Internal Carotid Artery Bifurcation Aneurysm Research Articles

Recurrent Artery of Heubner Guiding the Clip Application for Internal Carotid Artery Bifurcation Aneurysm: 2-Dimensional Operative Video.

Aneurysms of the bifurcation of the internal carotid artery (ICA) represent approximately 5% of intracranial aneurysms and tend to occur in younger patients.1-3 They typically have a superior orientation, in close relationship with the medial (branches of the anterior cerebral artery, segment A1) and lateral (branches of the middle cerebral artery, segment M1) lenticulostriate arteries (LSA), including recurrent artery of Heubner (RAH). RAH commonly originates in the junction of A1 and A2, courses medially to laterally between LSA and anterior cerebral artery, ICA bifurcation, and middle cerebral artery before entering the lateral portion of the anterior perforated substance.4-7 Damage to these arteries are catastrophic. This complex vascular anatomy makes treatment challenging, either endovascular or microsurgical.8-13 We present a video case of microsurgical clipping for the left ICA bifurcation aneurysm. This study was approved by the ethics committee of our institution. The patient, a 46-year-old man, was diagnosed with an unruptured ICA bifurcation aneurysm during workup for intermittent headache. Morphological characteristics of the aneurysm supported intervention over conservative treatment. Digital subtraction angiography showed a prominent proximal RAH crossing between the aneurysm neck and LSA, providing anatomical protection for clip application. Microsurgical clipping was chosen, and the procedure went uneventfully. The patient consented to the procedure and to the publication of his/her image. We discussed and demonstrated throughout the video how we used this anatomic variation and trajectory of the RAH to prevent clipping of LSA unwittingly and achieve complete occlusion of the aneurysm neck.

Microsurgical Management of Internal Carotid Artery Bifurcation Aneurysm After Failure of Endovascular Coiling and Flow Diversion: 2-Dimensional Operative Video.

We describe the case of a 51-year-old woman who underwent craniotomy and surgical clipping of a large internal carotid bifurcation aneurysm that was refractory to treatment with 2 rounds of endovascular coiling and internal carotid artery (ICA) to middle cerebral artery pipeline placement. The patient initially presented in 2004 with a 3-week history of sudden-onset headache with associated nausea. Computed tomography and lumbar puncture on presentation in 2004 were negative for subarachnoid hemorrhage. Digital subtraction angiography, however, demonstrated a large left ICA bifurcation aneurysm. The decision was made to proceed with endovascular coiling of the aneurysm. Six-month and 1-year follow-up imaging showed incomplete resolution of the aneurysm, and retreatment coiling was completed in 2005. After recoiling in 2005, the patient was lost to follow-up. During this period, she underwent pipeline placement from the ICA to the middle cerebral artery across the A1 segment at a different institution. Two years after flow diversion, the patient was referred back to our institution with further worsening of the aneurysm. Our surgical team opted for craniotomy and surgical clipping given the limited management options that this extremely complex case now presented. The patient consented to the procedure. Postoperative imaging demonstrated marked improvement in aneurysm severity. Although the current neurosurgical trend favors endovascular treatment over craniotomy, this case shows the vital importance of craniotomy and aneurysm clipping in the treatment of select patients. We also provide high-quality operative video of aneurysm clipping.1-7.

Hemichorea after internal carotid artery bifurcation aneurysm clipping

Abstract Involuntary movements following aneurysm surgery are rare. Here, we report the case of a patient who developed left hemichorea following surgical clipping of a right internal carotid artery bifurcation aneurysm. The movement disorder resulted from an acute infarct involving the head of the caudate nucleus. The patient responded well to symptomatic treatment, with complete resolution of chorea. The occurrence of new-onset involuntary movements following aneurysm surgery should raise the suspicion of infarcts involving basal ganglia structures.

Comparing treatment outcomes of various intracranial bifurcation aneurysms locations using the Woven EndoBridge (WEB) device

BackgroundThe Woven EndoBridge (WEB) device has Food and Drug Administration approval for treatment of wide-necked intracranial bifurcation aneurysms. The WEB device has been shown to result in adequate occlusion in...

Ipsilateral Internal Carotid Artery Bifurcation Aneurysm and Contralateral Middle Cerebral Artery Aneurysm Clipping: 2-Dimensional Operative Video.

