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  • Microsurgical Approach for a Giant Posterior Cerebral Artery Aneurysm after Unsuccessful Occlusion with Endovascular Flow Diversion

    Final Number:

    Dale Ding MD; Robert M. Starke MD MSc; Kenneth C. Liu MD

    Study Design:

    Subject Category:
    Aneurysm/Subarachnoid Hemorrhage

    Meeting: AANS/CNS Cerebrovascular Section 2015 Annual Meeting

    Introduction: Giant posterior circulation aneurysms have a very high risk of rupture. Treatment of these lesions, via endovascular or microsurgical approaches, carries a substantial rate of morbidity and mortality. While flow-diverting stents (FDS) represent a potent therapy for endovascular reconstruction of complex aneurysms, they are also associated with novel complications for which effective salvage techniques have not been described.

    Methods: We present a unique complication from failed treatment with a FDS.

    Results: A 51 year-old male presented with increasing headaches secondary to a giant, fusiform aneurysm of the left posterior cerebral artery (PCA) which was largely thrombosed. Due to progressive enlargement of the aneurysm corresponding to worsening clinical symptoms, the lesion was treated with two Pipeline Embolization Devices (PED). Three months after PED treatment, complete PCA occlusion was observed at the origin of the proximal stent. Despite the lack of arterial inflow, the aneurysm dome continued to grow, resulting in obstructive hydrocephalus. Therefore microsurgical intervention was performed to trap and excise the aneurysm. The sigmoid sinus was injured during the approach which resulted in extensive postoperative venous infarcts and patient mortality.

    Conclusions: Successful microsurgical obliteration of aneurysms previously treated with FDSs is extremely difficult. A combination of judicious preoperative planning and meticulous intraoperative surgical technique are requisite for effective management of these complex cases. The optimal microsurgical strategy for aneurysms which have failed endovascular treatment with a FDS is currently unknown.

    Patient Care: Flow-diverting stents have become commonly used to treat giant intracranial aneurysms. However, effective microsurgical strategies for aneurysms which have failed endovascular flow diversion have yet to be defined. We describe the potential pitfalls and perils associated with microsurgical treatment of these unique and challenging lesions.

    Learning Objectives: By the conclusion of this session, participants should be able to 1) Describe the importance of complete occlusion of giant intracranial aneurysms, 2) Discuss, in small groups the potential complications associated with microsurgical treatment of aneurysms which have undergone prior endovascular flow diversion, and 3) Identify an effective treatment for giant aneurysms which have failed endovascular occlusion with flow-diverting stents.

    References: 1. Unruptured intracranial aneurysms--risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med. 1998 Dec 10;339(24):1725-33. 2. Arrese I, Sarabia R, Pintado R, Delgado-Rodriguez M. Flow-Diverter Devices for Intracranial Aneurysms: Systematic Review and Meta-analysis. Neurosurgery. 2013 Aug;73(2):193-200. 3. Cantore G, Santoro A, Guidetti G, Delfinis CP, Colonnese C, Passacantilli E. Surgical treatment of giant intracranial aneurysms: current viewpoint. Neurosurgery. 2008 Oct;63(4 Suppl 2):279-89; discussion 89-90. 4. Dehdashti AR, Thines L, Willinsky RA, Tymianski M. Symptomatic enlargement of an occluded giant carotido-ophthalmic aneurysm after endovascular treatment: the vasa vasorum theory. Acta Neurochir (Wien). 2009 Sep;151(9):1153-8. 5. Ding D, Liu KC. Microsurgical extraction of a malfunctioned pipeline embolization device following complete deployment. J Cerebrovasc Endovasc Neurosurg. 2013 Sep;15(3):241-5. 6. Drake CG. Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg. 1979;26:12-95. 7. Kim YB, Lee JW, Huh SK, Kim BM, Kim DJ. Outcomes of multidisciplinary treatment for posterior cerebral artery aneurysms. Clin Neurol Neurosurg. 2013 Oct;115(10):2062-8. 8. Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med. 2012 Jun 28;366(26):2474-82. 9. Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol. 2011 Jan;32(1):34-40. 10. Parkinson RJ, Eddleman CS, Batjer HH, Bendok BR. Giant intracranial aneurysms: endovascular challenges. Neurosurgery. 2006 Nov;59(5 Suppl 3):S103-12; discussion S3-13. 11. Pistocchi S, Blanc R, Bartolini B, Piotin M. Flow diverters at and beyond the level of the circle of willis for the treatment of intracranial aneurysms. Stroke. 2012 Apr;43(4):1032-8. 12. Wajnberg E, Silva TS, Johnson AK, Lopes DK. Progressive Deconstruction: A Novel Aneurysm Treatment Using the Pipeline Embolization Device for Competitive Flow Diversion. Neurosurgery. 2013 Jun 19.

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