Treatment Of Giant Intracranial Aneurysms Research Articles

Flow diversion jet: A dangerous mechanism in the flow diversion treatment of giant intracranial aneurysms.

Cerebral hyperperfusion syndrome (CHS) occurs after the restoration of blood flow to a previously low-flow, low-pressure region of the cerebral vasculature, which subsequently responds with chronic compensatory vasodilation, leading to a dysregulated state. Sudden restoration of normal blood flow can overwhelm the vasculature leading to intracranial hemorrhage (ICH). Separately, the Windkessel phenomenon describes the capacity for elastic vessels to expand with systolic pressure and decompress with diastole, thereby suppressing distal pulse pressure. We encountered a case involving giant basilar aneurysms in which we believe the Windkessel phenomenon precipitated a catastrophic manifestation of CHS at treatment. We present a 60-year-old female found to have marked dolichoectasia of the right cervical internal carotid, vertebral, and basilar arteries concurrent with two large vertebrobasilar dissecting-type fusiform aneurysms. Managed conservatively for ten years before developing gait ataxia, new imaging revealed dramatic interval growth of the larger aneurysm. Flow diversion with partial coiling of the aneurysms was pursued. The patient suffered intra-procedural catastrophic thalamic and midbrain hemorrhage with intraventricular extension. A meticulous review of the case data was undertaken. Our findings suggest that giant aneurysms can act as a Windkessel reservoir, depressing the distal pulse pressure. Flow diversion bypasses the reservoir, increasing the distal pulse pressure beyond the autoregulatory capacity, resulting in ICH analogous to CHS. CHS and Windkessel phenomenon can contribute to catastrophic sequelae in the treatment of giant intracranial aneurysms with flow diversion. Awareness of this mechanism can protect future patients from harm.

Treatment of giant intracranial aneurysms: long-term outcomes in surgical versus endovascular management

Aneurysms with a major diameter > 25 mm are defined as giant intracranial aneurysms (GIAs). Different clinical, pathological, and radiological factors were revealed as playing a role in choosing the best strategy between surgical and endovascular approaches. Despite the improvement of both techniques, the efficacy and safety of these different management are still debated. We evaluated the differences in clinical and radiological outcomes of GIAs treated with surgical and endovascular techniques in a large retrospective mono-centric study. We compared aneurysm location, clinical, morphological features, treatment outcome, and complications on the ground of treatment technique. The final cohort consisted of 162 patients. All the patients were assigned on the ground of the type of eligible treatment: surgical (118 patients) and endovascular procedure (44 patients). The different treatment strategies were made through a multidisciplinary selection whereas clinical parameters, location, and morphologic features of the aneurysm were considered. The surgical group manifested a greater reduction in performance levels and neurological status in the post-operative phases than the endovascular group (p < 0.01) with a higher incidence of complications (p = 0.012) in contrast to a lower recurrence rate (p > 0.01). There is no significant difference in post-operative mortality and survival between surgical and endovascular groups. The surgical group manifested a higher incidence of complications after treatment. The endovascular group has a better post-operative outcome, but a higher risk of recurrence and the necessity of further treatment.

Risk factors and outcomes of postoperative stroke in surgical treatment for giant intracranial aneurysms

