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) 

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Fifteen patients (71.4%) had excellent outcomes, three (14.3%) had good outcomes, and three (14.3%) died ( Table 2 ). One patient (Case 13) died of an underlying pulmonary malignancy. Another (Case 6) presented with ex tensor posturing after intraoperative rupture of his giant basilar trunk aneurysm. He suffered a postoperative EDH and died of brainstem compression caused by the aneurysm. The third patient who died (Case 8) had experienced a brainstem stroke 6 years earlier. His giant basilar trunk aneurysm was treated with an STA-SCA bypass, followed by coil occlusion of the right VA distal to the PICA. Three months later, BA thrombosis developed on the morning that he was scheduled to undergo endovascular occlusion of the contralateral VA, and he died.

The mean follow-up duration for the 18 surviving patients was 20 months (range 1-48 months). Eleven patients were symptom and disease free at follow-up review. Four patients' symptoms were unchanged from presentation, including three who presented with mass effect and one who continued to suffer headaches. Three patients suffered mild strokes that resulted in a homonymous hemianopia after occlusion of their bypass graft.

Immediate postoperative angiography confirmed obliteration of the lesion in 20 patients and demonstrated residual aneurysm in the other one. Angiographic follow-up studies were obtained in 14 of the 18 surviving patients and demonstrated complete occlusion or stable residual aneurysm in 13 and a 1-cm enlarging residual lesion in one. The latter patient underwent stent-assisted coil placement in the residual aneurysm.

Procedure-related complications occurred in eight cases. One patient had an occlusion of an OA-PCA bypass graft and a homonymous hemianopia developed; no treatment was given, and the deficit was permanent. Five patients suffered EDHs, all of which occurred after heparinization and endovascular treatment (Cases 1, 4, 6, 8, and 19). Among these, one patient (Case 6) presented in a coma and died shortly after evacuation of the EDH. An other patient (Case 8) died 3 months later of a brainstem stroke.

Homonymous hemianopia developed in three patients treated with OA-PCA revascularization (Cases 1, 4, and 19). In one (Case 1) the complication resolved completely, in one (Case 19) an occlusion of the graft developed and this patient was found to have a left PCA infarct, and in one (Case 4) a mild permanent visual field deficit was found. In one patient (Case 18) a pseudoaneurysm developed at the femoral artery after a cavernous ICA aneurysm was treated with coils. One patient (Case 2) required placement of a ventriculoperitoneal shunt after surgery to control increased intracranial pressure.