K M Cockroft1, M P Marks, G K Steinberg. 1. Department of Neurosurgery, Stanford Stroke Center, Stanford University School of Medicine, California 94305, USA.
Abstract
OBJECTIVE AND IMPORTANCE: Treatment of complex, broad-based intracranial aneurysms with either microsurgical clipping or endovascular coiling alone is sometimes impossible. In this study, we report the planned combined endovascular and microsurgical treatment of four complex, wide-necked aneurysms in four patients. CLINICAL PRESENTATION: Three of the four patients presented with subarachnoid hemorrhage. The fourth patient presented with a progressive neurological deficit secondary to an associated arteriovenous malformation. Three of the aneurysms were located in the posterior circulation (two broad-necked basilar apex aneurysms and one bilobed vertebrobasilar junction aneurysm with a wide-necked ventral component). The fourth aneurysm was a broad-based paraclinoid/cavernous-carotid lesion. INTERVENTION: One of the patients with a basilar apex aneurysm and the patient with the paraclinoid aneurysm underwent surgery intended to create a narrow neck that would be amenable to future coiling. The patient with the bilobed vertebrobasilar junction aneurysm underwent surgery to treat the broad-necked ventral lobe, whereas the dorsal lobe, with the neck partially buried in the brainstem, was treated endovascularly. The second patient with a basilar apex aneurysm was in poor clinical condition after subarachnoid hemorrhage and was therefore treated with coil embolization to reduce the risk of rebleeding. After the patient made a good clinical recovery, the residual aneurysm was surgically clipped. Angiographic follow-up documented the complete obliteration of all four aneurysms. Clinically, all patients had good to excellent outcomes after a follow-up period of 6 to 30 months. CONCLUSION: Complex, broad-necked aneurysms that may be difficult to treat with a single mode of therapy can be safely and successfully treated with a combination of endovascular and microsurgical techniques. For patients with broad-based aneurysms that are difficult to access surgically without incurring significant morbidity, microsurgical clipping may be used as the initial procedure to create a smaller neck. Alternatively, for patients who are in poor clinical condition after subarachnoid hemorrhage and who harbor a broad-necked aneurysm in a surgically formidable location, partial coiling may be used initially to reduce the short-term risk of rebleeding.
OBJECTIVE AND IMPORTANCE: Treatment of complex, broad-based intracranial aneurysms with either microsurgical clipping or endovascular coiling alone is sometimes impossible. In this study, we report the planned combined endovascular and microsurgical treatment of four complex, wide-necked aneurysms in four patients. CLINICAL PRESENTATION: Three of the four patients presented with subarachnoid hemorrhage. The fourth patient presented with a progressive neurological deficit secondary to an associated arteriovenous malformation. Three of the aneurysms were located in the posterior circulation (two broad-necked basilar apex aneurysms and one bilobed vertebrobasilar junction aneurysm with a wide-necked ventral component). The fourth aneurysm was a broad-based paraclinoid/cavernous-carotid lesion. INTERVENTION: One of the patients with a basilar apex aneurysm and the patient with the paraclinoid aneurysm underwent surgery intended to create a narrow neck that would be amenable to future coiling. The patient with the bilobed vertebrobasilar junction aneurysm underwent surgery to treat the broad-necked ventral lobe, whereas the dorsal lobe, with the neck partially buried in the brainstem, was treated endovascularly. The second patient with a basilar apex aneurysm was in poor clinical condition after subarachnoid hemorrhage and was therefore treated with coil embolization to reduce the risk of rebleeding. After the patient made a good clinical recovery, the residual aneurysm was surgically clipped. Angiographic follow-up documented the complete obliteration of all four aneurysms. Clinically, all patients had good to excellent outcomes after a follow-up period of 6 to 30 months. CONCLUSION: Complex, broad-necked aneurysms that may be difficult to treat with a single mode of therapy can be safely and successfully treated with a combination of endovascular and microsurgical techniques. For patients with broad-based aneurysms that are difficult to access surgically without incurring significant morbidity, microsurgical clipping may be used as the initial procedure to create a smaller neck. Alternatively, for patients who are in poor clinical condition after subarachnoid hemorrhage and who harbor a broad-necked aneurysm in a surgically formidable location, partial coiling may be used initially to reduce the short-term risk of rebleeding.
Authors: Abdullah Alobaid; Erez Nossek; Katherine Wagner; Avi Setton; Amir R Dehdashti; David Langer; David Chalif Journal: Neurosurg Rev Date: 2017-01-14 Impact factor: 3.042
Authors: E Sato; Y Konishi; A Shimada; K Komatsubara; H Yazaki; M Fujitsuka; Y Shiokawa Journal: Interv Neuroradiol Date: 2006-06-15 Impact factor: 1.610
Authors: Keng Siang Lee; John J Y Zhang; Vincent Nguyen; Julian Han; Jeremiah N Johnson; Ramez Kirollos; Mario Teo Journal: Neurosurg Rev Date: 2021-04-23 Impact factor: 2.800