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Giant intracranial aneurysms bervini
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Giant intracranial aneurysms bervini

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  • 1. JCApril 19th 2012 D. Bervini EBS presentation 1
  • 2. INTRODUCTION1. Morbidity and mortality of surgery: 20-30% – Inherent treatment risks – Anatomy • Wide neck • Complex arterial branches • Intraluminal thrombus • Atherosclerotic degeneration • Adherent perforating arteries EBS presentation 2
  • 3. 2. Increase in use of endovascular treatment – Coiling (Guglielmi 1990) – Flow diversion and Endoluminal reconstruction (petrocavernous and paraclinoid ICA and BT)3. Old surgical series EBS presentation 3
  • 4. 4. Improved radiological imaging and earlier diagnosis of large aneurysm EBS presentation 4
  • 5.  Older publications do not reflect the current practice environment EBS presentation 5
  • 6. OBJECTIVE• Examine specific changes in surgical management• Examine the role of microsurgery in management strategy• Quantify surgical results for comparison with evolving endovascular therapies EBS presentation 6
  • 7. METHODS• Retrospective study• Single center• Patients with ≥ 25mm aneurysms (thrombus included)• 13 y period EBS presentation 7
  • 8. Patients• 140 patients • 6 recurrent• 141 GA aneurysms after• 64% F, 36% M coiling• mean age 54y • 1 recurrent aneurysm after• 16% (33) SHA clipping • HH I 5 • HH II 5 • HH III 6 • HH IV 7 EBS presentation 8
  • 9. Aneurysms• mean diameter 29mm EBS presentation 9
  • 10. Surgical managment• surgery VS coil on individual basis• Exclusion: – HH V – aneurysm calcifications – location on the basilar trunk or vertebrobasilar junction – advanced age – significant anesthetic risk – patient and family preferences EBS presentation 10
  • 11. • primary strategy: direct aneurysm clipping• alternative strategy = indirect occlusion: • clipping parent artery • bypass with clipping parent artery • bypass with endovascular occlusion EBS presentation 11
  • 12. Balloon test occlusion (BTO)• 26 patients• Cavernous or supraclinoid ICA aneurysms• Failed – 10 with BTO inflation alone  high-flow bypass – 16 with additional hypotensive challenge  low- flow bypass EBS presentation 12
  • 13. Outcomes• Aneurysm occlusion (angiography) – Complete – Minimal residual aneurysm (dog-ear) – Incomplete (>5%)• Aneurysm treatment failure = growth of residual aneurysm or rupture EBS presentation 13
  • 14. • Neurological outcome = GOS• Improved VS unchanged VS worse VS dead EBS presentation 14
  • 15. Results EBS presentation 15
  • 16. Bypass• 38% – ECA-MCA 26% – STA-MCA 20% – Intracranial-intracranial 28% EBS presentation 16
  • 17. OutcomeAneurysms• 77% complete occluded (79% clip / 72% indirect)• 10% minimal residual (clip)• 11 % incompletely occluded (parent artery clip with/without bypass)•  3.5% retreatment EBS presentation 17
  • 18. Post-operative durability of GA control EBS presentation 18
  • 19. Outcome EBS presentation 19
  • 20. • Posterior circulation aneurysms = more complications = independent risk factor.• SAH patients had worse outcomes, mortality 39% (8% for no-SAH) EBS presentation 20
  • 21. Discussion• Dolichoectatic morphology• Aberrant branch anatomy• Atherosclerotic neck  bypass• Intraluminal thrombus  47% clipping• Previous coil EBS presentation 21
  • 22. •  Heavy reliance on bypass techniques (38%)OR•  adjuncts that facilitate direct clipping, like deep hypothermic circulatory arrest EBS presentation 22
  • 23. Deep hypothermic circulatory arrest• Eliminate risk of aneurysm rupture• Permits clip collapse• Permits manipulation (remove thrombus, create supple neck) EBS presentation 23
  • 24. BUT• Significant operation morbidity – Compromise of distal circulation by cannulation – Cerebral ischemic injury – Postoperative bleeding complications – Cumulative mortality-morbidity 32% EBS presentation 24
  • 25. Complications of bypass and indirectaneurysm occlusion• Thrombotic occlusion of perforators or branch arteries (7%) EBS presentation 25
  • 26. FIGURE 3 . Case 15. A, axial T2-weighted MR imagingrevealed a giant left ICA bifurcation aneurysm and a largeanterior communicating artery aneurysm in this 51-year-old woman. B, 3D reconstructed angiogram (left ICAinjection) demonstrated its dolichoectatic morphology.An end-to-side anastomosis between radial artery andthe efferent MCA was part of an ECA-MCA bypass. C,supraclinoid ICA was occluded with a clip as it enteredthe aneurysm, distal to PCoA. Indocyanine greenvideoangiography demonstrated patency of the bypassgraft, filling of distal MCA branches, filling of thesupraclinoid ICA up to the clip, and faint flow of dyewithin the aneurysm. Postoperative CT angiographyshowed a thin layer of new intra-aneurysmal thrombusanteriorly, posteriorly, and inferiorly on axial (D) andcoronal (E) views. F, subsequent digital subtractionangiography demonstrated bypass patency andprogressive intraluminal thrombosis (left ICA injection,anteroposterior view). CTA on postoperative day 5revealed further intraluminal thrombosis with 2serpentine channels connecting the bypass with the A1segment on the opposite side of the aneurysm, as seenon axial (G) and coronal (H) views. Postsurgicalthrombosis occluded the anterior choroidal artery, andshe experienced a capsular infarct. This casedemonstrates that postsurgical aneurysm thrombosisafter proximal clip occlusion can occlude small brancharteries. ICA, internal carotid artery; MCA, middlecerebral artery; PCA, posterior cerebral artery; ECA,external carotid artery; PCoA, posterior communicatingartery; CTA, computed tomographic angiography. EBS presentation 26
  • 27. Computational fluid dynamic• Preferred treatment: – maintain robust flow in regions where branch arteries originate – accepting stagnation in perforator-free zones (dome and fundus) EBS presentation 27
  • 28. Conclusion EBS presentation 28
  • 29. Superiority of Surgical Managment• Good results – GOS 4-5 in 81% – Improved/unchanged in 78%• Mortality 13% (vs 29%)• Morbidity 9% (vs 32%)• Complete occlusion 77% (vs 36%)• endovascular treatment: multiple treatments, repeat risks exposure and relapsing clinical course. EBS presentation 29
  • 30. Weakness of the article• Retrospecive view• Lack of control group• Short follow-up duration (2y), especially for indirect treatment (bypass)• Selection biais (chose for surgical treatment because it was felt to offer better outcome)• Indirect treatment is not completely protective• No entirely surgical series (23 pts endovascular) EBS presentation 30
  • 31. EBS presentation 31