Endovascular management of large and giant intracranial aneurysms: Experience from a tertiary care neurosurgery institute in India

Dutta Gautam,Singh Daljit,Jagetia Anita,Srivastava Arvind K,Singh Hukum,Kumar Anil 대한뇌혈관외과학회 2021 Journal of Cerebrovascular and Endovascular Neuros Vol.23 No.2

Objective With the development of endovascular technique and devices, large and giant intracranial aneurysms are increasingly being managed by this less invasive method. Here we discuss our experience on managing such aneurysms via endovascular technique. Methods Retrospective data on 42 patients with large and giant intracranial aneurysms managed by endovascular techniques between September 2015 to December 2017 at our neurosurgery institute were included in this analysis. Results There were a total 42 patients with 9 giant and 33 large aneurysms in this study. Eight aneurysms were treated by parent vessel occlusion, 22 aneurysms with coils and rest 12 aneurysms were treated with stent assisted coiling. Following the procedure, Raymond class I occlusion was accomplished in 31 (73.8%) patients while class Ⅱ in 9 (21.4%) and class Ⅲ in 2 (4.8%) patients. Overall morbidity and mortality were 9.5% and 14.3% respectively and favorable outcome was seen in 80.9% patients. Significant correlation was observed with clinical outcome and initial neurological status. Conclusions The study indicates that endovascular intervention is a safe and effective method in managing large and giant intracranial aneurysms with lesser morbidity and mortality. Objective With the development of endovascular technique and devices, large and giant intracranial aneurysms are increasingly being managed by this less invasive method. Here we discuss our experience on managing such aneurysms via endovascular technique. Methods Retrospective data on 42 patients with large and giant intracranial aneurysms managed by endovascular techniques between September 2015 to December 2017 at our neurosurgery institute were included in this analysis. Results There were a total 42 patients with 9 giant and 33 large aneurysms in this study. Eight aneurysms were treated by parent vessel occlusion, 22 aneurysms with coils and rest 12 aneurysms were treated with stent assisted coiling. Following the procedure, Raymond class I occlusion was accomplished in 31 (73.8%) patients while class Ⅱ in 9 (21.4%) and class Ⅲ in 2 (4.8%) patients. Overall morbidity and mortality were 9.5% and 14.3% respectively and favorable outcome was seen in 80.9% patients. Significant correlation was observed with clinical outcome and initial neurological status. Conclusions The study indicates that endovascular intervention is a safe and effective method in managing large and giant intracranial aneurysms with lesser morbidity and mortality.

거대 뇌동맥류에 관한 임상적 고찰

엄진화,강창구,김동희,김대조 대한신경외과학회 1990 Journal of Korean neurosurgical society Vol.19 No.6

Intracranial aneurysms larger than 25mm in diameter are considered giant aneurysms and these comprise about 5% of all intracranial aneurysms. The authors report a series of 9 cases of giant cerebral aneurysms (>2.5㎝ in diameter) during a 7year period found among 212 cases with saccular cerebral aneurysms. Of the 9 patients, four patients were treated by direct neck clipping, one by trapping, and the other one by sac excision after direct neck clipping. This report presents an analysis of 9 cases of giant cerebral aneurysms. The results are as following : 1) In a review of our cases of giant aneurysms, approximately 4.3% were of all intracranial aneurysms. 2) Male : Female ratio was 4 : 5. 3) The greatest incidence was in the 6th decades of life. 4) The most common site was in the internal carotid artery portion. 5) Our all cases were saccular aneurysms. 6) In our cases, nonthrombosed aneurysms were more common. 7) Presenting symptom of SAH was more common. 8) There was no relationship between blood pressure and aneurysm rupture in our cases. 9) We found our all cases of ICA portion giant aneurysms presented with focal symptoms & signs. 10) The most commonly presented focal neurologic sign was visual failure.

Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

Lee, Sang Kook,Kim, Jae Min The Korean Neurosurgical Society 2013 Journal of Korean neurosurgical society Vol.54 No.6

Objective : Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications. Methods : Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography. Results : Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely. Conclusion : The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.

대 뇌동맥류 및 거대 뇌동맥류의 수술적 가료

임만빈,이창영,김일만,손은익,김동원,Yim, Man-Bin,Lee, Chang-Young,Kim, Ill-Man,Son, Eun-Ik,Kim, Dong-Won 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.6

Objectives : The goal of the surgical management of large and giant aneurysm is complete extirpation of the aneurysms with preservation or reconstruction of the parent artery. To improve the surgical management results of those aneurysms in the future, we review our experience and discuss technical maneuvers and strategies used to avoid potential complications of those aneurysm surgery. Material and Methods : During the past 12 years, thirty six cases of large and giant aneurysms(diameter>19mm) were managed by surgery. The clinical characteristics, treatment methods, surgical complications and outcome of those cases were analyzed and, based on the review of the literatures, the preventive methods of surgical complication related to the clipping of those aneurysms were discussed. Results : The locations of those aneurysms were anterior circulation in 34 cases and posterior circulation in 2 cases. The most frequent site of aneurysmal location was a paraclinoidal region of the anterior circulation. The aneurysms were managed surgically by direct clipping of aneurysmal neck in 31 cases, aneurysmal trapping followed by extracranial-intracranial bypass in 2 cases, proximal clipping of parent artery, aneurysmorrhaphy, and excision of aneurysm followed by end to end anastomosis of parent artery in each one case. Surgical complications occurred in 13 cases. A parent vessel occlusion by thrombus formation and parent vessel stenosis after clipping of aneurysm were the main complications. We obtained good outcome in 27, fair 5, poor 1 and dead in 3 case(s). Conclusion : We conclude that selection of suitable management method for each case, high quality of surgical technique and prevention of complication during operation are important key points for the successful treatment of large and giant aneurysm. The heparinization prior to application of temporary clip on parent vessels, aneurysmal decompression during dissection and clipping of aneurysm, complete closing of the aneurysmal neck and avoiding the narrowing of parent vessel after clipping of aneurysm were the main technical maneuvers used to avoid complications of those aneurysm surgery.

후뇌동맥에 발생한 蛇行性 內管 巨大動脈瘤 : 1예 보고 Csae Report

류태희,김상근,최기환,여형태,이정길 대한신경외과학회 1988 Journal of Korean neurosurgical society Vol.17 No.1

본원 신경외과에서는 최근 후뇌동맥에 발생한 사행성 내관 거대 동맥류를 하측두엽 도달법으로 후뇌동맥의 포획 및 동맥류 완전절제(trapping & excision)를 하였음에도 시야결손등의 신경학적 장애소견없이 치유된 경험을 하였기에 문헌고찰과 함께 보고하는 바이다. Aneurysms of the posterior cerebral artery are rare, furthormore giant serpentine aneurysms-partially thrombosed aneurysms containing a tortuous vascular channel-of the posterior cerebral artery are extremly rare. The author et al. were able to remove 3.9㎝×2.9㎝×3.0㎝ sized giant serpentine aneurysm of the distal PCA totally, without any significant postoperative neurological sequela except transient ipsilateral third cranial nerve paresis and transient hemihypesthesia. Various kinds of surgical treatment were proposed by several authors in managing unclippable giant aneurysms : excision including partial excision ; clipping of feeding artery and excision ; trapping and excision ; revascularization and excision : anastomosis only. We took subtemporal approach under the surgical microscope and trapping & excision was performed in several steps : proximal clipping of the PCA distal to the Pcom-PCA junction : reducing volume of the mass through piecemeal resection of the aneurysmal wall : distal clipping of the PCA ; total excision and final trapping just proximal and distal to the origin of the aneurysm. We are discussing the characteristics of the giant serpentine aneurysm, precognition of rich collateral circulation of the PCA distal to trapping and surgical management of the giant serpentine aneurysm.

