Endosaccular Treatment of Very Large and Giant Intracranial Aneurysms with Parent Artery Preservation : Single Center Experience with Long Term Follow-up

Dolenc approach for clipping of giant C6 and C7 segment aneurysms of the internal carotid artery

Objective

Surgical treatment for giant aneurysms of the ICA-ophthalmic segment (C6) and communicating artery segment (C7) is a challenge for neurosurgeons because of their high risks and poor outcomes. We aim to explore the advantages and disadvantages of the Dolenc approach in the treatment of giant C6-C7 segment aneurysms.

Methods

We retrospectively reviewed the clinical data of 13 cases with giant C6 aneurysms and 4 cases with giant C7 aneurysms treated with the Dolenc approach.

Results

All 17 cases of aneurysms were clipped successfully using the Dolenc approach, of which, 1 case with ipsilateral MCA occlusion underwent extracranial-intracranial artery bypass after the aneurysm clipping. Regarding clinical outcomes, six out of nine cases with preoperative visual impairment improved after surgery, two cases saw no change, and one case deteriorated. Of all the cases, one had new-onset vision loss, four had new-onset oculomotor paralysis, three had surgical side cerebral infarction, and two had diabetes insipidus. DSA or CTA examination within 2 weeks after surgery showed that all aneurysms were completely clipped without residual. After a follow-up of 9-12 months, 17 patients were evaluated based on GOS and CTA examination. A total of 14 cases had GOS 5 scores, 2 cases had GOS 4 scores, 1 case had GOS 2 scores, and no cases had death. None of the patients had recurrence based on CTA examinations.

Conclusion

Through the Dolenc approach, we could achieve more operation space and expose clinoid segments for temporary occlusion. Therefore, the Dolenc approach was shown to be a safe, effective, and feasible treatment for giant C6-C7 aneurysms.

Microsurgical Treatment of Previously Coiled Giant Aneurysms: Experience with 6 Cases and Literature Review

OBJECTIVE

Surgical treatment of insufficiently embolized (coiled) or recurrent giant aneurysms has not been well established in the literature. The aim of this study is to bring up the surgical difficulties of these rare aneurysms and to offer solutions.

METHODS

A database was queried for giant aneurysms that had been previously embolized and subsequently required surgical treatment. We only found 29 aneurysms in the literature and here, we report 6 more surgical cases with patient characteristics, radiological studies, applied surgical techniques, and outcomes which were reviewed retrospectively.

RESULTS

Four females and 2 males, with a mean age of 45.6 years took part in the study. The most common aneurysm location was the middle cerebral artery. While 5 aneurysms were successfully clipped, 1 was excised and the neck was closed with micro sutures. The coils were compulsorily removed in 3 patients. Postoperative digital subtraction angiography confirmed total occlusion of the aneurysms in all cases. Overall morbidity was 16.6%. There was no mortality. No recurrence was observed in the angiographic follow-up (mean 22.6 months, range 7-47 months). The literature review also determined that 97.1% of 35 previously coiled giant aneurysms (including ours) were occluded using various surgical techniques, with 82.8% good outcome.

CONCLUSIONS

Surgical clipping is a safe and effective procedure for the treatment of insufficiently embolized or recurrent giant aneurysms after coiling. If possible, the coils should not be removed. However, if safe clipping is not possible due to the coils, the removal of the coils should not be avoided.

Therapeutic Effects of Microsurgical Clipping at Different Time Points on Intracranial Aneurysm and Prognostic Factors

Background

Microsurgical clipping is effective for treating early rupture hemorrhage in intracranial aneurysm (IA) patients. We aimed to evaluate the therapeutic effects of microsurgical clipping at different time points on IA and to explore prognostic factors.

Methods

A total of 102 eligible patients were divided into good prognosis group (n = 87) and poor prognosis group (n = 15) according to Glasgow Outcome Scale (GOS) scores at discharge. The effects of microsurgical clipping at different time points (within 24 h, 48 h and 72 h) were compared. The incidence rates of postoperative complications in patients with different Hunt–Hess grades were compared. Prognostic factors were determined by multivariate logistic regression analysis. The nomogram prediction model was established based on independent risk factors and validated.

