions. The authors used the blind-alley formation technique, which is a simpler method than trapping and can avoid some complications.

OBJECTIVES

To report 7 cases of UVA with PICA involvement treated with blind-alley formation and occipital artery (OA)-PICA bypass as well as their surgical outcomes and complications and to describe the operative techniques.

RESULTS

Seven patients with UVA and PICA involvement underwent OA-PICA bypass and blind-alley formation (occlusions of the PICA origin and vertebral artery proximal to the aneurysm). Vertebral artery dissecting aneurysms and fusiform atherosclerotic vertebral artery aneurysms were detected in 6 patients and 1 patient, respectively. All patients presented with subarachnoid hemorrhage, and 71.4% of them were classified into the poor-grade group. Good bypass patency and complete aneurysm obliteration were achieved in all cases. Six aneurysms (85.7%) were completely obliterated according to computed tomography angiography performed immediately postoperatively. Another aneurysm was 50% and 100% thrombosed immediately and at 7 days after the operation, respectively. Surgical complications were found in 1 patient (14.3%) who had postoperative diparesis with dysphagia. Three patients (42.9%) achieved a Glasgow Outcome Score of 4 or 5 one month after the operation.

CONCLUSIONS

Blind-alley formation and OA-PICA bypass are simple, safe, and effective for the treatment of patients with UVA with PICA involvement.

Early and midterm results of treatment of giant internal carotid artery paraclinoid aneurysms with trapping and flow diverters

BACKGROUND

Flow diverter devices (FDD) carry risks of postoperative complications when treating aneurysms with wide necks, stenosis, and severe tortuosity of the parent vessel. In this study, we evaluated early and midterm results for the treatment of giant paraclinoid aneurysms managed by trapping and endovascular deployment of FDD.

METHODS

Medical records were analyzed for patients with giant paraclinoid aneurysms treated between July 2008 and December 2017 at National Centre for Neurosurgery with either a flow diverter or by trapping the aneurysm with or without extracranial-intracranial (EC-IC) bypass surgery. We recorded age, sex, clinical presentation, treatment modality, morbidity, and mortality. Clinical outcomes were assessed using a modified Rankin scale (mRS).

RESULTS

Among 29 consecutive patients, 13 were treated with FDD, and 16 patients were managed by trapping the aneurysm, where 7/16 cases had preliminary EC-IC bypass. Of 16 trapping patients, six were trapped endovascularly and ten were trapped surgically. During the follow-up period (mean 33 months, range 6-96), total exclusion of the aneurysm from the circulation was observed 100% of aneurysms in the trapping group and 84.6% in the FDD group (P = 0.192). Early postoperative morbidity was observed in three (23%) cases in the FDD group, and four (25%) in trapping group (P = 0.525). The FDD group had one (7.7%) fatal complication due to stent occlusion and severe ischemic stroke after three months postoperatively, despite appropriate antiplatelet therapy. There were no mortalities in the trapping group (P = 0.149). The rate of mRS 0-2 did not differ significantly across groups at discharge (81.3% vs. 69.2%; P = 0.667), and all patients had mRS 0-2 at follow-up (P = 1.000).

CONCLUSIONS

FDD deployment for giant paraclinoid aneurysms results in comparable angiographic and clinical outcomes to aneurysm trapping. Despite implementation of modern endovascular treatment methods, aneurysm trapping remains a valuable treatment option in carefully selected patients with giant paraclinoid aneurysms.

Treatment of a Fusiform Anterior Cerebral Artery Aneurysm by Remodeling the Circle of Willis with Flow Diversion: A Novel Technical Note

BACKGROUND

Fusiform aneurysms are challenging lesions to manage given their poorly understood natural history and lack of a distinct neck. Historically, they have been treated surgically but endovascular management has recently evolved as a viable alternative. In this case, we describe a novel flow diversion technique for treatment of a fusiform anterior cerebral artery (ACA) aneurysm by jailing the compromised parent vessel obtaining endovascular aneurysm trapping.