Contralateral clipping of a middle cerebral artery (MCA) aneurysm is challenging but possible with favorable anatomy. This patient had bilateral aneurysms, an ipsilateral internal carotid artery bifurcation aneurysm and a contralateral MCA aneurysm. The surgical goal was to clip both aneurysms if possible. After opening the ipsilateral sylvian fissure, the arachnoid planes were opened along the anterior cerebral arteries to the contralateral sylvian fissure. The arachnoid planes within the sylvian fissure were dissected to permit visualization of the contralateral proximal MCA and anatomy, which permitted the MCA to be followed to the aneurysm. If adequate proximal and distal control is present, the aneurysm is clipped. The surgeon needs to be comfortable in backing out if the exposure is too limited. The sequence of clipping should be to clip the contralateral aneurysm first to avoid inadvertent manipulation of the ipsilateral clip during the contralateral procedure. Postoperative angiography demonstrated that the bilateral aneurysms were clipped and that all vessels were patent. 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.

Insurance and Flow-Alteration Superficial Temporal Artery to Middle Cerebral Artery (STA-MCA) Bypass in Management of Complex Anterior Intracranial Circulation Aneurysms in Postendovascular Era

Optimal management of complex anterior circulation aneurysms is an enigmatic challenge because of frequent involvement of major vessel bifurcation, choroidal vessels, and lenticulostriate/thalamostriate perforators. Cerebral ischemia associated with prolonged clipping time is a major concern pertinent to their surgical management, especially in patients with poor cross-flow. To circumvent this hurdle, single/double-barrel low-flow superficial temporal artery (STA) to middle cerebral artery (M3/M4-MCA) can be performed, which can maintain distal cerebral perfusion while facilitating safe clip reconstruction of complex MCA and supraclinoidal internal carotid artery (ICA) aneurysms involving ICA bifurcation or supraclinoidal ICA aneurysms with poor cross-circulation-insurance bypass, as well as supplement/alter blood flow after MCA aneurysm trapping-flow-alteration bypass. A retrospective chart review of consecutive neurosurgical patients operated over 2 years at this center was performed. Patients with complex MCA and ICA aneurysms who were treated with STA-MCA bypass were included. The clinical profile, pre- and postoperative images, intraoperative imaging, and patient outcomes were recorded. Surgical reconstruction of aneurysm was the treatment of choice due to involvement of choroidal/thalamostriate perforators, MCA/ICA bifurcation, complex aneurysm morphology, or dissecting/thrombosed nature of aneurysm. STA-MCA low-flow bypass was performed using M3/M4 segment of MCA as the recipient in anticipation ofprolonged temporary clipping time on M1-MCA, supraclinoidal ICA aneurysms with suspected ICA terminus involvement, or need for possible trapping of fusiform MCA aneurysm. The saccular/fusiform part of aneurysm was clip reconstructed and the partially thrombosed dissecting segment was opened for thrombectomy and trapped using proximal and distal clips after good patency of bypass was confirmed. The distal MCA flow was restored adequately and confirmed intraoperatively using indocyanine green angiography and micro-Doppler ultrasonography. MCA (n= 4) and supraclinoid-ICA (n= 1) aneurysms were managed successfully using this strategy, which involved 6 STA-MCA bypass procedures (insurance and flow-alteration bypass, 3 each). Postoperative check angiograms demonstrated patent bypass in all 5 patients. Four patients had favorable outcome (modified Rankin Scale score 0/1); one had recovering hemiparesis and aphasia (modified Rankin Scale score 4). This series highlights the surgical strategy and safety for successfully managing complex MCA and ICA aneurysms using low-flow STA-MCA revascularization procedures.

Multiple Aneurysms Clipping Through the Eyebrow Approach: 2-Dimensional Operative Video.

