Combined Endovascular and Microsurgical Management of Giant and Complex Unruptured Aneurysms

Francisco A. Ponce, M.D.; Felipe C. Albuquerque, M.D.; Cameron G. Mcdougall, M.D.; Patrick P. Han, M.D.; Joseph M. Zabramski, M.D.; Robert F. Spetzler, M.D.


Neurosurg Focus. 2004;17(5) 

In This Article

Clinical Material and Methods

The records of 21 patients who underwent combination therapy for unruptured aneurysms between January 1997 and March 2003 were reviewed to determine aneurysm location, type of endovascular and surgical intervention, follow-up results of treatment, and associated complications. Only patients for whom a combined endovascular and surgical intervention was planned at the start of treatment were included in the study. Patients undergoing clip placement for the recurrence of an aneurysm previously treated with coil occlusion or coil occlusion for the recurrence of an aneurysm previously treated with clip placement were excluded. All patients were followed for the development of treatment-related sequelae by using a prospectively maintained database.

There were 21 patients (eight men and 13 women) included in this study. Their mean age was 55.1 ± 13.7 years (mean ± standard deviation). Their median age was 55 years (range 22-73 years). Fourteen patients presented with symptoms related to mass effect of the aneurysm, two with headaches, and two with ischemia. Aneurysms were diagnosed incidentally in two patients ( Table 1 ).

Of the 21 aneurysms, 11 (52.4%) were located in the anterior circulation and 10 (47.6%) were located in the posterior circulation. In the posterior circulation, six aneurysms (28.5%) involved the PCA, and two each (9.5%) the basilar apex and basilar trunk. In the anterior circulation, seven lesions (33.3%) involved the cavernous ICA, and one each (4.8%) the ACoA, the junction of the A2 and A3 segments of the ACA, the petrous ICA, and the cervical ICA. Factors contributing to the complexity of the lesions were identified and included nine giant, four dissecting, and four dolichoectatic aneurysms; previous clip occlusion of two lesions; a calcified neck in one; and significant scarring in one.

Treatment decisions were made for all 21 patients after the cases were reviewed by the neurovascular team, which included two cerebrovascular surgeons (R.F.S., J.M.Z.) and two endovascular neurosurgeons (C.G.M., F.C.A.). Microvascular procedures included 17 extracranial-intracranial bypasses, two intracranial-intracranial bypasses, one arterial clip placement for flow redirection, and one transposition of the cervical ICA to facilitate endovascular therapy ( Table 2 ). All but one of the endovascular techniques involved parent-vessel occlusion. One patient underwent stent-assisted coil placement.

Eight patients harbored anterior circulation aneurysms that were treated with microsurgical extracranial-intracranial bypass followed by endovascular parent-vessel occlusion. Among these patients, all eight underwent an STA-MCA bypass for seven aneurysms involving the cavernous ICA, including one pseudoaneurysm related to transsphenoidal surgery and one involving the petrous ICA.

The six patients with PCA aneurysms were treated with extracranial-intracranial revascularization and endovascular parent-vessel occlusion. Six patients harbored aneurysms of the PCA (one giant, four dissecting, one fusiform; four of the P1-P2 junction; one of the P2 segment; and one of the P3/P4 junction), five of whom underwent an OA-PCA anastomosis followed by endovascular coil placement and occlusion of the aneurysm and PCA. The other patient underwent an OA onlay. The patient with a dissecting aneurysm at the P3-P4 junction of the PCA underwent an OA onlay, followed by endovascular balloon occlusion of the parent vessel. A patient with a giant basilar apex aneurysm was treated with coil embolization followed by an STA-SCA bypass.

Four patients underwent flow redirection procedures. A patient with a giant basilar tip aneurysm underwent clip placement on P1 away from the aneurysm to redirect flow. She later underwent endovascular stent placement in the BA and contralateral PCA and stent-assisted coil placement in the basilar trunk aneurysm. A patient with a large right A2 aneurysm underwent a pericallosal artery microsurgical bypass followed by endovascular parent-vessel occlusion of the right A1 to redirect flow through the aneurysm. Two patients underwent STA-SCA anastomosis followed by endovascular occlusion of the VAs to reverse flow through the BA.

A patient with the giant ACoA aneurysm underwent an A3-A3 bypass followed by clip occlusion of the aneurysm. One day later, this patient underwent endovascular coil placement in the inflow into the giant ACA. Another patient with a high cervical ICA aneurysm was found to have a tortuous cervical carotid artery. To render the artery amenable to stent placement, the ICA was transposed surgically, thus straightening the portion of the artery that harbored the aneurysm. The aneurysm was then treated with stent placement and coil occlusion.