BackgroundGiant intracranial aneurysms (GIAs) are challenges for surgical treatment. Risk factors of postoperative stroke remain unclear. This study aims to investigate the predictors of postoperative stroke in GIAs and the impact of stroke on outcomes.MethodsWe performed a retrospective medical record review of patients with GIAs who received microsurgery at our institution between 2011 and 2018. Multivariate logistic regression analyses were carried out to identify risk factors for postoperative stroke. The clinical and angiographic outcomes were compared between patients with and without stroke.ResultsA total of 97 patients were included in this study. Surgical modalities included direct aneurysm neck clipping in 85 patients (87.7%), trapping with the bypass in 8 (8.2%), proximal artery ligation in 1 (1%), and bypass alone in 3 (3.1%). Postoperative stroke was found in 26 patients (26.8%). Independent factors that affect postoperative stroke were recurrent aneurysm (OR, 10.982; 95% CI, 1.976–61.045; P = 0.006) and size ≥ 3.5 cm (OR, 3.420; 95% CI, 1.133–10.327; P = 0.029). Combined perioperative mortality and morbidity was 26.8%. Follow-up was achieved from 89 patients (91.8%), with a mean follow-up period of 39 months (range 19 to 94 months). Good outcomes were observed in 75 patients (84.3%) and poor outcomes were observed in 14 patients (15.7%).ConclusionsPostoperative stroke was significantly associated with clinical outcome. Favorable outcomes can be achieved in most patients with GIAs after appropriate microsurgical modality. Recurrent aneurysm and size ≥ 3.5 cm are risk factors of postoperative stroke.

Treatment of giant intracranial aneurysms using the Pipeline flow-diverting stent: Long-term results from the International Retrospective Study of the Pipeline Embolization Device (IntrePED) study.

Traditional endovascular treatments of giant intracranial aneurysms are associated with high rates of complications and retreatment. Our objective was to examine the safety and long-term efficacy of the Pipeline Embolization Device for treatment of these aneurysms. This retrospective study using the IntrePED database included all patients with giant intracranial aneurysms treated with the Pipeline device between July 2008 and February 2013. Efficacy outcomes were stratified by using the Raymond-Roy Occlusion Classification. Predefined safety outcomes included spontaneous rupture of the target aneurysm; ipsilateral intracranial hemorrhage; ischemic stroke; parent artery stenosis; and sustained cranial neuropathy. Sixty-six embolizations were performed to treat 63 giant intracranial aneurysms (including 2 ruptured): 49 (77.8%) in the anterior and 14 (22.2%) in the posterior circulation. The median follow-up was 22.4 (0.1-60.5) months. Class I angiographic occlusion was achieved in 72.0% (36/50). The neurological morbidity/mortality rate was 23.8% (15/63), with higher rates in the posterior circulation than in the anterior circulation (22.4% vs. 28.6%). Among seven deaths, five had neurological causes. The procedure-related neurological morbidity and mortality rates were 22.7% (15/66) and 7.6% (5/66), respectively. The spontaneous rupture rate was 4.5% (3/66). Two spontaneous ruptures (1 death), 4/4 postprocedural intracranial hemorrhages, and 6/9 ischemic events occurred within 30 days. In-stent stenosis and new-onset cranial neuropathy were not observed during the angiographic follow-up period. Although procedure-related neurological morbidity/mortality rates were not insignificant, this study confirms the feasibility and long-term efficacy of the Pipeline Embolization Device to treat giant intracranial aneurysms.

Endovascular Treatment of Giant Intracranial Aneurysms.

ObjectiveGiant intracranial aneurysms (GIAs) are associated with a high risk of rupture and have a high mortality rate when they rupture (65-100%). The traditional microsurgical approach to secure these lesions is challenging, and as such endovascular embolization has been increasingly selected as a treatment option.MethodsWe performed a retrospective analysis of consecutive patients with ruptured and unruptured GIAs at three medical centers from October 2008 to April 2016. Clinical follow-up and digital subtraction angiography were conducted at six months post-treatment. Chi-square analysis was used to determine differences in outcomes between anterior and posterior circulation aneurysms and if a pipeline embolization device (PED) provided favorable outcomes in unruptured GIAs.ResultsA total of 45 consecutive patients (mean/median age = 57/59; range: 16-82 years) were included. The mean/median aneurysm size was 29.9/28.3 mm (range: 25-50 mm). Eight (18%) patients presented with aneurysmal subarachnoid hemorrhage and 37 (82%) with unruptured GIAs. Twenty-eight (62%) were treated with a PED: 11 (24.4%) with one PED, 1 (2.2%) with PED + coils, 11 (24.4%) with more than one PED, and 5 (13.5%) with multiple PED + coils. The overall mortality rate was 3/45 (6.7%). No deaths were procedure-related. Five (11.1%) patients experienced ischemic stroke but only 2 had a 90-day modified Rankin Scale (mRS) score of ≥3. Of 33 patients available for six-month angiography, Raymond scale (RS) scores were 1, 2, and 3 for 23/45 (70%), 7/45 (20.9%), and 3/45 (9.1%), respectively. Chi-square test demonstrated that overall, anterior circulation GIAs had better clinical (mRS score) and radiographic (RS score) outcomes than posterior GIAs. PED alone provided similar clinical mRS outcomes but had a higher rate of complete occlusion at six months compared with PED + coils and coils alone in unruptured GIAs (p < 0.05).ConclusionsEndovascular embolization using PED or PED + coils appears to be a moderately safe and effective treatment option for patients with GIAs.

