Endovascular trapping of giant serpentine aneurysms by using Guglielmi detachable coils: successful reduction of mass effect. Report of two cases

Therapeutic dilemmas regarding giant aneurysms of the intracranial vertebral artery causing medulla oblongata compression

BACKGROUND

Giant aneurysms of the intracranial vertebral artery are very rare cerebrovascular lesions. Due to the rarity of these aneurysms, we know little about them.

METHODS

We performed a systematic review of the English literature by searching the PubMed database. The inclusion criteria were as follows: (a) the full text was available and (b) complete clinical data were available.

RESULTS

A total of 45 articles were identified, containing 53 patients (53 aneurysms). The patients were aged from 5 to 77 years (48.8 ± 20.8 years). Four patients receiving conservative treatment died. The remaining 49 patients were divided into the aneurysm removal group (n = 17) and the aneurysm reserve group (n = 32). The outcomes of the 49 treated cases could be obtained in 45 cases, 31 of which (68.9%, 31/45) had a Glasgow outcome scale score of 4-5.

CONCLUSIONS

It is still difficult to treat intracranial giant vertebral artery aneurysms, regardless of the treatment selected. Because of the malignant natural history, aggressive treatment is still advocated.

Unruptured giant intracavernous aneurysms untolerate internal carotid artery occlusion test: Untreated and treated with flow-diversion

BACKGROUND AND OBJECTIVE

Giant intracavernous aneurysms (GICAs) are located in extradural space; their clinical manifestation and treatment are different from other intradural aneurysms. This study reports clinical outcomes of GICAs untolerate internal carotid artery occlusion tests.

METHODS

Between January 2012 and September 2017, 14 consecutive cases of GICAs untolerated internal carotid artery occlusion test were retrospectively reviewed. A total of nine patients were not treated and five patients were treated using a Pipeline Embolization Device.

RESULTS

Of the 14 patients, 12 had compression symptoms and 2 were incidental. In nine untreated patients, during 34 months' (range, 7-64 months) follow-up, four worsened to headaches or ablepsia (more than 34 months). One patient, who presented with ophthalmoplegia and diplopia, showed spontaneous resolution of symptoms at 32-month follow-up. Symptoms in four patients remained unchanged during less than 36-month follow-up period. In five (100%, 95% confidence interval 57% to 100%) treated patients, symptoms recovered completely during 11 months' follow-up after transient worsening of mass compression.

CONCLUSIONS

GICAs frequently result in intractable cranial neuropathy requiring treatment. The Pipeline Embolization Device is an effective option for these complex aneurysms in selective cases.

A 5-Year Follow-up of Intracranial Arterial Dolichoectasia: A Case Report and Review of Literature

A patient with multiple dolichoectasia of the intracranial cerebral artery was followed sequentially with clinical and radiological progression of disease in the past 5 years. The patient was treated in multiple stages in the past 5 years with the endovascular and microsurgical clipping method. The maximum diameter of each major intracranial artery segment was recorded and compared in the follow-up year. The progression in size of the dolichoectatic segment was observed in spite of surgical intervention. In review diagnostic criteria, etiopathogenesis and treatment options have been discussed.

Outcomes in Symptomatic Patients With Vertebrobasilar Dolichoectasia Following Endovascular Treatment

Objective: To evaluate whether the presenting symptoms of VBD predict outcomes following endovascular treatment.

Methods: We retrospectively reviewed our institutional clinical database and identified 22 patients (all men; mean age: 52.6 years, range: 11–73 years) with a diagnosis of VBD, who underwent endovascular treatment from January 2010 to December 2017.

Results: After analyzing the clinical and imaging data, we evaluated data for 22 symptomatic patients with VBD. At the time of VBD diagnosis, 13 patients (59%) had compressive symptoms, four (18%) had hemorrhagic symptoms, and five (23%) had ischemic symptoms. Nine of the 22 patients (41%), who presented with hemorrhagic and ischemic symptoms, achieved a satisfactory clinical and/or digital subtraction angiography imaging outcome after endovascular treatment. However, of the 13 patients who presented with compressive symptoms, seven (54%, 7/13) died from severe brainstem compression during follow-up; furthermore, magnetic resonance imaging showed worsening of the mass effect in eight patients with compressive symptoms (62%, 8/13).

Conclusions: VBD is considered a challenging lesion without an ideal treatment modality. Endovascular treatment of VBD in patients presenting with compressive symptoms at diagnosis may not be beneficial. However, long-term outcomes following endovascular treatment may be acceptable in patients with non-compressive symptoms at diagnosis compared with those with compressive symptoms.

