Two-Stage Revascularization and Clip Reconstruction of a Giant Ophthalmic Artery Aneurysm: 3-Dimensional Operative Video

Abstract Ophthalmic segment aneurysms (OSAs) are technically challenging lesions with a wide-neck morphology and proximity to the optic nerve. Revascularization and aneurysm trapping are occasionally needed to manage unclippable OSAs. Microsurgical treatment requires anterior clinoidectomy, optic strut drilling, and proximal/distal dural ring dissection for adequate exposure. This video demonstrates a two-stage revascularization and clip reconstruction of an OSA. A 62-yr-old woman was presented, with acute-onset expressive aphasia, right hemineglect, and hemiparesis. Neuroimaging revealed a partially thrombosed giant OSA measuring 2.5 × 2.3 cm2. Patient consent was obtained for bypassing, trapping, and decompressing the aneurysm. A pterional craniotomy was performed and an external carotid artery – radial artery graft – middle cerebral artery bypass was performed. The aneurysm was proximally occluded with a permanent clip on the clinoidal internal carotid artery (ICA). Adherence of the distal supraclinoid ICA to the aneurysm wall did not allow for aneurysm trapping. On postoperative day 8, the patient experienced acute mental status decline due to a frontal intraparenchymal hemorrhage. The aneurysm was trapped in a second surgery to occlude persistent retrograde aneurysm filling. The aneurysm sac was circumferentially dissected with temporary parent artery trapping. The OSA was opened and thrombectomized using an ultrasonic aspirator followed by trapping clip application. Postoperatively, the patient gradually returned to neurological baseline with minimal expressive aphasia. Although OSAs are preferentially treated with flow diversion, giant OSAs with significant mass effect may necessitate microsurgical clipping or trapping with decompressive thrombectomy. This case demonstrates that proximal clip occlusion may not be sufficient for aneurysm thrombosis and rupture prevention. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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External Carotid Artery-to-Middle Cerebral Artery Bypass Using a Saphenous Vein Graft With 3-Vessel Anastomosis for the Treatment of a Large, Ruptured Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa426 ◽

2021 ◽

Author(s):

Kristine Ravina ◽

Joshua Bakhsheshian ◽

Joseph N Carey ◽

Jonathan J Russin

Keyword(s):

Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Saphenous Vein ◽

Saphenous Vein Graft ◽

Artery Bypass ◽

Artery Aneurysm ◽

External Carotid Artery ◽

External Carotid ◽

Bifurcation Aneurysm

Abstract Cerebral revascularization is the treatment of choice for select complex intracranial aneurysms unamenable to traditional approaches.1 Complex middle cerebral artery (MCA) bifurcation aneurysms can include the origins of 1 or both M2 branches and may benefit from a revascularization strategy.2,3 A novel 3-vessel anastomosis technique combining side-to-side and end-to-side anastomoses, allowing for bihemispheric anterior cerebral artery revascularization, was recently reported.4 This 2-dimensional operative video presents the case of a 73-yr-old woman who presented as a Hunt-Hess grade 4 subarachnoid hemorrhage due to the rupture of a large right MCA bifurcation aneurysm. The aneurysm incorporated the origins of the frontal and temporal M2 branches and was deemed unfavorable for endovascular treatment. A strategy using a high-flow bypass from the external carotid artery to the MCA with a saphenous vein (SV) graft was planned to revascularize both M2 branches simultaneously, followed by clip-trapping of the aneurysm. Intraoperatively, the back walls of both M2 segments distal to the aneurysm were connected with a standard running suture, and the SV graft was then attached to the side-to-side construct in an end-to-side fashion. Catheter angiograms on postoperative days 1 and 6 demonstrated sustained patency of the anastomosis and good filling through the bypass. The patient's clinical course was complicated by vasospasm-related right MCA territory strokes, resulting in left-sided weakness, which significantly improved upon 3-mo follow-up with no new ischemia. The patient consented for inclusion in a prospective Institutional Review Board (IRB)-approved database from which this IRB-approved retrospective report was created.

