Giant Fusiform Aneurysm Research Articles

High-flow bypass for giant dolichoectatic vertebrobasilar aneurysms: illustrative cases

BACKGROUND Giant fusiform dolichoectatic vertebrobasilar artery aneurysms are challenging lesions with a poor natural history. When there is progressive brainstem compression from these lesions, endovascular treatment can be insufficient, and bypass surgery remains a possible salvage option. High-flow bypass surgery with proximal occlusion can potentially arrest aneurysm growth, promote aneurysm thrombosis, and reduce rupture risk. The authors describe their experience in two patients with giant fusiform dolichoectatic vertebrobasilar artery aneurysms treated with high-flow bypass. OBSERVATIONS Both patients presented with enlarging giant dolichoectatic vertebrobasilar aneurysms causing symptomatic brainstem compression. The authors performed staged treatment involving high-flow bypass from the external carotid artery to the posterior cerebral artery using a saphenous vein graft, Hunterian proximal vertebrobasilar occlusion, and finally posterior fossa decompression with or without direct aneurysm thrombectomy and debulking. Postoperative angiography revealed successful flow reversal, aneurysm exclusion, and no brainstem stroke. Clinically, one patient had improvement in their modified Rankin Scale (mRS) score from 3 preoperatively to 1 at 12-month follow-up. The second patient had a deterioration in their mRS score from 4 to 5 at 12-month follow-up. LESSONS High-flow bypass strategies remain high risk but can be a viable last resort in patients with neurological deficits and enlarging giant fusiform dolichoectatic vertebrobasilar artery aneurysms.

Failure of Reconstructive Technique to Repair a Giant Intracranial Fusiform Aneurysm of the Basilar Artery: Case Report and Literature Review in the Pediatric Population

AbstractTreatment of giant basilar aneurysm presents a major treatment challenge, especially in the pediatric population. Morbidity and mortality approach 80 and 30%, respectively. Both reconstructive and deconstructive techniques are associated with high rates of complete occlusion and good neurological outcomes. We report a 14-year-old male with a giant basilar trunk aneurysm treated with an endovascular approach. Clinical symptoms began following an ischemic stroke 2 weeks prior to admission. Endovascular treatment was performed through a reconstructive technique by single flow diverter device (FDD) in the basilar artery; however, this technique failed. At 1-year follow-up, without additional endovascular treatment, the mid-basilar artery and aneurysm were occluded, with vertebrobasilar flow maintained through collaterals from the right posterior communicating artery. We present a challenging management of giant basilar aneurysm in a pediatric patient experiencing a failure of FDD deployment; however, we highlight the importance of collateral flow development in progressive occlusions.

Recurrence of a large intracranial fusiform aneurysm treated with overlapping Pipeline embolization devices: illustrative case.

Flow diversion, specifically with the Pipeline embolization device (PED), represents a paradigm shift in the treatment of intracranial aneurysms. Several studies have demonstrated its efficacy and at times superiority to conventional treatment modalities for aneurysms with a fusiform morphology, giant size, or wide neck. However, there may be a nonsignificant risk of recurrence after flow diversion of these historically difficult-to-treat aneurysms, relative to aneurysms with a more favorable morphology and size (i.e., saccular, narrow necked). To date, only three papers in the literature have demonstrated the recurrence of a completely occluded aneurysm on follow-up. The authors describe a patient with a giant middle cerebral artery fusiform aneurysm treated with multiple telescoping PEDs. On the 3-month follow-up angiogram, there was complete occlusion of the aneurysm. The patient was lost to follow-up and presented 4 years later with a recurrence of the aneurysm between PED segments, requiring retreatment. The patient represented 3 years posttreatment with the need for repeat treatment of the fusiform aneurysm due to separation of the existing PEDs along with stent reconstruction. At the 20-month follow-up after the third treatment, the initial aneurysm target was found to be occluded. This case illustrates the need for long-term follow-up, specifically for patients with giant wide-necked or fusiform aneurysms treated with overlapping PEDs.

