Microsurgical partial trapping for the treatment of unclippable vertebral artery aneurysms: Experience from 27 patients and review of literature.

BACKGROUND: The efficacy and safety of partial trapping for the treatment of unclippable vertebral artery aneurysms (UVAs) are still questionable. The partial trapping method (proximal or distal occlusion) was used in the treatment of aneurysms to simplify the surgical procedure and avoid postoperative complications. METHODS: This study included 27 patients with UVAs who underwent microsurgical partial trapping between January 2015 and August 2022, and their postoperative outcomes and complications were retrospectively reviewed and evaluated. RESULTS: Ruptured UVAs were detected in 25 (92.6%) patients, and 13 (48.1%) patients had poor-grade status. Fusiform dissection, dissecting, and fusiform aneurysms were observed in 17 (63%), 7 (25.9%), and 3 (11.1%) patients, respectively. By location, preposterior inferior cerebellar artery (PICA), PICA, post- PICA, and non-PICA types were noted in 7 (25.9%), 9 (33.3%), 6 (22.2%), and 5 (18.5%) patients, respectively. Microsurgical partial trapping was performed in all patients (blind-alley formation in 96.3%). Complete aneurysm obliteration was achieved in 26 (96.3%) patients. Immediate complete obliteration was achieved in 21 (77.8%) patients, delayed thrombosis within 7 days in 5 (18.5%), and nearly complete obliteration in 1 (3.7%). No re-bleeding was detected in all patients. Favorable outcomes 3 months after the operation were achieved by 92.9% of the patients in the good-grade group and 85.2% overall. CONCLUSIONS: Microsurgical partial trapping, especially the blind-alley formation technique, was a safe and effective treatment of UVAs with high rates of aneurysm thrombosis. The appropriate sites for clip occlusion were dependent on the angioarchitecture of UVAs.

Blind-Alley Formation and Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for the Treatment of Unclippable Vertebral Artery Aneurysms with Posterior Inferior Cerebellar Artery Involvement.

BACKGROUND AND IMPORTANCE: Unclippable vertebral artery aneurysms (UVAs) are difficult to treat with direct clipping, especially in cases involving the origin of the posterior inferior cerebellar artery (PICA). Bypass with trapping is the common procedure used for these conditions. The authors used the blind-alley formation technique, which is a simpler method than trapping and can avoid some complications. OBJECTIVES: To report 7 cases of UVA with PICA involvement treated with blind-alley formation and occipital artery (OA)-PICA bypass as well as their surgical outcomes and complications and to describe the operative techniques. RESULTS: Seven patients with UVA and PICA involvement underwent OA-PICA bypass and blind-alley formation (occlusions of the PICA origin and vertebral artery proximal to the aneurysm). Vertebral artery dissecting aneurysms and fusiform atherosclerotic vertebral artery aneurysms were detected in 6 patients and 1 patient, respectively. All patients presented with subarachnoid hemorrhage, and 71.4% of them were classified into the poor-grade group. Good bypass patency and complete aneurysm obliteration were achieved in all cases. Six aneurysms (85.7%) were completely obliterated according to computed tomography angiography performed immediately postoperatively. Another aneurysm was 50% and 100% thrombosed immediately and at 7 days after the operation, respectively. Surgical complications were found in 1 patient (14.3%) who had postoperative diparesis with dysphagia. Three patients (42.9%) achieved a Glasgow Outcome Score of 4 or 5 one month after the operation. CONCLUSIONS: Blind-alley formation and OA-PICA bypass are simple, safe, and effective for the treatment of patients with UVA with PICA involvement.

Microsurgical outcome of unruptured giant intracranial aneurysms: A single-center experience.

