Treatment of complex intracranial aneurysm: Case report of the simultaneous use of endovascular and microsurgical techniques

Abstract

Background:The surgical treatment of complex intracranial aneurysms (CIAs) represents a significant challenge to the skill and expertise of the neurosurgeon. The natural history of complex cerebrovascular lesions is especially unfavorable because of the pressure effect on adjacent areas, the risk of embolism in the presence of intraluminal thrombi, and the possibility of hemorrhage through leakage or rupture of the aneurysm. The surgical strategy must be customized for each case in order to maximize the treatment effectiveness and the safety of the patient.Case Description:A 68-year-old woman presented with a 10-month history of atypical headaches but no other neurological symptoms. Computed tomography scan and digital subtraction angiography revealed an unruptured saccular aneurysm on the M1 segment of the right middle cerebral artery. The lesion was 21 mm in length in its largest diameter and with an undefined neck (extensive involvement of the walls of the afferent vessel). Craniotomy was performed in order to expose the lesion and allow microsurgical dissection of the neck of the aneurysm and its adjacent structures. A balloon catheter was navigated via the internal carotid artery to a position alongside the aneurysm neck. With the balloon fully inflated, the aneurysm was punctured and drained, and a guide clip was located at the neck of the aneurysm. Additional clips were applied using a similar procedure to ensure the exclusion of the aneurysm.Conclusion:The patient recovered without complications and complete occlusion of the CIA was confirmed on follow-up angiography. A modified Rankin score of 0 was attributed to the patient 6 months after treatment. A multidisciplinary perspective is important in planning and executing the treatment of CIAs.

Endovascular treatment of complex intracranial aneurysms

“…Features commonly recognised in association with CIA are: giant aneurysms, localisation of difficult or morbid access, broad neck, branches arising from aneurysms, parental artery incorporation, blister-like or dissecting aneurysms, calcification of the aneurysmal wall, intraluminal thrombus, absence of collateral circulation, embedding on surrounding brain, brainstem, and cranial nerves, and previous treatments [ 8 - 12 , 16 , 17 ]. Including only patients undergoing endovascular treatment in this study determined that not all of the above-mentioned criteria could be applied.…”

“…In the past few years, the authors of multiple publications tried to separate a group of complex intracranial aneurysms (CIA), which could be linked with worse treatment outcomes [ 8 - 12 ]. Andaluz and Zuccarello, in an article published in 2011, tried to specify some of CIA’s features, such as: giant size, difficult location, broad neck, branches arising from the aneurysm wall structure, calcification, the presence of intraluminal thrombus, or previous treatments [ 11 ].…”

AVM’s and Aneurysms, Hybrid Brain Vascular Surgery: A Case Report

“…When we decided to treat a patient with an AVM, as protocol states, we obtain a DSA and MRI to plan the surgery. In parietal AVM´s, Grade III, High flow, cerebellar AVM´s we always use preoperative embolization, in the same surgical room, and when the microsurgical resection finished we obtain a DSA to corroborate the complete resection [5][6][7][8].…”

“…Thorough a right femoral puncture and fluoroscope navigation the balloon catheter and their landmarks were positioned at the level of the aneurysm neck, and inflated to corroborate the correct position ( Figure 3). In order to diminish the embolism risk, a saline solution 0.9%, containing heparin dosage of 5,000 U/L was infused continually [6,7].…”

“…In this case the head was positioned with elevation 35º, rotation 30º and lateral flexion, we chose a trans-zygomatic approach to expose the lateral and ventral surface of the left temporal lobe. We made a Dandy´s incision, dissecting the temporal muscle and fascia in a conventional manner, we exposed the zygomatic arch and we performed an osteotomy improving the surgical view to the sub temporal exposure [7][8][9].…”