Abstract Number ‐ 137: Delayed aneurysmal rupture of a giant fusiform vertebrobasilar aneurysm after flow‐diversion embolization with adjunctive coiling

Introduction Vertebrobasilar aneurysms carry a high risk of operative morbidity and high mortality risk with rupture. Treatment with flow diversion embolization has gained popularity. While adjunctive coiling may lower the risk of delayed aneurysm rupture (DAR), DAR can occur during stent endothelialization. describe a case of DAR following flow diversion with adjunctive coil embolization of a giant vertebrobasilar aneurysm and review the literature to further characterize this phenomenon. Methods PubMed was queried using search terms: “delayed,” “aneurysm,” “rupture,” “flow diverter,” “flow diversion,” and “flow diverting stent” yielding 220 results. There were 47 studies describing 89 patients with DAR after flow diversion. Results A forty‐five‐year‐old male presented with posterior fossa compression symptoms secondary to a 30‐mm fusiform basilar artery aneurysm, which grew during short‐interval follow‐up to 35 mm. The patient consented to endovascular embolization. Tri‐axial catheter access system was used to deploy seven telescoping flow diverters from the basilar tip to the intradural left vertebral artery, and nine coils were subsequently deployed in the aneurysm dome. The right vertebral artery was coil embolized. The procedure was uncomplicated and the patient was continued on dual‐antiplatelet therapy. Four weeks later, the patient became unresponsive with absent brainstem reflexes, workup revealed diffuse subarachnoid hemorrhage with intraventricular hemorrhage. Digital subtraction angiography demonstrated contrast extravasation at the aneurysm neck. He succumbed to his neurological injury two days later. Out of 89 patients with DAR after flow diversion, only 3 occurred in fusiform basilar aneurysms treated with adjunctive coil embolization. Only one case, a 37.1‐mm aneurysm treated with 3 flow diverters with adjunctive embolization, occurred at greater than 30 days post‐intervention. Conclusions This case highlights the need to better characterize the role of adjunctive coiling with flow diversion for large or giant aneurysms, and to better understand risk factors related to delayed aneurysm rupture.

Ruptured giant fusiform aneurysm in an infant: Case report and review of the literature.

Background: Intracranial aneurysms are exceedingly rare in neonates, accounting for less than 2% of all relevant cases that occur during the first decade of life. More precisely, intracranial aneurysms in children (less than 18 years old) are rarely been recorded, and their epidemiology is poorly investigated. Details about this pathology in this specific population are lacking. Because of the scarcity of this entity along with the peculiar characteristics of this patient group, the treatment of aneurysms of the cerebral circulation of these patients is challenging. The prevalence of Intracranial aneurysms in children is much lower than in adults· apart from that, several differences exist, centered on their etiology, demographic variables, aneurysm location, aneurysm morphological characteristics, clinical presentation, and outcome in pediatric and adult intracranial aneurysms. We describe the case of aneurysmal subarachnoid hemorrhage and extra-axial hemorrhage in an infant, as well as the review of the relevant current literature. Case description: We report the case of a three months old infant who was admitted to our hospital due to episodes of vomiting, associated with loss of consciousness and an epileptic ictus. An MRI-MRA scan and a digital subtraction angiography were immediately performed, which revealed the presence of a giant fusiform aneurysm near the origin of the right anterior cerebral artery. Because of the location and shape of the aneurysmal sac, the ipsilateral internal carotid artery was totally occluded with detachable coils. At follow-up, the child experienced normal psychomotor development with no motor deficit. Conclusions: Intracranial aneurysms should be considered in the differential diagnosis of infants and neonates who present with acute raised intracranial pressure. Even though rupture of an intracranial aneurysm in this age group is rare, subarachnoid hemorrhage is the most common mode of presentation. Intracranial aneurysms are frequently larger than 10 mm and located on the middle cerebral artery. The treatment could be surgical or endovascular, depending on the characteristics of the aneurysm. Seizures and cranial nerve involvement are the most common presenting features in children. The most commonly encountered sites of origin for such aneurysms are the posterior circulation, along with the internal carotid artery bifurcation. Current literature and case series suggest that there is increased incidence of giant, posttraumatic, and mycotic aneurysms in children. Based on the most recently published data, the treatment of ruptured and unruptured pediatric aneurysms is related with an increased incidence of an uneventful outcome, which reaches 95% in the current series. Pediatric intracranial aneurysms are more commonly encountered in male patients and have a predilection for the terminal ICA bifurcation.

