Monitored gradual occlusion of the internal carotid artery followed by ligation for giant internal carotid artery aneurysms

Superficial Temporal Artery-Middle Cerebral Artery Bypass Combined with Internal Carotid Ligation in Treating Complex Internal Carotid Aneurysms. The Willis Polygon Score is an Effective Solution for Developing Countries

OBJECTIVE

Internal carotid complex aneurysms (ICCAs) management is challenging. Ligating the internal carotid artery (ICA) combined with Superficial Temporal Artery-Middle Cerebral Artery (STA-MCA) anastomosis is an effective treatment option. Balloon test occlusion (BTO) assessments for preoperative decision-making are unaffordable in developing countries. This article discusses the study of Willis polygon (WP) segments as an option and suggests a score for decision-making. Herein, we report the outcomes of a series of patients treated for ICCA aneurysms at a single institution.

METHODS

From September 2016 to December 2020, we conducted a retrospective cohort study that analyzed data from patients with ICCAs. Among them, 9 patients received treatment involving ICA ligation combined with STA-MCA anastomosis. Partial or total carotid ligation was determined by using the WP score (WPS).

RESULTS

All Patients underwent STA-MCA anastomosis, in addition to total ICA ligation in 7 patients and partial ICA ligation in 2 patients with a WPS of 7 and 5, respectively. Patients with partially ligated carotid arteries were referred to an overseas neurointerventional center 12 months after surgery. As the BTO test was negative, they underwent ICA occlusion by coiling. Postoperative clinical outcomes did not change in 8/9 patients. In 1 patient, we reported a minor parietal stroke; the patient recovered completely after 6 months. Total aneurysm exclusion by thrombosis was achieved in 7/9 patients after total ICA ligation alone and in 2/9 patients after partial ICA ligation combined with coiling.

CONCLUSIONS

Limited access to endovascular assessment techniques such as BTO poses challenges in managing ICCAs. The WPS for decision-making appears to be a simple and safe option. In addition to STA-MCA bypass surgery, total or partial ICA ligation may be proposed depending on the WPS. After 12 months, patients with low WPS who underwent partial ICA ligation combined with bypass had postoperative normal BTO.

Management of Double Carotid Blow Out with Definitive Repair After Temporizing Stent Graft Placement

Carotid blowout syndrome is a life-threatening complication for patients with head and neck cancer. Temporizing stent graft procedures improve short-term survival and can be the definitive treatment for various reasons, including a poor oncologic prognosis, unsuitability for definitive reconstruction, or a lack of operative options. A second carotid blowout will often be fatal. Preventing such events requires multidisciplinary strategic planning because of a hostile reoperative field. We have described a case of a 44-year-old man with a history of laryngeal cancer who had experienced a carotid blowout. Treated with a stent graft, the patient had experienced a second event 6 weeks later. Treatment involved excision and suture ligation with rotational muscle flap coverage.

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.

Flow Diversion for the Treatment of Petrous Internal Carotid Artery Aneurysms

Petrous internal carotid artery (ICA) aneurysms are rare and pose a unique management dilemma. They are most commonly fusiform. They are difficult to treat surgically and typically not amenable to selective aneurysmal obliteration. The advent of flow diverters, such as the Pipeline endovascular device, has offered a new approach to these historically challenging lesions. The unique utility of flow diversion in treatment of petrous ICA aneurysms is reviewed and discussed.

Rationale for graft selection in patients with complex internal carotid artery aneurysms treated with extracranial to intracranial high-flow bypass and therapeutic internal carotid artery occlusion

