Basilar Apex Aneurysms Research Articles

Maximizing the Carotid-Oculomotor Triangle and Oculomotor-Trochlear Corridor for Microsurgical Clipping of a Large Wide-Neck Low-Lying Basilar Apex Aneurysm: 2-Dimensional Operative Video.

Maximizing the Carotid-Oculomotor Triangle and Oculomotor-Trochlear Corridor for Microsurgical Clipping of a Large Wide-Neck Low-Lying Basilar Apex Aneurysm: 2-Dimensional Operative Video.

Rare Case of a Delayed WEB Device Collapse in a Large Basilar Apex Aneurysm (P9-5.013)

Rare Case of a Delayed WEB Device Collapse in a Large Basilar Apex Aneurysm (P9-5.013)

Contour device implantation for treatment of intracranial aneurysms in the basilar tip

Introduction Treatment of basilar apex aneurysms will remain challenging regarding the nobility of the parent vessel and their often wide-necked configuration. With endovascular techniques being the treatment approach of choice, novel intrasaccular flow-disruption devices constitute an endovascular embolization option. In this research, we report our experiences in embolizing basilar tip aneurysms with the novel Contour device. Material and methods Retrospective analysis of eight patients after Contour implantation into a basilar apex aneurysm. Periprocedural data on intervention times, radiation dose, procedural success and complications were gathered. All patients received follow-up digital subtraction angiography after six months. Further follow-up examination results were analysed given their availability. Results Contour implantation was successful in all patients. The mean device instrumentation time was 18.8 ± 7.7 min with a mean full intervention time of 100 ± 65.8 min. The mean full procedure radiation dose was 1917 (421–5107) cGy/cm2. After six months, six aneurysms were occluded (Raymond Roy Scale (RRS) 1/2), one showed perfusion inside the device (RRS 3a) and one patient had undergone reintervention due to progression. The aneurysm with constant perfusion at six months was seen to be occluded after 24 months. Conclusion Contour device implantation is a promising feasible alternative endovascular method for embolization of intracranial aneurysms located in the basilar tip with short intervention times and low radiation dosages. Short- and medium-term follow-ups show promising results concerning aneurysm occlusion and reinterventions, however further research is needed to show long-term stability.

Sphenoparietal Sinus Transposition: Operative Technique for Optimizing Pretemporal Posterior Circulation Access While Preserving the Sylvian Venous Complex

Transsylvian approaches are a cornerstone of complex cranial operations, with wide applicability across cerebrovascular, skull base, and neuro-oncology operations. Deep lesions, especially those involving the basilar apex, midbrain, or interpeduncular fossa, require wide exposures that may be inhibited by the presence of a large complex of superficial sylvian veins (SSV) draining into the sphenoparietal sinus. This report describes technical and clinical aspects of the sphenoparietal sinus transposition (SPST) technique. Technical case report of the SPST technique, including a step-by-step neuroanatomic description, overview of common indications, clinical pearls and pitfalls, and illustrative case examples. Once the benefits of proceeding with SPST have been established, the maneuver is initiated with 2 stepwise dural incisions: an incision from lateral to medial along the lateral margin of the lesser sphenoid wing, followed by an orthogonal cut across the temporal pole down the middle fossa floor. The pretemporal dura is peeled off the lateral wall of the cavernous sinus, allowing mobilization of the SSV complex and temporal pole posteriorly without disrupting or straining the connection point at the sphenoparietal sinus. Illustrative case examples include a clip reconstruction of a basilar apex aneurysm for which earlier endovascular treatment had failed and microsurgical resection of a peduncular cavernous malformation. SPST is a simple but versatile technique with important applications in complex cranial surgery. By mobilizing the SSV complex together with its dural attachment, the transsylvian corridor can be markedly widened, allowing access to the basilar apex region and ventral midbrain.

Frontotemporal Orbitozygomatic Transcavernous Approach: Stepwise Cadaveric Dissection for a Safe Corridor.

