Microsurgical treatment strategy for large and giant aneurysms of the internal carotid artery

Abstract BACKGROUND: Optimal treatment of intracranial aneurysms involves complete occlusion of the aneurysm with preservation of the parent artery and all of its branches. Attempts to occlude the aneurysm and preserve the parent artery may be associated with a higher level of risk than parent vessel occlusion or trapping. OBJECTIVE: To evaluate our series of patients with large and giant aneurysms who underwent treatment via endovascular coiling with parent artery sacrifice or surgical ligation of the common carotid artery (CCA) and gain insight into the advantages and risks of each of these alternatives. METHODS: We retrospectively reviewed all patients with aneurysms who underwent carotid sacrifice via endovascular occlusion or surgical CCA ligation during an 8-year period at our institution. RESULTS: Twenty-seven patients with large and giant aneurysms of the internal carotid artery underwent carotid artery sacrifice via endovascular occlusion (n = 15) or CCA ligation (n = 12). Of the patients who underwent endovascular occlusion, 3 developed groin complications, 1 developed a new sixth nerve palsy, 1 died from vasospasm related to subarachnoid hemorrhage, and 1 died secondary to rupture of an associated 3-mm anterior communicating artery aneurysm 5 days postoperatively. Of the patients undergoing CCA ligation, 1 patient developed a partial hypoglossal palsy. Clinical improvement of presenting symptoms was observed in all surviving patients regardless of the method of treatment. Complete aneurysm obliteration was documented in all patients during the initial hospital stay. The mean radiographic long-term follow-up was 14.2 months, which was available in 20 of the 25 surviving patients (80%). Complete obliteration was confirmed at follow-up in all but 2 patients with large cavernous aneurysms; 1 was initially treated with endovascular occlusion and the other with carotid ligation. CONCLUSION: Parent artery sacrifice is still a viable treatment for some complex aneurysms of the internal carotid artery. CCA ligation is a reasonable alternative to endovascular arterial sacrifice.

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Therapeutic Internal Carotid Artery Occlusion for Large and Giant Aneurysms: A Single Center Cohort of 146 Patients

American Journal of Neuroradiology ◽

10.3174/ajnr.a4487 ◽

2015 ◽

Vol 37 (1) ◽

pp. 125-129 ◽

Cited By ~ 15

Author(s):

R.S. Bechan ◽

C.B. Majoie ◽

M.E. Sprengers ◽

J.P. Peluso ◽

M. Sluzewski ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Internal Carotid Artery Occlusion ◽

Single Center ◽

Giant Aneurysms ◽

Large And Giant Aneurysms

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Suction decompression assisted clipping of large and giant internal carotid artery aneurysms

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v19i4.691 ◽

2018 ◽

Vol 19 (4) ◽

pp. 14-20

Author(s):

Sumit Sinha ◽

Takeya Watabe ◽

Yoko Kato ◽

Daikichi Oguri ◽

Shei Imizu ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Surgical Management ◽

Internal Carotid ◽

Preoperative Assessment ◽

Balloon Occlusion ◽

Unruptured Aneurysms ◽

Giant Aneurysms ◽

Proximal Internal Carotid Artery ◽

Large And Giant Aneurysms

Background: The microsurgical treatment of large and giant aneurysms poses a challenge and direct clipping is still prefferred: this is very dificulttask withrisksofintraoperativerupture. Microsurgical clipping with angioplastic arrangement of clips at the neck along with retrograde suction evacuation of the blood from the proximal internal carotid artery and aneurysm have been advocated in order to avoid these problems. Methods: This is a retrospective study of 13 patients with 13 large/ giant internal carotid artery aneurysms, who were managed surgically with retrograde suction decompression assisted clipping at our center over a period of last 2 years. The clinical profile, details of surgical management, complications and outcome of these patients were analysed. In the preoperative assessment, MRI/MR Angiography brain, 3Dimensional- Computed Tomography scan along with diagnostic angiography and balloon occlusion test were performed. The surgical technique has been described in detail. Results: The age ranged from 36-79 years old. There were 7 males and 6 females. 11 patients had unruptured aneurysms, while 2 presented with subarachnoid hemmorrhage. There were no peri-operative complications. In the post-operative period, one patient had severe disabilty with right sided hemiparesis due to the thrombo-embolic phenomenon, while the rest had an excellent outcom, with no mortality. Conclusions: Retrograde suction decompression is an effective aid in surgical management of large and giant aneurysms with many advantages. It is certainly an extremely useful adjunct for obtaining early proximal control so that safe clip application can be achieved. Intra-operative angiography can be performed easily to check adequacy of aneurysm clipping. Integration of endovascular techniques in management of complex aneurysms has made posible the advancement of the therapeutic armentarium.