Clinical Analysis of Giant Intracranial Aneurysms with Endovascular Embolization

Sang Woo Ha,Suk Jung Jang 대한뇌혈관외과학회 2012 Journal of Cerebrovascular and Endovascular Neuros Vol.14 No.1

Objective: The purpose of this study was to perform a clinical analysis of nine patients with giant aneurysms managed with endovascular embolization. Methods: From March 2000 to September 2009, nine cases of giant intracranial aneurysms were treated (five unruptured and four ruptured). The nine patients included two males and seven females who were 47 to 72 years old (mean, 59.2 years old). The types of giant intracranial aneurysms were eight internal carotid artery aneurysms and one vertebral artery aneurysm. Treatment for each aneurysm was chosen based on anatomic relationships, aneurysmal factors, and the patients’ clinical state. Three patients underwent endovascular coiling with stent and six initially underwent endovascular coiling alone. Medical records, operation records, postoperative angiographies, and follow-up angiographies were reviewed retrospectively. Results: Eight out of nine patients showed good clinical outcomes. (six were excellent and two were good) after a mean follow-up period of 27.9 months. Six (67%) of the nine patients had a near-complete occlusions on the post-operative angiogram (mean, 13.5 months after the procedure). Occlusion rates of 90% or higher were obtained for eight (89%) of all the patients. One patient died due to multiple organ failure. Stents were ultimately required at some point for managing four aneurysms. Two patients needed additional procedures because of aneurysm regrowth. Conclusion: Endovascular treatment could be an alternative option for managing giant aneurysms adjuvant to surgical intervention.

Endosaccular Treatment of Very Large and Giant Intracranial Aneurysms with Parent Artery Preservation : Single Center Experience with Long Term Follow-up

Huh, Chae Wook,Lee, Jae Il,Choi, Chang Hwa,Lee, Tae Hong,Choi, Jae Young,Ko, Jun Kyeung The Korean Neurosurgical Society 2018 Journal of Korean neurosurgical society Vol.61 No.4

Objective : Very large (20-25 mm) and giant (${\geq}25mm$) intracranial aneurysms have an extremely poor natural course, and treatment of these aneurysms remains a challenge for endovascular and surgical strategies. This study was undertaken to describe our experiences of endosaccular treatment of very large and giant intracranial aneurysms with parent artery preservation. Methods : From January 2005 to October 2016, twenty-four very large or giant aneurysms in 24 patients were treated by endosaccular coil embolization with parent artery preservation. Nine (37.5%) aneurysms were ruptured and 15 were unruptured, and of these 15, 11 were symptomatic cases and 4 were incidentally discovered. The cohort comprised 17 women and 7 men of mean age 58.5 years (range, 26-82). Mean aneurysm size was 26.0 mm (range, 20-39) and 13 of the 24 aneurysms were giant. Results : Immediate angiographic results were complete occlusion in nine (37.5%) cases, remnant neck in six (25.0%), and remnant sac in nine (37.5%). Overall procedural related morbidity and mortality rates were 12.5% and 4.2%, respectively. Angiographic follow-up was available in 16 patients (66.7%). Mean and median follow-up periods were 27.2 (range, 2-77) and 10.5 months, respectively. In 12 cases (12/16, 75%) stable occlusion was achieved, four cases (4/16, 25%) had recanalized, and two of these were retreated with additional coiling. At clinical follow-up of the nine ruptured cases, three patients (33.3%) achieved a good clinical outcome (Glasgow outcome scale [GOS] score of 4 or 5), two (22.2%) a poor outcome (GOS score of 2 or 3), and four patients (44.4%) expired (GOS 1). On the other hand, of the 15 unruptured cases, 13 patients (86.7%) achieved a good clinical outcome (GOS 4 or 5), one patient a poor outcome (GOS score of 2 or 3), and one patient expired (GOS 1). Conclusion : The present study shows endosaccular treatment of very large or giant intracranial aneurysms with parent artery preservation is both feasible and effective with acceptable morbidity and mortality.