The eyebrow approach is a versatile technique that may apply to various vascular and tumoral pathologies of the anterior skull base. We present a case of multiple aneurysms clipping through the eyebrow approach and we discuss the nuances of this technique. A 44-yr-old patient presented with incidentally found aneurysms. Angiography showed 2 4.5-mm aneurysms on the left middle cerebral artery (MCA) and internal carotid artery (ICA) bifurcations. At surgery, the patient is positioned supine with the head elevated, slightly rotated, and extended in order to obtain good access and gravity retraction of the brain. A 3-cm incision is placed in the eyebrow and a small supraorbital bone flap is raised. The floor of the orbit and the edges of the craniotomy are thoroughly drilled in order to maximize the working space. After dural opening, the sylvian fissure was widely dissected and the MCA aneurysm was identified. A large opening of the sylvian and carotid cistern allows retractor free surgery. The ICA bifurcation aneurysm is then dissected and clipped. The MCA aneurysm is treated last in order to avoid a conflict between instruments especially during clipping. Aneurysms occlusion and vessel permeability is verified by Doppler ultrasonography and indocyanine green (ICG) angiography. After achieving hemostasis, the dura is closed and a subcuticular continuous suture is used at the skin. The postoperative course was uneventful. The eyebrow approach allows simultaneous treatment of multiple aneurysms of the anterior circle of Willis in selected cases. Proper positioning, drilling of the orbital floor and extensive arachnoid dissection are the key steps of this procedure.

ICA Bifurcation Aneurysms: Clinical Features and Surgical Outcome in a Tertiary Referral Center in South India.

To study the clinical profile, imaging features, intra-operative findings, post-operative outcome at discharge and at 6 months in patients with internal carotid artery (ICA) bifurcation aneurysm. Present study is a retrospective analysis of data of patients who underwent surgery for ICA bifurcation aneurysm between the period of 1st January 2011 to 31st December 2015 at our institute. Demographic variable, clinical grade, radiological finding was assessed. Outcome was measured using modified Rankin score (mRs) at discharge and at 6 months follow up. All ICA bifurcation aneurysms were clipped using a standard pterional craniotomy. A total of 28 patients were included in the study out of which 4 had bilateral ICA bifurcation aneurysms. Mean age was 44.15 (age range 14-65) years, with 43.75% of patient were < 40yrs. Multiple aneurysms were seen in 11 (39.28%) patients, with superior projection being the most common in 53.12%. Vasospasm was seen in 12 (42.85%) with 4 patients undergoing chemical angioplasty. At discharge good outcome (mRs < 3) was seen in 4/5 (80%) patients in the un-bled category, whereas 18/23 (78.2%) in bled category. At 6 months follow up, mRs < 3 was seen 4 (100%) patients in unbled category, and 84.21% (16 of 19) patients in bled group. The findings of the present study have shown an increased incidence of bilaterality and multiplicity for ICA bifurcation aneurysms. The direction of the dome of aneurysm and temporary clipping do not affect the treatment outcomes. These aneurysms have excellent outcomes following surgery.

Clip reconstruction of a giant internal carotid artery bifurcation aneurysm in hybrid operating room: 2-Dimensional operative video

Giant internal carotid artery (ICA) bifurcation aneurysms are technically difficult to treat because of lack of a definable neck, which makes direct clipping impossible. In addition, these lesions are related to multiple perforating arteries, posing a different challenge to surgical operators. This video demonstrates clip reconstruction of a giant ICA bifurcation aneurysm in a hybrid operating room. A 32-year-old female presented with dizziness for one year. Angiography demonstrated a giant left ICA bifurcation aneurysm. The patient was consented for both clip reconstruction and extracranial-intracranial bypass if needed. A left pterional craniotomy was performed. After dural opening, the sylvian fissure was opened widely until the aneurysm was identified. The proximal ICA was then identified. The aneurysm projected posteriorly, involving the origins of both the A1 and M1 segments. After temporary clipping, the critical perforators were dissected free from the aneurysm wall. Tandem fenestrated clipping was used to reconstruct the parent artery. Finally, curved clips were used to occlude the distal part of the neck. Vessel patency was evaluated using intraoperative Doppler and indocyanine green angiography. Intraoperative somatosensory and motor evoked potential monitoring remained unchanged after final clipping. Intraoperative angiography confirmed complete obliteration of the aneurysm and reconstruction of the parent artery. The patient recovered well without any complications. Giant ICA bifurcation aneurysms are complex lesions that require preoperative planning and intraoperative monitoring. Adherence to general principles, including careful dissection of aneurysmal wall from adjacent perforators and clip reconstruction using tandem fenestrated clipping, these lesions can be treated safely and effectively.

