Parent Artery Sacrifice Research Articles

Surgical management of vertebral and basilar artery aneurysms: a single center experience in 41 patients

To study an effective method for surgical management of vertebral and basilar artery aneurysms. Forty-one patients with 43 aneurysms of the vertebral and basilar arteries were managed by microsurgical clipping. Cerebral angiography revealed basilar apex aneurysms in 17 patients, basilar trunk in six patients, vertebrobasilar (VB) junction aneurysms in three patients and vertebral aneurysms in 15 patients. One patient had two basilar aneurysms, and another had bilateral vertebral artery aneurysm. We used a pterional approach in basilar apex aneurysms (n = 17 patients), orbitozygomatic and its variants in upper basilar trunk aneurysms (n = 2 patients), combined petrosal and far-lateral approach in mid basilar trunk aneurysms (n = 4 patients), far-lateral and transcondylar approach for the aneurysms at VB junction (n = 3 patients) and transcondylar approach for the vertebral aneurysms (n = 15 patients). Bypass graft was performed in 14 patients with fusiform and wide neck aneurysms, to prevent potential cerebral ischemia due to prolonged temporary occlusion or possibility of intraoperative parent artery sacrifice. Neurological outcomes were measured on the basis of Glasgow Outcome Score (GOS). The rate of back-to-normal life after surgery in basilar tip aneurysm, basilar trunk aneurysms, VB junction aneurysms and vertebral artery aneurysms was 15/17 (82.5 %), 5/6 (83 %), 3/3 (100 %) and 14/15 (93.3 %), respectively. Thirty-six (87.8 %) patients had uneventful postoperative courses. Two patient with basilar apex aneurysm suffered severe neurological deficits related to midbrain ischemia, two patient with occipital artery (OA) graft bypass had postoperative partial lower cranial nerve palsy, and one death with basilar trunk aneurysm occurred after the 20th day of surgery. Thirty-nine patients accepted postoperative digital subtraction angiography (DSA) and eight patients accepted computed tomography (CT) angiogram, whereas two patient denied either one. All the images demonstrated afferent and efferent vessels without aneurysm in situ. Out of 14 patients with graft bypass, 11 patients on cerebral angiographies disclosed the aneurysm clip and the graft bypass patency, one patient on angiography had unidentified graft bypass patency but no symptom related to the graft bypass patency, and two patients denied the postoperative cerebral angiographies. In 40 patients with a mean follow-up of 3.4 years, 37 patients had good outcome, two patients needed assistance for daily living, and one death occurred due to brainstem infarction related to surgery. Selection of proper cranial base approach with adequate exposure is effective in clipping VB aneurysms, minimizing the postoperative complications. Graft bypass may avoid parent artery sacrifice and its branches occlusion in patients with fusiform and wide neck aneurysms.

Giant Extracranial Aneurysm of the Internal Carotid Artery in Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by cutaneous pigmentations, neurofibromas, Lisch nodules and neuroectodermal tumors. Supra-aortic vessel aneurysms may affect patients with NF-1 and can be associated with rupture, ischemic complications and compression symptoms. We describe a 48-year-old woman with NF-1 and an extracranial 3×5 cm right internal carotid artery aneurysm. After balloon test occlusion the patient was treated with parent artery sacrifice which led to significant shrinkage on follow-up MR and reduction of compression symptoms. The literature concerning internal carotid artery aneurysms associated with NF-1 is reviewed evaluating the possible therapeutic options.

E-058 The ultimate sacrifice of a recalcitrant common carotid pseudoaneurysm after carotid endarterectomy

Common Carotid Artery (CCA) pseudoaneurysms are uncommon vascular lesions. They are most likely to occur as a sequelae of previous neck surgery (CEA incidence <1%), blunt or penetrating injuries to...

P-039 Changes in a neuroendovascular practice after introduction of flow diverters

IntroductionFlow diversion represents a major paradigm shift in the treatment of unruptured intracranial aneurysms. The potential impact of this technique on coil utilization and adjunctive techniques such as balloon-assisted and...

Marked decrease in coil and stent utilization following introduction of flow diversion technology

BackgroundFlow diversion represents a major paradigm shift in the treatment of unruptured intracranial aneurysms. The potential impact of this technique on coil utilization and adjunctive techniques such as balloon-assisted and...

