Balloon test occlusion and endosurgical parent artery sacrifice for the evaluation and management of complex intracranial aneurysmal disease

Abstract

The lifetime risk of developing a cerebral aneurysm is about 5%. For some patients, aneurysms can be reasonably managed by conservative measures, including periodic clinical and imaging surveillance. However, the definitive treatment of cerebral aneurysm disease requires securing the aneurysm by surgically excluding it from the cerebrovascular circulation. Most commonly, this can be achieved by either open surgical clipping or embosurgery. Unfortunately, for a minority of patients, these interventions are inadequate because of many aneurysmal factors, such as complex anatomy, giant and wide neck aneurysmal morphology, peripheral small branch origin and skull base location. In situations like these, sacrifice of the parent artery may be preferable, especially when clinical tolerance or image based vascular reserve can be preoperatively demonstrated during temporary occlusion of the vessel. This preoperative procedure, which is known as the Balloon Test Occlusion (BTO), has several variations and technical nuances that can assist the surgeon in predicting which patients may best benefit from parent artery sacrifice (PAS). Together, BTO and PAS are invaluable tools in the management of complicated and atypical cerebral aneurysms. With regard to cerebrovascular aneurysm disease, this review will summarize the development of these procedures, condense the predictability of the numerous BTO variations and provide an overview of the currently available PAS techniques.

Giant cavernous carotid artery aneurysm mimicking a fungal granuloma and presenting with massive epistaxis

“…Approximately 15% of patients may develop neurological deficits despite tolerating a normotensive BTO. This can be circumvented by a hypotensive challenge during the BTO; this reduces the risk of developing fresh neurological deficits by 5% 20. Occasionally, the aneurysm may continue to fill from cross-circulation across the anterior communicating artery of the circle of Willis as in the present case 11.…”

Treatment strategies for dissecting aneurysms of the posterior cerebral artery

“…While there is a wealth of clinical experience showing that BTO is useful for occluding the internal carotid and vertebral arteries [7,22,32,33], much less is known about the usefulness of selective BTO for the PCA. Jayakumar et al reported selective BTO of the PCA associated with rebleeding from aneurysms in the P2 segment.…”

Endovascular Treatment of Distal Cerebral Aneurysms

“…In the case of difficult aneurysm morphology, deconstructive technique is sometimes necessary treatment solution, often with unpredictable consequences [1][2][3]6 .…”