Surgical Treatment for Giant or Thrombosed Aneurysms: Safe Reconstruction of the Main Trunk and Perforating Artery

Abstract

Summary: Giant and complex intracranial aneurysms are associated with poor prognosis because of the high risk of rupture, mass effects on the surrounding brain tissue, and a propensity to lead to the formation of emboli in the downstream vascular territories. The preferred treatment for these aneurysms is direct clipping, but this technique is typically unfeasible. Reconstruction of the main trunk (such as the internal carotid artery, middle cerebral artery, anterior cerebral artery, vertebral artery, or basilar artery) and aneurysm trapping may enable safe treatment for the lesion and simultaneously reduce the risk of ischemic complications. For safe reconstruction of the main trunk, back-up bypass and pressure monitoring during the operation are important. Back-up bypass can serve as a precautionary measure during vessel reconstruction if the reconstructed artery does not function adequately.Monitoring of the pressure in other branches of the back-up bypass is important for the estimation of performance of the reconstructed artery. If the main trunk is occluded as a blind end, delayed thrombosis may be observed. Thus, the preoperative strategy must avoid formation of a blind end. In case the perforating artery is injured, reconstruction using the superficial temporal artery or occipital artery should be attempted.