Multimodal treatment for complex intracranial aneurysms: clinical research

High-Flow Bypass with Radial Artery Graft for Cavernous Carotid Aneurysms: A Case Series

Background:

The incidence of cavernous carotid aneurysms (CCAs) of intracranial aneurysms is low. Majority of cases presented as incidental findings with benign natural progression. The most common presenting symptoms are multiple cranial neuropathies among symptomatic patients. The treatment modalities for symptomatic patients include direct surgical clipping, endovascular coil embolization, or placement of flow diverter, or indirect procedures such as occlusion of parent artery with and without revascularization techniques. The advancement in the microsurgical treatments and endovascular devices have enable a high success rate in the treatment of patients with CCAs with low morbidity and mortality rates.

Objective:

To study the surgical outcomes of patients with cavernous aneurysm who underwent high-flow bypass between 2015 and 2020 in our institution.

Materials and Methods:

A total of six patients in a single institution presented with CCAs who were treated with high-flow bypass surgery were included in this case-series. A single-case illustration was presented focusing on the details of surgical case management of CCA. The intraoperative middle cerebral artery (MCA) pressure monitoring during bypass surgery was also described.

Results:

All five female patients and one male patient who were diagnosed with cavernous carotid aneurysms were studied. The mean age was 68.8 years old (range: 24-84 years old) and the mean size of the aneurysm was 19.6mm (range: 9.7 – 30mm). There were successfully treated with high flow bypasses using radial artery graft without any neurological sequelae.

Conclusion:

The surgical treatments of cavernous carotid aneurysms should be limited to experienced neurosurgeons in view of significant risk of morbidity and mortality. Endovascular procedures may be the main stay of treatments. The success shown in this case series with parent artery occlusion and bypass surgery may provide an safe alternative to the endovascular treatment.

Endovascular management of intracranial pseudoaneurysm: an institutional experience

Objective

Pseudoaneurysms (PSAs) of the internal carotid artery (ICA) and vertebral artery are rare entities but with varied treatment options. PSAs can be spontaneous or secondary to trauma, infections, malignancies or iatrogenic. To find out the efficacy of various endovascular interventions in the management of ICA and vertebral PSAs.

Methods

The study included 14 patients diagnosed with intracranial PSAs who underwent endovascular interventions in SMS Medical College, Jaipur (Rajasthan) between June 2015 to January 2019. The clinical and radiological findings (computed tomography angiography and digital subtraction angiography) were reviewed and the consequent endovascular intervention carried out and their results were analyzed.

Results

Total 14 patients were studied out of which 8 (57.1%) were anterior circulation PSAs and 6 (42.9%) were posterior circulation PSAs There were 10 (71.4%) females and 4 (28.5%) males between the age of 9 to 65 years. Only 2 patients with PSA had past history of trauma. Coiling was done in 8 patients (57.1%), stenting in 2 patients (14.2%), parent artery occlusion in 1 patient (7.1%), glue embolization in 1 patient (7.1%) while coiling with glue in 1 patient (7.1%) and flow diverter in 2 patients (14.2%). Immediate and complete occlusion was achieved in 11 (78.6%) patients while 3 (21.4%) patients had subtotal occlusion. 11 patients under follow up till June 2019 did not report recurrence or new neurological deficit.

Conclusions

Endovascular interventions is minimally invasive and safe treatment strategy for intracranial PSAs. The ultimate choice of technique depends on clinical and imaging characteristics.

Microsurgical Treatment of Paraclinoid Aneurysms by Extradural Anterior Clinoidectomy: The Fujita Experience

Introduction:

Paraclinoid aneurysms pose technical difficulty in their approach, mainly because of their close proximity to neurovascular structures, deeper location, and a smaller corridor. Extradural anterior clinoidectomy is a highly beneficial technique in such cases, making more space to deal with these aneurysms. We describe our method of performing extradural anterior clinoidectomy in such patients.

Materials and Methods:

A total of 33 cases of paraclinoid internal carotid artery aneurysms presenting to Fujita Health University Banbuntane Hospital, Japan, were included. Females comprised the majority with 32 cases; the mean age was 54.8 years (range: 35–74 years). The mean size of the paraclinoid aneurysm was 5.3 mm (range: 3–12 mm).