The Longest Angiographic and Clinical Follow-Up of Microsurgically Treated Giant Intracranial Aneurysms: Experience with 70 Cases

Giant intracranial aneurysms (GIAs), if left untreated, have an extremely poor natural history. Despite many reports about the surgical treatment of GIAs, their long-term clinical and angiographic results are unclear. To our knowledge, this study reports the longest clinical and angiographic follow-up of microsurgically treated GIAs in the English literature. Between January 1997 and December 2017, 70 patients with giant anterior circulation aneurysms treated using microsurgery were retrospectively reviewed. The applied microsurgical techniques and especially long-term clinical and angiographic follow-up data were evaluated. The mean aneurysm size was 29.2 mm (range, 25-58 mm). The aneurysm neck was occluded in 61 patients (87.2%). Nine aneurysms were clipped using an aneurysm clip compression technique. In 8 patients (11.4%), the aneurysm neck was found smaller at surgery than expected according to angiographic findings. Postoperative angiograms showed complete occlusion in 52 of 61 patients (85.2%). The treatment results at discharge were excellent-good (modified Rankin Scale score ≤2) in 75.3% of the patients. The overall mortality was 7.6%. At long-term clinical follow-up (mean, 105.2 months), 48 patients (78.6%) showed excellent-good outcome. At late angiographic follow-up (mean, 98.0 months), no recurrence was seen in patients with complete aneurysm closure. Most giant anterior circulation aneurysms can be successfully clipped, with acceptable morbidity and mortality. Some giant aneurysms have a smaller neck than expected. The aneurysm clip compression technique is useful in clipping of GIAs. This longest clinical and angiographic follow-up in the literature shows that clip ligation has excellent durability in GIAs, also.

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.

Superficial Temporal Artery to Middle Cerebral Artery Bypass and Endovascular Parent Artery Occlusion in the Treatment of Giant Intracranial Aneurysms

The authors are reporting on a study drawn from unpublished dissertation done by the corresponding author when he completed his neurosurgical training in Paris, France in 2004, few years before the advent of flow diverters. The study was a retrospective review of giant intracranial aneurysms treated by superficial temporal artery to middle cerebral artery bypass combined with endovascular occlusion of the parent artery. From 1990 to 2003, 29 consecutive cases of giant cerebral aneurysms, not suitable to selective treatment were managed in that way. Twenty-one medical records had enough data to allow objective evaluation. Sixteen female and five male patients bearing 21 giant aneurysms were involved. Their mean age was 46 years. The aneurysm was revealed by mass effect in 13 cases and subarachnoid hemorrhage in one case. On admission 19 patients presented with unruptured aneurysms and two have sustained a subarachnoid hemorrhage. The balloon occlusion test before the bypass operation was not tolerated in 18 patients. The treatment was completed in 19 patients and 17 of them had parent artery occlusion with latex detachable balloons. The only death of the series occurred before the endovascular treatment. The mean follow-up period was 30 months. After completion of the treatment, 16 (84%) patients had no symptom. Aneurysm recanalization or rupture was not observed after the parent artery occlusion. With the combination of superficial temporal artery to middle cerebral artery bypass + endovascular parent artery occlusion, 90% of giant intracranial aneurysms untreatable selectively were permanently excluded with a good outcome in 95%.

