Giant Internal Carotid Artery Research Articles

A technique for reconstruction of a giant extracranial internal carotid artery aneurysm: A technical note.

Surgery is effective for extracranial internal carotid artery (EICA) aneurysms. However, the risk of cranial nerve injury associated with surgical repair, such as graft-assisted resection and extracranial-intracranial bypass techniques, is relatively high. Here, we report two cases of surgical treatment for EICA aneurysms and describe the surgical techniques and strategies to avoid cranial nerve injury. Two patients presented to our facility with an increasing cervical pulsatile mass and no neurological symptoms. Angiography showed a large aneurysm in the cervical internal carotid artery. Surgical treatment was performed to prevent rupture of the aneurysm. In both patients, the aneurysm was strongly attached to the vagus nerve. The aneurysm and vagus nerve were carefully dissected using a low-power bipolar (20 Malis; 3 watts), leaving connective tissue on the vagus nerve side. The aneurysm was detached from the vagus nerve without injury. Based on intraoperative findings, one patient underwent clipping, and the other underwent aneurysmectomy and primary closure for aneurysm obliteration and angioplasty. Both patients were discharged without any cranial nerve dysfunction. The selection of a strategy based on intraoperative findings and low-power bipolar cutting is important for the treatment of extracranial carotid artery aneurysms to preserve cranial nerves.

Abstract TP151: Usefulness of 3D I-Flow Application in Predicting the Outcome of Flow Diverter Stenting for Large or Giant Carotid Aneurysms

Background and Purpose: The flow diverter (FD) has dramatically improved the treatment outcome of large / giant internal carotid artery (IC) aneurysms. However, it is difficult to predict the treatment outcome of FD just after the treatment. 3D iFlow is a novel application of 4D-digital subtraction angiography (4D-DSA) that can evaluate the arrival time of contrast media in 3D images, but its usefulness for neurointervention is unclear. Therefore, the aim of this study was to elucidate the utility of 3D iFlow in predicting the outcome of FD treatment for large / giant IC aneurysms. Methods: A total of 8 cases of large / giant aneurysms at IC cavernous portion treated with FD and were enrolled in this study. 3D iFlow images before and after placement of FD were acquired in all cases. Treatment outcome was evaluated by O’Kelly-Marotta(OKM) Grading Scale with DSA 6 months after treatment. The regions of interests (ROI) were set in IC bifurcation and petrous segment with 3D iFlow application, and the 3D iFlow transit time was measured by comparing the peak contrast intensities in 2 ROIs. We investigated the rate of changes in 3D iFlow transit time before and after the placement of FD. Results: FD was deployed successfully in all cases without coils. The number of OKM grade B, C and D with DSA 6 months after treatment were 2, 3 and 3 cases, respectively. The rate of changes in 3D iFlow transit time was significantly shorter in OKM grade D cases compared with grade B and C (52.5% vs 84.7%, p=0.03). Conclusion: 3D iFlow application may be effective to predict the treatment outcome of FD.

Retraction: Giant Unruptured Internal Carotid Artery Aneurysm.

[This retracts the article DOI: 10.7759/cureus.20423.].

Proximal Internal Carotid Artery Occlusion and Extracranial-Intracranial Bypass for Treatment of Fusiform and Giant Internal Carotid Artery Aneurysms

To discuss the treatment of intracranial fusiform and giant internal carotid artery (ICA) aneurysms via revascularization based on our institutional experience. An institutional review board-approved retrospective analysis was performed of patients with unruptured fusiform and giant intracranial ICA aneurysms treated from November 1991 to May 2020. All patients were evaluated for extracranial-intracranial (EC-IC) bypass and ICA occlusion. Thirty-eight patients were identified. Initially, patients failing preoperative balloon test occlusion were treated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and concurrent proximal ICA ligation. We then treated them with STA-MCA bypass, followed by staged balloon test occlusion, and, if they passed, endovascular ICA coil occlusion. We treat all surgical medically uncomplicated patients with double-barrel STA-MCA bypass and concurrent proximal ICA ligation. The mean length of follow-up was 99 months. Symptom stability or improvement was noted in 85% of patients. Bypass graft patency was 92.1%, and all surviving patients had patent bypasses at their last angiogram. Aneurysm occlusion was complete in 90.9% of patients completing proximal ICA ligation. Three patients experienced ischemic complications and 4 patients experienced hemorrhagic complications. Not all fusiform intracranial ICA aneurysms require intervention, except when life-threatening rupture risk is high or symptomatic management is necessary to preserve function and quality of life. EC-IC bypass can augment the safety of proximal ICA occlusion. The rate of complete aneurysm occlusion with this treatment is 90.9%, and long-term bypass graft-related complications are rare. Perioperative stroke is a major risk, and continued evolution of treatment is required.