Sequential Flow Diversion After Nitinol Stent Placement for a Large, Matricidal Cavernous Internal Carotid Artery Aneurysm: Technical Video.

The Surpass Evolve flow diverter is a novel 64-wire braided intravascular stent approved to treat unruptured large or giant saccular wide-neck or fusiform intracranial aneurysms of the intracranial internal carotid artery.1-3 Flow diverting stents have been used for the treatment of previously stented aneurysms, including residual aneurysms following prior flow diversion.5-8 This patient initially presented with a large symptomatic matricidal cavernous ICA aneurysm4 that was treated with stand-alone Neuroform Atlas stenting at an outside hospital. Here we present a video demonstrating the placement of sequential Surpass Evolve flow diverter stents within a Neuroform Atlas nitinol stent.

Giant Fusiform and Dolichoectatic Aneurysms of the Basilar Trunk and Vertebrobasilar Junction—Clinicopathological and Surgical Outcome

Nakatomi, Hirofumi MD, PhD; Kiyofuji, Satoshi MD; Ono, Hideaki MD, PhD; Tanaka, Minoru MD, PhD; Kamiyama, Hiroyasu MD; Takizawa, Katsumi MD; Imai, Hideaki MD, PhD; Saito, Nobuhito MD, PhD; Shiokawa, Yoshiaki MD, PhD; Morita, Akio MD, PhD; Flemming, Kelly D MD; Link, Michael J MD Author Information

Giant Fusiform and Dolichoectatic Aneurysms of the Basilar Trunk and Vertebrobasilar Junction-Clinicopathological and Surgical Outcome.

BACKGROUNDGiant fusiform and dolichoectatic aneurysms of the basilar trunk and vertebrobasilar junction (BTVBJ-GFDA) are extremely difficult to treat.OBJECTIVETo evaluate factors influencing survival and outcome of BTVBJ-GFDA by performing a retrospective multicenter cohort study.METHODSA total of 32 patients with BTVBJ-GFDA were included in this study. Clinicopathological characteristics, treatment measures, and outcomes were collected from medical records and imaging studies. Autopsy and histological findings of the aneurysm and adjacent brain tissue were also obtained in 9 cases.RESULTSA total of 11 patients did not undergo surgery, of whom 10 died; 3 from progressive brainstem compression, 4 from subarachnoid hemorrhage, 2 from brainstem infarction, and 1 from associated atherosclerotic disease. The remaining 21 patients underwent a surgical treatment, consisting of immediately proximal parent artery occlusion, remotely proximal parent artery occlusion, clip reconstruction, and distal bypass and achieved significantly longer overall survival compared with those who received conservative therapy (adjusted hazard ratio 1.508, 95% CI 1.058-2.148, P = .02). Histological examination of the aneurysms demonstrated staged clots, open lumen, and intrathrombotic channels with endothelial lining. The patients younger than 45 yr of age showed statistically longer survival than those equal and older than 45 yr (P = .03).CONCLUSIONSurgical intervention achieved greater survival than conservative management in BTVBJ-GFDA. Narrow ideal treatment window of the blood flow within the aneurysm to maintain sufficient but not excess supply should be targeted based on the hemodynamics of both the posterior communicating arteries and perforating vessel collaterals.

Ischemic stroke in a patient with giant fusiform aneurysm of dolichoectatic basilar artery and Covid-19 infection

Ischemic stroke in a patient with giant fusiform aneurysm of dolichoectatic basilar artery and Covid-19 infection

Giant fusiform splenic aneurysm with anomalous origin.

Giant fusiform splenic aneurysm with anomalous origin.

