Endosaccular Treatment of Very Large and Giant Intracranial Aneurysms with Parent Artery Preservation: Single Center Experience with Long Term Follow-up

OBJECTIVE: Very large (20–25 mm) and giant (≥25 mm) intracranial aneurysms have an extremely poor natural course, and treatment of these aneurysms remains a challenge for endovascular and surgical strategies. This study was undertaken to describe our experiences of endosaccular treatment of very large and giant intracranial aneurysms with parent artery preservation.METHODS: From January 2005 to October 2016, twenty-four very large or giant aneurysms in 24 patients were treated by endosaccular coil embolization with parent artery preservation. Nine (37.5%) aneurysms were ruptured and 15 were unruptured, and of these 15, 11 were symptomatic cases and 4 were incidentally discovered. The cohort comprised 17 women and 7 men of mean age 58.5 years (range, 26–82). Mean aneurysm size was 26.0 mm (range, 20–39) and 13 of the 24 aneurysms were giant.RESULTS: Immediate angiographic results were complete occlusion in nine (37.5%) cases, remnant neck in six (25.0%), and remnant sac in nine (37.5%). Overall procedural related morbidity and mortality rates were 12.5% and 4.2%, respectively. Angiographic follow-up was available in 16 patients (66.7%). Mean and median follow-up periods were 27.2 (range, 2–77) and 10.5 months, respectively. In 12 cases (12/16, 75%) stable occlusion was achieved, four cases (4/16, 25%) had recanalized, and two of these were retreated with additional coiling. At clinical follow-up of the nine ruptured cases, three patients (33.3%) achieved a good clinical outcome (Glasgow outcome scale [GOS] score of 4 or 5), two (22.2%) a poor outcome (GOS score of 2 or 3), and four patients (44.4%) expired (GOS 1). On the other hand, of the 15 unruptured cases, 13 patients (86.7%) achieved a good clinical outcome (GOS 4 or 5), one patient a poor outcome (GOS score of 2 or 3), and one patient expired (GOS 1).CONCLUSION: The present study shows endosaccular treatment of very large or giant intracranial aneurysms with parent artery preservation is both feasible and effective with acceptable morbidity and mortality.

Treatment Outcomes with Selective Coil Embolization for Large or Giant Aneurysms : Prognostic Implications of Incomplete Occlusion

OBJECTIVE: The objectives of this study were to evaluate the immediate and long-term efficacy and safety of coil embolization for large or giant aneurysms.METHODS: One hundred and fifty large or giant aneurysm cases treated with endovascular coil embolization between January 2005 and February 2014 at a single institute were included in this study. Medical records and imaging findings were reviewed. Statistical analysis was performed to evaluate prognostic factors associated with major recurrence (major recanalization or rupture) and delayed thromboembolism after selective coil embolization.RESULTS: Procedure-related symptomatic complications occurred in five (3.3%) patients. The mean clinical and radiological follow-up periods were 38 months (range, 2–110) and 26 months (range, 6–108), respectively. During the follow-up period, the estimated recurrence rate was 4.6% per year. Multivariate analysis using Cox regression showed the degree of occlusion to be the only factor associated with recurrence (p=0.008, hazard ratio 3.15, 95% confidence interval 1.34–7.41). The patient’s history of rupture in addition to the size and location of the aneurysm were not associated with recurrence in this study. Delayed infarction occurred in eight cases, and all were incompletely occluded.CONCLUSION: Although immediate postprocedural safety profiles were reasonable, longterm results showed recanalization and thromboembolic events to occur continuously, especially in patients with incomplete occlusion. In addition, incomplete occlusion was associated with delayed thromboembolic complications. Patients with incomplete occlusions should be followed carefully for delayed recurrence or delayed thromboembolic events.

Endosaccular Treatment of Very Large and Giant Intracranial Aneurysms with Parent Artery Preservation: Single Center Experience with Long Term Follow-up

OBJECTIVE: Very large (20–25 mm) and giant (≥25 mm) intracranial aneurysms have an extremely poor natural course, and treatment of these aneurysms remains a challenge for endovascular and surgical strategies. This study was undertaken to describe our experiences of endosaccular treatment of very large and giant intracranial aneurysms with parent artery preservation. METHODS: From January 2005 to October 2016, twenty-four very large or giant aneurysms in 24 patients were treated by endosaccular coil embolization with parent artery preservation. Nine (37.5%) aneurysms were ruptured and 15 were unruptured, and of these 15, 11 were symptomatic cases and 4 were incidentally discovered. The cohort comprised 17 women and 7 men of mean age 58.5 years (range, 26–82). Mean aneurysm size was 26.0 mm (range, 20–39) and 13 of the 24 aneurysms were giant. RESULTS: Immediate angiographic results were complete occlusion in nine (37.5%) cases, remnant neck in six (25.0%), and remnant sac in nine (37.5%). Overall procedural related morbidity and mortality rates were 12.5% and 4.2%, respectively. Angiographic follow-up was available in 16 patients (66.7%). Mean and median follow-up periods were 27.2 (range, 2–77) and 10.5 months, respectively. In 12 cases (12/16, 75%) stable occlusion was achieved, four cases (4/16, 25%) had recanalized, and two of these were retreated with additional coiling. At clinical follow-up of the nine ruptured cases, three patients (33.3%) achieved a good clinical outcome (Glasgow outcome scale [GOS] score of 4 or 5), two (22.2%) a poor outcome (GOS score of 2 or 3), and four patients (44.4%) expired (GOS 1). On the other hand, of the 15 unruptured cases, 13 patients (86.7%) achieved a good clinical outcome (GOS 4 or 5), one patient a poor outcome (GOS score of 2 or 3), and one patient expired (GOS 1). CONCLUSION: The present study shows endosaccular treatment of very large or giant intracranial aneurysms with parent artery preservation is both feasible and effective with acceptable morbidity and mortality.

