Fig 2 - available via license: Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
Content may be subject to copyright.
Therapeutic options considered preoperatively. Trapping with high flow bypass (A), and flow alteration with a combination of high flow bypass with proximal carotid occlusion between the anterior choroidal artery (AchoA) and posterior communicating artery (PcomA), and clipping of the proximal A 1 (B) or M 1 (C). ATA: anterior temporal artery, ICA: internal carotid artery, LSA: lenticulostriate artery, RA: radial artery.
Source publication
A 33-year-old woman presented with a ruptured, partially thrombosed carotid bifurcation aneurysm after partial coiling, which was successfully treated by "tasuki" (a cloth sash crossing from one shoulder to the opposite hip, worn by relay marathon runners) clipping combined with radial artery and external carotid artery-to-middle cerebral artery by...
Context in source publication
Citations
... [9,11,13,15] These problems can cause incomplete obliteration of the aneurysm, neck remnants, and deterioration of local branch patency. Several advanced strategies such as reconstructive clipping [2,7] or proximal occlusion with distal revascularization [14,17] have been recently proposed, which require a great deal of special techniques and are not highly versatile. Surgical treatment of giant thrombosed aneurysms located on the distal anterior cerebral artery (DACA) is highly challenging because of the narrow corridor in the interhemispheric space, adhesion between the cingulate gyri, and difficulty in controlling the parent artery. ...
Background
Giant thrombosed aneurysms often present with thickened walls and a hard thrombus, including in the near-neck aneurysmal sac. These usually make it difficult to achieve complete neck clipping with preservation of local branch patency. Here, we demonstrate a simple but safe and effective technique to overcome these problems in a patient with a 6-cm giant thrombosed distal anterior cerebral artery aneurysm.
Case Description
A 77-year-old-man suffered from loss of volitional activity due to the frontal mass effect. The aneurysm was exposed with unilateral paramedian craniotomy and an interhemispheric approach. The clip was applied to the aneurysmal neck but it slipped onto the parent artery, which caused branch artery occlusion. Intra-aneurysmal thrombectomy was immediately performed near the aneurysmal neck with ultrasonic aspiration. The next clip was added along the aneurysm side of the preceding clip, which was then removed. This procedure was repeated twice so that complete neck clipping was achieved while preserving the branch patency. All the residual thrombus and aneurysmal wall were subsequently removed. Postoperatively, there was no additional neurological deficit. The patient's mental function was significantly improved.
Conclusions
We conclude that the sequential, progressive clipping technique is a robust option for successful neck clipping of giant thrombosed aneurysms.
... Surgical flow modification of the anterior cerebral artery-anterior communicating artery complex in the management of giant aneurysms of internal carotid artery bifurcation: An alternative for a difficult clip reconstruction aneurysm enlargement and intraparenchymal hemorrhage into the basal ganglia simulating hypertensive hemorrhage may appear as the presenting symptoms. [6][7][8][9][10] The advocated surgical strategy to treat ICAb aneurysms include delicate dissection of its dome and reconstruction of its walls with preservation of the ACA, MCA, recurrent artery of Heubner, basal vein of Rosenthal, deep sylvian veins, and lenticulostriate perforators. [1][2][3][11][12][13][14][15][16] This surgical strategy might be difficult to achieve in cases of giant, complex, and partially thrombosed aneurysms. ...
... Cohen-Gadol [1] reported successful treatment of giant ICAb aneurysm with bypass using a radial graft. Iihara et al. [6] used a combined technique of clipping and bypass in a case of partially thrombosed giant ICAb aneurysm. Gupta et al. [3] reported seventy patients with ICAb aneurysms, of whom only one was above 20 mm. ...
Background:
Internal carotid artery bifurcation (ICAb) aneurysms account for about 2-15% of all intracranial aneurysms. In giant and complex cases, treatment may be difficult and dangerous, once some aneurysms have wide neck and anterior cerebral artery (ACA) and middle cerebral artery (MCA) may arise from the aneurysm itself. Clip reconstruction may be difficult in such cases. Whenever possible, the occlusion of ACA transform the bifurcation in a single artery reconstruction (ICA to MCA), much easier than a bifurcation reconstruction.
Methods:
In patients with giant and complex ICAb aneurysms, we propose routine preoperative angiography with anatomical evaluation of anterior communicating artery (ACoA) patency during cervical common carotid compression with concomitant contralateral carotid artery injection. This allowed visualization of the expected reversal of flow in the A1 segment-ACoA complex. When test is positive, we can perform ipsilateral ACA (A1 segment) clip occlusion and flow modification of the ACA-ACoA complex transforming a three vessel (ICA, ACA, and MCA) reconstruction into a two vessel (ICA and MCA) reconstruction.
Results:
Two patients were treated, with 100% of occlusion and good outcome.
Conclusions:
Surgical treatment of giant and complex ICAb may be achieved with acceptable morbidity.
In the present report, we describe a case of dissecting aneurysm of the vertebral artery (VA) involving the posterior inferior cerebellar artery (PICA). A 64-year-old woman presented with vomiting and disturbed consciousness. Computed tomography (CT) imaging revealed a subarachnoid hemorrhage with intraventricular hemorrhage. Three-dimensional computed tomography angiography revealed a dissecting aneurysm of the left VA involving the PICA, located at the proximal end of its dissection. The aneurysm was successfully treated by trapping and diagonal proximal occlusion, which enabled the preservation of the PICA.