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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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Opening of unusual vascular collaterals leads to early recanalization of a giant intracavernous carotid artery aneurysm following common carotid artery occlusion: A Case report and literature review

Surgical Neurology International ◽

10.25259/sni_597_2019 ◽

2020 ◽

Vol 11 ◽

pp. 62

Author(s):

Ana M. Castaño-Leon ◽

Jose F. Alen ◽

Alfonso Lagares

Keyword(s):

Carotid Artery ◽

Common Carotid Artery ◽

Artery Aneurysm ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

External Carotid Artery ◽

External Carotid ◽

Parent Artery ◽

Parent Artery Occlusion ◽

Intracavernous Carotid Artery

Background: Parent artery occlusion (PAO) with or without bypass surgery is a feasible treatment for large intracavernous carotid artery (ICCA) aneurysms. The ideal occlusion site (internal or common carotid artery [CCA]) and ischemic complications after PAO have received special attention since the description of the technique. Unfrequently, some patients can also develop unusual external carotid artery-internal carotid artery collateral pathways distal to the ligation site that can explain the failure to aneurysm size reduction. Case Description: We describe a rare case of delayed refilling of a large ICCA aneurysm partially thrombosed which early recanalized after surgical ligation of the cervical CCA through an unusual collateral pathway. Conclusion: Based on our experience, we recommend periodic long-term follow-up neuroimaging, especially in those cases where potential collateral branches have not been clearly identified in the preoperative studies.

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Transvenous Coil Embolization of a Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa454 ◽

2021 ◽

Author(s):

Santiago Gomez-Paz ◽

Yosuke Akamatsu ◽

Mohamed M Salem ◽

Justin M Moore ◽

Ajith J Thomas ◽

...

Keyword(s):

Carotid Artery ◽

Arteriovenous Fistula ◽

Coil Embolization ◽

Dural Arteriovenous Fistula ◽

External Carotid Artery ◽

Sigmoid Sinus ◽

Definitive Treatment ◽

External Carotid ◽

Type I ◽

Patient Consent

Abstract This case is a 66-yr-old woman with a 2-mo history of left-sided tinnitus. Workup with magnetic resonance angiography showed early opacification of the left sigmoid sinus and internal jugular vein as well as asymmetric and abundant opacification of the left external carotid artery branches, suspicious for a dural arteriovenous fistula (dAVF). Diagnosis was confirmed with cerebral angiography, consistent with a left-sided Cognard type I dAVF.1 Initial treatment attempt was made with transarterial 6% ethylene-vinyl alcohol copolymer (Onyx 18) embolization of feeders from the occipital and middle meningeal arteries. However, embolization was not curative and there was a recurrence of a highly bothersome tinnitus 3 wk following treatment. Angiography redemonstrated the transverse sinus dAVF with new recruitment arising from several feeders, including the left external carotid artery, middle meningeal artery, and superficial temporal artery, now Cognard type IIa. Definitive treatment through a transvenous coil embolization provided permanent obliteration of the fistula without recrudescence of symptoms on follow-up. In this video, the authors discuss the nuances of treating a dAVF via a transvenous embolization. Patient consent was given prior to the procedure, and consent and approval for this operative video were waived because of the retrospective nature of this manuscript and the anonymized video material.

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Cerebral hyperperfusion syndrome after external carotid artery–middle cerebral artery bypass for carotid artery giant aneurysm

Journal of Clinical Anesthesia ◽

10.1016/j.jclinane.2018.10.041 ◽

2019 ◽

Vol 54 ◽

pp. 41-42

Author(s):

Devika Bharadwaj ◽

Indu Kapoor ◽

Charu Mahajan ◽

Hemanshu Prabhakar

Keyword(s):

Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Artery Bypass ◽

Giant Aneurysm ◽

External Carotid Artery ◽

External Carotid ◽

Cerebral Hyperperfusion Syndrome ◽

Hyperperfusion Syndrome ◽

Cerebral Hyperperfusion

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Cerebral Protection with a Temporary Ascending Aorta–External Carotid Artery Bypass during Common Carotid Artery Revascularization

Annals of Vascular Surgery ◽

10.1016/j.avsg.2017.08.026 ◽

2018 ◽

Vol 46 ◽

pp. 368.e13-368.e17

Author(s):

Murat Ugurlucan ◽

Yilmaz Onal ◽

Didem Melis Oztas ◽

Cagla Canbay ◽

Ibrahim Demir ◽

...