Treatment Outcomes with Selective Coil Embolization for Large or Giant Aneurysms : Prognostic Implications of Incomplete Occlusion

OBJECTIVE: The objectives of this study were to evaluate the immediate and long-term efficacy and safety of coil embolization for large or giant aneurysms. METHODS: One hundred and fifty large or giant aneurysm cases treated with endovascular coil embolization between January 2005 and February 2014 at a single institute were included in this study. Medical records and imaging findings were reviewed. Statistical analysis was performed to evaluate prognostic factors associated with major recurrence (major recanalization or rupture) and delayed thromboembolism after selective coil embolization. RESULTS: Procedure-related symptomatic complications occurred in five (3.3%) patients. The mean clinical and radiological follow-up periods were 38 months (range, 2–110) and 26 months (range, 6–108), respectively. During the follow-up period, the estimated recurrence rate was 4.6% per year. Multivariate analysis using Cox regression showed the degree of occlusion to be the only factor associated with recurrence (p=0.008, hazard ratio 3.15, 95% confidence interval 1.34–7.41). The patient’s history of rupture in addition to the size and location of the aneurysm were not associated with recurrence in this study. Delayed infarction occurred in eight cases, and all were incompletely occluded. CONCLUSION: Although immediate postprocedural safety profiles were reasonable, longterm results showed recanalization and thromboembolic events to occur continuously, especially in patients with incomplete occlusion. In addition, incomplete occlusion was associated with delayed thromboembolic complications. Patients with incomplete occlusions should be followed carefully for delayed recurrence or delayed thromboembolic events.

Neurological Deterioration after Decompressive Suboccipital Craniectomy in a Patient with a Brainstem-compressing Thrombosed Giant Aneurysm of the Vertebral Artery

We experienced a case of neurological deterioration after decompressive suboccipital craniectomy (DSC) in a patient with a brainstem-compressing thrombosed giant aneurysm of the vertebral artery (VA). A 60-year-old male harboring a thrombosed giant aneurysm (about 4 cm) of the right vertebral artery presented with quadriparesis. We treated the aneurysm by endovascular coil trapping of the right VA and expected the aneurysm to shrink slowly. After 7 days, however, he suffered aggravated symptoms as his aneurysm increased in size due to internal thrombosis. The medulla compression was aggravated, and so we performed DSC with C1 laminectomy. After the third post-operative day, unfortunately, his neurologic symptoms were more aggravated than in the pre-DSC state. Despite of conservative treatment, neurological symptoms did not improve, and microsurgical aneurysmectomy was performed for the medulla decompression. Unfortunately, the post-operative recovery was not as good as anticipated. DSC should not be used to release the brainstem when treating a brainstem-compressing thrombosed giant aneurysm of the VA.

Carotid-Cavernous Fistula Due to Giant Aneurysm in a Postpartum Woman

A carotid-cavernous fistula (CCF) is an abnormal communication between the venous cavernous sinus and the carotid artery. The rupture of an intracavernous aneurysm is usually caused by trauma, but spontaneous rupture can also occur, with pregnancy being a contributing factor. We report a case of direct CCF due to rupture of a giant aneurysm in a postpartum woman.

Crisis parciales como presentación atípica de aneurisma gigante / Partial seizures as atypical presentation giant aneurysm

Los aneurismas gigantes suelen manifestarse en forma de hemorragia subaracnoidea o cefalea. La presentación clínica de un aneurisma gigante intracraneal como epilepsia parcial es inusual, como lo indican los pocos casos recogidos en la literatura. Se presenta el caso de un aneurisma gigante intracraneal de arteria carótida interna derecha, que debuta con crisis focales del lóbulo temporal, manteniéndose sin otra manifestación a lo largo de años a pesar de las llamativas dimensiones.

Giant intracranial aneurysms are usually manifested as subarachnoid hemorrhage or headache. The clinical debut of a giant intracranial aneurysm as partial epilepsy is unusual and indicates the few cases reported in the literature. For giant aneurysm of an intracranial internal carotid artery occurs. Debuts with focal seizures of the temporal lobe, remaining without further demonstration over the years despite the striking dimensions.