A systematic review of pipeline embolization device for giant intracranial aneurysms.

The experience with respect to the treatment of giant intracranial aneurysms with flow-diversion devices is limited. The aim of the present systematic review was to evaluate the effect of the pipeline embolization device (PED) on giant intracranial aneurysms. Eligible related articles were identified by searching the PubMed, Web of Science, Springer, ScienceDirect, and OVID databases using "giant aneurysm" and "pipeline" as the search items. The date of the last search was November 20, 2015. This systematic review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In a total of 9 eligible studies with 200 patients and 215 aneurysms, 40 (18.6%) giant (aneurysm diameter >25mm) intracranial aneurysms treated with PED were analyzed. During a 6 to 34 month follow-up, complete occlusion was achieved in 23 (57.5%) cases. Seven patients (17.5%) developed intracranial hemorrhage, 5 developed ischemic attack (12.5%), and 13 (32.5%) developed a mass effect after PED treatment. The complication rate was 77.8% in PED for giant vertebrobasilar artery aneurysms. The cumulative mortality rate for giant paraclinoid carotid artery and middle cerebral artery aneurysms was 13.3% and increased up to 50% for giant vertebrobasilar artery aneurysms. The complete obliteration rate of PED for giant intracranial aneurysms was approximately 60%. Mass effect is the most mechanism of complications. Complication and mortality rates associated with PED for giant vertebrobasilar artery aneurysms are still extremely high.

Outcome of Surgical or Endovascular Treatment of Giant Intracranial Aneurysms, with Emphasis on Age, Aneurysm Location, and Unruptured Aneuryms - A Systematic Review and Meta-Analysis

Background: Designing treatment strategies for unruptured giant intracranial aneurysms (GIA) is difficult as evidence of large clinical trials is lacking. We examined the outcome following surgical or endovascular GIA treatment focusing on patient age, GIA location and unruptured GIA. Methods: Medline and Embase were searched for studies reporting on GIA treatment outcome published after January 2000. We calculated the proportion of good outcome (PGO) for all included GIA and for unruptured GIA by meta-analysis using a random effects model. Results: We included 54 studies containing 64 study populations with 1,269 GIA at a median follow-up time (FU-T) of 26.4 months (95% CI 10.8-42.0). PGO was 80.9% (77.4-84.4) in the analysis of all GIA compared to 81.2% (75.3-86.1) in the separate analysis of unruptured GIA. For each year added to patient age, PGO decreased by 0.8%, both for all GIA and unruptured GIA. For all GIA, surgical treatment resulted in a PGO of 80.3% (95% CI 76.0-84.6) compared to 84.2% (78.5-89.8, p = 0.27) after endovascular treatment. In unruptured GIA, PGO was 79.7% (95% CI 71.5-87.8) after surgical treatment and 84.9% (79.1-90.7, p = 0.54) after endovascular treatment. PGO was lower in high quality studies and in studies presenting aggregate instead of individual patient data. In unruptured GIA, the OR for good treatment outcome was 5.2 (95% CI 2.0-13.0) at the internal carotid artery compared to 0.1 (0.1-0.3, p < 0.1) in the posterior circulation. Patient sex, FU-T and prevalence of ruptured GIA were not associated with PGO. Conclusions: We found that the chances of good outcome after surgical or endovascular GIA treatment mainly depend on patient age and aneurysm location rather than on the type of treatment conducted. Our analysis may inform future research on GIA.

Treatment of Giant Intracranial Aneurysms: a Review Based on Experience from 286 Cases

Aneurysms are classified as giant when their largest diameter is equal to or greater than 25 mm, which represents approximately 5–7% of intracranial aneurysms. Severe disease with poor natural history presents with 68% mortality in two years and 85% in five years for untreated cases. Thus, in the majority of cases, the patients require treatment, despite the risks of therapeutic options. We discuss the epidemiology, natural history, diagnosis, and treatment of giant aneurysms based on the experience of 286 operations and literature data.