Keyword(s):

Carotid Artery ◽

Common Carotid Artery ◽

Artery Bypass ◽

External Carotid Artery ◽

Ascending Aorta ◽

Cerebral Protection ◽

External Carotid

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Supraclinoid Internal Carotid Artery Aneurysm: Giant Supraclinoid Internal Carotid Artery Aneurysm, Treatment with Extra-Intracranial Bypass and Parent Artery Occlusion

The Aneurysm Casebook ◽

10.1007/978-3-319-77827-3_6 ◽

2020 ◽

pp. 271-282

Author(s):

Yerbol Makhambetov ◽

Assylbek Kaliyev

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Artery Aneurysm ◽

Artery Occlusion ◽

Parent Artery ◽

Carotid Artery Aneurysm ◽

Internal Carotid Artery Aneurysm ◽

Parent Artery Occlusion ◽

Supraclinoid Internal Carotid Artery

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Creation of a Middle Communicating Artery With External Carotid Artery-Radial Artery Graft-M2 Middle Cerebral Artery Interpositional Bypass and M2 Middle Cerebral Artery-M2 Middle Cerebral Artery Reimplantation for a Recurrent Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa244 ◽

2020 ◽

Vol 20 (1) ◽

pp. E44-E45

Author(s):

Fabio A Frisoli ◽

Joshua S Catapano ◽

Dimitri Benner ◽

Michael T Lawton

Keyword(s):

Carotid Artery ◽

Middle Cerebral Artery ◽

Radial Artery ◽

Cerebral Artery ◽

Artery Aneurysm ◽

External Carotid Artery ◽

External Carotid ◽

Radial Artery Graft ◽

Lenticulostriate Arteries ◽

Artery Graft

Abstract Dolichoectatic aneurysms of the middle cerebral artery (MCA) bifurcation pose unique treatment challenges.1 One treatment consists of an extracranial-intracranial (EC-IC) interpositional bypass and double-reimplantation of the M2 divisions.2-8 We present a variation of this construct in which an M2 MCA-M2 MCA end-to-side reimplantation was performed, creating a middle communicating artery (MCoA). The patient, a 61-yr-old woman, had previously undergone a “picket fence” clip reconstruction of an unruptured, giant left MCA bifurcation aneurysm in 2014.9 After the patient provided informed written consent for treatment, a 5-yr surveillance angiogram revealed substantial aneurysm regrowth opposite the clips. A pterional craniotomy was performed, and the aneurysm was exposed through a transsylvian approach. Proximal external carotid artery-radial artery graft (ECA-RAG) anastomosis was performed to arterialize the graft. The distal RAG was anastomosed end-to-side to the temporal division of the M2 segment, and the vessel proximal to the bypass inflow was transected from the aneurysm. We repurposed this “dead-end” as an MCoA by end-to-side reimplantation onto a branch of the frontal M2 trunk. The superior trunk was then clip occluded at its origin at the aneurysm. The aneurysm could not be proximally occluded due to lenticulostriate arteries arising from the back of the bifurcation. Postoperative angiography confirmed patency of the MCoA and its donor bypasses. The aneurysm no longer filled, and the lenticulostriate arteries were preserved. The patient was discharged on postoperative day 3 and made an excellent recovery (3-mo modified Rankin Scale [mRS] = 1). The MCoA is a novel construct that redistributed flow from the interpositional graft into the superior trunk, without the need for additional ischemia time while working with the inferior trunk. Used with permission from Barrow Neurological Institute.

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Cervical Vertebral Artery to Facial Branch External Carotid Artery Bypass: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa028 ◽

2020 ◽

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Carotid Artery ◽

Vertebral Artery ◽

Artery Bypass ◽

Video Recording ◽

Distal Segment ◽

External Carotid Artery ◽

External Carotid ◽

Transverse Foramen ◽

Institutional Review ◽

V1 Segment

Abstract Posterior circulation ischemia often presents with dizziness, ataxia, visual disturbances, or motor-sensory deficits. The vertebral artery stenosis most frequently involves the V1 segment proximal to the foraminal segment. This patient demonstrated critical stenosis of the left V1 segment of the vertebral artery related to atherosclerotic disease. A left cervical dissection was performed, and the cervical transverse foramen was opened to permit exposure of the vertebral artery in the V2 segment. The vertebral artery was proximally occluded and transected. An endarterectomy was performed, and an end-to-end anastomosis of the facial branch of the external carotid artery to the distal segment of the transected vertebral artery was completed. Indocyanine green angiography was used to confirm patency of the anastomosis. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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