Background Advances in skull base surgery have increased the need for a detailed understanding of skull base anatomy and its intrinsic relationship to surrounding structures. This has resulted in an improvement in patient outcomes. The frontotemporal orbitozygomatic (FTOZ) transcavernous approach (TCA) is an excellent option for treating complex lesions involving multiple compartments of the skull base, including the sellar and parasellar, third ventricle, orbit, and petroclival region. Objective This article aimed to provide a detailed cadaveric dissection accompanying a thorough procedure description, including some tips and pitfalls of this technique. Methods Microsurgical dissection was performed in four freshly injected cadaver heads at the Cranial Base Neuroanatomy Laboratory, Cleveland Clinic Florida. The FTOZ TCA was performed on both sides of the four specimens. The advantages and disadvantages were discussed based on the anatomic nuances of this approach. Results The FTOZ TCA represented a wide access to the anterior, middle, and posterior fossa. When combined with an anterior clinoidectomy, it allowed for significant and safe internal carotid artery mobilization. This approach created numerous windows, including opticocarotid, carotid-oculomotor, supratrochlear, infratrochlear, anteromedial, anterolateral, and posteromedial triangles. The only drawback was the length of the dissection and the level of surgical acumen required to perform it. Conclusion Despite its technical difficulty, the FTOZ TCA should be considered for the surgical management of basilar apex aneurysms and tumors surrounding the cavernous sinus, sellar/parasellar, retrochiasmatic, and petroclival region. Continuous training and dedicated time in the skull base laboratory can help achieve the necessary skills required to perform this approach.

Microsurgical clipping as a retreatment strategy for previously ruptured aneurysms treated with the Woven EndoBridge (WEB) device: a mono-institutional case series

BackgroundSince its approval by the US Food and Drug Administration (FDA) in 2018, the flow disruptor Woven EndoBridge (WEB) device has become increasingly popular for the endovascular treatment of unruptured and ruptured cerebral aneurysms. However, the occlusion rates seem rather low and the retreatment rates rather high compared to other treatment methods. For initially ruptured aneurysms, a retreatment rate of 13 % has been reported. A variety of retreatment strategies has been proposed; however, there is a paucity of data concerning microsurgical clipping of WEB-pretreated aneurysms, especially previously ruptured ones. Thus, we present a single-center series of five ruptured aneurysms treated with the WEB device and retreated with microsurgical clipping.MethodsA retrospective study including all patients presenting with a ruptured aneurysm undergoing WEB treatment at our institution between 2019 and 2021 was performed. Subsequently, all patients with an aneurysm remnant or recurrence of the target aneurysm retreated with microsurgical clipping were identified.ResultsOverall, five patients with a ruptured aneurysm treated with WEB and retreated with microsurgical clipping were included. Besides one basilar apex aneurysm, all aneurysms were located at the anterior communicating artery (AComA) complex. All aneurysms were wide-necked with a mean dome-to-neck ratio of 1.5. Clipping was feasible and safe in all aneurysms, and complete occlusion was achieved in 4 of 5 aneurysms.ConclusionsMicrosurgical clipping for initially ruptured WEB-treated aneurysms is a feasible, safe, and effective treatment method in well-selected patients.

Commentary: Twenty Years, 10 Fellows, 1 Article: Reflections on Cerebrovascular Training and the Evolution of Basilar Apex Aneurysm Treatments.

Graffeo, Christopher S. MD, MS‡; Srinivasan, Visish M. MD§; Frisoli, Fabio MD‖; Lang, Michael J. MD¶; Mascitelli, Justin R. MD#; Burkhardt, Jan-Karl MD§; Walcott, Brian P. MD*; Owen, Christopher M. MD††; Rodriguez-Hernandez, Ana MD, PhD‡‡; Abla, Adib A. MD§§ Author Information

Impact of size ratio on thromboembolic events based on diffusion-weighted imaging after coil embolization for unruptured basilar apex aneurysm