METHODS

A 25-year-old man underwent brain magnetic resonance imaging and magnetic resonance angiography for workup of a headache, which revealed a fusiform right ACA A1 segment aneurysm. The patient subsequently underwent catheter digital subtraction angiography, which confirmed a 9 × 5.5 mm fusiform right ACA A1 segment aneurysm. The patient elected to undergo endovascular treatment. A Pipeline Embolization Device (Medtronic, Dublin, Ireland) was placed from the right anterior cerebral artery to the right middle cerebral artery, thereby jailing the right ACA A1 segment.

RESULTS

At 6-month follow-up, the patient was asymptomatic and his headache had resolved. An angiogram was obtained, showing patency of the Pipeline Embolization Device and near complete occlusion of the right ACA A1 segment. The right ACA A2 segment remained patent via collateral flow through the anterior communicating artery. These findings were confirmed on magnetic resonance imaging. The patient remained asymptomatic for the duration of the follow-up.

CONCLUSIONS

This case illustrates the efficacy of the Pipeline Embolization Device for treatment of a fusiform anterior circulation aneurysm via remodeling the circle of Willis.

Interval growth in an ICA bifurcation aneurysm treated with balloon occlusion, and possible contribution of vasa vasorum hypertrophy

We present a rare case of an ICA aneurysm recurrence despite treatment with ICA balloon occlusion. There was evidence of ICA recanalization bypassing the balloons on a catheter angiogram follow-up 1 year post-procedure. Although initially stable in size, at 5 years after the original procedure, the aneurysm demonstrated evidence of enlargement and on angiography there was further enlargement of the recanalized ICA around the occluding balloons. We postulate that this has been caused by increasing antegrade flow through hypertrophied vasa vasorum in response to persistently increased demand for blood flow by the ipsilateral hemisphere; this indirectly may have also contributed to some extent to the aneurysm enlargement.

Does Universal Bypass before Carotid Artery Occlusion Obviate the Need for Balloon Test Occlusion: Personal Experience with Extracranial-Intracranial Bypass in 23 Patients

Aim

Carotid artery ligation carries a potential risk of ischemic complications even in patients with good collaterals and adequate cross-circulation. Preoperative assessment through balloon test occlusion (BTO) is technically challenging and not feasible in all patients. We analyze our experience with universal bypass without performing detailed cerebrovascular reserve (CVR) studies in 23 patients before carotid artery ligation.

Patients and Methods

This was a retrospective analysis of the case records of 23 patients who underwent cervical carotid artery ligation for various indications since January 2009.

Results

The study included 21 patients with cavernous carotid aneurysms, one patient with a large fusiform petrous carotid aneurysm, and one patient with recurrent glomus jugulare encasing the cervical internal carotid artery. The initial 12 patients underwent preoperative BTO with hypotensive challenge. All patients underwent a bypass procedure followed by carotid artery ligation irrespective of the BTO findings. Patients who successfully completed a BTO underwent a low-flow superficial temporal artery to middle cerebral artery bypass. A high-flow extracranial-intracranial bypass using a saphenous vein graft from external carotid artery to middle cerebral artery was done in all patients who either failed the BTO or did not undergo BTO. We had two operative mortalities and one poor outcome. All the other patients had a good recovery with a Glasgow outcome score of 5 at the last follow-up. Graft patency rates were 81.1% in both the low-flow and high-flow groups.

Conclusion

Universal high-flow bypass is safe, effective, and should be preferred in all patients before carotid artery ligation. It obviates the need for detailed CVR assessment, especially in centers with limited resources.

Endovascular plug for internal carotid artery occlusion in the management of a cavernous pseudoaneurysm with bifrontal subdural empyema: technical note

The authors demonstrate the use of an endovascular plug in securing a carotid artery pseudoaneurysm in an emergent setting requiring craniotomy for a concurrent subdural empyema. They describe the case of a 14-year-old boy with sinusitis and bifrontal subdural empyema who underwent transsphenoidal exploration at an outside hospital. An injury to the right cavernous segment of the ICA caused torrential epistaxis. Bleeding was successfully controlled by inflating a Foley balloon catheter within the sphenoid sinus, and the patient was transferred to the authors' institution. Emergent angiography showed a dissection of the right cavernous carotid artery, with a large pseudoaneurysm projecting into the sphenoid sinus at the site of arterial injury. The right internal carotid artery was obliterated using pushable coils distally and an endovascular plug proximally. The endovascular plug enabled the authors to successfully exclude the pseudoaneurysm from the circulation. The patient subsequently underwent an emergent bifrontal craniotomy for evacuation of a left frontotemporal subdural empyema and exenteration of both frontal sinuses. He made a complete neurological recovery. Endovascular large-vessel sacrifice, obviating the need for numerous coils and antiplatelet therapy, has a role in the setting of selected acute neurosurgical emergencies necessitating craniotomy. The endovascular plug is a useful adjunct in such circumstances as the device can be deployed rapidly, safely, and effectively.

