Intracranial Fusiform and Circumferential Aneurysms of the Main Trunk: Therapeutic Dilemmas and Prospects

Abstract

Intracranial fusiform and circumferential aneurysms (IFCAs), especially those located on the main trunk, are uncommon and difficult to manage. Currently, literature focused on IFCAs on the main trunk of cerebral arteries is lacking. The treatment of IFCAs is still under debate. Therefore, in this review, we further explore the treatment of this complicated entity. In addition, we also present some interesting cases. Based on the literature review and our experience, we found that IFCAs are often located in the vertebrobasilar system and that ruptured or large symptomatic IFCAs are associated with increased mortality and higher rebleeding rates. The treatment strategies for IFCAs can be classified as deconstructive and reconstructive methods via open surgery and/or endovascular treatment (EVT). Currently, EVT is a popular method and the main therapeutic choice. In particular, flow diversion has revolutionized the treatment of IFCAs. Parent artery occlusion (PAO) with or without revascularization may still be considered a suitable choice. Complex IFCAs that cannot be resolved by EVT can also be treated via open surgery with or without extracranial–intracranial bypass. Targeted embolization for the weak points of IFCAs is a temporary or palliative choice that is rarely used. In summary, despite complications, both surgical treatment and EVT are effective options for appropriately selected cases. Due to the development of endovascular implants, EVT will have better prospects in the future.

Flow Diversion vs. Stent-Assisted Coiling in the Treatment of Intradural Large Vertebrobasilar Artery Aneurysms

“…As reported by Mizutani et al ( 13 ), once the rupture of VBA aneurysms occurred, if untreated, about 70% of patients subsequently underwent rerupture and about half of them subsequently died. Open surgical procedures, including trapping, clipping, and parent artery occlusion along with bypass, have been attempted to treat intradural VBA aneurysms in the past ( 14 , 15 ). However, due to the limited surgical accessibility and relatively high mortality of open surgical procedures, endovascular reconstructive therapies, including SAC and FD, have been increasingly used.…”

Prospects and Dilemmas of Endovascular Treatment for Vertebrobasilar Dolichoectasia

“…EVT for fusiform aneurysms remains challenging ( 40 ). For large fusiform aneurysms in VBD, conventional self-expandable stents assisted with coiling have difficulty completely curing these aneurysms, especially those with branches arising from the aneurysmal wall; however, the technique is still useful for target embolization, which targets weak points or blebs ruptured by coiling assisted by conventional stents to await subsequent treatment ( 54 ).…”

Endovascular treatment of aneurysms of the paraophthalmic segment of the internal carotid artery: Current status

“…Saccular aneurysms originate as branch-related aneurysms at the OphA and SHA. When the paraophthalmic segment is dilated, if the diameter of the dilatation is 1.5 times that of the normal ICA, fusiform aneurysms have formed, and they may be from dissection (Figure 4A) (24). Fusiform aneurysms often involve the long paraophthalmic segment and are called transitional aneurysms (25,26).…”

“…For large or giant paraophthalmic segment aneurysms, after FDS deployment, aneurysm volume can increase, resulting in a worse mass effect or delayed rupture due to thrombosis (24,34,88,90). In addition, coiling embolization for large or giant aneurysms can be associated with the progression of mass effect and/or perianeurysmal inflammation, resulting in acute or delayed visual impairment (50,(91)(92)(93).…”