Evaluation of flow changes after telescopic stenting of a giant fusiform aneurysm of the vertebrobasilar junction

BackgroundThe use of flow-diverters for non-saccular cerebral posterior circulation aneurysms requires complex deployment techniques and is associated with high mortality and morbidity. Therefore, further studies are required to clarify the effect of stenting on post-treatment hemodynamics in such aneurysms. In this study, we evaluated flow alterations in a treated giant fusiform aneurysm of the vertebrobasilar junction and correlated them with the clinical outcome.MethodsA patient-specific aneurysm model was acquired by rotational angiography, and three SILK flow-diverters (4.5 × 40, 5 × 40 and 5.5 × 40 mm) were virtually deployed in series along the basilar and right vertebral arteries. Image-based blood flow simulations before and after the treatment were performed under realistic pulsatile flow conditions. The flow reduction, velocity and wall shear stress (WSS) distribution, streamlines and WSS-derived parameters were evaluated before and after the treatment.ResultsThe computed velocity streamlines showed substantial alterations of the flow pattern in the aneurysm and successful redirection of blood flow along the series of flow-diverters with no flow through the overlapping stents. The obtained flow reduction of 86% was sufficient to create thrombogenic flow conditions. Moreover, a 6.2-fold increase in relative residence time and a decrease by 87% of time-averaged WSS contributed to a successful treatment outcome observed during the follow-up.ConclusionsWe found a correlation between the numerically predicted flow alterations and the available treatment outcome. This shows the potential of image-based simulations to be used in clinical practice for treatment planning and estimation of possible risk factors associated with a complex stent deployment in fusiform aneurysms of the posterior circulation.

Reconstructive endovascular treatment of symptomatic large or giant unruptured vertebrobasilar fusiform aneurysm with LVIS stent-assisted partial coil embolization

Abstract Objectives Large or giant vertebrobasilar fusiform aneurysms (VFAs) remain one of the most formidable lesions. The purpose of this study was to evaluate the technical feasibility, clinical and angiographic outcomes of LVIS SACP-SWS technique in patients with large or giant unruptured VFAs. Patients and methods Eleven patients with large or giant unruptured VFAs underwent LVIS SACP-SWS technique between Jun 2015 and May 2017. Thirty-eight (38) LVIS stents were completely deployed at desired position. Outcomes were evaluated based on the modified Rankin Scale (mRS) score and angiography. Results The LVIS SACP-SWS was successful without any treatment-related complications in all 11 patients. In regard to clinical outcome, mRS was 3.55 ± 1.29 at pre-operative stage that significantly (p = 0.01) decreased to 1.91 ± 1.92 at last follow-up. The mean decrease in mRS was 1.63 ± 1.69. Near-complete occlusion of dissecting aneurysmal sac (NO) was seen in 5 patients at DSA follow-up and complete occlusion of dissecting aneurysmal sac (CO) was in 4 patients, the remaining patient was re-treated by occluding the V4 segment of right verbal artery. Conclusions Our results provide an encouraging support for the LVIS stent-assisted coil partial embolization combined with stent-within-a-stent technique. Further studies of the technique as an alternative strategy for treatment of large or giant unruptured VFAs are warranted.

Management of intact giant fusiform aneurysm of distal aortic arch with impeding risk of rupture using midline sternotomy

Management of intact giant fusiform aneurysm of distal aortic arch with impeding risk of rupture using midline sternotomy

Endovascular reconstructive treatment of large and giant posterior circulation fusiform aneurysms

Objective To explore the feasibility, safety and efficacy of endovascular reconstructive treatment of large and giant posterior circulation fusiform aneurysms. Methods A retrospective review was conducted on 22 cases of posterior circulation large and giant fusiform aneurysms who underwent endovascular reconstructive treatment between September 2007 and August 2017 at Neurosurgery Department of Beijing Hospital. Among the 22 cases, stent-assisted coiling was performed in 18 cases and sole stenting was applied in 4. Postoperative follow-up was conducted every 3-6 months at outpatient clinic or by phone. The modified Rankin scale (mRS) was used for outcome assessment. Imaging follow-up was conducted 3-24 months post operation. The outcomes was classified into stable, relieved and recurrent cases. Results Technical success rate was 100%. Peri-procedural complications occurred in 2 (9.1%) patients. One died from postoperative hemorrhagic complication and the other developed infarction and recovered well at discharge. A total of 21 patients were clinically followed-up for an average of 42.1±26.3 months (range: 4-105 months) and included 18 (85.7%) cases with good outcomes (mRS score: 0-2) and 3 (14.3%) with poor outcomes (mRS score: 4-6). Among 19 patients with angiographic follow-up of 11.9±6.9 months (range: 3-47 months), 10 patients achieved complete occlusion, 5 reported relief or stable conditions, 3 developed recurrence and 1 had in-stent occlusion. Conclusion Reconstructive endovascular treatment seems relatively safe for posterior circulation large and giant fusiform aneurysms with satisfactory mid-term results. Key words: Intracranial aneurysm; Embolization, therapeutic; Treatment outcome; Posterior circulation