O-020 treatment of giant intracranial aneurysms with pipeline: aspire (aneurysm study of pipeline in an observational registry) results

Purpose To assess the outcomes of patients with giant intracranial aneurysms who have undergone treatment with the Pipeline Embolic Device (PED) during the ASPIRE (Aneurysm Study of Pipeline In an Observational Registry) study. Methods ASPIRe was a prospective, global, multi-center, single-arm, observational evaluation of the treatment of intracranial aneurysms using the Pipeline ™ Embolization Device. PED was evaluated when used in routine practice according to its country-specific IFU. 28 Sites (20 US, 7 Europe, 1 Canada) obtained approval by local IRB/EC for study enrollment and treated patients with an intracranial aneurysm meeting the labeled indication for the relevant geography. Results A total 191 patients with 207 aneurysms were treated in ASPIRE with 21 patients harboring 21 giant aneurysms (18 ICA, 2 MCA, 1 Basilar). Patients with giant aneurysms were enrolled and followed for a mean duration of 6 months (SD 5, range 0.0–16.3). Median age was 63 years. 18 (85.7%) were females. 16 (76.2%) of 21 aneurysms were saccular and 5(23.8%) were fusiform or dissecting. All lesions were unruptured. 6 (28.6%) were treated with multiple PEDs. Primary safety events were noted in 5 (23.8%) of cases. Mortality occurred in 2 patients (9.5%) Delayed aneurysm rupture occurred in 2 of 21 cases (9.5%); Parenchymal hemorrhage in 1/21 (4.8%) and Ischemic Strokes in 2/21 (9.5%). At present time, mean follow up is 10 months, 11 patients have completed follow up image demonstrating total occlusion of 73% (8/11). Conclusions The present analysis of ASPIRE subjects harboring giant intracranial aneurysms demonstrates higher risk of delayed aneurysm ruptured when compared to smaller lesions. There is very good long term results with similar peri-operative morbidity and mortality rates as alternative endovascular treatment options. Disclosures R. Hanel: 2; C; Covidien, Codman, Stryker. 4; C; Blockade. 6; C; SAB - Medina. A. Bonafe: None. S. Fischer: None. O. Diaz: None. D. Kallmes: None. S. Barnwell: None. H. Woo: None.

E-111 endovascular treatment of giant intracranial aneurysms: a single center experience

Introduction/purpose Giant intracranial aneurysms are defined as ≥2.5 cm in diameter. Currently, there are no standardized treatment guidelines for these aneurysms and their endovascular management remains challenging. We reviewed our aneurysm database in order to provide a better understanding of the demographics, clinical presentation, and various endovascular treatment modalities of these rare aneurysms. Methods Institutional Review Board approval was obtained for this study. Retrospective review of our database containing 943 patients with aneurysm treatment between 2001–2015. Patient demographics, clinical presentation, aneurysm characteristics, treatment details, complications and outcomes based on follow-up imaging and clinical information was collected. Angiographic follow-up used MRA or DSA or both. Clinical outcome was evaluated at the last known clinical follow-up based on Glasgow outcome Score (GOS). Results 33 patients (21 (62%) females, 13 (38%) males with 34 giant aneurysms were included. The mean age at presentation was 49 years (range, 15–75 years). 76% patients (n = 25) presented with seizures or cranial neuropathies from mass effect; 15% (n = 5) patients with hemorrhage and 9% (n = 3) had aneurysms discovered during evaluation for headaches. 76% (n = 26) aneurysms were in the anterior and 24% (n = 8) in the posterior circulation. Treatment modalities included parent vessel occlusion only (PVO) (N = 18; 53%), PVO + EC-IC bypass (PVO + bypass) (N = 5; 15%), coiling without PVO (N = 5; 15%), Pipeline stenting (N = 2; 6%), and stent-assisted coil embolization (N = 2; 6%). One patient was managed conservatively. The median clinical follow-up (following the first aneurysm treatment procedure) was 8.5 months (mean 28.7 months, SD 39.5 months). All patients treated with PVO (n = 18; 17 unruptured and 1 ruptured) had prior successful balloon test occlusion of the parent artery. 89% of patients with PVO (n = 16) had Glasgow Outcome Scale (GOS) scores of 5 (excellent); the remaining two patients (unruptured) had a mean GOS score of 3.5. All patients treated with PVO had eventual complete aneurysmal thrombosis/occlusion, did not require any additional treatments, and did not experience distal embolic events. Five patients (all unruptured aneurysms) with failed balloon test occlusion were treated via PVO + bypass. The clinical outcomes in this group of patients were excellent, with a mean GOS of 4.8. Five patients (4 ruptured, 1 unruptured) were treated with aneurysm coil embolization without PVO. All required additional treatment modalities in order to treat recanalization, or had an unsuccessful initial procedure. Pipeline stenting was successful in the 2 patients (both unruptured aneurysms) it was performed, including a 3.0 cm fusiform aneurysm of the cavernous internal carotid artery. Conclusions Parent vessel occlusion (PVO) is a safe and effective treatment option for intracranial giant aneurysms in patients with successful balloon test occlusion or extracranial - intracranial bypass. Flow diversion is promising but still evolving. In contradistinction, coil embolization with parent vessel preservation has high recurrence rate. Disclosures S. Boddu: None. D. Kimball: None. M. Crimmins: None. A. Banihashemi: None. J. Knopman: None. A. Patsalides: None. P. Gobin: None.