Mass Effect After Flow Diversion for Unruptured Large and Giant Cavernous or Paraclinoid Internal Carotid Artery Aneurysm

The mass effect associated with large or giant intracranial aneurysms is difficult for traditional endovascular treatment. This study investigated whether flow diverters can relieve the aneurysmal mass effect caused by aneurysmal compression symptoms. Fifty-five patients with unruptured large and giant intracranial aneurysms treated by a flow diverter at our institution from January 2014 to February 2022 were retrospectively evaluated. In this study, 53 patients were included. Initially, 27 patients (51.9%), including 10 with compressive optic neuropathy, 12 with third nerve palsy, 2 with facial hyperesthesia, and 11 with sixth nerve palsy, were symptomatic. The symptom duration was shorter in the improved group (n=2.2±4.0 vs. n=3.1±3.9, P=0.49). Thrombus formation following the flow diversion procedure was typically observed on magnetic resonance imaging (MRI) performed immediately and was not significantly associated with symptomatic improvement (OR=0.395; 95% CI (0.058-2.698), P=0.343). However, symptomatic improvement was seen in most patients when the aneurysm size decreased on MRI. A reduction in the aneurysm size on the MRI at the 3-month follow-up was correlated with symptomatic improvement in the multivariate analysis (OR=0.08, 95% CI (0.013-0.485), P<0.05). A flow diverter might help alleviate compression symptoms caused by large or giant intracranial aneurysms. Shrinkage of the aneurysm within 3months postoperatively and a shorter duration of symptoms contribute to the favorable outcomes of mass effect. Ultimately, prompt treatment is crucial for improving symptomatic intracranial artery aneurysms.

Safety and efficacy of transgraft internal trapping after proximal internal carotid artery ligation with high-flow bypass.

Proximal internal carotid artery (ICA) ligation with high-flow bypass is an important vascular reconstructive technique for giant ICA aneurysms or skull base tumors involving the ICA to control intraoperative bleeding. Retrograde or collateral blood flow occasionally remains postoperatively and requires complete internal trapping. Although transgraft internal trapping is one of the options, there are few reports on transgraft treatment. The purpose of this study was to report our experience of transgraft internal trapping and evaluate the safety and efficacy of this procedure. We retrospectively selected patients who underwent transgraft internal trapping after proximal ICA ligation with high-flow bypass between January 2012 and June 2020. We encountered five cases of this procedure (one aneurysm case and four tumor cases). The median duration between the bypass and transgraft internal trapping was 12 days. In four out of five cases, a guiding catheter could be placed in the graft. No disruption of the anastomosis was observed. Transgraft internal trapping was achieved in all five cases with detachable coils. All treatments could be completed safely without any adverse events, including ischemic and hemorrhagic complications. Transgraft internal trapping after proximal ICA ligation with high-flow bypass may be an option for preventing residual retrograde blood flow.

Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video.