Successful endovascular treatment for thrombosed giant aneurysm of the V1 segment of the vertebral artery: A case report

Thrombosed giant aneurysm of the V1 segment of the vertebral artery is rare, and there is controversy regarding the optimal method of treatment in this portion. Here, we report a thrombosed giant aneurysm of the V1 segment of the vertebral artery with a good clinical course with endovascular proximal artery occlusion of the vertebral artery. A 59-year-old woman presented with a large mass in the left side of the neck. Echographic examination revealed a mass measuring 42 × 38 × 48 mm in the left neck. Angiography showed a thrombosed giant aneurysm of the V1 segment of the left vertebral artery. Endovascular proximal artery occlusion of the vertebral artery was performed, and the aneurysm lessened gradually. Although a number of procedures have been developed to treat extracranial vertebral artery aneurysms, endovascular proximal artery occlusion is a good option to treat aneurysms in this portion.

Endovascular treatment of carotid-cavernous vascular lesions

Objective:

to evaluate the endovascular treatment of vascular lesions of the cavernous segment of the internal carotidartery (ICA) performed at our institution.

Methods:

we conducted a descriptive, retrospective and prospective study of patients with aneurysms of the cavernous portion of the ICA or with direct carotid-cavernous fistulas (dCCF) undergoing endovascular treatment.

Results:

we included 26 patients with intracavernous aneurysms and ten with dCCF. All aneurysms were treated with ICA occlusion. Those with dCCF were treated with occlusion in seven cases and with selective fistula occlusion in the remaining three. There was improvement of pain and ocular proptosis in all patients with dCCF. In patients with intracavernous aneurysms, the incidence of retro-orbital pain fell from 84.6% to 30.8% after treatment. The endovascular treatment decreased the dysfunction of affected cranial nerves in both groups, especially the oculomotor one.

Conclusion:

the endovascular treatment significantly improved the symptoms in the patients studied, especially those related to pain and oculomotor nerve dysfunction.

Objetivo:

avaliar o tratamento endovascular de lesões vasculares da artéria carótida interna (ACI), segmento cavernoso, realizado na Santa Casa de São Paulo.

Métodos:

estudo descritivo, retrospectivo e prospectivo, de pacientes com aneurisma da porção cavernosa da ACI ou com fístulas carótido-cavernosas diretas (FCCd) submetidos a tratamento endovascular.

Resultados:

foram incluídos 26 pacientes com aneurismas intracavernosos e dez com FCCd. Todos os aneurismas foram tratados com oclusão da ACI. Os com FCCd foram tratados com oclusão, em sete casos, e com oclusão seletiva da fístula nos outros três. Houve melhora da dor e proptose ocular em todos os pacientes com FCCd. Nos pacientes com aneurisma intracavernoso, a incidência de dor retro-orbitária caiu de 84,6% para 30,8% após o tratamento. Após o tratamento endovascular houve uma melhora importante da disfunção de nervos cranianos afetados em ambos os grupos, sobretudo no nervo oculomotor.

Conclusão:

o tratamento endovascular trouxe melhora para os pacientes deste estudo, especialmente nos critérios dor e acometimento do nervo oculomotor.

Surgical distal outflow occlusion for the treatment of complex intracranial aneurysms: experience with 18 cases

BACKGROUND

Selected intracranial aneurysms still require parent artery occlusion. Although such occlusion is usually performed proximal to the aneurysm, in rare instances, it may be difficult or impossible to access the proximal parent artery.