Internal Carotid Artery Bifurcation Aneurysms: Microsurgical Strategies and Operative Nuances for Different Aneurysmal Directions

Internal carotid artery bifurcation aneurysms (ICAbifAs), comprising approximately 5% of intracranial aneurysms, are characterized clinically by their tendency to occur at a younger age and surgically by the technical difficulties posed by their domes being adherent to the frontal lobe, their location at the apex of the sylvian fissure, and their relation to myriad perforator complexes. To review the nuances of technique and operative strategy specific to aneurysmal direction in the light of our experience with ICAbifAs. ICAbifAs managed at our institute from January 2001 to July 2016 were analyzed. Detailed analysis of clinical data, pre- and postoperative radiology, operative notes and videos, and clinical outcome was done. Fifty-one patients with ICAbifAs were treated in the study period out of which 40 patients underwent microsurgical clipping. The median age was 48 yr (range 14-68 yr). Nearly 95% of the patients presented in a good clinical grade (World Federation of Neurological Surgeons grade 1 and 2). At 6-mo follow-up, 36 patients (90%) had good clinical outcome (Glasgow Outcome Scale 4 and 5). According to their direction, ICAbifAs were grouped as anteriorly directed (10 cases), superiorly directed (23 cases), and posteriorly directed (7 cases). Operative techniques and nuances utilized depend on aneurysmal direction and are presented here. An appropriate surgical strategy based on the direction of ICAbifAs as per the preoperative radiology, meticulous dissection of aneurysmal wall from adjacent perforators, and clip application with the aim of remodeling the ICA bifurcation are integral to achieving a good outcome.

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.

Risk factor analysis of recanalization and retreatment for patients with endovascular treatment of internal carotid artery bifurcation aneurysms.

Only a few reports of internal carotid artery (ICA) bifurcation aneurysms using the endovascular technique have been published in the current literature. The purpose of this study was to assess how multiple risk factors including angioarchitectural features of ICA bifurcation characteristics may have influenced aneurysmal rupture, recanalization, and retreatment. Fifty-one patients with 52 ICA bifurcation aneurysms treated with endovascular coiling between July 2003 and July 2015 were retrospectively analyzed. The patients' clinical records, endovascular reports, and clinical and angiographic outcomes were reviewed. We also evaluated risk factors for recanalization and retreatment, including the angioarchitectural anatomy. The clinical outcomes were observed to be satisfactory in 49 patients (96.0%) and unfavorable in 2 patients (4.0%). The risk factor for aneurysmal rupture was young age (P = 0.024). Symptomatic complications due to thromboembolism occurred in 1.9% of cases; no patients suffered a fatal complication. Eleven of 52 ICA bifurcation aneurysms (21.2%) were recanalized within an average of 54.3 ± 33.5months of follow-up. Among the aneurysms, 4 (7.7%) underwent recoiling. Multivariate analysis showed that ruptured aneurysms (P = 0.006) and a lower packing density (P = 0.048) were risk factors for recanalization. A lower packing density was the only risk factor for retreatment (P = 0.019). Endovascular treatment of ICA bifurcation aneurysms is considered safe and acceptable. This study showed that the ICA bifurcation aneurysms ruptured more frequently at a younger age. A higher packing density has been shown to reduce major recanalization and retreatment.

Surgically Managed Pediatric Intracranial Aneurysms: How Different Are They from Adult Intracranial Aneurysms?

Purpose: Intracranial aneurysms in children are rare compared to those in adults, and their causes, presentations, and outcomes also vary. Thus, they need to be studied intricately and as an independent entity. Methods: We retrospectively reviewed intracranial saccular aneurysms in 44 children of <19 years of age who had been surgically treated during the last 30 years at our institute. We analyzed presentation, characteristics, size, multiplicity, cause, and eventual outcome, and compared these to the adult cases of aneurysms operated on during the same period. Results: The commonest site of aneurysm was the internal carotid artery (ICA), in 47.7%. Follow-up was available for 38 (86.4%) children. The median duration of follow-up was 14 months (range 1-89 months). A favorable outcome was seen in 31 cases (81.6%) and an unfavorable outcome (including 1 death) in 7 (18.4%). Conclusion: Intracranial aneurysms in children present with subarachnoid hemorrhage in a good grade. ICA bifurcation aneurysms are the commonest sites of occurrence. Surgery is safe and effective, and children seem to have a better outcome.

