Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion

Abstract

<jats:p>Pipeline Embolization Devices (PEDs) have been shown to be effective for intracranial internal carotid artery (ICA) aneurysms, and are now approved by the FDA specifically for this use. Potential pitfalls, however, have not yet been described in the pediatric neurosurgical literature. The authors report on a 10-year-old boy who presented to the Barrow Neurological Institute after progressive visual decline. He had undergone placement of a total of 7 telescoping PEDs at another facility for a large ICA aneurysm. Residual filling of the aneurysm and significant expansion of intraaneurysmal thrombus with chiasmal compression on admission images were causes for concern. The patient underwent a surgical bailout with a superficial temporal artery–middle cerebral artery bypass, with parent artery occlusion. Postoperative vascular imaging was notable for successful occlusion of the parent vessel, with no evidence of filling of the aneurysm.</jats:p> <jats:p>Reports on the pitfalls of PEDs in the neurosurgical literature are scarce. To the authors' knowledge this represents the first paper describing a successful open surgical bailout for residual aneurysmal filling and expansion of thrombus after placement of a PED.</jats:p>

Letter to the Editor: Surgical bailout of giant supraclinoid ICA aneurysm following treatment with Pipeline Embolization Device

“…surgical bailout of giant supraclinoid ica aneurysm following treatment with Pipeline embolization Device TO THE EDITOR: We read with great interest the recent article by Abla et al, 1 wherein the authors describe the case of a giant fusiform internal carotid artery (ICA) aneurysm that was treated with a Pipeline Embolization Device (PED) (Abla AA, Zaidi HA, Crowley RW, et al: Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion. J Neurosurg Pediatr 14:31-37, July 2014).…”

Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases

“…Data on the results of the use of flow diverters in children have been considered positive, and potential pitfalls have been overlooked. All of the previously reported cases, except a case described by Abla et al, 9 were technically successful and produced good clinical outcomes, and all devices except 1 were patent on follow-up. These reports suggest that flow diversion can be a good alternative for the treatment of challenging pediatric cerebral aneurysms.…”

“…However, there are few case reports on the use of flow diverters in the pediatric population. [2][3][4][5][6][7][8][9][10][11] In this retrospective study, we report our experience with of flow diverters in 5 children with intracranial aneurysms and 2 children with carotid cavernous fistulas (CCFs). Through a review of our patient data and the relevant literature, we also summarize the current antiplatelet regimens used for children undergoing cerebrovascular interventions involving the placement of stents and flow diverters.…”

“…Analyzing the 35 cases reported in the literature in which there is a somewhat detailed description of the placement of cerebral vascular scaffolds in children, we found that antiplatelet administration for endovascular treatment was extremely variable (On-line Table 2). [2][3][4][5][6][7][8][9][10][11]25,[31][32][33][34][35][36][37][38][39][40][41][42][43] There are neither guidelines published on antiplatelet therapy (APT) in children with cerebrovascular diseases 25 nor conclusive trials on pediatric APT regimens. 44,45 Weight-based dose calculations extrapolated from an adult dosing of 75 mg per day are not only misleading but also may lead to lifethreatening consequences.…”

Temporary surgical clipping of flow-diverted arteries in an experimental aneurysm model

“…1,5,8 In narrow surgical corridors, or when the flow diverter spans a long arterial segment, it may be difficult to gain access to a normal artery proximal or distal to the device to place an aneurysm clip, and temporarily clipping the segment of artery containing the flow diverter may become necessary. 4,9 Clipping of a flow-diverted arterial segment, to our knowledge, has not been reported in the literature.…”