Carotid endarterectomy and local intraarterial thrombolysis: Simultaneous procedure in acute occlusion of the internal carotid artery and middle cerebral artery embolism

Background: Very large and giant aneurysms (≥20 mm) of the internal carotid artery (ICA) bifurcation (ICAbif) are definitely rare, and optimal treatment is not established. Endovascular treatments are reported as suboptimal due to difficulties of complete occlusion and tendencies to recanalization. Therefore, direct surgery remains an effective strategy if the clipping can be performed safely and reliably, although very difficult. Case Description: Two cases of ICAbif aneurysms (>20 mm) were treated. Prior assistant superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed to avoid ischemic complications during prolonged temporary occlusion of the arteries in both cases. In Case 1 (22-mm aneurysm), the dome was inadvertently torn in applying the clip because trapping had resulted in insufficient decompression. Therefore, in Case 2 (28-mm aneurysm), almost complete trapping of the aneurysm and subsequent dome puncture was performed, and the aneurysm was totally deflated by suction from the incision. This complete aneurysm decompression allowed safe dissection and successful clipping. Conclusion: Trapping, deliberate aneurysm dome puncture, and suction decompression from the incision in conjunction with assistant STA-MCA bypass can achieve complete aneurysm deflation, and these techniques enable safe dissection of the aneurysm and direct clipping of the aneurysm neck. Direct clipping with this technique for very large and giant ICAbif aneurysms may be the optimal treatment choice with the acceptable outcome if endovascular treatment remains suboptimal.

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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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Middle cerebral artery dissections: Differences between isolated and extended dissections of internal carotid artery

Journal of the Neurological Sciences ◽

10.1016/j.jns.2005.03.047 ◽

2005 ◽

Vol 235 (1-2) ◽

pp. 37-44 ◽

Cited By ~ 29

Author(s):

Chin-Hsien Lin ◽

Jiann-Shing Jeng ◽

Ping-Keung Yip

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Internal Carotid

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Critical neurovascular brain anatomy

The Neurosurgeon's Handbook ◽

10.1093/med/9780198570677.003.0390 ◽

2010 ◽

pp. 504-517

Author(s):

George Samandouras

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Basilar Artery ◽

Internal Carotid ◽

Anterior Cerebral Artery ◽

Brain Anatomy ◽

Vertebral Arteries ◽

System P

Chapter 9.1 covers critical neurovascular brain anatomy, including internal carotid artery, the middle cerebral artery, the anterior cerebral artery, the vertebral arteries (VAs), the basilar artery (BA), and the venous system.

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