Pipeline Embolization Device for Giant Internal Carotid Artery Aneurysms: 9-Month Follow-Up Results of Two Cases

The pipeline(TM) embolization device (PED) is a braided, tubular, bimetallic endoluminal implant used for occlusion of intracranial aneurysms through flow disruption along the aneurysm neck. The authors report on two cases of giant internal carotid artery aneurysm treated with the PED. In the first case, an aneurysm measuring 26.4 mm was observed at the C3-C4 portion of the left internal carotid artery in a 64-year-old woman who underwent magnetic resonance imaging (MRI) for dizziness and diplopia. In the second case, MRI showed an aneurysm measuring 25 mm at the C4-C5 portion of the right internal carotid artery in a 39-year-old woman with right ptosis and diplopia. Each giant aneurysm was treated with deployment of a PED (3.75 mm diameter/20 mm length and 4.5 mm diameter/25 mm length, respectively). Nine months later, both cases showed complete radiological occlusion of the giant intracranial aneurysm and sac shrinkage. We suggest that use of the PED can be a therapeutic option for giant intracranial aneurysms.

Clinical Analysis of Giant Intracranial Aneurysms with Endovascular Embolization

OBJECTIVE: The purpose of this study was to perform a clinical analysis of nine patients with giant aneurysms managed with endovascular embolization. METHODS: From March 2000 to September 2009, nine cases of giant intracranial aneurysms were treated (five unruptured and four ruptured). The nine patients included two males and seven females who were 47 to 72 years old (mean, 59.2 years old). The types of giant intracranial aneurysms were eight internal carotid artery aneurysms and one vertebral artery aneurysm. Treatment for each aneurysm was chosen based on anatomic relationships, aneurysmal factors, and the patients' clinical state. Three patients underwent endovascular coiling with stent and six initially underwent endovascular coiling alone. Medical records, operation records, postoperative angiographies, and follow-up angiographies were reviewed retrospectively. RESULTS: Eight out of nine patients showed good clinical outcomes. (six were excellent and two were good) after a mean follow-up period of 27.9 months. Six (67%) of the nine patients had a near-complete occlusions on the post-operative angiogram (mean, 13.5 months after the procedure). Occlusion rates of 90% or higher were obtained for eight (89%) of all the patients. One patient died due to multiple organ failure. Stents were ultimately required at some point for managing four aneurysms. Two patients needed additional procedures because of aneurysm regrowth. CONCLUSION: Endovascular treatment could be an alternative option for managing giant aneurysms adjuvant to surgical intervention.

Síndrome de Wallenberg secundária a aneurisma gigante de artéria vertebral / Wallenbergïs syndrome due to giant aneurysm of the vertebral artery

Descrevemos um caso de síndrome bulbar lateral, também conhecida pelo epônimo síndrome de Wallenberg, em uma paciente do sexo feminino de 46 anos, com todos os sinais e sintomas clássicos, determinada por aneurisma gigante do segmento intracraniano da artéria vertebral. A síndrome de Wallenberg, apesar de comum a sua apresentação como consequência de aneurisma gigante de artéria vertebral, não é frequente, e na patogênese da sintomatologia o efeito de massa dessas lesões deve ser considerado.

We present a case of lateral bulbar syndrome, or Wallenbergïs syndrome, in a 46 year-old woman with all classic signs and symptoms, due to giant aneurysm of the vertebral artery at its intracranial segment. Even though common, Wallenberg syndrome due to giant aneurysm is not frequent, and in its pathogenesis the mass effect of this lesions may have a significant role.

Giant Intracranial Aneurysm with Blind Sac on Middle Cerebral Artery: Case Report / 대한뇌혈관외과학회지

A case of a giant intracranial aneurysm (GIA) with a blind sac on the left middle cerebral artery (MCA) accompanied by mural thrombosis is described. A 62-year-old male presented with headache and motor dysphasia. Magnetic resonance imaging and digital subtraction angiography revealed a GIA that arose from the proximal MCA. The M2 segment of the MCA was not visualized due to intramural thrombosis. The patient was treated with an extracranial-intracranial arterial bypass and trapping of the aneurysm. Literature relevant to the management of this rare lesion is reviewed and discussed.

A Case of Giant Intracranial Aneurysm Treated with Total Circulatory Arrest, Hypothermia, and Barbiturate Cerebral Protection

We are reporting a case of giant intracranial aneurysm operated under circulatory arrest. The patient was a 36-year-old woman with right hemiparesis and dysarthria. Brain MRI and angiographgy disclosed a partially thrombosed, dumbbell-shaped giant aneurysm involving the left distal ICA and M1 portion of the MCA. The patient was treated with direct clipping under total circulatory arrest, hypothermia, and barbiturate cerebral protection. The clipping could be done more easily than with conventional methodology because the aneurysm was softened. But the patient didn't recover due to postoperative intracerebral hemorrhage and possible embolic infarct.

Thrombosed Giant Posterior Communicating Aneurysm Simulating Brain Neoplasm: A Case Report

A giant intracranial aneurysm(GIA) is an aneurysm greater than 2.5cm in size. GIA may simulate brain tumor on computed tomography scans. We report a case of giant thrombosed posterior communicating artery aneurysm simulating brain tumor. To minimize brain retraction and achieve excellent exposure in the shortest possible distance during the operation, we used a new surgical technique, an orbitozygomatic infratemporal approach, with good results.