PurposeCoil embolization is one of the main endovascular treatment for basilar apex aneurysms (BAAs), and thromboembolic events are important complications of coil embolization. Even in small aneurysms, there is a risk of rupture, and aggressive treatment should be considered for unruptured BAAs. Using diffusion-weighted imaging (DWI), the study aimed to investigate thromboembolic events after coil embolization for unruptured BAAs by focusing on the absolute aneurysm size and relative aneurysm size (size ratio [SR]). MethodsTo evaluate the predictors of thromboembolic events, patients were divided into those with and without hyperintensity on DWI after coil embolization. Patient and radiographic characteristics were compared between the two groups. SR was defined as the maximum aneurysm diameter divided by the average parent artery diameter. ResultsFifty-six unruptured BAAs in 56 patients were investigated. The mean aneurysm size and SR were 7.61 ± 2.18 mm and 2.74 ± 1.45, respectively. Postprocedural hyperintensity on DWI was detected in 17 patients (30.4%). SR was significantly larger in the group with hyperintensity on DWI (3.75 ± 1.97 vs. 2.3 ± 0.82, P < 0.01) in the univariate analysis. Multivariate analysis revealed that SR> 3.0 was a significant predictor of thromboembolic events after coil embolization for unruptured BAAs (odds ratio: 12.15; 95% confidence interval: 2.95–49.98; P < 0.01). ConclusionsThis study showed that SR is a predictor of thromboembolic events after coil embolization for unruptured BAAs. Therefore, if even in small BAAs, if the BAAs dome height is large compared to the diameter of the posterior cerebral artery (e.g., there is a large SR), preoperative evaluation of the use of antiplatelet therapy is important, particularly to prevent thromboembolic events.

Selection of Surgical Approaches for Anterior Circulation and Basilar Artery Apex Aneurysms

Selection of Surgical Approaches for Anterior Circulation and Basilar Artery Apex Aneurysms

The off-label uses of pipeline embolization device for complex cerebral aneurysms: Mid-term follow-up in a single center.

To describe the off-label uses of pipeline embolization device for a variety of types of aneurysms including ruptured aneurysms, posterior circulation aneurysms, small aneurysms, distal aneurysms, and recurrent aneurysms. Clinical and angiographic data of patients who underwent pipeline embolization device treatment on off-label use at our center were retrospectively reviewed. For categorical variables, Fisher's exact test was used, and a two-sample Wilcoxon rank-sum test was used for patients' age to analyze the correlation with outcomes. In this study, 121 aneurysms in 107 patients received off-label pipeline embolization device treatments. The overall rate of complete aneurysm occlusion was 77.8% (28/36 in 35 patients) for posterior circulation aneurysms and 95.3% (81/85 in 72 patients) for anterior circulation aneurysms. The posterior circulation aneurysms have a lower rate of aneurysm occlusion (p = 0.0372). The small aneurysms have a higher rate of aneurysm occlusion (p = 0.0104). The patient's sex, age, and aneurismal size were associated with ischemic stroke complications (p = 0.0397, 0.0166, and 0.0178). In posterior circulation aneurysm patients, only two basilar apex aneurysms underwent pipeline embolization device treatment, both of whom died of thrombotic complications. There was no difference in mortality between posterior circulation aneurysm patients (8.6%, 3/35) and anterior circulation aneurysm patients (1.4%, 1/72) (p = 0.1015). Patients of older age have a higher risk of death rate (p = 0.0053). The off-label use of pipeline embolization device is often performed in clinical practice and can achieve efficacy in complex aneurysms. The off-label use of pipeline embolization device was found to carry an increased rate of mortality in older patients. Excluding basilar apex aneurysms, the pipeline embolization device is as safe as anterior circulation aneurysms in the treatment of posterior circulation aneurysms elsewhere.

Woven EndoBridge embolization in the retreatment of basilar apex aneurysm.

The Woven EndoBridge (WEB) device was approved by the U.S. FDA for its excellent angiographic occlusion of intracranial aneurysms and high safety profile, based on the landmark WEB-IT (WEB Intrasaccular Therapy) trial. There remains, however, a few cases of aneurysm recurrence that necessitate retreatment after the initial WEB procedure. In this technical video, the authors present the case of a middle-aged patient who showed significant basilar apex aneurysm recurrence and growth along with device compaction that required retreatment. Various aspects of treating aneurysms with a prior WEB device, including procedural technique, are discussed. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID21152.