OBJECTIVE After internal carotid artery (ICA) sacrifice without revascularization for complex aneurysms, ischemic complications can occur. In addition, hemodynamic alterations in the circle of Willis create conditions conducive to the formation of de novo aneurysms or the enlargement of existing untreated aneurysms. Therefore, the revascularization technique remains indispensable. Because vessel sizes and the development of collateral circulation are different in each patient, the ideal graft size to prevent low flow-related ischemic complications (LRICs) in external carotid artery (ECA)-middle cerebral artery (MCA) bypass with therapeutic ICA occlusion (ICAO) has not been well established. Authors of this study hypothesized that the adequate graft size could be calculated from the size of the sacrificed ICA and the values of MCA pressure (MCAP) and undertook an investigation in patients with complex ICA aneurysms treated with ECA-graft-MCA bypass and therapeutic ICAO. METHODS In the period between July 2006 and January 2016, 80 patients with complex ICA aneurysms were treated with ECA-MCA bypass and therapeutic ICAO. Preoperative balloon test occlusion (BTO) was performed, and the BTO pressure ratio was defined as the mean stump pressure/mean preocclusion pressure. Low flow-related ischemic complications were defined as new postoperative neurological deficits and ipsilateral cerebral blood flow reduction. Initial MCAP (iMCAP), MCAP after clamping the ICA (cMCAP), and MCAP after releasing the graft (gMCAP) were intraoperatively monitored. The MCAP ratio was defined as gMCAP/iMCAP. Based on the Hagen-Poiseuille law, the expected MCAP ratio ([expected gMCAP]/iMCAP) was hypothesized as follows: (1 - cMCAP/iMCAP)(graft radius/ICA radius)² + (cMCAP/iMCAP). Correlations between the BTO pressure ratio and cMCAP/iMCAP, and between the actual and expected MCAP ratios, were evaluated. Risk factors for LRICs were also evaluated. RESULTS The mean BTO pressure ratio was significantly correlated with the mean cMCAP/iMCAP (r = 0.68, p < 0.0001). The actual MCAP ratio correlated with the expected MCAP ratio (r = 0.43, p < 0.0001). If the expected MCAP ratio was set up using the BTO pressure ratio instead of cMCAP/iMCAP (BTO-expected MCAP ratio), the mean BTO-expected MCAP ratio significantly correlated with the expected MCAP ratio (r = 0.95, p < 0.0001). During a median follow-up period of 26.1 months, LRICs were observed in 9 patients (11%). An actual MCAP ratio < 0.80 (p = 0.003), expected MCAP ratio < 0.80 (p = 0.001), and (M₂ radius/graft radius)² < 0.49 (p = 0.002) were related to LRICs according to the Cox proportional-hazards model. CONCLUSIONS Data in the present study indicated that it was important to use an adequate graft to achieve a sufficient MCAP ratio in order to avoid LRICs and that the adequate graft size could be evaluated based on a formula in patients with complex ICA aneurysms treated with ICAO.

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.

Rescue Bypass for Revascularization After Ischemic Complications in the Treatment of Giant or Complex Intracranial Aneurysms

BACKGROUND

Surgical trapping or endovascular deconstruction commonly is used for the treatment of giant or complex intracranial aneurysms. Preoperative balloon test occlusion and cerebral blood flow studies and intraoperative neurophysiologic monitoring can indicate whether sufficient collateralization exists or whether revascularization is needed. Hemodynamic insufficiency can occur, however, despite passing these tests, necessitating posttreatment revascularization.

METHODS

We conducted a retrospective review of patients who underwent surgical or endovascular parent vessel occlusion for the management of giant or complex intracranial aneurysms and subsequently required rescue bypass for symptoms of hemodynamic insufficiency. Pre- and postrevascularization functional status was measured with the modified Rankin Scale.

RESULTS

During a 15-year period from 1997 to 2012, a rescue bypass was performed in 5 patients each harboring a giant or complex intracranial internal carotid artery (ICA) aneurysm that was treated with surgical trapping or endovascular deconstruction in a previous procedure. All bypasses were extracranial-to-intracranial and included cervical ICA to middle cerebral artery, subclavian to middle cerebral artery, and cervical ICA to supraclinoid ICA anastomoses via either a saphenous vein or radial artery graft. Functional outcome at time of last follow-up was improved in each patient (improvement in modified Rankin Scale of 1-3 points).

CONCLUSIONS

Ischemic complications must always be anticipated in the treatment of giant or complex intracranial aneurysms, even if pre- and intraoperative blood flow studies indicate sufficient collateralization. Here we show that extracranial-to-intracranial bypass is an effective option to rescue unanticipated hemodynamic insufficiency after parent vessel occlusion. This study emphasizes the need for cerebrovascular surgeons to maintain proficiency in complex bypass techniques.

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.