Evaluation of Balloon Occlusion Test for Giant Brain Aneurysms under Local Anaesthesia

We describe our experience in balloon test occlusion for giant carotid or basilar aneurysms under hypotension. Twenty-four patients underwent balloon test occlusion (BTO) during the year 2008. Only patients showed absence of any neurological deficits after 20 minutes under normal tension then another 20 minutes under hypotension were considered tolerable for occlusion of the parent artery. Of the 24 patients, four (16.67%) had deficits at normal tension and two (8.33%) had deficits at hypotensive phase. None of the 18 (75%) patients who clinically tolerated test occlusion and had parent artery sacrifice show any complication at follow-up period of two years. Two patients with clinical intolerability underwent carotid artery sacrifice after STA-MCA bypass without sequelae. Balloon test occlusion with hypotension is a useful, competent and simple technique in the evaluation of tolerance to parent artery occlusion in case of giant and complex intracranial aneurysms.

Endovascular treatment for cerebral perforating artery aneurysms

<title/>Objective: Cerebral perforating artery (CPA) aneurysms are rarely reported in the literature, making management decisions challenging. This study is to report neurological outcomes in a single institution experience of perforating artery aneurysms treated endovascularly.Methods: All cases involving patients with CPA aneurysms who presented to Beijing Tiantan Hospital between September 2006 and September 2009 were reviewed retrospectively.Results: Over 3 years, four patients with four CPA aneurysms were treated. The Hunt and Hess grade on admission ranged from 0 to IV, with intracranial hemorrhage in three of the four patients. Conventional angiography confirmed the presence of the aneurysms, and all patients underwent endovascular embolization using liquid embolic materials with parent artery sacrifice. Associated risk factor in our series of patients was brain arteriovenous malformation. The locations of aneurysm were lenticulostriate artery, anterior choroidal artery and medial posterior choroidal artery. The mean size of the aneurysms was 2·5 mm. The mean modified Rankin scale score at follow-up was 1·25. Three patients in whom the perforating artery was sacrificed had good outcomes, suggesting that loss of the artery is clinically well tolerated.Conclusions: This case series reveals that endovascular treatment of CPA aneurysms may be an appropriate, effective, and safe therapy.

Carotid Artery Sacrifice for Unclippable and Uncoilable Aneurysms: Endovascular Occlusion Vs Common Carotid Artery Ligation

Optimal treatment of intracranial aneurysms involves complete occlusion of the aneurysm with preservation of the parent artery and all of its branches. Attempts to occlude the aneurysm and preserve the parent artery may be associated with a higher level of risk than parent vessel occlusion or trapping. To evaluate our series of patients with large and giant aneurysms who underwent treatment via endovascular coiling with parent artery sacrifice or surgical ligation of the common carotid artery (CCA) and gain insight into the advantages and risks of each of these alternatives. We retrospectively reviewed all patients with aneurysms who underwent carotid sacrifice via endovascular occlusion or surgical CCA ligation during an 8-year period at our institution. Twenty-seven patients with large and giant aneurysms of the internal carotid artery underwent carotid artery sacrifice via endovascular occlusion (n = 15) or CCA ligation (n = 12). Of the patients who underwent endovascular occlusion, 3 developed groin complications, 1 developed a new sixth nerve palsy, 1 died from vasospasm related to subarachnoid hemorrhage, and 1 died secondary to rupture of an associated 3-mm anterior communicating artery aneurysm 5 days postoperatively. Of the patients undergoing CCA ligation, 1 patient developed a partial hypoglossal palsy. Clinical improvement of presenting symptoms was observed in all surviving patients regardless of the method of treatment. Complete aneurysm obliteration was documented in all patients during the initial hospital stay. The mean radiographic long-term follow-up was 14.2 months, which was available in 20 of the 25 surviving patients (80%). Complete obliteration was confirmed at follow-up in all but 2 patients with large cavernous aneurysms; 1 was initially treated with endovascular occlusion and the other with carotid ligation. Parent artery sacrifice is still a viable treatment for some complex aneurysms of the internal carotid artery. CCA ligation is a reasonable alternative to endovascular arterial sacrifice.