Results:

Nine paraclinoid aneurysms were found projecting dorsally, 7 laterally, and 17 medially (Kazuhiko Kyoshim et al's. classification). An immediate complete occlusion rate of 100% was present. Visual disturbance was found in 6.2% of our patients. One of our patients developed permanent loss of vision.

Conclusion:

Extradural anterior clinoidectomy enables a better exposure to paraclinoid aneurysms. Precise anatomical knowledge along with microsurgical tactics is required to prevent and manage potential complications to achieve good outcomes.

Endovascular treatment of complex intracranial aneurysms

PURPOSE

Complex intracranial aneurysms (CIA) are heterogenous group of intracranial vascular malformations. Due to its giant size, difficult location, broad neck, branches arising from the aneurysm, wall structure, calcification, presence of intraluminal thrombus or previous treatments it requires more careful approach. The aim of this study was to evaluate endovascular treatment results of CIA in our Department.

MATERIAL AND METHODS

In order to differentiate CIA from all the aneurysms, treated endovascularly in years 2008-2014, authors proposed their own qualification criteria. Additionally, subgroup of patients with CIA with simultaneous subarachnoid haemorrhage (SAH) was divided. Clinical outcomes of patients were assessed with Glasgow Outcome Scale (GOS), while radiological outcomes were assessed with Montreal Scale. Aneurysm localization, incidence of aborted procedures, intraoperative complications were also evaluated.

RESULTS

Internal carotid artery was the most common localization in both CIA and non-complex (nCIA) groups. Incidence of aborted procedures was significantly higher in CIA group than in nCIA (25% vs. 7%; p < 0.01). CIA group had worse Montreal scores then nCIA group (1.90 vs. 1.49; p < 0.01). Clinical outcome in GOS scale in patients with SAH and CIA was significantly worse than in SAH and nCIA (2.86 vs. 4.06; p = 0.04).

CONCLUSIONS

To conclude, proposed criteria of CIA should be taken into consideration during diagnosis and qualification to invasive treatment. Classifying aneurysm as CIA is related to greater possibility of aborting endovascular procedure due to technical difficulties.

Risk Factors to Predict Neurologic Complications After Endovascular Treatment of Unruptured Paraclinoid Aneurysms

OBJECTIVE

Unruptured paraclinoid aneurysms are often asymptomatic, and endovascular coiling is the main treatment. However, endovascular treatment of these lesions still leads to neurologic complications. We aimed to identify predictors of neurologic complications in these lesions.

METHODS

We retrospectively analyzed patients with unruptured paraclinoid aneurysms who were treated with endovascular coiling between January 2014 and December 2015. A neurologic complication was defined as any transient or permanent increase in the modified Rankin Scale score after aneurysm embolization. Univariate and mulitivariate logistic regression analyses were performed to assess the risk factors of neurologic complications.

RESULTS

Of the 443 unruptured paraclinoid aneurysms that were included in this study, the incidence of neurologic complications was 5.2%. Neurologic complications were highly correlated with hypertension (odds ratio [OR], 3.147; 95% confidence interval [CI], 1.217-8.138; P = 0.018), cerebral ischemic comorbidities (OR, 3.396; 95% CI, 1.378-8.374; P = 0.008), and aneurysm size (OR, 7.714; 95% CI, 1.784-31.635; P < 0.001), and irregular shape (OR, 3.157; 95% CI, 1.239-8.043; P = 0.016) in the univariate analysis. Cerebral ischemic comorbidities (OR, 2.837, 95% CI, 1.070-7.523; P = 0.036) and aneurysm size as dichotomous variables (OR, 7.557; 95% CI, 2.975-19.198; P < 0.001) were strongly correlated with neurologic complications in the final adjusted multivariate logistic analysis.

CONCLUSIONS

Unruptured paraclinoid aneurysms after endovascular treatments had 5.2% of neurologic complications. Cerebral ischemic comorbidities and aneurysm size were predictors of neurologic complications.

