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.

Disclosures

Neurosurg Focus. 2004;17(5) 

In This Article

Illustrative Cases

This 65-year-old woman had a 3-month history of progressive proptosis, double vision, and intermittent headaches. Magnetic resonance imaging and magnetic resonance angiography revealed a mesial right temporal mass, and four-vessel angiography demonstrated a giant cavernous ICA aneurysm (Figure 1A).

Case 16. Cerebral angiograms and artist's rendering depicting the anterior circulation. Left: Preoperative lateral view of the right ICA demonstrating a giant cavernous carotid artery aneurysm. Center: Lateral view obtained after bypass and coil occlusion confirming obliteration of the aneurysm and occlusion of the ICA. Right: Illustration depicting the combined technique.

A right STA-MCA bypass was performed, and patency was documented using intraoperative angiography. Three days later the patient tolerated temporary test occlusion of the right ICA. Seven GDCs were inserted into the petrous and high cervical segments of the right ICA (Figure 1B and C). Complete occlusion of the vessel was documented, and a right external carotid artery injection demonstrated excellent filling of the distal MCA branches through the bypass graft. At her 6-month follow-up examination, the patient reported resolution of her symptoms. Angiography confirmed obliteration of the aneurysm and patency of the bypass graft.

This 51-year-old woman with a history of lung cancer presented with the sudden onset of slurred speech and weakness of the right arm. Imaging studies revealed a calcified basilar apex aneurysm extending into the third ventricle (Figure 2A) and an infarction of the left temporal lobe and posterior aspect of the left subinsular cortex. A three-stage approach, including clip placement, endovascular stent insertion, and embolization was recommended.

Case 13. Cerebral angiograms and artist's rendering depicting the posterior circulation. A: Anteroposterior view demonstrating a large basilar apex aneurysm. B: Anteroposterior view of the aneurysm after microsurgical clipping of the right P1 segment of the PCA. Subsequently, a stent was placed extending from the distal BA to the left P1 segment of the PCA. C: Angiogram obtained when the patient returned for further endovascular obliteration of the aneurysm with seven GDCs 3 weeks after placement of the stent. D: Illustration depicting the combined technique.

During surgery, the neck of the aneurysm could not be clipped satisfactorily because of the extensive thrombosis and calcification at its base. Therefore, the P1 segment of the right PCA was clipped as it emerged from the base of the aneurysm. The posterior communicating artery reconstituted the distal right PCA (Figure 2B). The second stage of treatment was stent placement. After the initial angiograms were obtained a 3 x 14-mm stent (Radius; Boston Scientific, Watertown, MA) was placed, extending from the left PCA down to the BA proximal to the SCAs. Three weeks later, the residual aneurysm was embolized with seven GDCs, which were placed without incident (Figure 2C and D). The patient later died of her underlying malignancy.

This 65-year-old man had received a diagnosis of a giant left PCA aneurysm 3 years earlier and had been told that the lesion was inoperable. He presented to us with progressive decline, including dizziness, right hemiparesis, and intermittent diplopia. Angiography confirmed the presence of the aneurysm (Figure 3A), and an OA-distal PCA bypass followed by coil embolization of the distal P2 segment of the PCA was recommended.

Case 19. Cerebral angiograms and artist's rendering depicting the posterior circulation. Left: Anteroposterior view demonstrating a large right-sided P1/P2 junction aneurysm. Center: Anteroposterior view of the aneurysm after OA-PCA bypass and coil embolization and occlusion of the lesion and parent artery. Right: Illustration depicting the combined technique.

Initially, the patient underwent a bioccipital craniotomy and microsurgical anastomosis of the right OA to the distal PCA. Two days later angiography demonstrated patency of the bypass, and the patient underwent coil embolization and occlusion of the aneurysm and parent artery (Figure 3B and C). Seven GDCs were deposited within the aneurysm. Subsequent angiography demonstrated filling of the PCA through the bypass graft but no filling of the aneurysm from the VA injections.

The patient's postoperative course was complicated by an occipital EDH, which caused right homonymous hemianopia. The hematoma was evacuated and the patient's left visual field cut resolved. At 1-year follow-up examination, the patient had resumed all activities of daily living.

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