Intracranial Serpentine Aneurysms: Spontaneous Changes of Angiographic Filling Pattern

BACKGROUND AND PURPOSE

Serpentine aneurysms are partially thrombosed aneurysms with an eccentrically located tortuous intra-aneurysmal vascular channel. The large size, distinctive neck anatomy, and supply of the brain parenchyma by the outflow tract pose technical challenges in treatment. The aim of this study was to discuss the endovascular treatment results and illustrate the dynamic nature of serpentine aneurysms. Spontaneous transformation of saccular and fusiform aneurysms into serpentine morphology, along with a case of serpentine-into-fusiform aneurysm transformation during follow-up, is presented.

MATERIALS AND METHODS

A retrospective analysis from 3 institutions revealed 15 patients with serpentine aneurysms who underwent diagnostic evaluation and endovascular treatment. Nine of the 15 patients underwent endovascular occlusion of the parent vessel with detachable balloon or coils. Six of the 15 patients underwent aneurysm and parent artery occlusion with coiling.

RESULTS

In 11 patients, improvement or resolution of symptoms was achieved by an endovascular approach without any treatment-related morbidity. Morbidity related to treatment in the immediate postoperative period was seen in 3 patients, with resolution of the deficits at long-term follow-up in 2 patients and persistence of a mild deficit in 1 patient. Endovascular treatment failed to achieve resolution of symptoms in a case with a basilar tip aneurysm treated by aneurysm coiling.

CONCLUSIONS

Serpentine aneurysms are dynamic structures with spontaneous transformation possible from a saccular or fusiform shape into a serpentine configuration. An endovascular approach by parent vessel occlusion or intra-aneurysmal occlusion is a successful treatment technique for serpentine aneurysms.

Treatment of a Giant Serpentine Aneurysm in the Anterior Cerebral Artery

A giant serpentine aneurysm (GSA) in the anterior cerebral artery (ACA) poses a technical challenge in treatment given its large size, unique neck, and dependent distal vessels. Here we report the case of a GSA in the ACA successfully treated with a combined surgical and endovascular approach. A 54-year-old woman presented with dull headache. On brain computed tomography (CT), a large mass (7 cm × 5 cm × 5 cm) was identified in the left frontal lobe. Cerebral angiography revealed a GSA in the left ACA. Bypass surgery of the distal ACA was performed, followed byocclusion of the entry channel via an endovascular approach. Follow-up CT performed 5 days after treatment revealed disappearance of the vascular channel and peripheral rim enhancement. Follow-up imaging studies performed 7 months after treatment revealed gradual reduction of the mass effect and patency of bypass flow. No complications were noted over a period of 1 year after surgery.

Study and Therapeutic Progress on Intracranial Serpentine Aneurysms

An intracranial serpentine aneurysm (SA) is a clinically rare entity, and very few multi-case studies on SA have been published. The present study reviewed the relevant literature available on PubMed. The studied information included the formation mechanism and natural history of SA as well as its clinical manifestation, imaging characteristics, and current treatments. After reviewing the literature, we conclude that intracranial SA can be managed surgically and by endovascular embolization, but the degree of blood flow in normal brain tissue distal to the SA must be evaluated. A balloon occlusion test (BOT) or cross compression test is recommended for this evaluation. If the collateral circulation is sufficiently compensatory, direct excision or embolization can be performed. However, if the compensatory collateral circulation is poor, a bypass surgery is necessary. Satisfactory results can be achieved in the majority of SA patients after treatment. However, the size of the aneurysm may increase in some patients after endovascular treatment. Special attention should be paid to cases exhibiting a significant mass effect to avoid subsequent SA excision due to an intolerable mass effect. Satisfactory results can be achieved with careful treatment of SA.

Pathophysiology, presentation, prognosis, and management of intracranial arterial dolichoectasia

Up to 12% of patients with stroke have intracranial arterial dolichoectasia (IADE) and the basilar artery is affected in 80% of these cases. Diagnostic criteria and prognosis studies of IADE are based on basilar artery diameter, which is a good quantitative marker for the severity of the disease. The pathophysiology is largely unknown, but IADE can be viewed as a common final pathway of arterial wall response or damage in the tunica media due to various mechanisms, such as matrix metalloproteinase dysfunction or muscle cell or elastic fibre injury. No randomised controlled trials have been undertaken in IADE and thus little high-level evidence is available on which to base treatment guidelines. IADE management depends on clinical presentation and disease severity, and includes blood pressure control, antithrombotic treatments, endovascular procedures, and surgery. Further studies are needed to better define IADE in the general population, to establish its prevalence and pathophysiology, to identify subgroups at risk of life-threatening complications, and to offer effective treatment options.

