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

Neurosurgery ◽  
2017 ◽  
Vol 80 (2) ◽  
pp. 235-247 ◽  
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.

Internal Carotid Artery Occlusion for Cavernous Segment Aneurysm

Neurosurgery ◽  
1989 ◽  
Vol 25 (3) ◽  
pp. 398-404 ◽  
Author(s):  
John R. Little ◽  
Jeffrey V. Rosenfeld ◽  
Issam A. Awad
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Brain Ischemia ◽  
Internal Carotid ◽  
Artery Bypass ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Flow Monitoring

Abstract We review our recent experience with occlusion of the cervical internal carotid artery (ICA) in 15 patients with symptomatic aneurysms of the cavernous segment. All the patients were women and ranged in age from 38 to 74 years. Ten patients sought treatment initially for ophthalmoplegia, 9 for retro-orbital pain, 8 for facial paresthesia, and 3 for loss of vision. Two patients had symptoms of transient ocular or brain ischemia. The diameter of the aneurysm was greater than 3 cm in 10 patients. Ten patients underwent gradual occlusion of the ICA by Selverstone clamp under anticoagulation and monitoring of neurological status. One patient underwent ligation of a severely stenotic ICA under general anesthesia and electroencephalographic monitoring. Four patients underwent trapping of the aneurysm (after attempts at direct obliteration) under electroencephalographic and cerebral blood flow monitoring. Two patients with incompetent circle of Willis collaterals underwent prophylactic superficial temporal artery to middle cerebral artery bypass surgery prior to ICA occlusion. There was no postoperative clinical change in 9 patients. Ophthalmoplegia improved in 2 patients, and facial pain improved in 3. Three patients developed new extraocular muscle palsies within hours of ICA occlusion; these resolved in all patients by 1 week postoperatively. No change in aneurysm size was documented by serial postoperative computed tomographic or magnetic resonance imaging scans. After a follow-up of 5 to 6 years (range, 6 months-9 years), 11 patients have remained neurologically stable. Two patients experienced delayed transient worsening of visual or facial symptoms. Two patients developed delayed ipsilateral brain ischemia: one patient had a visibly patent superficial temporal artery to middle cerebral artery bypass; the second patient had an occluded A-1 segment that previously had been patent. These results are discussed in light of direct approaches and recent techniques of intervention.

scholarly journals Extracranial vertebral artery to middle cerebral artery bypass in therapeutic internal carotid artery occlusion for epipharyngeal carcinoma: A technical case report

2021 ◽  
Vol 12 ◽  
pp. 149
Author(s):  
Nakao Ota ◽  
Johan Carlos Valenzuela ◽  
Daiki Chida ◽  
Rokuya Tanikawa
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Vertebral Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Internal Carotid ◽  
Artery Bypass ◽  
High Flow ◽  
Radiographic Findings ◽  
Carotid Artery Rupture

Background: Vertebral artery (VA) to middle cerebral artery (MCA) bypass is a rarely selected technique because a complex expanded dissection is required, and often, a better donor artery than VA exists. A good indication for VA-MCA bypass is the treatment of head-and-neck malignancies with the sacrifice of the internal carotid artery (ICA) or for carotid artery rupture. Methods: A 23-year-old man with epipharyngeal carcinoma, treated by ligating the carotid artery with a VAMCA bypass before chemoradiotherapy, was reported. Radiographic findings showed that the bone of the carotid canal was dissolved, and the right ICA was engulfed by the tumor. As epipharyngeal carcinoma is hypersensitive to radiation, in cases where the tumor rapidly disappears, ICA may dangle in the pharynx and rupture may occur. In addition, to irradiate sufficiently, the ICA may become an obstacle. Hence, we decided to perform carotid ligation with a VA-MCA bypass before radiation and chemotherapy for the primary lesion. We selected the V3 portion of the VA as the donor on the ipsilateral side, as it can supply high-flow cerebral blood flow, which is not influenced by carcinoma and less influenced by irradiation for the epipharynx. Results: The VA-MCA bypass was completed without complications followed by endovascular occlusion of the ICA. Induction chemotherapy was initiated for the patient 2 weeks after surgery. The patient achieved a complete response following chemoradiotherapy. Conclusion: ICA ligation with VA-MCA high-flow bypass earlier than chemoradiotherapy is useful for epipharyngeal carcinoma as it prevents carotid artery rupture and allows radical intervention.

scholarly journals Middle cerebral artery revascularization: anatomical studies and considerations on the anastomosis site

1997 ◽  
Vol 55 (1) ◽  
pp. 16-23 ◽  
Author(s):  
Murilo S. Meneses ◽  
Ricardo Ramina ◽  
Andrea P. Jackowski ◽  
Ari A. Pedrozo ◽  
Robertson B. Pacheco ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Internal Carotid ◽  
Vascular Diseases ◽  
Anatomical Study ◽  
External Carotid Artery ◽  
External Carotid ◽  
Venous Graft

In the surgical management of skull base lesions and vascular diseases such as giant aneurysms, involvement of the internal carotid artery may require the resection or the occlusion of the vessel. The anastomosis of the external carotid artery and the middle cerebral artery with venous graft may be indicated to re-establish the blood flow. To determine the best suture site in the middle cerebral artery, an anatomical study was carried out. Fourteen cerebral hemispheres were analysed after the injection of red latex into the internal carotid artery. The superior and inferior trunk of the main division of the middle cerebral artery have more than 2 mm of diameter. They are superficial allowing an anastomosis using a venous graft. The superior trunk has a disadvantage, it gives rise to branches for the precentral and post-central giri. The anastomosis with the inferior trunk presents lower risk of neurological deficit even though the angular artery originates from it.

Rupture of Previously Unruptured Giant Carotid Aneurysm after Superficial Temporal-Middle Cerebral Artery Bypass and Internal Carotid Occlusion

Neurosurgery ◽  
1985 ◽  
Vol 16 (2) ◽  
pp. 177-184 ◽  
Author(s):  
Masayuki Matsuda ◽  
Akihiko Shiino ◽  
Jyoji Handa
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Internal Carotid ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Superficial Temporal Artery ◽  
Fatal Hemorrhage ◽  
Risk Of Rupture

Abstract A 51-year-old woman with an unruptured giant aneurysm of the internal carotid artery was treated by gradual occlusion of the internal carotid artery in the neck combined with a superficial temporal artery to middle cerebral artery bypass graft. Visual field defects improved after the operation, and thrombosis of the aneurysm was confirmed by angiography and computed tomography. Nevertheless, a fatal hemorrhage occurred 34 days after the final turn of the Selverstone clamp. The possible mechanism of rupture of the apparently thrombosed aneurysm is discussed. There is a risk of rupture of the aneurysm as long as the aneurysmal lumen remains after proximal ligation, no matter how small it may be.

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