Abstract
Giant cavernous aneurysms of the internal carotid artery (ICA) are challenging lesions associated with high surgical morbidity. Prior to the past several years, these were treated by surgical reconstruction, proximal ligation, or stent-assisted coiling techniques. Flow diversion has become the standard of care for these lesions, providing a high rate of obliteration with a much better safety profile. However, flow diverters rely upon a navigable vasculature and, usually, a tri-axial support system. Cases in which such access is difficult require unique approaches to combine the strengths of both surgical and endovascular therapy. A woman with a giant cavernous ICA aneurysm and an ophthalmic artery aneurysm presented for treatment, but access was challenging due to cervical ICA tortuosity and pseudoaneurysms. We elected a staged, combined approach with surgical reconstruction of the cervical ICA followed by flow diverter placement for the intracranial aneurysms. Our case features an “outside-the-box” approach that synergistically applied both microsurgical and endovascular techniques to treat a challenging pathology. Classic microsurgical techniques remain important in cases that are refractory or not amenable to endovascular therapy alone.
Highlights
Prior to the development of modern neurointerventional surgery, giant cavernous aneurysms presented a treatment challenge; surgery was associated with high technical difficulty and morbidity and endovascular options were limited
Flow diversion is not without caveats. It requires dual antiplatelet therapy (DAPT) prior to treatment, which is a contraindication in cases of ruptured aneurysm/intracranial hemorrhages [2]
“Comprehensive” cerebrovascular neurosurgeons with training and expertise in both modalities are uniquely positioned to address such aneurysms [5]. We present such a case that lent itself to a combined approach, where we used surgical techniques that facilitated endovascular access for two intracranial aneurysms, including a giant cavernous aneurysm
Summary
Prior to the development of modern neurointerventional surgery, giant cavernous aneurysms presented a treatment challenge; surgery was associated with high technical difficulty and morbidity and endovascular options were limited. How to cite this article Srinivasan V M, Kaufmann A, Kan P, et al (March 28, 2018) Surgical Reconstruction to Allow Endovascular Access for Flow Diversion of Giant Cavernous Aneurysm: A Combined Approach. “Comprehensive” cerebrovascular neurosurgeons with training and expertise in both modalities are uniquely positioned to address such aneurysms [5] We present such a case that lent itself to a combined approach, where we used surgical techniques that facilitated endovascular access for two intracranial aneurysms, including a giant cavernous aneurysm. The only feasible open approach for the giant cavernous aneurysm would have been trapping and bypass This procedure would have carried the attendant risks and morbidity associated with extracranial-intracranial bypass, would have required two separate incisions, and would not necessarily address her multiple cervical pseudoaneurysms. We instead opted for the surgical correction of the ICA, which would improve access to the fusiform giant cavernous aneurysm as well as the ophthalmic aneurysm
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