J Korean Neurosurg Soc.  2015 Dec;58(6):518-527. 10.3340/jkns.2015.58.6.518.

Surgical Flow Alteration for the Treatment of Intracranial Aneurysms That Are Unclippable, Untrappable, and Uncoilable

• Lee SH
• Ahn JS
• Kwun BD
• Park W
• Park JC
• Roh SW

• KMID: 2151153
• DOI: http://doi.org/10.3340/jkns.2015.58.6.518

Abstract

OBJECTIVE
The treatment of complex intracranial aneurysms remains challenging. One approach is the application of surgical flow alteration to treat aneurysms that are neither clippable, trappable, or coilable. The efficacy and limitations of surgical flow alteration have not yet been established.
METHODS
Cases of complex aneurysms treated with surgical flow alteration (proximal occlusion with or without bypass, distal occlusion with or without bypass and bypass only) were included in this retrospective study.
RESULTS
Among a total of 16 cases, there were 7 giant aneurysms (> or =25 mm diameter) and 9 large aneurysms (>10 mm diameter); 15 of 16 aneurysms were unruptured. There were 8 aneurysms located in the anterior circulation, while the other 8 were in the posterior circulation. Aneurysms were treated with proximal occlusion in 10 cases and distal occlusion in 5 cases; in 1 case, the aneurysm occluded spontaneously after bypass without parent artery occlusion. All but 2 cases underwent prior or concurrent bypass surgery. Complete obliteration of the aneurysm at the latest imaging follow-up was shown in 12 of 16 cases (75.0%). Bypass patency was confirmed in 13 of 15 cases (86.7%). Surgery-related morbidity developed in 3 cases (18.8%, Glasgow outcome scale of 4) and all were perforator infarctions. There were no mortalities.
CONCLUSION
Surgical flow alteration resulted in a high rate of aneurysmal obliteration with acceptable morbidity. Although several limitations remained, it could represent an alternative method for treating complex aneurysms.

Keyword

Aneurysm; Revascularization; Clipping; Bypass; Surgery; Brain

MeSH Terms

Aneurysm
Arteries
Brain
Follow-Up Studies
Glasgow Outcome Scale
Humans
Infarction
Intracranial Aneurysm*
Mortality
Parents
Retrospective Studies

Figure

• 

  Fig. 1 Proximal occlusion with bypass (Case No. 4). A : An MR T1-weighted sagittal image suggestive of a giant fusiform aneurysm of the left anterior cerebral artery (ACA) with a thrombus compressing the genu of the corpus callosum. B : Lateral view of left internal carotid angiography showing a giant serpentine aneurysm that developed from a post-communicating segment of the ACA (A2) along its distal segments. C : 3D-reconstructed angiography revealing the frontopolar artery arising from the aneurysmal sac (arrow). Right A2 (arrowhead) is deviated to the opposite side because of the mass effect. D : Indocyanine green videoangiography that was performed to follow dual anastomosis showing patency from the frontal (arrow) and parietal (arrowhead) branches of the superficial temporal artery (STA) to the cortical branches of the distal ACA. E : 3D-angiography at postoperative day (POD) 4 showing proximal occlusion was performed by clipping the left A2 immediately distal to the anterior communicating artery and right A2 (arrowhead). F : The frontopolar artery (arrow) is filled in a retrograde fashion through the bypass in a left external cerebral artery angiography at POD 4. The aneurysmal sac is minimally stained via the frontopolar artery. Anastomosis of the parietal branch of the STA-distal ACA is not observed.

• 

  Fig. 2 Proximal occlusion with bypass (Case No. 12). A : 3D angiography showing a basilar artery (BA) aneurysm with a broad neck and involvement of the left posterior cerebral artery (PCA) and superior cerebellar artery (SCA). B : Angiography at the end of coil embolization suggesting the successful obliteration of the aneurysm. C : An MR angiogram obtained two months later revealing compaction of the coil and regrowth of the sac. D : An intraoperative photo showing end-to-side anastomosis of the parietal branch of the left superficial temporal artery (STA, arrow) and ipsilateral SCA (arrowhead), followed by proximal occlusion by clipping of the distal BA. E : An anterior-posterior view of the vertebral angiography at postoperative day 3 showing occlusion at the distal BA. F : External carotid angiography at postoperative day 3 showing near-total obliteration of the aneurysm and intact patency of both SCAs and both PCAs through the bypass (arrowhead) and the posterior communicating artery.

• 

  Fig. 3 Distal occlusion with bypass (Case No. 7). A : 3D-reconstructed angiography showing an aneurysm of the middle cerebral artery (MCA) 20×11 mm in size with a broad neck. B : In the operative view, a large medial lenticulostriate artery (arrow) developed from the medial side of the aneurysm. C : Brain CT angiography taken immediately postoperatively showing distal occlusion of the parent artery and a smaller, but still visible, aneurysmal sac. The distal MCA is filled in retrograde fashion via a superficial temporal artery-radial artery interposition graft-insular segment of the MCA bypass. D : MR diffusion performed on the second day after surgery suggesting acute lacunar infarction at the right basal ganglia and corona radiata. E : In a CT angiogram obtained on postoperative day 7, the aneurysmal sac is not visualized. F : In a CT angiogram taken 20 months after surgery, patent bypass flow and no recurrence of the aneurysm were observed.

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