EXPERIENCE OF EXTRACRANIAL-INTRACRANIAL BYPASS WITH USING MAXILLARY ARTERY

Objective is to present the first experience of creating extracranial-intracranial (EC-IC) bypass using the maxillary artery (MA) as an arterial donor for treatment of giant intracranial aneurysms (GIA), as well as for treatment of internal carotid artery (ICA) occlusion. Materials and methods. We performed EC-IC bypasses using MA at 4 patients: at 3 patients with GIA of the anterior part of the Willis circle (giant fusiform aneurysm of the М1 segment of middle cerebral artery (MCA), giant fusiform aneurysm of the supraclinoid part of ICA, giant ICA bifurcation aneurysm) and at patient with ICA occlusion. All patients with aneurysms had tumor-like clinical manifestation. Patient with ICA occlusion had crescendo ipsilateral MCA transient ischemic attacks. Creation of the traditional EC-IC bypass was impossible because of superficial temporal artery injury as result of prior surgery in other hospital. Results. We used transzygomatic pterional craniotomy, MA as a donor artery, M2 segment of MCA as a recipient artery and radial artery as an interposition graft in all cases. At patient with ICA occlusion surgical treatment included bypass creation, at all patients with GIA after bypass creation we performed aneurysm trapping (distal clipping of М1 segment at patient with MCA aneurysm, cervical ICA ligation at patient with supraclinoid ICA GIA, temporary trapping, thrombectomy and aneurysm clipping at patient with bifurcation ICA GIA). We confirmed bypass patency by intraoperative Doppler sonography and flowmetry and computed tomography or magnetic resonance imaging in postoperative period. In all cases bypasses were patent with flow 33–57 ml per min. Patient with ICA bifurcation GIA suffered from contralateral hemiparesis due to ischemia in anterior choroid artery territory in early postoperative period, which partially regressed at discharge. In other cases there were not any complications. Conclusion. EC-IC bypasses with using MA as a donor and radial artery as an interposition graft can provide sufficient replacement blood flow in the MCA territory in cases of giant cerebral aneurysms and in patients with occlusion of the ICA. This type of bypasses is less traumatic compared with high-flow bypasses. Given the shorter length and less tortuosity of the graft, its more secure localization, we can assume a lower risk of bypass thrombosis in the early and late postoperative periods and higher patency of the graft.

Surpassing Expectations - A Novel Use of Flow Diverting Stent-in-Stent Technique for the Management of a Carotid-Venous Fistula

Internal carotid artery aneurysms are rare pathologies. Endovascular treatment of these disorders is new and emerging field of interventional neurology. A 50 year old male presented to our unit with progressive headaches, visual disturbance and panhypopituitarism. Investigations revealed a giant fusiform right cavernous internal artery aneurysm (39 x 33 x 37 mm). He underwent endovascular treatment with a Surpass flow diverting stent and subsequently developed a cavernous sinus syndrome and carotid-venous fistula. A novel stent-in-stent technique was utilized and a Surpass Streamline 3 x 25 mm flow-diverting stent was placed across the fistulating zone of the initial stent, with clinical resolution of symptoms.