OBJECTIVE

To describe the use of parent artery sacrifice distal to the aneurysm (distal outflow occlusion) in the management of complex aneurysms not amenable to standard microsurgical or endovascular therapy.

METHODS

We reviewed a comprehensive database of intracranial aneurysms evaluated between 1997 and 2013. Hospital records, neuroimaging studies, operative reports, and outpatient clinic notes were examined for all patients treated with distal outflow occlusion.

RESULTS

Eighteen patients (11 women, 7 men; ages 28-69 years) underwent surgical distal outflow occlusion. Eight (44%) underwent concomitant distal revascularization. Intraoperative and delayed postoperative angiography was performed in every case. Nine presented with acute subarachnoid hemorrhage, 1 had a remote bleeding episode. The remaining lesions were unruptured; 3 were discovered incidentally, 3 had symptomatic cerebral edema, 1 had transient ischemic attacks, and 1 had cranial neuropathy. The average follow-up period was 6.5 years; no patient was lost to follow-up review. Two aneurysms required delayed endovascular treatment. Overall, 16 patients achieved a good outcome, 1 had moderate disability, and 1 died.

CONCLUSION

We describe our experience with distal outflow occlusion in the treatment of complex aneurysms not amenable to primary clip reconstruction or endovascular therapy. This technique has been described in very limited fashion in the past and may be particularly useful for patients requiring parent artery occlusion when proximal occlusion is challenging or impossible.

Carotid sacrifice with a single Penumbra occlusion device: a feasibility study in a swine model

Introduction

Carotid sacrifice is a valuable tool in the treatment of select vascular lesions. Traditional coil embolization as the primary means of carotid sacrifice can be expensive, with high radiation exposure. We investigated the feasibility of a novel hybrid coil, the Penumbra occlusion device (POD), for carotid sacrifice in a swine model.

Methods

A total of eight common carotid artery sacrifices were performed in fully heparinized pigs under fluoroscopic guidance. A single POD device was deployed within each vessel, and intermittent follow-up angiography was performed to assess flow.

Results

Complete carotid occlusion was achieved in all cases with a single POD (time range 2–15 min) without any coil migration or intraprocedural complications. Once the anchor zone was stable, no distal migrations were observed during either proximal soft coil packing or during hand injected angiography. Complete occlusion was verified between 2 and 15 min following POD deployment.

Conclusions

Carotid artery sacrifice using a novel POD device is safe and effective, allowing for reduced radiation and material costs compared with any other described endovascular technique.

The Value of syngo DynaPBV Neuro During Neuro-Interventional Hypotensive Balloon Occlusion Test

AIM

This study explored the value of flat detector computed tomography based brain perfusion imaging in assessing patient's tolerance prior to the permanent internal carotid artery occlusion.

MATERIALS AND METHODS

Ten patients diagnosed with neurovascular diseases through digital subtracted angiography (DSA) were enrolled into this study. Temporary balloon occlusion test (BOT) was performed for each patient with hypotensive challenge. During the test, parametric color-coded quantitative DSA (CCQ-DSA) was generated to evaluate the venous filling symmetry on both hemispheres. In addition, cerebral blood volume (CBV) maps were acquired before and during the test. Regions of interests were defined to quantitatively extract CBV value from affected and unaffected hemispheres and calculate relative CBV (rCBV), indicating perfusion symmetry.

RESULTS

All the patients showed good perfusion symmetry before the test with rCBV close to 1.00. During the test, good perfusion symmetry was detected in 7 patients with averaged rCBV 1.03 ± 0.06. Only short venous delay and no ischemic complications were recognized. One patient had neither neurologic deficits nor long venous delay detected, however, showed hyper-perfusion in specific regions in the CBV maps. Two patients failed to pass the test, which showed significantly low CBV value from the affected hemisphere with maximum rCBV reduction close to 45%.

CONCLUSION

CBV map had in general good consistency with clinical manifestations as well as venous filling in the BOT. Besides, it may provide further evidence of hemodynamic variations and delayed ischemic complications, and thus, had a potential to reduce risks and increase treatment safety.