Bouchal, Samantha M. BS*; Patra, Devi P. MD, MCh, MRCSEd‡,§; Qazi, Zeeshan MBBS‡,§; Bendok, Bernard R. MD‡,§,‖,¶,# Author Information

Acute loading dose of antiplanets before Stent-assisted repair of cerebral aneurysm associated with reduced ischemic events and good outcomes (P8-5.016)

<h3>Objective:</h3> Objective is to evaluate if loading doses of aspirin and clopidogrel (LDAC) reduces TEE without increased intracranial hemorrhage (IH) and improves outcomes in SARIA. <h3>Background:</h3> There are no universal antiplatelets regimens to prevent Thromboemboembolic event (TEE) in stent-assisted repair of intracranial aneurysms (SARIA). Antiplatelets effects are highest in first 4 hours. <h3>Design/Methods:</h3> Consecutive patients underwent SARIA with LDAC; aspirin 324 mg (4 baby aspirin) and clopidogrel 300 mg in 2 to 4 hours before procedure were enrolled from 2011 to 2022. Outcome was measured using modified Rankin Scale (mRS) score. <h3>Results:</h3> 112 patients with mean age of 53 ± 13 underwent SARIA (7 ruptured and 55 symptomatic). Aneurysms are; Right internal carotid artery (ICA) 27, left ICA 35, middle cerebral artery 25, basilar artery 19 and anterior communicating artery 6. There are no intra-operative ruptures. Small left subarachnoid hemorrhage developed on a right MCA aneurysm on day 3, which resolved spontaneously. Stent thrombosis in one; resolved with intraarterial integrilin with no stroke. Clinical TEE were observed in 2 cases (1.8%); first event was in a 42 years old woman with a giant right ICA giant aneurysm and achieved mRS 1. Second event was visual distortion and diplopia in a 66 years old woman with basilar artery aneurysm and achieved mRS1. Ruptured and symptomatic were repaired and no subarachnoid hemorrhages during follow-up. Immediate complete and near complete obliteration of aneurysm was observed in 72% and subtotal in 28%. There was no mortality or permanent disability in our series. 90 days mRankins 0 and 1 was observed in 98 (92.5%), mRS 2 in 7(6.6%) at baseline and mRS 3 in 2 (1.9%), which sustained in 12 months. <h3>Conclusions:</h3> LDAC in SARIA is associated with reduced TEE without increased IH and good outcome. LDAP may be an option in SARIA to prevent TEE. Further studies are required. <b>Disclosure:</b> Dr. Lodi has nothing to disclose.

Abstract Number ‐ 132: Stent‐assisted repair of the intracranial aneurysms with loading dose of antiplanets and perioperative events.

Introduction Introduction: Thromboemboembolic event (TEE) remains the mail perioperative challenge in addition to the potential intracranial hemorrhage (IH) in stent‐assisted repair of intracranial aneurysms (IA), and there are no standard antiplatelet strategies. Bases on the data, antiplatelets effects are more pronounce in first 4 hours after administration of antiplatelets. Objectives: To evaluate the effect of acute loading doses of aspirin and clopidogrel (LDAC) in TEE and hemorrhagic events associate with stent‐assisted repair of intracranial aneurysm. Additionally, to review the outcome of those patient who underwent stent‐assisted coiling using LDAC. Methods Consecutive patients underwent stent‐assisted repair of aneurysm using loading doses of aspirin 324 mg (4 baby aspirin) and clopidogrel 300 mg 2 to 4 hours before the procedure were enrolled from 2011 to 2022. Patients demographics including intra‐operative and post operative events were recorded. Outcome was measured using modified Rankin Scale (mRS) score. Results 96 patients (6 had baseline mRS 2) with mean age of 53 ± 13 underwent 98 stent‐assisted procedures including two Y‐stent neck reconstructions to treat 98 (6 ruptured and 41 symptomatic aneurysms) IA. Aneurysms are Right internal carotid artery (ICA) 25, left ICA 30, middle cerebral artery (MCA) 22, basilar artery 17 and anterior communicating artery 2.Stent deployment was achieved in all cases. Coil prolapsed and stretching occurred in one right ICA case, required deployment of additional 3 intracranial stents and one carotid artery stent with no clinical events. There was no intra‐operative rupture or IH. A small perioperative left hemispheric subarachnoid hemorrhage was observed on a right MCA aneurysm on day 3 after discharged, which resolved spontaneously without stopping antiplatelet. Intra‐operative stent thrombosis developed in one who had two aneurysms in right ICA with significant cerebrovascular risk factors; resolved with intraarterial integrilin followed by intravenous for infusion with no clinical consequences immediately and 12 months follow‐up; was resistant to clopidrogel and placed on ticagrelor.Post‐operative TEE were observed in 2 cases (2%); first event was observed on day 2 in a 42 years old woman with a giant right ICA giant aneurysm with NIHSS 6 and who recovered completely (NIHSS 0, mRS 1) in 90 days. The second event was visual distortion and diplopia (NIHSS 0) developed on day 2 in a 66 years old woman with basilar artery aneurysm. Her symptoms resolved completely and return to nursing job. All ruptured and symptomatic aneurysms were secure immediately and there are no subarachnoid hemorrhages during follow‐up. TEE was associated withperiorerative smoking. Immediate complete and near complete obliteration of aneurysm was observed in 66% and subtotal in 34%. There was no mortality or permanent disability in our series. 90 days mRankins 0 and 1 was observed in 96% and mRS 2 in 7% (baseline mRS) Conclusions Our study revealed that LDAC in stent‐assisted repair of IA is associated with a low TEE without added risk of IH with clinical good outcome. Our antiplatelets loading regimen may be an option in stent‐assisted repair of IA, especially when patients are unreliable and aneurysms are symptomatic. Further studies are required.

Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video.

*Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; ‡Neurorestoration Center, University of Southern California, Los Angeles, California, USA Correspondence: Jonathan J. Russin, MD, Department of Neurological Surgery, The Keck School of Medicine, University of Southern California, 1200 N State St # 4250, Los Angeles, CA90033, USA. Email: [email protected]

СЛУЧАЙ УСПЕШНОГО ОТКРЫТОГО ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ГИГАНТСКОЙ АНЕВРИЗМЫ СУПРАКЛИНОИДНОГО ОТДЕЛА ВНУТРЕННЕЙ СОННОЙ АРТЕРИИ

Methods: Despite the progress in developing high-tech methods for neurosurgical patient treatment, managing giant internal carotid artery (ICA) aneurysms remains challenging. We report a case of the successful surgical treatment of a patient with a highly complex clinical problem – a giant aneurysm (GA) at the right supraclinoid ICA. First, the extent of an open surgical intervention was as follows: the ICA was exposed using a linear neck incision and mobilized. Then, osteoplastic skull trepanation in the pterional region and the aneurysmal portion of supraclinoid ICA was performed. The chosen surgical tactics prevented recurrent subarachnoid and intracerebral hemorrhage, ischemia, edema, and brain compression, which are closely related to death and disability. Based on the above, the treatment method has been considered a practical option for treating this cohort of patients. Keywords: Internal carotid artery, aneurysm, clipping, intracranial hemorrhage, intraventricular hemorrhage.

Preliminary Experience of the Surpass Streamline Flow Diverter for Large and Giant Unruptured Internal Carotid Artery Aneurysms.

As of January 2021, the Surpass Streamline (SS) is the most recently approved flow diverter in Japan. A total of 28 Japanese patients, including 9 clinical trial patients, with 28 large or giant unruptured internal carotid artery (ICA) aneurysms, underwent SS embolization at Juntendo University Hospital. Procedural failure occurred in two patients due to the difficulty to navigate the device in the tortuous parent artery. Therefore, 26 patients with 26 aneurysms were available for clinical and anatomical assessments. Patients' mean age was 62.6 years (range 46-86), and 24 patients (92.3%) were female. Mean aneurysm size and neck width were 15.4 mm and 7.7 mm, respectively, with 20 saccular and 6 fusiform aneurysms. Seven aneurysms were symptomatic due to the aneurysmal mass effect. Twenty patients underwent a 6-month follow-up angiography to evaluate the degree of occlusion. Anatomical outcomes were 12 (60%) complete occlusion (CO), 4 (20%) residual neck (RN), and 4 (20%) residual aneurysm. Favorable aneurysm occlusion consisted of CO, and RN was achieved in 16 (80.0%). There were no significant device stenoses. Aneurysmal mass effect improved in one and was unchanged in eight patients. There were three device-related complications, namely, delayed aneurysm rupture, minor ischemic stroke, and device occlusion (11.5%). One patient with minor ischemic stroke fully recovered before 30 days, and our series showed 7.7% risk of major ipsilateral stroke and neurological death at 30 days. The SS embolization for large and giant unruptured ICA aneurysms offers satisfactory anatomical and clinical outcomes with a low risk of device-related complications.