Giant intracranial aneurysms in the paediatric population: Suggested management and a review of the literature

OBJECTIVES

Intracranial aneurysms are rare in children although giant aneurysms more commonly occur in adolescence. The aims of our study were to perform an extensive review of the literature over the past two decades and assess intracranial aneurysm management.

METHODS

Based on a Pubmed search, we carried out a review of the literature from 1990 to 2012 regarding giant intracranial aneurysms diagnosed in the paediatric population. This descriptive study concerned clinical presentation, cerebral aneurysm characteristics, therapeutic management procedures and outcome.

RESULTS

Forty-six cases were reported in 31 papers. The male/female sex ratio was 1.15, the clinical presentation was a tumour mass syndrome in 56.6%, followed by rupture in 30.4%. The aneurysm location was the posterior circulation in 41.3%, and microsurgical treatment (52.2%) predominated over endovascular coiling (28.3%).

CONCLUSION

To date, no evidence-based medicine recommendation has been accepted for the management of rare intracranial aneurysms. Each reported patient was the object of a multidisciplinary clinical decision. Management of this challenging pathology should be performed on a case-to-case basis.

Giant serpentine aneurysm of the distal anterior cerebral artery

We report a case of a 38-year-old man with a giant serpentine aneurysm arising from the distal anterior cerebral artery. This aneurysm grew from a fusiform aneurysm to a huge aneurysm within 5 months before manifesting as a mass lesion. The aneurysm was largely filled with thrombus, and 4 distal branches arose from the aneurysm dome. Selective balloon test occlusion of the distal anterior cerebral artery using an intravascular technique was performed to confirm the tolerance of the brain tissue. The balloon test occlusion elicited adequate leptomeningeal collateral circulation and no neurologic symptoms; thus, the aneurysm was treated with trapping and resection. The patient had no ischemic complications after the surgery and returned to his job 1 month later. No ischemia developed in the 2 years after surgery. Selective balloon test occlusion of the distal cerebral artery using an intravascular technique can be a very useful tool in planning the therapeutic strategy for a complicated distal cerebral aneurysm.

Successful obliteration of unclippable large and giant middle cerebral artery aneurysms following extracranial-intracranial bypass and distal clip application

Large to giant middle cerebral artery aneurysm is a challenging disease, especially when incorporating important perforating arteries. Surgical risk increases by perforator infarction and anatomical complexity. In this clinical setting, extensive consideration of surgical options is needed. The two cases described here were unruptured and had rather stable wall. Because of their large and giant size, hardness and incorporated arteries, it was not affordable to isolate them by means of clipping or trapping. The procedure as the alternative to conventional treatment modalities, extracranial-intracranial bypass followed by clipping of only the efferent artery successfully treated the aneurysms.

Giant serpentine aneurysms

Segal and McLaurin first described giant serpentine aneurysms, based on their distinct angiographic features, in 1977. These lesions are >or= 25 mm, partially thrombosed aneurysms with a patent, serpiginous vascular channel that courses through the aneurysm. There is a separate inflow and outflow of the aneurysm, of which the outflow channel supplies brain parenchyma in the territory of the parent vessel. Given the large size, unique neck, and dependent distal vessels, these aneurysms pose a technical challenge in treatment. Initial management has included surgical obliteration, but as endovascular techniques have evolved, treatment options too have expanded. In this review the authors attempt to summarize the existing body of literature on this rare entity and describe some of their institutional management strategies.

Current status and future prospect of endovascular neurosurgery

Recently, due to the evolution of technology, the field of neurosurgery is receiving spotlight. In particular endovascular neurosurgery has gained a great interest along with the advancement of the modern neurosurgery. The most remarkable advances were made in embolization of the cerebral aneurysms, arteriovenous malformations and intracranial stenosis during the past 10 years. These advances will further change the role of neurosurgeons in treating cerebrovascular disease. Because interventional neuroradiologists have performed most of procedures in the past, neurosurgeons have been deprived of chances to learn endovascular procedure. This article discusses the development of technological aspect of endovascular neurosurgery in chronological order. By understanding the history and current status of the endovascular surgery, the future of neurosurgery will be promising.

Giant Serpentine Aneurysm in a Patient with Multiple Endocrine Neoplasia Type 1 Syndrome

Giant serpentine aneurysms (GSA) are a rare, distinct group of giant intracerebral aneurysms. Multiple endocrine neoplasia type 1 (MEN 1) syndrome is characterised by tumours of the parathyroid glands, pancreatic islets and the pituitary.

We report a case of a GSA in a diabetic patient diagnosed with MEN 1 syndrome.