Balloon-augmented Onyx endovascular ligation: initial human experience and comparison with coil ligation

INTRODUCTION

Carotid artery sacrifice remains an important procedure for cerebral vascular disorders despite the development of new endovascular devices. Conventional carotid artery sacrifice with detachable coils alone often requires numerous coils to complete occlusion.

OBJECTIVE

To describe the initial human experience with balloon-augmented Onyx and coil vessel sacrifice based on our previous experience with animals.

METHODS

We performed a retrospective review of patients who underwent carotid artery sacrifice between 2008 and 2012 in accordance with local investigational review board approval. Two methods were used to occlude carotid arteries-namely, combined Onyx and coil embolization and traditional coil embolization. We compared the two methods for the cost of embolizate, time to occlude the vessels, and the number of coils.

RESULTS

Eight consecutive patients (combined group n=3, traditional group n=5) were assessed. The median cost of embolic material was $6321 in the combined Onyx and coil embolization group and $29 996 in the traditional coil embolization group. The median time from first coil placement to achievement of vessel occlusion was 52 min in the Onyx group and 113 min in the coil embolization group. The median number of coils used was 4 in the Onyx group and 35 in the coil embolization group (p<0.05). No symptomatic complications or recurrences were seen in the combined group.

CONCLUSIONS

Balloon-augmented Onyx endovascular ligation may reduce costs and fluoroscopy times during vessel sacrifice. Further studies in a larger number of patients are needed to confirm these findings.

Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience

Several treatment strategies are available to manage large and giant cerebral aneurysms, including surgical, endovascular and combined approaches. We present our experience with microsurgical clipping of large and giant aneurysms. A total of 138 patients with 139 aneurysms of which 128 were large (≥10mm) and 11 were giant (≥25mm) were treated at our institution between 2004 and 2011. Data were collected from a prospectively maintained neurovascular database. Of 138 patients, 53 (38.4%) patients presented with subarachnoid hemorrhage (SAH). Peri-operative complications occurred in 16.7% of patients causing permanent morbidity in 4.4% and death in 0.7%. Complete occlusion, as evident on intra-operative angiography, was achieved in all clipped aneurysms (100%). Long-term follow-up angiography showed no recurrence (mean follow-up time, 43.9 months; range: 1-72 months). Favorable outcomes at discharge (Glasgow Outcome Scale score 4 or 5) were noted in 64.1% of SAH patients and 93% of non-SAH patients. Favorable outcomes at follow-up (mean follow up time, 42.5 months) were seen in 96% of patients. In our experience, microsurgical clipping of large and giant aneurysms carries low rates of morbidity and mortality with high rates of favorable outcomes. The excellent durability of surgical treatment stands in stark contrast with the high recurrence rates observed with coiling for this subset of aneurysms. These data suggest that microsurgical clipping continues to be a viable option that can be offered for patients with large and giant aneurysms.

EC-IC bypass for cavernous carotid aneurysms: An initial experience with twelve patients

AIMS

Need for performing a bypass procedure prior to parent artery occlusion in patients with good cerebral vascular reserve is controversial. We analyze our experience of 12 giant internal carotid artery aneurysms treated with extracranial-intracranial (EC-IC) bypass and proximal artery occlusion.

MATERIALS AND METHODS

Retrospective analysis of the case records of all complex carotid aneurysms operated in our institute since January 2009.

RESULTS

The study included eleven cavernous carotid aneurysms and one large fusiform cervical carotid aneurysm reaching the skull base. Preoperative assessment of cerebral vascular reserve was limited to Balloon test occlusion with hypotensive challenge. Eleven patients who successfully completed a Balloon test occlusion (BTO) underwent low flow superficial temporal artery to middle cerebral artery (STA-MCA) bypass, while one patient with a failed BTO underwent a high flow bypass using a saphenous vein graft. Parent artery ligation was performed in all patients following the bypass procedure. Check angiogram revealed thrombosis of the aneurysm in all patients with a graft patency rate of 81.8%. We had one operative mortality, probably related to a leak from the anastomotic site. The only patient who had a high flow bypass developed contralateral hemispheric infarcts and remained vegetative. All the other patients had a good recovery and with a Glasgow outcome score of 5 at last follow-up.