Challenging access during flow diversion treatment of a giant cavernous ICA aneurysm.

A man in his 60s presented with severe ophthalmoparesis and loss of visual acuity in his right eye. He was found to have a giant aneurysm of the cavernous internal carotid artery (ICA). Treatment with a flow diverter was recommended. The aneurysm caused matricidal outflow restriction of the ICA. Microwire and microcatheter access through the aneurysm was challenging, requiring multiple wires, stentriever reduction, and more. Eventually, a construct of 3 Pipeline embolization devices was created across the aneurysm. Troubleshooting access across giant aneurysms is an important part of treatment. Informed consent was obtained for the procedure and for publication. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2258.

Blood flow stagnation after treatment of a giant internal carotid artery aneurysm: a computed fluid dynamics analysis

Balloon test occlusion (BTO) is an angiographic test to evaluate ischemic tolerance after permanent occlusion of an internal carotid artery (ICA). BTO can simulate ischemia caused by parent artery occlusion and can be used to select a suitable bypass surgery using specific criteria. On the other hand, a postoperative thrombus can form despite proper case selection, optimal radiological evaluation, and an appropriate surgical strategy. Postoperative ischemic complications related to perforating branches are clinically significant. This simulation study aimed to analyze postoperative flow characteristics and elucidate the cause of ischemic complications related to the perforating branch using computational fluid dynamics (CFD). An unexpected postoperative thrombus formation related to the perforating branch occurred after treating a giant aneurysm in the cavernous portion of the ICA in a patient. Three-dimensional digital subtraction angiography was used to acquire flow data and set up the CFD simulation. The flow simulations were performed at various bypass flow rates. The CFD analysis indicated flow stagnation in the ICA only when surgical treatment using a low-flow bypass graft was performed. Thrombus formation may lead to ischemic complications related to the perforating branch, such as the anterior choroidal artery. BTO did not reflect the influence of bypass blood flow. Therefore, recognizing that blood flow stagnation may occur and comprehensively deciding on the surgical strategy by CFD analysis can be helpful to prevent ischemic complications in patients with giant aneurysms.

Expression of Concern: Giant Unruptured Internal Carotid Artery Aneurysm.

Expression of Concern: Giant Unruptured Internal Carotid Artery Aneurysm.

No reason to smile: giant internal carotid artery aneurysm

Giant cerebral aneurysms account for approximately 5% of all intracranial aneurysms, affecting morecommonly women in the 5th to 7th decade. When untreated, giant intracranial aneurysms face a poor prognosis withan estimated 2-year mortality of 68%. We present the case of an 82-year-old woman admitted at the emergencydepartment due to two focal to bilateral tonic-clonic seizures with a giant aneurysm of the supraclinoid segment ofthe right internal carotid artery on the CT scan. We discuss different management approaches for giant internalcarotid artery aneurysms, including direct surgical clipping, reconstructive endovascular procedures (coiling, balloon-/stent-assisted coiling, and flow diversion), deconstructive endovascular techniques (parent artery occlusion), andconservative management.

Intra-aneurysmal thrombosis and turbulent flow on MRI of large and giant internal carotid artery aneurysms

ObjectiveLarge and giant intracranial aneurysms are vascular pathologies associated with high morbidity and mortality. The purpose of this study was to assess large and giant internal carotid artery (ICA) aneurysms and their intra-aneurysm thrombosis and turbulent flow on magnetic resonance (MR) imaging. MethodsThis study investigated the large and giant ICA aneurysms in 12 patients. MR images, angiograms, and their treatment were retrospectively reviewed. ResultsMR imaging demonstrated high and intermediate signals in addition to the normal flow void. The heterogeneous MR intensities correspond to turbulent flow, laminar flow, or intramural thrombosis. Turbulent flow in 8 cases and intramural thrombosis in 4 cases. Angiography showed turbulent blood flow in saccular and fusiform aneurysms with smooth walls. Intra-aneurysm thrombosis was found in fusiform aneurysms associated with pathology of adjacent ICA wall. A growing saccular aneurysm of the ICA with regular wall involving a turbulent flow was observed. ConclusionThe turbulent flow and thrombosis in large and giant aneurysms can be detected on MR images. Most large and giant aneurysm is not fill with thrombus but turbulent blood flow. Partially thrombosed lesions are caused by pathology vessel wall not turbulent flow. Aneurysm growth can be caused by turbulent blood flow and intra-aneurysm thrombosis.