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The modern role of microsurgery in treatment of large and giant aneurysms of the internal carotid artery

Voprosy neirokhirurgii imeni N N Burdenko ◽

10.17116/neiro201680551-61 ◽

2016 ◽

Vol 80 (5) ◽

pp. 51 ◽

Cited By ~ 2

Author(s):

O. D. Shekhtman ◽

Sh. Sh. Eliava ◽

S. B. Yakovlev ◽

Yu. V. Pilipenko ◽

An. N. Konovalov

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Giant Aneurysms ◽

Large And Giant Aneurysms

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Treatment strategy for giant aneurysms in the cavernous portion of the internal carotid artery

Surgical Neurology ◽

10.1016/j.surneu.2006.03.037 ◽

2007 ◽

Vol 67 (2) ◽

pp. 148-155 ◽

Cited By ~ 51

Author(s):

Yutaka Kai ◽

Jun-ichiro Hamada ◽

Motohiro Morioka ◽

Shigetoshi Yano ◽

Takamasa Mizuno ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Treatment Strategy ◽

Internal Carotid ◽

Giant Aneurysms

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Blister Aneurysms of the Internal Carotid Artery: Microsurgical Results and Management Strategy

Neurosurgery ◽

10.1227/neu.0000000000001259 ◽

2017 ◽

Vol 80 (2) ◽

pp. 235-247 ◽

Cited By ~ 27

Author(s):

Christopher M. Owen ◽

Nicola Montemurro ◽

Michael T. Lawton

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Treatment Strategy ◽

Internal Carotid ◽

Artery Bypass ◽

External Carotid ◽

Parent Artery ◽

Intraoperative Rupture

Abstract BACKGROUND: Blister aneurysms of the supraclinoid internal carotid artery (ICA) are challenging lesions with high intraoperative rupture rates and significant morbidity. An optimal treatment strategy for these aneurysms has not been established. OBJECTIVE: To analyze treatment strategy, operative techniques, and outcomes in a consecutive 17-year series of ICA blister aneurysms treated microsurgically. METHODS: Seventeen patients underwent blister aneurysm treatment with direct clipping, bypass and trapping, or clip-reinforced wrapping. RESULTS: Twelve aneurysms (71%) were treated with direct surgical clipping. Three patients required bypass: 1 superficial temporal artery to middle cerebral artery bypass, 1 external carotid artery to middle cerebral artery bypass, and 1 ICA to middle cerebral artery bypass. One patient was treated with clip-reinforced wrapping. Initial treatment strategy was enacted 71% of the time. Intraoperative rupture occurred in 7 patients (41%), doubling the rate of a poor outcome (57% vs 30% for patients with and without intraoperative rupture, respectively). Severe vasospasm developed in 9 of 16 patients (56%). Twelve patients (65%) were improved or unchanged after treatment, and 10 patients (59%) had good outcomes (modified Rankin Scale scores of 1 or 2). CONCLUSION: ICA blister aneurysms can be cautiously explored and treated with direct clipping as the first-line technique in the majority of cases. Complete trapping of the parent artery with temporary clips and placing permanent clip blades along normal arterial walls enables clipping that avoids intraoperative aneurysm rupture. Trapping/bypass is used as the second-line treatment, maintaining a low threshold for bypass with extensive or friable pathology of the carotid wall and in patients with incomplete circles of Willis.

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Successful management of bilateral internal carotid artery fusiform giant aneurysms in a patient with intimal fibroplasia using multiple flow diverters: With long-term imaging follow up

Interventional Neuroradiology ◽

10.1177/15910199211049129 ◽

2021 ◽

pp. 159101992110491

Author(s):

Jieun Roh ◽

Seung Kug Baik ◽

Jeong A Yeom ◽

Joo-Young Na ◽

Sang-Won Lee

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Flow Diverter ◽

Giant Aneurysms ◽

The Past ◽

Effective Treatment Modality ◽

Flow Diverters

The authors report a rare case of sequentially developed bilateral internal carotid artery (ICA) fusiform giant aneurysms in a patient with pathologically confirmed intimal fibroplasia. Both ICA fusiform aneurysms were treated with multiple flow diverter insertion and were well-managed over the past 5.5 years of follow-up. The development of aneurysms in this rare disease entity appears to be a lifelong process based on the authors’ observations in serial angiographic follow-up studies. Reconstruction therapy using flow-diverting stents in this unique condition may be a safe and effective treatment modality.

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