Surgical management and alternative strategies for neighboring intracranial aneurysms.

AIM: Neighboring aneurysms are misidentified or named as a single multi-lobulated aneurysm, despite the demonstration of angiographic cleavage, because of the close proximity and different size. During surgery, neighboring intracranial aneurysms represent an interesting subset of aneurysms that may pose unique management challenges. Meticulous preoperative radiological planning is necessary to properly appreciate the local anatomy. Intraoperative microsurgical dissection of these aneurysm complexes may be difficult if a plane cannot be created between the neighboring lesions with dissection of the aneurysm necks and preservation of blood flow becoming a challenging situation. METHODS: A retrospective review over a 10-year period, of all patients with intracranial aneurysms treated by our service was performed to identify those patients with neighboring aneurysms. RESULTS: We encountered 73 instances of neighboring aneurysms (MCA-22, PCOMMA/AChA-20, ACOMMA-15, paraclinoid-5, upper basilar-4, pericallosal-3, ICA bifurcation-2, VB junction-2). Most patients were managed with either microsurgery for both aneurysms or coiling for both. Seven patients with severe SAH underwent coiling of the presumed ruptured (much larger) aneurysm with subsequent microsurgery for the neighboring aneurysm which was not considered amenable to endovascular therapy. In the setting of neighboring lesions, microsurgery was sometimes deemed significantly more difficult than usual, particularly when the aneurysm domes were adherent precluding optimal visualization of the local vascular anatomy. Temporary vascular occlusion was often helpful to allow for proper inspection and identification of all perforating vessels initially hidden by the adherent sacs. CONCLUSION: Neighboring intracranial aneurysms represent an interesting subset of aneurysms that may pose unique management challenges. Careful evaluation of preoperative angiography is necessary to properly appreciate the local anatomy in these cases. Microsurgical dissection of these aneurysm complexes may be difficult if a plane cannot be created between the neighboring lesions. Because neighboring aneurysms tend to obscure the local anatomy, intraoperative angiography and innovative surgical strategies were useful in our experience.

Non-infected carotid artery pseudoaneurysm 29 years after endarterectomy, endovascular management with covered stent.

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA). Arterial pseudoaneurysms lack all three layers of the arterial wall that include the intima, media and adventitia. Pseudoaneurysms are most commonly seen after injuries to the artery in the form of blunt trauma and puncture, and are less common after surgeries such as carotid endarterectomy. These lesions present most frequently as enlarging, pulsatile, expandable masses associated with swelling and pain. Management of this complication is challenging. Traditionally, open surgical repair has been the preferred treatment. Recently, endovascular techniques using stent graft implantation alone or combined graft and coil embolization have offered a less invasive approach for the management of this lesion. Pseudoaneurysm development has been described within hours to several years after initial arterial injury, normally presenting within 5 years. To our knowledge, this is the first case report of pseudoaneurysm formation in a patient presenting 29 years after a carotid endarterectomy; during that time the patient remained completely asymptomatic until 2 months prior to his admission. The patient is an 84-year-old male with a history of stroke which prompted a left carotid endarterectomy in 1981. Twenty-nine years post procedure it was noted that the patient had a lump that was progressively enlarging on the left side of his neck, zone 1. It was pulsatile on examination. MRI/A imaging suggested a left carotid bulb aneurysm. The consulting vascular surgeon felt the patient would not be a good surgical candidate and so stenting was considered. Carotid and cerebral angiogram demonstrated a large 6 cm left carotid pseudoaneurysm off the carotid bulb. The diagnostic procedure was followed by a successful placement of an 8 x 10 cm Viabahn covered stent from the left common carotid artery to the left internal carotid artery. Following the procedure, the carotid artery was patent and there was minimal to no further residual filling of the pseudoaneurysm. Poststenting, the patient remained at his neurological baseline. This case demonstrates that pseudoaneurysm formation can occur as a long term complication after carotid endarterectomy. It may present as a rapidly expandable, pulsatile, vascular lesion in the absence of clinical and sub-clinical infection. Placement of an endovascular stent graft may be a safe and effective option for treatment of infected and non-infected carotid pseudoaneurysm.

Intracranial aneurysm formation in siblings with pseudoxanthoma elasticum: case report.

Although intracranial aneurysms have been associated with many hereditary collagen disorders, the incidence of brain aneurysms in pseudoxanthoma elasticum (PXE) appears to be exceedingly low and uncertain. We describing a rare case of a sisters with PXE who both developed intracranial aneurysms. This report supports the previously questioned hypothetical association between PXE and intracranial aneurysms.