Unruptured internal carotid artery bifurcation aneurysms: general features and overall results after modern treatment.

Internal carotid artery bifurcation aneurysms (ICAbifAs) present unique challenges to endovascular and surgical operators, and little is known about their natural history. We reviewed our institution's experience with ICAbifAs studying outcomes of surgical and endovascular management and natural history. Consecutive patients with unruptured ICAbifAs evaluated and/or treated over an 8-year interval were studied. Baseline demographics, neurovascular risk factors, aneurysm location and size, clinical presentation, treatment recommendations, and outcomes were prospectively collected and retrospectively analyzed. Continuous variables were compared with Student's ttest and categorical variables with Chi-square tests. Fifty-nine patients with 61 unruptured ICAbifAs were included. Seven aneurysms were treated surgically (11.5%), 22 underwent endovascular treatment (36%), and 32 were managed conservatively (52.5%). In the surgical group, short- and long-term complete aneurysm occlusion rates were 100% with no cases of perioperative or long-term permanent morbidity or treatment-related mortality. In the endovascular group, two patients (11.7%) with giant aneurysms had perioperative thromboembolic events with transient morbidity. There was one case of aneurysm rupture at follow-up in a giant aneurysm treated with partial coil embolization. Complete/near-complete occlusion rates were 63%. There was one case of aneurysm rupture after 114 aneurysm-years of follow-up in the conservative management group (0.89%/year), but no ruptures were observed in small aneurysms selected for conservative management. Unruptured small ICAbifAs have a benign natural history. In patients selected for treatment, excellent results can be achieved in the vast majority of patients with judicious use of endovascular and surgical therapy.

Surgical flow modification of the anterior cerebral artery-anterior communicating artery complex in the management of giant aneurysms of internal carotid artery bifurcation: An alternative for a difficult clip reconstruction.

Background:Internal carotid artery bifurcation (ICAb) aneurysms account for about 2–15% of all intracranial aneurysms. In giant and complex cases, treatment may be difficult and dangerous, once some aneurysms have wide neck and anterior cerebral artery (ACA) and middle cerebral artery (MCA) may arise from the aneurysm itself. Clip reconstruction may be difficult in such cases. Whenever possible, the occlusion of ACA transform the bifurcation in a single artery reconstruction (ICA to MCA), much easier than a bifurcation reconstruction.Methods:In patients with giant and complex ICAb aneurysms, we propose routine preoperative angiography with anatomical evaluation of anterior communicating artery (ACoA) patency during cervical common carotid compression with concomitant contralateral carotid artery injection. This allowed visualization of the expected reversal of flow in the A1 segment–ACoA complex. When test is positive, we can perform ipsilateral ACA (A1 segment) clip occlusion and flow modification of the ACA-ACoA complex transforming a three vessel (ICA, ACA, and MCA) reconstruction into a two vessel (ICA and MCA) reconstruction.Results:Two patients were treated, with 100% of occlusion and good outcome.Conclusions:Surgical treatment of giant and complex ICAb may be achieved with acceptable morbidity.

Perforating Artery Injury during Microsurgery for Internal Carotid Artery Bifurcation Aneurysms

Internal carotid artery bifurcation aneurysms(ICB-ANs)are relatively rare and are difficult to occlude by direct clipping without perforating artery injury(PAI). We retrospectively analyzed 11 aneurysms in 10 cases. PAI was identified in 5 of 10 cases on postoperative computed tomography(CT)or magnetic resonance imaging(MRI), and 2 of these patients were symptomatic. PAIs were distributed in the caudate nucleus and/or the genu of the internal capsule. PAI occurred in 3 of 5 cases in which indocyanine green videoangiography(ICG-VAG)was performed. ICG-VAG is a helpful tool visualizing blood flow of vessels in surgical fields. However, PAI is a potential risk in direct clipping of ICB-ANs even if adjacent perforating arteries were observed using ICG-VAG.