The Dolenc technique was used to clip 14 cases of ruptured basilar apex aneurysms and posterior cerebral artery aneurysms.

ObjectiveTo investigate the surgical techniques and their clinical effects for ruptured basilar artery apex and posterior cerebral aneurysms via the Dolenc approach.MethodsWe retrospectively analyzed the clinical data of 14 patients with ruptured basilar artery apex and posterior cerebral aneurysms who underwent surgical clipping by the Dolenc approach from July 2017 to June 2020 in Beijing Tiantan Hospital affiliated with Capital Medical University and Lianyungang Hospital affiliated with Xuzhou Medical University. The modified Rankin scale (mRs) scores were used to evaluate the prognosis of patients.ResultsAll 14 cases of aneurysms were successfully clipped. Overall, 1, 2, and 1 cases of postoperative new-onset visual loss, oculomotor nerve palsy, and contralateral hemiplegia, respectively, were reported. Digital subtraction angiography (DSA) or computed tomography angiography (CTA) examination of the aneurysm within 2 weeks after surgery revealed that the aneurysm was completely clipped without residue. The observations during the follow-up within 12–18 months after surgery were as follows: 1 case of vision loss returned to normal, 2 cases of oculomotor nerve palsy, 1 case of return to normal, 1 case of improved, 1 case of contralateral hemiplegia improved after rehabilitation treatment, and 1 case of hydrocephalus ventriculoperitoneal shunt surgery was performed. Overall, 11, 2, and 1 case had mRs scores of 0, 1, and 2, respectively. No death was reported.ConclusionFor the small number of basilar apical and posterior cerebral aneurysms treated non-invasively, the Dolenc approach may offer advantages over other modalities.

Brainstem Infarctions Caused by a Proximal Marker of the PulseRider Device Obstructing the Origin of a Perforator

The PulseRider (Cerenovus, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA) is a neck reconstruction device that is used for the treatment of unruptured wide-necked bifurcation aneurysms. Herein, we describe the case of a 51-year-old male patient with a basilar apex aneurysm who was treated with PulseRider but had post-procedural brainstem infarctions caused by one of the proximal markers covering the origin of a perforator. In such cases, repositioning of the PulseRider should be performed to avoid infarctions.

Combined subtemporal and pterional approach for clipping of multiple aneurysms

Background: Despite ongoing improvements in endovascular techniques, open surgical management of basilar apex aneurysms is occasionally necessary.[2] Critical dissection of perforating vessels from the aneurysm is facilitated by the lateral trajectory of the subtemporal approach.[1] Incorporation of additional trajectories can facilitate treatment of multiple aneurysms within the same procedure.Case Description: A 48-year-old woman presented with a Hunt and Hess 1 and Fisher Grade 3 subarachnoid hemorrhage from a small and broad-necked basilar apex aneurysm that was not amenable to endovascular management. An unruptured left A1-A2 anterior cerebral artery aneurysm was also noted on vascular imaging. The patient underwent a combined right subtemporal and pterional approach for sequential clipping of the basilar and anterior communicating artery aneurysms. The third nerve, running between the posterior cerebral artery and the superior cerebellar artery, guided dissection to the basilar artery in the subtemporal approach. A temporary clip was placed on a vessel-free zone of the basilar trunk during dissection of perforators off the posterior aspect of the aneurysm dome. A fenestrated clip around the right P1 segment was used to ensure complete occlusion of the aneurysm. Indocyanine green angiography was used to confirm successful clipping and patency of parent and perforating vessels. The unruptured A1-A2 aneurysm was clipped without difficulty from the pterional trajectory. The patient had an uneventful postoperative recovery with the exception of transient right third nerve palsy.Conclusion: As highlighted by this case, maintenance of open surgical skills for the treatment of complex aneurysms unamenable to endovascular therapies is critical.