CONCLUSION

We feel that combining EC-IC bypass prior to parent vessel occlusion helps in reducing the risk of post operative ischemic complications especially in situations where a complete mandated cerebral blood flow studies are not feasible.

Evolution of management strategies for cavernous carotid aneurysms: a review

OBJECTIVE

Cavernous carotid aneurysms are considered benign lesions with indolent natural history. Apart from idiopathic aneurysms, traumatic, iatrogenic, and mycotic aneurysms are common in the cavernous segment of the carotid artery. With rapid advances in endovascular therapy, management of cavernous carotid aneurysms has evolved. Our aim was to review the management options available for cavernous carotid aneurysms.

METHODS

The English literature was searched for various studies describing the management of cavernous carotid aneurysms and the evolution of various treatments was studied.

RESULTS

Numerous treatment options are available such as conservative management, Hunterian ligation, surgical clipping, and endovascular therapy. The introduction of flow-diverting stents has revolutionized the management of these lesions. The evolution of various treatment strategies are described.

CONCLUSIONS

A thorough knowledge of all the options is paramount to individualize therapy. We discuss the indications of treatment, various management options for cavernous carotid aneurysms and their outcomes.

Bow hunter's syndrome unmasked after contralateral vertebral artery sacrifice for aneurysmal subarachnoid hemorrhage

Bow hunter's syndrome (BHS), or positional vertebrobasilar insufficiency, is a rare disorder characterized by positional stenosis or occlusion of the dominant vertebral artery (VA) with concordant signs and symptoms of brainstem ischemia. Many etiologies have been described, with the most common level of obstruction occurring at the craniocervical junction. The authors report acquired BHS after the patient's contralateral VA was sacrificed for ruptured aneurysm. A 44-year-old man was referred to our institution for years of continued positional tinnitus, vertigo, and nausea. This symptomatology began 5 years prior, immediately after the patient's right VA was endovascularly sacrificed to treat a ruptured VA aneurysm. From the time of treatment, right head turning caused instantaneous symptoms consistent with brainstem ischemia. Evaluations performed during the 5 year interim before referral included computed tomography angiography, MRI, and diagnostic cerebral angiography (DCA). All failed to identify a causal etiology. A diagnosis of BHS was made with dynamic DCA. With the patient's head turned to the right, angiography of the left VA demonstrated a positional block. The patient underwent left VA decompression. Intraoperative dynamic DCA was utilized to demonstrate adequacy of decompression. The patient tolerated the procedure without complication. Symptomatology immediately completely subsided and remained absent at his 3 month follow-up. An acquired BHS should be recognized as a possible complication if VA sacrifice is considered for an unclippable or uncoilable aneurysm.

Surgical management of giant posterior communicating artery aneurysms

BACKGROUND

Giant posterior communicating artery (PCoA) aneurysms (> 25 mm) are rare lesions associated with a poor prognosis and high rates of morbidity and mortality.

OBJECTIVE

To review the clinical results of giant PCoA aneurysms surgically treated at our institution, focusing on operative nuances.

METHODS

All cases of giant PCoA aneurysms treated surgically at our institution were identified from a prospectively maintained patient database. Patient demographic factors, medical comorbidities, rupture status, neurological presentation, clinical outcomes, and surgical records were critically reviewed.

RESULTS

From 1989 to 2010, 11 patients (10 women) underwent surgical clipping of giant PCoA aneurysms. Presenting signs and symptoms included cranial nerve palsies, diminished mental status, headache, visual changes, and seizures. Five aneurysms were ruptured on admission. All aneurysms were clipped primarily except 1, which was treated by parent artery sacrifice and extracranial-to-intracranial bypass after intraoperative aneurysm rupture. Perioperative morbidity and mortality rates were 36% (4 of 11) and 18.3% (2 of 11), respectively. Excellent or good clinical outcomes, defined as modified Rankin Scale scores ≤ 2, were achieved in 86% (5 of 6) of patients available for long-term clinical follow-up (mean, 12.5 ± 13.6 months).

CONCLUSION

Giant PCoA aneurysms are rare vascular lesions that may present with a variety of neurological signs and symptoms. These lesions can be successfully managed surgically with satisfactory morbidity and mortality rates. To the best of our knowledge, this is the largest surgical series of giant PCoA aneurysms published to date.