Microsurgical treatment of carotid-ophthalmic aneurysm associated with multiple anterior and posterior circulation aneurysms: A case report

BACKGROUND

The clipping of multiple intracranial aneurysms in 1 stage is uncommon. In this case, we report clipping of an ophthalmic aneurysm associated with multiple anterior and posterior circulation aneurysms via the Dolenc approach.

METHODS

The main symptoms of the patient are headache, along with nausea and vomiting. The patient's arteriogram revealed a wide-necked aneurysm of the right ophthalmic artery, an irregular aneurysm of the anterior communicating artery, and a basilar artery aneurysm. The surgical intervention for these aneurysms is a challenge because of the complex anatomical relationship with the surrounding structures. The 3 aneurysms, which were not amenable to a single intervention, were successfully clipped in 1 incision.

RESULTS

After surgery, the patient reported feeling well. One year after surgery, the patient had no SAH recurrence.

CONCLUSIONS

Occasionally, surgical treatment was used even for aneurysms of the carotid-ophthalmic artery with aneurysms of anterior communicating artery and basilar artery, which are contraindicated for interventional therapy.

Larger inflow angle and incomplete occlusion predict recanalization of unruptured paraclinoid aneurysms after endovascular treatment

BACKGROUND

Unruptured paraclinoid aneurysms have a high incidence of aneurysm recanalization (AR) after endovascular treatment. We aimed to identify the incidence and predictors of AR in these lesions.

METHODS

We retrospectively analyzed consecutive patients with unruptured paraclinoid aneurysms who underwent endovascular treatment between January 2013 and December 2014. Patients with fusiform aneurysms, dissection aneurysms, traumatic aneurysms, or without digital subtraction angiography (DSA) at follow-up, were excluded. AR was defined as any aneurysm remnant that had increased in size or contrast filling that was observed via DSA at the follow-up. Univariate and multivariate logistic regression analyses were performed to assess the predictors of AR.

RESULTS

We included 145 patients with 150 unruptured paraclinoid aneurysms in the analysis. The incidence of AR was 8.7% (95% confidence interval (CI): 4.7-13.3%) at a mean follow-up of 7.4 months. In the univariate analysis, AR was associated with aneurysm size (odd ratio (OR): 6.098; 95% CI: 1.870-19.886; p = 0.003), location (OR: 3.88; 95% CI: 1.196-12.583; p = 0.024), inflow angle (OR: 6.852; 95% CI: 1.463-32.087; p = 0.015), and Raymond scale (OR: 12.473; 95% CI: 2.7496-56.59; p < 0.001). In the adjusted multivariate analysis, AR was independently predicted by Raymond scale (OR: 9.136; 95% CI: 1.683-49.587; p = 0.001) and inflow angle (OR: 16.159; 95% CI: 3.211-81.308; p = 0.01).

CONCLUSIONS

Unruptured paraclinoid aneurysms had a high incidence of AR after endovascular treatment. An inflow angle of ≥90 degrees and incomplete occlusion were significant predictors of AR.

Treatment strategies for complex intracranial aneurysms: review of a 12-year experience at the university of cincinnati

Complex intracranial aneurysms (CIAs) include those classified as giant, those located in brain regions of technically difficult access, or that involve arterial trunks/branches, and/or have complicated wall structure. We reviewed retrospectively our management of such lesions in a 12-year period. From 1997 to 2009, 192 patients were admitted with CIAs (133 females, 59 males; average age 55 years); 128 presented with subarachnoid hemorrhage (SAH) and 64 with unruptured, symptomatic CIAs. The SAH group had 73 anterior- and 55 posterior-circulation aneurysms. Most frequent location was middle cerebral artery. Treatment strategies included clipping (65.6%), coiling/stenting (28.1%), bypass (3.1%), no treatment (3.1%). Coiling/stenting was exclusively used for posterior-circulation aneurysms. Outcomes were good (modified Rankin Scale [mRS] 0 to 2) in 54 patients (42.2%), fair (mRS = 3 to 4) in 38 (29.7%), and poor (mRS = 5 to 6) in 36 (28.1%). Among unruptured CIAs, there were 47 anterior- and 17 posterior-circulation aneurysms. Most frequent location was ophthalmic. Thirty (46.9%) were clipped, 19 (29.7%) coiled, 6 (9.4%) by-passed, 2 (3.1%) wrapped, and 7 (10.9%) had no treatment. Outcomes were good in 57 patients (89%) and fair in 7 (11%). Good outcomes were obtained in unruptured CIAs using a multidisciplinary approach. Ruptured CIAs carry a significantly worse prognosis than overall SAH patients.