Horizontal stent deployment via extracranial-intracranial bypass in coil embolization of basilar apex aneurysms: technical report.

The endovascular treatment of large, wide-necked basilar apex aneurysms (BAAs) remains challenging. Although horizontal stent deployment across both P1 segments of the posterior cerebral arteries (PCAs) would be an optimal strategy in coil embolization of wide-necked BAAs, this is only feasible in cases with anatomically favorable access. In rare circumstances, large-diameter conduits of extracranial-intracranial (EC-IC) bypass can also provide a good access route for endovascular treatment of complex intracranial aneurysms. We describe the technique of accessing the PCA via EC-IC bypass grafts and deploying a stent horizontally across the neck of BAA and its coil embolization. We provide a detailed technical review and describe some pitfalls of the procedure. Two patients underwent EC-IC bypass surgery prior to the treatment of a large, wide-necked BAA. The radial artery and saphenous vein were used as grafts, respectively. To facilitate coil embolization for a large BAA, a PCA-to-PCA horizontal stent was deployed via the bypass graft. Trans-cell and jailing techniques were used, respectively. Both aneurysms were completely occluded, and the patients were discharged without any neurological deficit. Horizontal stent deployment via EC-IC bypass grafts can be performed safely, providing proper closure of the aneurysmal neck and apposition to both PCAs, facilitating complete coil embolization.

Endovascular Treatment of Basilar Bifurcation Aneurysms With PulseRider-Assisted Coiling: 2-Dimensional Operative Video.

Wide-necked bifurcation aneurysms pose technical and anatomical challenges to endovascular treatment, which make the simpler assisted (balloon or single stent) coiling techniques less effective.1 Consequently, unique endovascular solutions to treat such aneurysms have been devised.2,3 One such device is PulseRider (Cerenovus, New Brunswick, New Jersey), which is designed to provide neck support for a coil mass while protecting the bifurcation.3 The device comprises a body or stem that is deployed in the parent artery and a saddle component that sits at the aneurysm neck to keep the coil mass away from the bifurcation. There are several technical nuances involved in successful use of the device during positioning, deployment, and detachment.3 We present a surgical video detailing the steps of PulseRider-assisted coiling of unruptured basilar bifurcation (or basilar apex) aneurysms. The first case highlights index treatment at diagnosis and the second showcases treatment of a recurrent basilar apex aneurysm. Both patients provided informed consent to the procedure. We also briefly discuss the rationale for treating basilar apex aneurysms.4,5.

Thrombectomy and Clip Occlusion of a Giant, Stent-Coiled Basilar Bifurcation Aneurysm: 3-Dimensional Operative Video.

Giant basilar apex aneurysms are associated with significant therapeutic challenges.1-6 Multiple techniques exist to treat giant basilar apex aneurysms, including direct clipping, stent-assisted coil embolization, and proximal occlusion with bypass revascularization.7-9 Hypothermic circulatory arrest was a useful adjunct for surgical repair of these aneurysms but has been abandoned because of associated risks.10,11 Rapid ventricular pacing can achieve similar aneurysm softening with minimal risks and assist in clip occlusion. This case illustrates clip occlusion of a giant, partially thrombosed, previously stent-coiled basilar apex aneurysm in a 15-yr-old boy with progressive cranial neuropathies and sensorimotor impairment. Although a wire was placed preoperatively for ventricular pacing, it was not needed during the procedure. Patient consent was obtained. A right-sided orbitozygomatic craniotomy transcavernous approach with anterior and posterior clinoidectomies was performed. The basilar quadrification was dissected, and proximal control was obtained. After aneurysm trapping, the aneurysm was incised and thrombectomized using an ultrasonic aspirator. Back-bleeding from the aneurysm was anticipated, and ventricular pacing was ready, but back-bleeding was minimal. With the coil mass left in place, stacked, fenestrated clips were applied in a tandem fashion to occlude the aneurysm neck. Indocyanine green videoangiography confirmed occlusion of the aneurysm and patency of parent and branch arteries. The patient was at a neurological baseline after the operation, with improvement in motor skills and cognition at 3-mo follow-up. This case demonstrates the use of trans-sylvian-transcavernous exposure, rapid ventricular pacing, and thrombectomy amid previous coils and stents to clip a giant, thrombotic basilar apex aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Morphometric Comparison of the Pterional Trans-Sylvian and the Pretemporal Trans-Clinoidal Approaches to the Posterior Communicating Artery.