Efficacy of intraoperativeelectroencephalography monitoring and indocyanine green angiography to assess the safetyof parent artery sacrifice

：Objective To explore theefficacy of intraoperative electroencephalography (EEG) monitoring and indocyanine green(ICG) angiography to assess the safety of parent artery sacrifice in intracranial aneurysmsurgery.Methods From May to November 2008,intraoperative EEG monitoring and/or ICGangiography were used to assess the safety of sacrificing the parent artery in fivepatients.Intraoperative EEG monitoring was used in two patients,ICG angiography inone,both intraoperative EEG monitoring and ICG angiography in two.Results One patient withpoor cerebral collateral circulation evaluated by intraoperative EEG monitoring underwentcerebral revaseularization.The other one with poor cerebral collateral circulationevaluated by ICG angiography underwent parent artery sacrifice only and tolerated theiatrogenie isehemia postoperatively.Three patients underwent permanent occlusion of parentartery had no isehemie complication postoperatively,in which intraoperative EEG monitoringand/or ICG angiography demonstrated sufficient collateral blood flow.ConclusionIntraoperative EEG monitoring and ICG angiography can be used during intracranial aneurysmsurgery to determine patients' ability to tolerate permanent oeclusion of parentartery,combination of them may be more effective.

Intraoperative monitoring of cerebral blood flow by laser speckle contrast analysis

Currently, reliable low-cost and noninvasive techniques to assess cerebral perfusion in the operating room are not available. The authors report on their first clinical experience with laser speckle contrast analysis (LASCA) as a complementary imaging tool for the noninvasive and dynamic assessment of cerebral blood flow (CBF) during neurovascular surgery. The purpose of this preliminary study was to address the general feasibility of LASCA in terms of handling and image quality and to provide an example of its clinical implications. Laser speckle contrast analysis was performed in patients undergoing cerebral revascularization procedures for the treatment of hemodynamic compromise and complex aneurysms. The portable LASCA device was centered over the surgical field, and continuous 5-minute recordings of relative CBF were obtained. In the case of flow augmentation for hemodynamic compromise, CBF monitoring was performed before and after completion of the anastomosis. In the case of flow replacement for parent artery sacrifice, CBF monitoring was performed during consecutive 30-second test occlusions of the radial artery graft after proximal internal carotid artery sacrifice and the subsequent initiation of blood flow through the bypass. In all cases, the authors achieved good visualization of relative CBF in addition to flow imaging in both the bypass graft and the cortical vasculature. During a sudden CBF decrease after test occlusion of the radial artery graft and subsequent flow initiation through the bypass, LASCA allowed immediate visualization and measurement of relative CBF in excellent spatiotemporal resolution. In this study LASCA offered noninvasive and rapid intraoperative assessment of relative CBF, which can be used for optimizing neurovascular procedures.

Surgical clipping of vertebral and basilar artery aneurysms

Objective To study an effective method for clipping vertebral and basilar artery aneurysms. Method There were 26 patients with 28 aneurysms of vertebral and basilar arteries. Aneurysms ruptured in 9 patients,the aneurysms in 16 patients were located in basilar artery including two aneurysms in one patient,and 10 aneurysms were located in vertebral artery including bilateral vertebral artery aneurysms in one patient and vertebral AVMs in one patient. Pterional approach underwent in 5 patients with basilar tip aneurysms,orhitozygomatic approach in 5 patients with basilar tip aneurysms and 2 patients with the upper basilar aneurysms, combination of presigmoid with far-lateral approach in 4 patients with mid basilar aneurysms. Of 10 patients with aneurysms of vertebral arteries, combination of far lateral with transpetrosal approaches were performed in 4 patients and combination of far lateral with condylar approaches in 6 patients. In 11 patients with bypass grafts because of the likehood of prolonged temporary occlusion or possibility of intraoperative parent artery sacrifice, the internal carotid artery to P2 segment of posterior cerebral artery bypass were performed in 2 patients, the external carotid artery to P2 segment of posterior cerebral artery bypass were performed in 4 patients, cervical vertebral to cranial vertebral artery bypass in 2 patients,and occipital to PICA bypass in 3 patients. Results There were back to normal life without neurological deficits after surgery in 9 patients with basilar tip aneurysms, 5 patients with basilar trunk aneurysms,and 10 patients with vertebral artery aneurysms. Total good outcome reached 24 (92%) patients after surgery. One patient need assistant for his daily life related to severe neurological deficits after surgery, one patient with basilar trunk aneurysm die of brain stem ischemia from the perforating arteries occlusion 20 days after surgery. Conclusions The selection of proper cranial base approaches should be benefit to obtain an adequate operative space for clipping of vertebrobasilar aneurysms. The adjunctive use of graft bypass may be till required to avoid parent and major branch occlusion during protracted temporary clipping of the parent artery and the sacrifice of either the parent vessel or one of the major branches for management of a complex intracranial aneurysm. Key words: Vertebrobasilar artery; Intracranial aneurysm; Surgical procedures,operative

Intra-mural propagation of a large cavernous internal cerebral artery aneurysm after parent artery sacrifice

The mechanism of aneurysm growth after isolation from the circulation is not well known. We report a case of a woman who presented with mass effects of a large cavernous internal carotid artery (ICA) aneurysm. The parent vessel harboring the aneurysm was sacrificed but the aneurysm continued to enlarge with propagation of the disease along the vessel wall progressively extending to the middle cerebral artery (MCA) leading to ischemic stroke. This case provides imaging evidence of the role of mural inflammation in the development of certain aneurysms.