Long-term clinical and imaging follow-up of complex intracranial aneurysms treated by endovascular parent vessel occlusion

BACKGROUND AND PURPOSE

Flow-diverting stents are increasingly being used for the treatment of complex intracranial aneurysms, but the indications for their use in lieu of traditional endovascular PVO have yet to be precisely defined. The purpose of this study was to review the clinical and imaging outcomes of patients with intracranial aneurysms treated by PVO.

MATERIALS AND METHODS

A total of 28 patients with intracranial aneurysms, treated by PVO between July 1992 and December 2009, were reviewed. Aneurysms arising from peripheral arteries were excluded. Clinical and imaging data were retrospectively analyzed from a prospectively maintained data base.

RESULTS

There were 28 patients with 28 aneurysms treated by PVO. Aneurysms of the anterior circulation presenting with mass effect (n = 11) or discovered incidentally (n = 1), and dissecting-type VB aneurysms presenting with subarachnoid hemorrhage (n = 6) faired the best with high obliteration rates (83.3% and 83.6%, respectively) and no permanent major ischemic complications. In contrast, VB aneurysms presenting with mass effect (n = 7) demonstrated the lowest obliteration rate (57.1%), the highest rate of permanent major ischemic complications (28.6%), and a high mortality rate (28.6%).

CONCLUSIONS

PVO is a safe and effective treatment for complex intracranial aneurysms of the carotid artery and dissecting-type VB aneurysms presenting with SAH. In contrast, PVO for aneurysms of the VB circulation presenting with mass effect is less efficacious and associated with significant morbidity and mortality. It is hoped that flow diverters may represent a better treatment technique for these most difficult-to-treat lesions.

Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results

BACKGROUND AND PURPOSE

Flow-diverting devices now offer a new treatment alternative for cerebral aneurysms. We present the results of a large single-center series of patients treated with the PED, including long-term follow-up.

MATERIALS AND METHODS

Between November 2008 and September 2011, sidewall aneurysms with a wide neck (≥4 mm) or unfavorable dome-neck ratio (≤1.5); large/giant, fusiform, dissecting, blister-like, and recurrent sidewall aneurysms; aneurysms at difficult angles; and aneurysms in which a branch was originating directly from the sac were treated with the PED. Patients were premedicated with dual antiplatelet medications. Data, including demographics, aneurysm features, clinical presentation, complications, results, and follow-up information, for up to 2 years are presented.

RESULTS

Two hundred fifty-one aneurysms in 191 patients were treated. Of these, 96 (38.3%) were large or giant (≥10 mm). In 34/251 (13.5%), PEDs were used for retreatment. Adjunctive coiling was performed in 11 aneurysms (2.1%). The mean number of devices per aneurysm was 1.3. One aneurysm ruptured in the fourth month posttreatment (0.5%), and symptomatic in-construct stenosis was detected in 1 patient (0.5%) treated with percutaneous transarterial angioplasty. Any event rate was 27/191 (14.1%), with a permanent morbidity of 1% and mortality of 0.5%. Control angiography was available in 182 (95.3%) patients with 239 (95.2%) aneurysms. In 121 aneurysms (48.2%), 1- to 2-year control angiography was available. The aneurysm occlusion rate was 91.2% in 6 months, increasing to 94.6%.

CONCLUSIONS

Use of the PED is safe, efficacious, and durable in cerebral aneurysm treatment, with low morbidity-mortality and high occlusion rates as confirmed with mid- to long-term control angiography.

Surgical strategies for aneurysms deemed unclippable and uncoilable

Although most cerebral aneurysms can nowadays be successfully treated either by standard clipping or sole coiling, a subset of aneurysms may not be amenable to standard clipping or coiling and require alternative treatment options. Surgical options, other than clipping and/or endovascular options other than sole coiling, may be the optimal treatment plan for some complex aneurysms. Surgical strategies for such complex aneurysms include parent artery occlusion, revascularization procedures and flow redirection. In this article, we review which factors are predictive of failure of conventional aneurysm treatment options; summarize key information needed to orient treatment decision; and discuss surgical options for unclippable and uncoilable aneurysms.