Results

The good recovery and success rates of complete aneurysm clipping were significantly higher in patients undergoing surgery within 24 h after rupture. The incidence rate of complications was significantly higher in patients with Hunt–Hess grade IV. Good and poor prognosis groups had significantly different age, history of hypertension, preoperative intracranial hematoma volume, aneurysm size, preoperative Hunt–Hess grade, later surgery, postoperative complications and National Institute of Health Stroke Scale (NIHSS) score, as independent risk factors for prognosis. The nomogram model predicted that poor prognosis rate was 14.71%.

Conclusion

Timing (within 24 h after rupture) microsurgical clipping benefits the prognosis of IA patients. Age, history of hypertension, preoperative intracranial hematoma volume, aneurysm size, preoperative Hunt–Hess grade, later surgery, postoperative complications and NIHSS score are independent risk factors for poor prognosis.

Incidental Microaneurysms During Microvascular Surgery: Incidence, Treatment, and Significance

BACKGROUND

Although new imaging tools have been developed for the detection of smaller aneurysms, angiographically negative microaneurysms are still encountered during cerebral microsurgery. Currently, only limited information regarding incidence and efficacy of treatment of these microaneurysms is available.

METHODS

We investigated the incidence and treatment of incidental microaneurysms (IMAs) in the last 5 years. IMAs are unidentifiable and invisible on preoperative angiography, but are detected during microvascular surgery. The inclusion criteria were aneurysm cases treated with microsurgery via transsylvian approaches, and those undergoing preoperative digital subtraction angiography.

RESULTS

This study enrolled 484 surgical cases (248 cases of subarachnoid hemorrhage and 236 cases of unruptured aneurysms) in 460 patients, and 33 tiny aneurysms were found in 31 operative cases (6.4% incidence per operation). The most typical type was located on another branching site of the middle cerebral artery found during neck clipping of the middle cerebral artery bifurcation aneurysm. A patient with multiple aneurysms presented a statistically significant risk (375/78 vs. 15/16; P < 0.001) of IMA identification. IMAs were treated by clipping and wrapping in 18 and 15 cases, respectively, without complications.

CONCLUSIONS

This study revealed a 6.4% incidence of IMAs; however, this could be underestimated because of the limited range of inspection. Early detection of an IMA through careful inspection during microvascular surgery could be beneficial, especially in patients with multiple aneurysms.

Predictors of Periprocedural Complications and Angiographic Outcomes of Endovascular Therapy for Large and Giant Intracranial Posterior Circulation Aneurysms

OBJECTIVE

To explore the predictors of periprocedural complications and angiographic outcomes in large and giant intracranial posterior circulation aneurysms after endovascular treatment.

METHODS

Data from 99 patients with 103 large (≥10 mm; n = 94) and giant (>25 mm; n = 9) posterior circulation aneurysms treated with endovascular therapy at a single center were retrospectively analyzed. The treatment procedures included endovascular trapping (n = 15), coiling (n = 6), stent only (n = 10), stent-assisted coiling (n = 48), and pipeline embolization device (PED; n = 24). The outcome endpoints were the number of periprocedural complications and number of complete occlusions without any complication.

RESULTS

Multivariate analysis revealed that intradural vertebral aneurysms (P = 0.041) and aneurysms ≤25 mm (P = 0.042) were associated with low periprocedural complication rates after endovascular therapy. Aneurysms not involving side branches (P = 0.024) and intradural vertebral aneurysms (P = 0.032) were predictors of complete aneurysm obliteration. No statistically significant differences were found in aneurysmal complete obliteration (P = 0.119) or periprocedural complications (P = 0.248) between a PED and traditional stent and coiling. Additionally, aneurysms not involving side branches (P = 0.030), intradural vertebral artery aneurysms (P = 0.003), and aneurysms treated with a PED (P = 0.020) were more likely to achieve complete occlusion over time.

CONCLUSIONS

Aneurysm location, aneurysm size, and side branch involvement were predictors of periprocedural complications and angiographic outcomes of endovascular therapy for large and giant intracranial posterior circulation aneurysms. PED use provided no advantages compared with traditional stent and coiling in aneurysmal occlusion rates and periprocedural complications. Large case-control and long-term follow-up studies are needed to further explore the predictors of complications and angiographic outcomes and optimal treatment options for these aneurysms.