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Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series

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Title: Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series
Authors: Robert C. Rennert, Vincent N. Nguyen, Aidin Abedi, Nadia A. Atai, Joseph N. Carey, Matthew Tenser, Arun Amar, William J. Mack, Jonathan J. Russin
Source: Frontiers in Neurology, Vol 14 (2023)
Publisher Information: Frontiers Media S.A., 2023.
Publication Year: 2023
Collection: LCC:Neurology. Diseases of the nervous system
Subject Terms: cerebral revascularization, bypass, aneurysm, neuroendovascular approach, embolization, Neurology. Diseases of the nervous system, RC346-429
More Details: Background and purposeThe treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk.Materials and methodsRetrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization/occlusion for complex intracranial aneurysms from 1/2016 to 6/2022.ResultsTen patients (4 male [40%]; mean age 51.9 ± 8.7 years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9/10 (90%), were ruptured and 8/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7/10 [70%]) and extracranial-to-intracranial (EC-IC; 3/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm/vessel sacrifice in 9/10 patients) were performed early after surgery (0.7 ± 1.5 days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4–72 months). Good outcomes (defined as a Glasgow Outcomes Scale ≥4 and modified Rankin Scale ≤2) occurred in 6/10 patients (60%).ConclusionA variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.
Document Type: article
File Description: electronic resource
Language: English
ISSN: 1664-2295
Relation: https://www.frontiersin.org/articles/10.3389/fneur.2023.1102496/full; https://doaj.org/toc/1664-2295
DOI: 10.3389/fneur.2023.1102496
Access URL: https://doaj.org/article/88581207dbb3439ea4d370a0adcdf6a8
Accession Number: edsdoj.88581207dbb3439ea4d370a0adcdf6a8
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  Data: Frontiers in Neurology, Vol 14 (2023)
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  Data: Background and purposeThe treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk.Materials and methodsRetrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization/occlusion for complex intracranial aneurysms from 1/2016 to 6/2022.ResultsTen patients (4 male [40%]; mean age 51.9 ± 8.7 years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9/10 (90%), were ruptured and 8/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7/10 [70%]) and extracranial-to-intracranial (EC-IC; 3/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm/vessel sacrifice in 9/10 patients) were performed early after surgery (0.7 ± 1.5 days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4–72 months). Good outcomes (defined as a Glasgow Outcomes Scale ≥4 and modified Rankin Scale ≤2) occurred in 6/10 patients (60%).ConclusionA variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.
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      – Text: English
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