Treatment of giant intracranial aneurysms: What is the best option?

Treatment of giant intracranial aneurysms: What is the best option?

Pipeline Embolization Device: Lessons Learned After 1000 Aneurysms

Giant intracranial aneurysms (GIAs) can be approached via microsurgical and endovascular techniques. Use of flow diversion devices has yielded favorable outcomes, and indications for cerebral revascularization have dramatically decreased.To evaluate the safety and validity of using internal maxillary artery (IMA) bypass with an interposed graft to treat GIAs.During a 6-year period, high-flow IMA bypass procedures were performed in 32 patients with GIAs at our institute. Intraoperative Doppler sonography, indocyanine green, and postoperative angiography were used to assess the patency of the graft conduit and the stability of the aneurysm. Neurologic function was assessed with the modified Rankin Scale.The mean GIA size was 33.7 mm (range, 25.3–64 mm), and all showed a nonsaccular morphology, except for 1 patient who underwent a first attempt at surgical clipping of a saccular aneurysm. Complete occlusion (65.6%, n = 21) or great diminishment (28.1%, n = 9) of the GIA was shown in 30 patients and the graft patency rate was 90.6% (n = 29). No deaths resulting from bypass surgery occurred. Functionally favorable outcomes (modified Rankin Scale score of 0–2) were recorded in 65.6% of patients at discharge, and the rate increased to 71.9% at the most recent follow-up (mean, 40.6 months). Surgical-related complications involving hydrocephalus and ischemic and hemorrhagic episodes were encountered in 5 patients, but 4 had complete regression of their neurologic symptoms.Considering the grave natural history and treatment complexity of these lesions, this study showed satisfactory results in the treatment of GIAs with IMA bypass.

"How I Do It:" Non-occlusive High Flow Bypass Surgery.

Giant intracranial aneurysms are a formidable challenge for treatment, considering their grim prognosis. Until lately, endovascular treatment options have been disappointing, and neurosurgical treatment results are by far the most promising. In the neurosurgical treatment of giant intracranial aneurysms, the non-occlusive nature of the ELANA anastomosis technique is a major advantage in flow replacement bypass surgery where large proximal arteries with higher flows need to be replaced or reconstructed. The construction of a deep intracranial anastomosis using the ELANA technique needs less vessel exposure than when using a conventional occlusive technique. This extra advantage facilitates the construction of anastomoses even on the ICA, MCA, ACA, P1, P2, SCA or BA, using the trans-Sylvian route only, without major skull base surgery. Several different types of EC-IC and IC-IC flow replacement bypass are now safely applicable due to the non-occlusive character of this technique.Future improvements of the technique are focused on sutureless applications, graft improvements and Flow Model Simulation. It is clear that not only conventional bypass techniques, but also, and even especially, the ELANA bypass technique, are of great value in the treatment of giant aneurysms.