Salvage flow diverter stent across the posterior communicating artery for persistent retrograde filling of a giant internal carotid artery aneurysm after parent vessel occlusion

Manzoor Muhammad Usman,AlRashed Abdullah A.,Alghabban Fatimah A.,Alqahtani Sultan M.,Alturki Abdulrahman Y. 대한뇌혈관외과학회 2021 Journal of Cerebrovascular and Endovascular Neuros Vol.23 No.2

Giant internal carotid artery (ICA) aneurysms are complex vascular lesions which are difficult to treat with open as well as endovascular surgery. Parent vessel occlusion is a well-established treatment option for such aneurysms. However, there have been a few reported cases of ruptured aneurysms related to the persistent retrograde filling after parent vessel occlusion. We report a case which highlights the usage of the flow diverter stent as a potential treatment strategy for the management of retrograde filling of aneurysms. A 54-year-old female was found to have a giant left ICA aneurysm on a brain magnetic resonance imaging during workup for headaches. She underwent occlusion of the left ICA proximal to the aneurysm using multiple coils. However, follow up angiograms after 6 months and 2 years demonstrated persistent retrograde filling of the left ICA aneurysm through the posterior communicating (PCOM) artery. Eventually, she was successfully treated with a flow diverter stent across the PCOM artery into the distal ICA. Follow up angiogram after 6 months showed patent flow in the PCOM artery and the distal ICA. with complete occlusion of the aneurysm. Using a flow diverter stent after insufficient parent vessel occlusion for giant intracranial aneurysms may be a feasible treatment option and an addition to the neurovascular treatment armamentarium.

Pipeline Embolization Device for Giant Internal Carotid Artery Aneurysms: 9-Month Follow-Up Results of Two Cases

전홍준,김동준,김병문,이재환 대한뇌혈관외과학회 2014 Journal of Cerebrovascular and Endovascular Neuros Vol.16 No.2

The pipelineTM embolization device (PED) is a braided, tubular, bimetallicendoluminal implant used for occlusion of intracranial aneurysms throughflow disruption along the aneurysm neck. The authors report on two casesof giant internal carotid artery aneurysm treated with the PED. In thefirst case, an aneurysm measuring 26.4 mm was observed at the C3-C4portion of the left internal carotid artery in a 64-year-old woman whounderwent magnetic resonance imaging (MRI) for dizziness and diplopia. In the second case, MRI showed an aneurysm measuring 25 mm at theC4-C5 portion of the right internal carotid artery in a 39-year-old womanwith right ptosis and diplopia. Each giant aneurysm was treated with deploymentof a PED (3.75 mm diameter/20 mm length and 4.5 mm diameter/25 mm length, respectively). Nine months later, both cases showedcomplete radiological occlusion of the giant intracranial aneurysm and sacshrinkage. We suggest that use of the PED can be a therapeutic optionfor giant intracranial aneurysms.

Giant Serpentine Aneurysm of the Middle Cerebral Artery

Lee, Seung-Joo,Ahn, Jae-Sung,Kwun, Byung-Duk,Kim, Chang-Jin The Korean Neurosurgical Society 2010 Journal of Korean neurosurgical society Vol.48 No.2

Giant serpentine aneurysms are rare and have distinct angiographic findings. The rarity, large size, complex anatomy and hemodynamic characteristics of giant serpentine aneurysms make treatment difficult. We report a case of a giant serpentine aneurysm of the right middle cerebral artery (MCA) that presented as headache. Treatment involved a superficial temporal artery (STA)-MCA bypass followed by aneurysm resection. The patient was discharged without neurological deficits, and early and late follow-up angiography disclosed successful removal of the aneurysm and a patent bypass graft. We conclude that STA-MCA bypass and aneurysm excision is a successful treatment method for a giant serpentine aneurysm.