Microsurgical treatment of unruptured giant intracranial aneurysms (GIAs) is challenging. Although previous studies regarded clipping as the first option to repair GIAs, quite a number of GIAs are not clippable. We conducted this study to evaluate the postoperative complications and long-term outcome of patients with unruptured GIAs treated by different microsurgical modalities. We retrospectively reviewed 505 consecutive patients with unruptured intracranial aneurysms (UIAs) who were surgically treated in our department from 2012 to 2015. Patients with UIAs of which diameter ≥2.5 cm were studied. We reported the characteristics of patients and GIAs. Postoperative major complications were observed, and patient functional status were assessed with the modified Rankin Scale (mRS) at discharge and at the last follow-up. Twenty-one patients with unruptured GIAs were analysed, of whom 12 patients were treated by clipping, whereas 9 patients with unclippable aneurysms were treated by trapping or parent vessel occlusion. Fourteen aneurysms were saccular, and 7 were fusiform or serpentine. The mean aneurysm size was 3.7 ±â€¯1.5 cm. After surgery, major complications were observed in 13 of the 21 (61.9%) patients. One (4.8%) patient died during hospital. After a mean 5.2-year follow-up, 9 (75.0%) patients treated by clipping and 7 (77.8%) treated by non-clipping experienced a good outcome (mRS ≤2). We found no significant difference in both postoperative complications and long-term outcome between clipping and non-clipping group. Favorable prognosis can be obtained in most patients with unruptured GIAs treated by appropriate microsurgical modality.

Subtemporal approach for distal basilar occlusion for giant aneurysm. Nuances and advantages of the subtemporal approach.

We described the subtemporal approach, which was used for distal basilar artery occlusion in a patient with a symptomatic giant unclippable aneurysm. We discuss issues related to positioning and lumbar drainage. We illustrate the basic steps: identification of the tentorial notch; sharp opening of the arachnoid behind the third nerve; placement of a fixed mechanical retractor to "hold" the brain; identification of the third nerve and mobilization from arachnoid attachments; identification of the course and insertion of the fourth nerve; division and retraction of the tentorial edge to enhance exposure; preparation of the "perforator-free zone"; and final clip application followed by ICG fluorescein angiography. We show some of the areas exposed with this approach. The video can be found here: http://youtu.be/S_NLIjKQL_o .

Long-term clinical and angiographic outcomes of wrap-clipping strategies for unclippable cerebral aneurysms.

PURPOSE: To evaluate the efficacy and stability of the wrap-clipping methods as a reconstructive strategy in the treatment of unclippable cerebral aneurysms. MATERIALS AND METHODS: Twenty four patients who had undergone wrap-clipping microsurgery were retrospectively reviewed. Type and morphology of the treated aneurysm, utilized technique for wrap-clip procedure, and clinical outcome with angiographic results at their last follow-up were evaluated. RESULTS: Of 24 patients, eleven patients had internal carotid artery (ICA) blister-like aneurysms, three had dissecting type aneurysms, and ten had fusiform aneurysms. The follow-up period for the late clinical and angiographic results ranged from 10 to 75 months (mean 35 months). Wrap-clipping was performed in eleven, wrap-holding clipping was in ten, and combination of wrap-clip and wrap-holding clip was in three cases. At the last angiographic follow-up study, twelve aneurysms (50%) were found to have completely healed, and nine aneurysms (38%) were at least stable. However, wrap-holding clip for the elongated blister type of ICA aneurysm was found failed, leading to fatal rebleeding in one case, and two cases of combination of wrap-clip-wrap-holding clip revealed delayed branch occlusion and marked regrowing, respectively. CONCLUSION: Wrap-clipping strategy could be an easy and safe alternative for unclippable aneurysms. The wrapped aneurysm mostly disappeared, or at least remained stationary, after a long-term period. However, surgeons should be aware of that the wrapped aneurysm might become worse. Therefore, follow-up surveillance for an extended period should be mandatory.

Long-Term Clinical and Angiographic Outcomes of Wrap-Clipping Strategies for Unclippable Cerebral Aneurysms

PURPOSE: To evaluate the efficacy and stability of the wrap-clipping methods as a reconstructive strategy in the treatment of unclippable cerebral aneurysms. MATERIALS AND METHODS: Twenty four patients who had undergone wrap-clipping microsurgery were retrospectively reviewed. Type and morphology of the treated aneurysm, utilized technique for wrap-clip procedure, and clinical outcome with angiographic results at their last follow-up were evaluated. RESULTS: Of 24 patients, eleven patients had internal carotid artery (ICA) blister-like aneurysms, three had dissecting type aneurysms, and ten had fusiform aneurysms. The follow-up period for the late clinical and angiographic results ranged from 10 to 75 months (mean 35 months). Wrap-clipping was performed in eleven, wrap-holding clipping was in ten, and combination of wrap-clip and wrap-holding clip was in three cases. At the last angiographic follow-up study, twelve aneurysms (50%) were found to have completely healed, and nine aneurysms (38%) were at least stable. However, wrap-holding clip for the elongated blister type of ICA aneurysm was found failed, leading to fatal rebleeding in one case, and two cases of combination of wrap-clip-wrap-holding clip revealed delayed branch occlusion and marked regrowing, respectively. CONCLUSION: Wrap-clipping strategy could be an easy and safe alternative for unclippable aneurysms. The wrapped aneurysm mostly disappeared, or at least remained stationary, after a long-term period. However, surgeons should be aware of that the wrapped aneurysm might become worse. Therefore, follow-up surveillance for an extended period should be mandatory.