Posterior communicating (Pcom) aneurysms in the modern era have tended toward increased complexity and technical difficulties. The pretemporal approach is a valuable extension to the pterional approach for basilar apex aneurysms, but its advantages for Pcom aneurysms have not been previously elucidated. To quantify characteristics of the pretemporal approach to the Pcom. We dissected 6 cadaveric heads (12 sides) with a pretemporal transclinoidal approach and measured the following variables: (1) exposed length of internal carotid artery (ICA) proximal to the Pcom artery; (2) exposed circumference of ICA at the origin of Pcom; (3) deep working area between the optic nerve and tentorium/oculomotor nerve; (4) superficial working area; (5) exposure depth; and (6) the frontotemporal (superior posterolateral) and (7) orbito-sphenoidal (inferior anterolateral) angles of exposure. Compared with pterional craniotomy, the pretemporal transclinoidal approach increased the exposed length of the proximal ICA from 3.3 to 11.7 mm (P=.0001) and its circumference from 5.1 to 7.8 mm (P=.0003), allowing a 210° view of the ICA (vs 137.9°). The deep and superficial working areas also significantly widened from 53.7 to 92.4 mm2 (P=.0048) and 252.8 to 418.2 mm2 (P=.0001), respectively; the depth of the exposure was equivalent. The frontotemporal and spheno-Sylvian angles increased by 17° (P=.0006) and 10° (P=.0037), respectively. The pretemporal approach can be useful for complex Pcom aneurysms by providing easier proximal control, wider working space, improved aneurysm visualization, and more versatile clipping angles. Enhanced exposure results in a potentially higher rate of complete aneurysm obliteration and complication avoidance.

Microsurgical Clipping of an Unruptured Basilar Apex Aneurysm: 2-Dimensional Operative Video.

Aneurysms of the basilar artery apex are generally at an increased risk of rupture compared with aneurysms in other locations, and the risk of rupture increases with increasing aneurysm size. Therefore, these lesions necessitate treatment to decrease the risk of rupture. The location, size, and directionality of dome projection influence the difficulty of microsurgical treatment. The patient presented with an incidental basilar apex aneurysm identified on workup for headaches. The aneurysm projected superoposteriorly into the interpeduncular cistern. The surgical approach involved a wide exposure of the basilar apex complex and meticulous identification and preservation of P1 perforators during clip applications. It was imperative to visualize all perforators on both sides of the clip prior to application, given the severe morbidity associated with a perforator infarct. The patient tolerated the procedure well and remained neurologically intact after the operation. This video is an exemplary demonstration of basilar apex aneurysm clip application for an incidentally discovered aneurysm. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Clipping of Basilar and Middle Cerebral Artery Aneurysms: 2-dimensional operative video.

Careful preoperative planning for patients with multiple intracranial aneurysms is paramount given the importance of an appropriate trajectory and exposure for each aneurysm that will be clipped. The general principle is to clip aneurysms in a retrograde manner, such that more distal aneurysms are clipped earlier, and more superficial aneurysms are clipped later. This patient had unruptured middle cerebral artery (MCA) and basilar artery (BA) apex aneurysms and elected for surgical clipping of both lesions. An orbitozygomatic craniotomy ipsilateral to the MCA aneurysm was performed to permit clipping of both lesions. The dissection initially focused on exposure of the MCA aneurysm and then focused on the carotid-oculomotor triangle to permit basilar apex exposure and aneurysm clipping. The MCA aneurysm was clipped second. Postoperative imaging demonstrated complete obliteration of both aneurysms. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.