Surgical treatment for posterior inferior cerebellar artery aneurysms

Objective To explore the clinical characteristics and surgical managements of posterior inferior cerebellar artery (PICA) aneurysms. Methods Retrospective analysis of the clinical features, imaging characteristics and clipping results of 21 PICA artery aneurysms. This series included 9 men and 12 women, mean age was 40.6 years. One presented with mass pressure effects of infrotentoria fossa; 20 patients presented with severe and sudden onset of symptoms, reflecting a hemorrhage from a PICA aneurysm. Hunt-Hess and Hess grades at presentation were: Grade Ⅰ in 1 patient, Grade Ⅱ in 14 patients, Grade Ⅲ in 5 patients, Grade Ⅳ in 1 patient. The bleeding was confined to the infrotentoria subarachnoid space (SAH) and/or the fourth ventricle. Arteriographies revealed 13 proximal PICA aneurysms and 8 distal PICA aneurysms. Results Lateral suboccipital and midline suboccipital surgical approaches were used to secure the aneurysms in all patients, either by direct clipping in 19 cases, parent artery's occlusion in 1 case and parent artery's sacrifice in 1 case. Transient CSF leak occurred in 3 patents; paresis and lower cranial nerve dysfunction and long-term coma occurred in 1 patient; mild lower cranial nerve dysfunctions occurred in 2 patients, and had good recovery at 3 months of follow-up; no complication in other patients. Conclusions The favorable outcomes and low postoperative morbidity in our patients argues that surgical clipping be considered a first-line therapeutic option. The protection of the low cranial nerves and the preservations of PICA are major contributors to good long-term results. Key words: Posteroinferior cerebellar artery; Aneurysm clipping; Subarachnoid hemorrhage

Endovascular management of a ruptured cavernous carotid artery aneurysm associated with a carotid cavernous fistula with an intracranial self-expanding microstent and hydrogel-coated coil embolization: case report and review of the literature

Background Ruptured CCAs are traditionally treated with endovascular management. Advances in microstent and coil technology have allowed improved intracranial navigation, increased coil packing density, and coil volume expansion to facilitate complete coil embolization of aneurysms/fistulae. We report a case of a ruptured CCA with an associated CCF treated with an intracranial, self-expanding microstent in combination with coil embolization using hydrogel-coated platinum coils. Case Description A 50-year-old woman presented with a 7-day history of severe headache and 2 days of progressive left-sided ptosis, ophthalmoplegia, and facial dysesthesias. A cerebral angiogram demonstrated a left ruptured wide-necked CCA with an associated CCF. An intracranial, self-expanding microstent (Neuroform 3, Boston Scientific, Natick, MA) was placed across the aneurysmal neck. The aneurysm was subsequently embolized with hydrogel-coated platinum coils (Hydro Coil). A 3-month follow-up angiogram showed complete resolution of arteriovenous shunting with near-complete occlusion of the CCA. The patient's ocular pain and facial dysesthesias resolved completely, with near-complete resolution of ophthalmoplegia. Conclusions This case demonstrates near-complete occlusion of a ruptured CCA and obliteration of an associated CCF using endovascular combinational therapy of an intracranial, self-expanding microstent with hydrogel-coated platinum coils. Use of this newer-generation stent-coil combination may allow more complete and durable lesion occlusion because of increased coil packing density and coil volume expansion without the need for parent artery sacrifice or balloon-remodeling techniques, thus avoiding the potential complications of such therapies.

Microsurgical and Endovascular Treatment of Giant Intracavernous Aneurysms

Treatment of giant intracavernous carotid artery aneurysms (ICCA), rare but formidable challenging lesions, requires scrupulous review of the clinical and radiographic studies and involves several different or successive surgical approaches. To attain complete permanent exclusion of the ICCAs from the circulation while preserving the parent carotids, microsurgical or endovascular techniques should be employed. Three kinds of surgical approaches can be addressed: (1) direct surgical aneurysm obliteration with parent artery preservation, (2) indirect obliteration using parent artery sacrifice, and (3) indirect aneurysm obliteration followed by extracranial-to-intracranial bypass or interposition grafts. In most instances, however, endovascular intervention with or without vessel reconstruction is now the initial treatment. When one considers parent carotid occlusion, balloon test occlusion should be performed irrespective of surgical options.