Right coronary artery with multiple giant aneurysms fistulizing into left ventricle

Coronary computed tomography angiography (CCTA) was performed to further identify the abnormality, which revealed the enlargement of the opening in approximately 3cm and diffusely dilated of RCA. The distribution of RCA could be showed graphically by the volume rendering technique (VRT) (Fig 3), which was travelling tortuously into the LV. A saccular aneurysm was found in size of about 12cm × 12cm and located in its proximal portion (Fig 4). Another giant fusiform aneurysm could be found next to the fistula. The fistula was about 2cm in diameter. Right atrium and ventricle were crushed obviously. Pericardial effusion was observed. The LCA was normal.

Giant Fusiform Vertebral Artery Aneurysm Treated with Microsurgical Bypass and Endovascular Coiling after Failed Flow Diversion: A Case Report and Discussion

Background Giant vertebral and vertebrobasilar aneurysms have proven to be extremely challenging vascular entities to treat despite many advances in microsurgical and endovascular techniques. In recent years, there has been more attention paid to combined approaches, including combinations of endovascular and surgical procedures in hopes of decreasing the associated morbidity and mortality of these lesions. Clinical Presentation We present a case of a giant fusiform vertebral artery aneurysm that was initially treated with flow-diverting stents. After the failure of flow diversion to occlude the aneurysm, the lesion was definitively treated with an occipital artery to the posterior inferior cerebellar artery (PICA) bypass and coil embolization of residual aneurysm. Conclusion After bypass and parent vessel deconstruction, angiography confirmed the aneurysm has remained occluded and the PICA patent. This case highlights the use of an extracranial-to-intracranial bypass to salvage a complex residual aneurysm after failed flow diversion.

Endovascular reconstructive treatment of vertebrobasilar fusiform aneurysms by multiple overlapping stents with or without coils

To explore the feasibility, safety and efficacy of endovascular reconstructive treatment by multiple overlapping stents with or without coils. Totally 17 patients of vertebrobasilar fusiform aneurysms treated by multiple overlapping stents with or without coils between September 2011 and September 2015 in Department of Neurosurgery, Beijing Hospital were retrospectively reviewed. There were 15 male and 2 female patients with mean age of (47±13) years. Clinical manifestations included subarachnoid hemorrhage in 5 patients, cerebral ischemia or infarction in the posterior circulation in 5 patients, mass effect accompanied with brainstem infarction in 1 patients, headache or dizziness in 4, and incidental findings in 2 patients. Aneurysm located in intracranial vertebral artery in 11 patients, vertebrobasilar junction in 2 patients, and basilar trunk in 4 patients. Mean aneurysmal size was 18.5 mm×8.0 mm(length×width). Sole stenting with overlapping stents was performed in 8 patients, and overlapping stents with coils was applied in 9 patients. Post-procedural hemorrhage occurred in a patient with a giant basilar trunk fusiform aneurysm and led to death. The 16 surviving patients were clinically followed up for a mean of 21.1 months. One patient had a modified Rankin score of 4, and the other patients had a good recovery. Among 15 patients with a mean angiographic follow-up of 8.6 months, 9 patients had their aneurysms further thrombosed, 3 patients were stable, and 3 patients with a recurred aneurysm. Final complete occlusion was achieved in 7 patients. Reconstructive treatment by overlapping stents with or without coils is feasible and relative safe in vertebrobasilar fusiform aneurysms.

Pipeline embolization device induced collateral channels in elective flow diversion treatment.

The pipeline embolization device (PED) is a well recognized treatment for intracranial aneurysms. However, uncertainty remains regarding its effects on flow alteration, which is particularly highlighted by persistently perfused aneurysmal remnants and non-regressing, non-perfused aneurysmal masses. Here we present a 68-year-old woman with an incidental giant fusiform right paraophthalmic aneurysm electively treated with a PED. After lowering her antiplatelet therapy to promote aneurysm thrombosis, she was found to have a progressively enlarging perfused aneurysmal remnant. Angiography revealed PED occlusion, but curiously the development of a peri-construct collateral channel which feeds the aneurysmal remnant, and gives rise to distal branches and contributes to middle cerebral artery flow. The large 'thrombosed' aneurysmal mass showed tiny internal vessels on cone beam CT angiography as well as florid enhancement on MRI, further confirming that apparently thrombosed remnants are biologically active and may be remodeled depending on flow demand.