The avoidance of microsurgical complications in the extradural anterior clinoidectomy to paraclinoid aneurysms

OBJECTIVE

Paraclinoid segment internal carotid artery (ICA) aneurysms have historically been a technical challenge for neurovascular surgeons. The development of microsurgical approach, advances in surgical techniques, and endovascular procedures have improved the outcome for paraclinoid aneurysms. However, many authors have reported high complication rates from microsurgical treatments. Therefore, the present study reviews the microsurgical complications of the extradural anterior clinoidectomy for treating paraclinoid aneurysms and investigates the prevention and management of observed complications.

METHODS

Between January 2004 and April 2008, 22 patients with 24 paraclinoid aneurysms underwent microsurgical direct clipping by a cerebrovascular team at a regional neurosurgical center. Microsurgery was performed via an ipsilateral pterional approach with extradural anterior clinoidectomy. We retrospectively reviewed patients' medical charts, office records, radiographic studies, and operative records.

RESULTS

IN OUR SERIES, THE CLINICAL OUTCOMES AFTER AN IPSILATERAL PTERIONAL APPROACH WITH EXTRADURAL ANTERIOR CLINOIDECTOMY FOR PARACLINOID ANEURYSMS WERE EXCELLENT OR GOOD (GLASGOWS OUTCOME SCALE : GOS 5 or 4) in 87.5% of cases. The microsurgical complications related directly to the extradural anterior clinoidectomy included transient cranial nerve palsy (6), cerebrospinal fluid leak (1), worsened change in vision (1), unplanned ICA occlusion (1), and epidural hematoma (1). Only one of the complications resulted in permanent morbidity (4.2%), and none resulted in death.

CONCLUSION

Although surgical complications are still reported to occur more frequently for the treatment of paraclinoid aneurysms, the permanent morbidity and mortality resulting from a extradural anterior clinoidectomy in our series were lower than previously reported. Precise anatomical knowledge combined with several microsurgical tactics can help to achieve good outcomes with minimal complications.

Circulatory arrest and deep hypothermia for the treatment of complex intracranial aneurysms--results from a single European center

BACKGROUND

Vascular neurosurgery faces the controversial discussion about the need for deep hypothermia and circulatory arrest (dh/ca) for the treatment of complex cerebral aneurysms. In this retrospective analysis, we present our experience in the treatment of 26 giant and large cerebral aneurysms under profound hypothermia and circulatory arrest.

METHODS

All patients were treated surgically under dh/ca. Seventeen patients had aneurysms of the anterior circulation, and nine patients had aneurysms of the posterior circulation. Thrombosis or calcification was found in ten patients. Eleven patients presented with subarachnoid hemorrhage. The seven patients with the longest circulation arrest time were analyzed in detail.

RESULTS

Subarachnoid hemorrhage led to hospital admission in 42% (n = 11) of cases. The overall mortality was 11.5%, and the overall morbidity was 15%. Ten patients deteriorated transiently but fully recovered. The mean age, Glasgow Coma Score, Fisher, and Hunt and Hess Score correlated significantly with the long-term outcome. Circulation arrest time correlated significantly to the neurological outcome on discharge. All patients with prolonged circulation arrest times had wide aneurysmal necks, and four had adjacent vessels to the dome or the parent vessel included in the neck. We observed a significant increase of neurological deficits immediately postoperatively, but this neurological deterioration resolved over time.

CONCLUSIONS

We observed neurological deterioration immediately postoperatively in 13 patients, but all patients fully recovered within 6 months except for four patients. A long cardiac arrest time reflected complex pathoanatomical conditions. We conclude that the clipping procedure under deep hypothermia and circulatory arrest remains a pivotal armament in complex vascular neurosurgery.