Endovascular Treatment of Giant Intracranial Aneurysms: A Work in Progress

Endovascular Treatment of Giant Intracranial Aneurysms: A Work in Progress

Direct Surgical Treatment of Giant Intracranial Aneurysms on the Anterior Communicating Artery or Anterior Cerebral Artery

Giant intracranial aneurysms on the anterior communicating artery (AComA) or anterior cerebral artery (ACA) are rare and treatment is very difficult. The outcome of direct surgical treatment of giant intracranial aneurysms on the AComA or ACA using vascular reconstruction techniques was assessed in five patients treated between 2006 and 2009. In all five patients, cerebral revascularization of ACA territory was performed to ensure blood flow in the distal ACA prior to treating the aneurysm. Trapping was performed in two patients, trapping and partial removal of the aneurysm in two patients, and total removal of the aneurysm with reanastomosis of ACA in one patient. Minor ischemic complication due to perforator ischemia was recognized in one patient and frontal lobe contusion in one patient. All patients were able to achieve functionally favorable outcome (modified Rankin scale 0 or 1). Insurance cerebral revascularization of the ACA territory enabled appropriate direct surgical strategies for giant AComA or ACA aneurysms tailored to each individual case, including trapping with or without removal of the aneurysm, and reanastomosis of the ACA with removal of the aneurysm.

Solitaire FR Stent as an Adjunctive Tool for Pipeline Stent Deployment in the Treatment of Giant Intracranial Aneurysms

The use of flow-diverting stents has gained acceptance during the past few years for the treatment of numerous intracranial aneurysms, especially large or giant ones. However, successful catheterization of the distal parent artery in giant intracranial aneurysms with a microcatheter can be extremely challenging. Forming a microcatheter loop in the aneurysm sac can aid distal catheterization. We report the use of a Solitaire FR stent as an adjunctive tool in the successful treatment of 2 giant intracranial unruptured aneurysms with a Pipeline Embolization Device. After having formed a loop inside the aneurysm sac, the microcatheter was anchored distally by a Solitaire FR stent. With the Solitaire FR device opened, the loop in the giant aneurysm sac was completely reduced without loss of the microcatheter position in the distal parent artery. A Pipeline Embolization Device could be delivered in both cases without any difficulty. There were no complications. The technique described results in ideal microcatheter alignment with a secure distal position before deployment of a flow-diverting stent.

Complications After Treatment With Pipeline Embolization for Giant Distal Intracranial Aneurysms With or Without Coil Embolization

The Pipeline Embolization Device (PED) is a flow diverter designed to treat intracranial aneurysms through endoluminal parent vessel reconstruction. The role of adjunctive coil embolization is unknown. This report details the authors' experience with the PED in 2 patients with symptomatic, giant distal intracranial aneurysms (1 basilar artery and 1 M1 segment middle cerebral artery). Both patients had successful parent vessel reconstruction. In the first patient, the basilar artery aneurysm was treated with PEDs alone, and the patient experienced early fatal brainstem hemorrhage from aneurysm rupture. In the second patient, the M1 aneurysm was treated with 2 PEDs along with dense coil embolization, with a good initial angiographic result. This patient experienced acute thrombosis of the PED post-procedure, likely related to mass effect and thrombogenicity of the dense coil mass. Flow diversion is an evolutionary step in the treatment of giant intracranial aneurysms. However, complete aneurysm occlusion occurs over a delayed period. The authors recommend placement of coils in addition to PED in the treatment of large or giant distal intracranial aneurysms in an attempt to protect the dome. However, robust packing is to be avoided because it can lead to acute PED thrombotic or compressive occlusion.