Trunkal intracranial aneurysms: dissecting and fusiform aneurysms

Aneurysms arising along the arterial trunk are uncommon and not well-characterized lesions in contrast to saccular aneurysms. According to pathological studies, most of spontaneous trunkal aneurysms are related to dissecting phenomena. On the basis of clinical presentation, dissecting aneurysms can be separated into acute or chronic lesions. Understanding of the underlying pathological mechanisms associated with these aneurysms is useful for planning appropriate treatment. This article reviews the etiopathogenesis, the angiographic aspects, and the endovascular treatment of dissecting aneurysms. Fusiform aneurysms and aneurysms in atherosclerotic disease also are discussed briefly.

Endovascular treatment of vertebral artery aneurysm manifesting as progressive hemifacial spasm

A 62-year-old woman presented with right hemifacial spasm persisting for 6 months. Brain magnetic resonance imaging and digital subtraction angiography showed a wide-neck aneurysm of the intracranial portion of the right vertebral artery. The patient underwent endovascular trapping of the aneurysm by coil embolization of the parent vessel on both sides of the aneurysm. The patient experienced gradual disappearance of the hemifacial spasm within 3 months. No relapses occurred during a follow-up period of 3 years. Magnetic resonance imaging revealed shrinkage of the vertebral artery aneurysm which had compressed the facial nerve. Endovascular trapping of a vertebral artery aneurysm can be used to treat hemifacial spasm caused by an aneurysm instead of surgical microvascular decompression.

Treatment of giant fusiform aneurysms of the basilar trunk with intra-aneurysmal and basilar artery coil embolization

OBJECTIVE

The authors report their experience in endovascular treatment of basilar artery (BA) trunk aneurysms by intra-aneurysmal and BA occlusion.

METHODS

Four patients were referred to our hospital from 1995 until 2002 with variable clinical presentations and radiologic appearances. All the patients were subjected for tolerability to balloon BA occlusion test to verify the collateral supply from the posterior communicating arteries. The patients were treated by intra-aneurysmal embolization together with basilar artery occlusion.

RESULTS

All the aneurysms were successfully isolated from the circulation. Transient postoperative neurologic deficits were constant findings in all the cases. Outcome was finally good for all the patients.

CONCLUSIONS

Endovascular treatment of complex BA trunk aneurysm by intra-aneurysmal embolization and BA occlusion method is a valuable alternative for management and successful isolation in patients with good collateral arterial flow.

Giant intracranial aneurysms: development, clinical presentation and treatment

The natural history of giant intracranial aneurysms are grave. More than 50% of patients suffer from rupture of these aneurysms and mortality is >60% in 2 years. Modern technology and advancement of knowledge in neurosurgery and interventional neuroradiology have altered its natural course for the better. As many reports have shown, the majority of these aneurysms can be treated either by surgery or by endovascular approach, even though morbidity is higher than when treating smaller aneurysms. Certain aneurysms are more suitable to direct surgical clipping and others may have better chances of good clinical outcome by endovascular treatment. It is imperative to analyse the location, morphology, hemodynamics and circulation of normal brain of each aneurysm before the mode of treatment is decided. Needless to say, the individual patient's age, neurological and medical condition should be considered. For endovascular treatment, application of each technique, endosaccular occlusion or parent artery occlusion depends on the aneurysm location and geometry as well as its pathology. Several reports indicated that clinical outcome is better in patients treated by parent artery occlusion since it eliminates any blood flow to the aneurysm and it provides a more effective reduction of the mass effect. However, not all parent arteries can be sacrificed. In addition, endosaccular treatment is effective in preventing haemorrhage if the aneurysm is not re-canalised. It is also demonstrated that symptoms of mass effect can be reversed by endosaccular coiling. The patients who are treated this way should be closely monitored for re-canalisation.

Treatment Strategy for Cerebral Aneurysms Based on the Evidence of the Efficacy of GDC Embolization

SUMMARY

The authors reviewed 531 patients with cerebral aneurysms treated with Guglielmi detachable coils (GDCs) over 5 years to clarify both the advantages and disadvantages of embolization based on the evidence of complications by aneurysm profile. There were 52 technical complications, 25 of which resulted in unfavorable patient outcomes. Intraoperative rupture, the most serious complication exacerbating the patient's condition, occurred in 19 patients, 4 of whom expired. All of these aneurysms were very small and were mostly located in the AcomA and PICA portions. Thirteen patients encountered thromboembolic complications, 6 of whom were elderly with acute ruptured aneurysms at MCA and the tip of BA. For large or giant aneurysms manifesting the mass effect, particularly those in the ICA-C2 portion compressing the optic nerve, the saccular packing did little to ameliorate the symptoms, and subsequent surgical or endovascular trapping was needed. Therefore, saccular embolization of endovascularly difficult, very small AcomA aneurysms and large C2 aneurysm with visual symptoms should be used sparingly based on a risk-benefit assessment.