Long-term Follow-up Results after Flow Diverter Therapy Using the Pipeline Embolization Device for Large or Giant Unruptured Internal Carotid Artery Aneurysms: Single-center Retrospective Analysis in the Japanese Population.

Flow diverter (FD) therapy using Pipeline embolization device (PED) has become an important alternative to treat internal carotid artery (ICA) aneurysms. Herein, we report the long-term outcome for 3 years after FD therapy using PED for ICA aneurysms in Japan. The patients who underwent angiographical and/or clinical follow-up for 3 years after the FD therapy using PED of large or giant unruptured ICA aneurysms from December 2012 at our university hospital are the subjects of this study. We retrospectively reviewed the in- and outpatients’ medical charts, and written operative and radiological records. There were 84 patients with 90 aneurysms who could be clinically and/or angiographically followed up for 3 years. Of these, 7 aneurysms were only available for clinical follow-up. Of the remaining 83 aneurysms, 6 aneurysms had vessel occlusion due to stent thrombosis or parent artery occlusion, and 60 of the remaining 77 (77.9%) had complete occlusion. In multivariate analysis, older age (>70 years), wide neck, and non-adjunctive coiling contributed statistically significantly to incomplete occlusion. Of the 84 patients, 2 patients (2.4%) had delayed complications between 6 months and 3 years after the initial FD placement. Three patients (3.6%) had poor outcome due to postoperative major stroke complications, 2 of which were acute complications. The long-term results after FD therapy are good both angiographically and clinically. Endothelialization of the aneurysmal neck and intra-aneurysmal thrombosis contribute to complete occlusion. The primary reason for the somewhat low complete occlusion in Japan may be the patients are generally older.

Comparative Analysis of Feasibility of the Retrograde Suction Decompression Technique for Microsurgical Treatment of Large and Giant Internal Carotid Artery Aneurysms.

ObjectiveRetrograde suction decompression (RSD) is an adjuvant technique used for the microsurgical treatment of large and giant internal carotid artery (ICA) aneurysms. In this study, we analyzed the efficacy and safety of the RSD technique for the treatment of large and giant ICA aneurysms relative to other conventional microsurgical techniques. MethodsThe aneurysms were classified into two groups depending on whether the RSD method was used (21 in the RSD group vs. 43 in the non-RSD group). Baseline characteristics, details of the surgical procedure, angiographic outcomes, clinical outcomes, and procedure-related complications of each group were reviewed retrospectively. ResultsThere was no significant difference in the rates of complete neck-clipping between the RSD (57.1%) and non-RSD (67.4%) groups. Similarly, there was no difference in the rates of good clinical outcomes (modified Rankin Scale score, 0–2) between the RSD (85.7%) and non-RSD (81.4%) groups. Considering the initial functional status, 19 of 21 (90.5%) patients in the RSD group and 35 of 43 (81.4%) patients in the non-RSD group showed an improvement or no change in functional status, which did not reach statistical significance. ConclusionIn this study, the microsurgical treatment of large and giant intracranial ICA aneurysms using the RSD technique obtained competitive angiographic and clinical outcomes without increasing the risk of procedure-related complications. The RSD technique might be a useful technical option for the microsurgical treatment of large and giant intracranial ICA aneurysms.

Combined standard bypass and parent artery occlusion for management of giant and complex internal carotid artery aneurysms

BackgroundComplex aneurysms do not have a standard protocol for treatment. In this study, we investigate the safety and efficacy of microsurgical revascularization combined with parent artery occlusion (PAO) in giant...