Therapeutic Endovascular Treatments for Traumatic Carotid Artery Injuries

The diagnosis and management of traumatic carotid vessel injuries continue to be controversial, with direct surgical repair with parent artery preservation still presenting difficulties. The purpose of this report is to review the endovascular therapy of patients with traumatic carotid vessel injuries for preservation of the parent artery, and to determine the safety and efficacy of endovascular therapy. Ten patients with traumatic carotid lesions were treated using therapeutic endovascular methods. Endovascular therapy was accomplished by implanting balloons, porous or polytetrafluoroethylene-covered stents, and/or embolic materials including coils or glue. All fistulas and pseudoaneurysms were successfully embolized with no periprocedural complications including vessel disruption/rupture, distal embolization, or new neurologic deficits. The parent arteries of all patients except one were preserved. The reason for the parent artery sacrifice was a thrombus formation due to coil migration into the parent artery. No additional surgical procedures for vascular lesions were required. There were no delayed neurologic or vascular complications, and no lesions recurred during the follow-up periods (mean 20.3 months). The goal of endovascular therapy is the selective elimination of the vascular pathology with the normal patency of the cerebral arteries. The authors' experience demonstrates that endovascular therapy using stents, balloons, and coils is both feasible and safe for treatment of traumatic carotid injuries. Of these endovascular methods, the stent can be used to exclude the aneurysm or fistula from the circulation and preserve the parent artery in selective cases. Long-term follow-up review of these repairs will be necessary to provide a full evaluation of the safety and efficacy of these devices.

Endovascular management of intracranial vertebral artery dissecting aneurysms

Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and dramatic neurological injury. The authors reviewed the management of 23 cases in an effort to evaluate treatment efficacy and outcomes. The records of 23 patients who underwent endovascular treatment were reviewed to determine symptoms, type of therapy, complications, and clinical outcomes. All patients were evaluated using records kept in a prospectively maintained database. Ten men and 13 women (age range 35-72 years; mean age 49 years) were treated over an 8-year period. Twelve patients presented with poor-grade SAH, five with good-grade SAH, three with headache, and two with stroke. The other patient's aneurysm was discovered incidentally. Treatment included coil occlusion of the artery at the aneurysm in 21 patients and stent-assisted coil placement in two. Parent artery sacrifice was successful in all cases, whereas both patients treated with stent-assisted coil insertion suffered recurrences. No patient sustained permanent complications as a result of treatment. Two patients died due to the severity of their original SAH. Findings were normal in 14 patients on follow-up review (including five of the 12 presenting with poor-grade SAH), five had fixed neurological deficits but were able to care for themselves, and one was permanently disabled. Despite their often aggressive neurological presentation, intracranial VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery. Even patients presenting in poor neurological condition may improve dramatically.

Selective cerebral revascularization as an adjunct in the treatment of giant anterior circulation aneurysms

Cerebral revascularization, an indispensable component of neurovascular surgery, has been performed in the treatment of cranial base tumors, complex cerebral aneurysms, and occlusive cerebrovascular disease. The goal of a revascularization procedure is to augment blood flow distally. It can therefore be used as an adjunctive measure in the treatment of complex neurosurgical disease processes that require parent artery sacrifice for definitive treatment. In the treatment of giant anterior circulation aneurysms, for instance, a cerebral revascularization procedure may be considered in patients in whom the collateral circulation is marginal and in whom lesions may be treated either using a Hunterian-based strategy or clip-assisted reconstruction requiring a prolonged period of temporary occlusion. To date, there is no entirely effective method known to produce long-term tolerance to carotid artery (CA) sacrifice and, largely for that reason, some neurovascular surgeons advocate universal revascularization. The authors of this report, however, prefer to perform revascularization only in the limited subset of patients in whom preoperative assessment has revealed risk factors for cerebral ischemia due to hypoperfusion. In this paper, the authors introduce their protocol for assessing cerebrovascular reserve capacity, indications for cerebral revascularization in the treatment of complex anterior circulation aneurysms, and discuss their rationale for choosing to practice selective, rather than universal, revascularization.