Extracranial-intracranial bypass of the bilateral anterior cerebral circulation using a thoracodorsal axis artery-graft.

Bilateral extracranial-intracranial (EC-IC) bypass-grafting of the cerebral circulation is uncommon. We report a case of anterior cerebral artery EC-IC bypass using the thoracodorsal axis artery-graft. The bifurcation of the thoracodorsal axis allows bypass of both anterior hemispheres, while matching appropriate small-vessel dimensions.

Revascularization in the Management of Complex Cerebral Aneurysm / 대한뇌혈관외과학회지

The objective of aneurysm surgery is to exclude the aneurysm from the circulation while preserving blood flow distal to the lesion. In certain situations, the aneurysm neck cannot be clipped safely or the parent vessel reconstructed, primarily in large or giant size with incorporation of parent vessels or perforating arteries, calcification at the aneurysm base, and fusiform or dissecting aneurysms. In such cases, occlusion of the parent vessel is a treatment of option. In many patients, however, sacrifice of the parent artery has an associated risk of ischemic stroke. Therefore, sacrifice of the parent vessel can be supplimented with distal revascularization to provide the necessary distal blood flow while allowing the aneurysm to be trapped. The indications, options, and surgical approaches are described with review of literatures. Finally the authors' experiences of revascularization in 7 patients with unclippable aneurysms are reported.

Bypass Graft for Cerebral Revascularization / 대한뇌혈관학회지

OBJECTIVE: The authors were performed bypass graft for cerebral revascularization in the treatment of hemodynamic cerebral ischemia and unclippable traumatic aneurysm, which acute sacrifice of the internal carotid artery is necessary. The aim of this study was to assess effectiveness bypass graft for cerebral revascularization. METHOD: Of 6 patients, Four patients were hemodynamic cerebral ischemia and two patients were traumatic cerebral aneurysm and traumatic carotid-cavernous fistula (CCF). Revascularization was performed external carotid artery (ECA) to middle cerebral artery (MCA) bypass with radial artery (n=1), ECA to MCA bypass with long saphenous vein (n=1), main trunk of superficial temporal artery (STA) to MCA with short saphenous vein (n=2), and internal carotid artery (ICA) to MCA with long saphenous vein (n=2). RESULTS: There were two graft occlusion, which one is recanalization case of preoperative MCA obstruction and the other is traumatic CCF. Four patients with good patiency through bypass showed significant increase of postoperative cerebral blood flow and good surgical outcome. There was not operative complication except for graft failure of 2 cases. CONCLUSION: Extracranial to intracranial bypass graft with radial artery or saphenous vein is thought to alternative method for cerebral revascularization in cases with unsuitable STA to bypass, and ICA reconstruction, which acute sacrifice of ICA is necessary.

Treatment of Carotid-Cavernous Fistula and Internal Carotid Aneurysm with Debrun's Latex Detachable Balloon Catheter Technique

The two cases, one carotid-cavernous fistula and one giant aneurysm of internal carotid artery, treated with Debrun's latex detachable balloon catheter technique are reported. Case 1 was a 50-year-old man who had proptosis, chemosis and 3rd nerve palsy in his right eye. His cerebral angiography showed typical traumatic carotid-cavernous fistula. Following complete radiologic and neurologic examination, the fistulous opening was successfully occluded with preservation of the internal carotid artery using latex detachable balloon. Immediately after occlusion of the fistula the clinical symptoms were markedly improved. Only transient facial pain occurred as a complication. Case 2 was a 21-year-old woman who had a dizziness and left facial nerve palsy. The cerebral angiography showed a giant aneurysm at the petrous portion of left internal carotid artery. The patient tolerated occlusion of the left carotid artery. The left internal carotid artery was completely occluded with 3 detachable balloons. The patient had no complications during 9 days follow-up. The procedures and complications of detachable balloon catheter technique will be described and discussed.