Simultaneous stent expansion/balloon deflation technique to salvage failed balloon remodeling

Herniation, with possible embolization, of coils into the parent vessel following aneurysm coiling remains a frequent challenge. For this reason, balloon or stent assisted embolization remains an important technique. Despite...

Endoscopic controlled clipping of anterior circulation aneurysms via keyhole approach: Our initial experience.

Surgical clipping is the most definite treatment for intracranial aneurysms. Its aim is to achieve complete aneurysmal occlusion without compromising the lumen of a parent vessel or perforators, and with minimal brain tissue trauma. To evaluate the role of endoscopic controlled keyhole approach in clipping of anterior circulation aneurysms. In this retrospective study, all consecutive patients undergoing endoscopic controlled clipping via the keyhole approach by the senior author during the last 1 year were included. The cases in which a microscope was used at any stage of surgery were excluded. Fourteen patients with anterior circulation aneurysms underwent clipping via the endoscopic keyhole approach (supraorbital and mini-pterional). Seven patients had anterior communicating (ACom) artery aneurysms, four had middle cerebral artery (MCA) bifurcation aneurysms, two had internal carotid artery bifurcation aneurysms, and one had a posterior communicating artery aneurysm. Ten patients presented with subarachnoid hemorrhage (Hunt and Hess grade I in 6 and grade II in 4 patients), whereas the remaining four were incidentally detected. The pre-clipping dissection as well as the clipping were successfully performed endoscopically in all patients. The post-clipping inspection revealed inclusion of a perforator within the clip blades in 2 patients (ACom and MCA bifurcation) that required clip readjustment. There was no residual neck/incompletely clipped aneurysm detected on post-clipping inspection. There was no morbidity directly attributable to the use of keyhole approach or the endoscope. Endoscopic keyhole approach for intracranial aneurysms combines the advantages of both keyhole approach and endoscopy. Endoscopic visualization can help to reduce chances of an incompletely clipped aneurysms/residual neck and the risk of parent vessel/perforator occlusion. However, the use of an endoscope in narrow corridors with space constraints has a learning curve that can be overcome by practicing on cadavers and initially performing several simple endoscopic procedures.

Endovascular treatment of internal carotid artery bifurcation aneurysms: a single-center experience and a systematic review and meta-analysis.

Endovascular coiling of internal carotid artery bifurcation aneurysms can be challenging due to unfavorable morphologic features. With improvements in endovascular techniques, several series have detailed the results and complications of endovascular treatment of aneurysms at this location. We performed a systematic review and meta-analysis of published series on the endovascular treatment of ICA bifurcation aneurysms, including a tertiary referral center experience. We performed a comprehensive literature search for reports on contemporary endovascular treatment of ICA bifurcation aneurysms from 2000 to 2013, and we reviewed our experience. We extracted information regarding periprocedural complications, procedure-related morbidity and mortality, immediate angiographic outcome, long-term clinical and angiographic outcome, and retreatment rate. Event rates were pooled across studies by using random-effects meta-analysis. Including our series of 37 patients, 6 studies with 158 patients were analyzed. Approximately 60% of the aneurysms presented as unruptured; 88.0% (95% CI, 68.0%-96.0%) of aneurysms showed complete or near-complete occlusion at immediate postoperative angiography compared with 82.0% (95% CI, 73.0%-88.0%) at last follow-up. The procedure-related morbidity and mortality were 3.0% (95% CI, 1.0%-7.0%) and 3.0% (95% CI, 1.0%-8.0%), respectively. The retreatment rate was 14.0% (95% CI, 8.0%-25.0%). Good neurologic outcome was achieved in 93.0% (95% CI, 86.0%-97.0%) of patients. Endovascular treatment of ICA bifurcation aneurysms is feasible and effective and is associated with high immediate angiographic occlusion rates. However, retreatment rates and procedure-related morbidity and mortality are non-negligible.

Microsurgical Management of Giant (&gt;5 cm) Internal Carotid Artery Bifurcation Aneurysms Presenting With Brainstem Compression Using Radial Artery Interposition Bypass Graft

Microsurgical Management of Giant (&gt;5 cm) Internal Carotid Artery Bifurcation Aneurysms Presenting With Brainstem Compression Using Radial Artery Interposition Bypass Graft