Carotid artery occlusion for the treatment of symptomatic giant carotid aneurysms: a proposal of classification and surgical protocol

Abstract

Giant intracranial aneurysms are rare disorders that represent only 5% of all intracranial aneurysms; they have a wide variety of presentations including rupture, embolic effects, and mass effect symptoms that can mislead the diagnosis to tumors rather than aneurysms. Their treatment is difficult and carries higher morbidity and mortality than usual aneurysms due to their complex nature. This study involved retrospective analysis of data of 28 patients, managed between 2006 and 2012, suffering from giant internal carotid artery (ICA) aneurysms with various presenting symptoms, none of which was hemorrhage. They were all evaluated by BOT prior to any intervention; they were subjected to various treatment strategies including selective coiling, parent artery occlusion with or without bypass, aneurysm trapping with or without bypass, and patients were followed for a period ranging from 6 months to 5 years. Out of 26 patients with giant aneurysms with mass effects, 16 patients showed full recovery (61.5 %), 5 showed partial improvement (19.2 %), and 5 showed no change in mass effect symptoms (19.2 %). One patient died (3.5 %). Symptoms such as TIA or epistaxis showed complete recovery. This study shows that a well-designed protocol aiming at parent artery sacrifice will yield good to excellent results in managing ICA giant aneurysms, and it also shows that parent artery sacrifice is superior to other forms of treatment of these lesions regarding recurrence rates, morbidity, and mortality.

Magnetic Resonance Angiography-based Prediction of the Results of Balloon Test Occlusion

“…Balloon test occlusion (BTO) is the gold-standard test used to diagnose the risk of cerebral ischemia after ICA sacrifice. 1–3) BTO is performed not only for cases of planned ICA sacrifice but also for cases with intraoperative ICA injury to confirm collateral flow. 3,4) Therefore, precautious BTO is sometimes performed in high-risk cases of intraoperative ICA injury before surgery for invasive skull base tumors.…”

Prevention of Retrograde Blood Flow Into Large or Giant Internal Carotid Artery Aneurysms by Endovascular Coil Embolization with High-Flow Bypass: Surgical Technique and Long-Term Results

“…This suggests that immediate complete exclusion of aneurysms from the circulation is preferable to proximal ICA occlusion. We and other investigators (1,20) posit that postoperative recanalization and rupture are due to retrograde filling of the aneurysm by the bypass graft or by ICA branches in the ECA network such as the OphA or the MHT (Figure 2). In our case 1, intraoperative selective angiography of the ECA obtained after temporary occlusion of the cervical ICA revealed late filling of the aneurysm through the surgically created bypass and the OphA.…”

“…Becske et al (5) showed that at 1-year followup, 87% of their large or giant ICA aneurysms were completely occluded. However, unstable scaffolding, intraparenchymal hemorrhage unrelated to rupture of the target aneurysms, and thromboembolic complication requiring prolonged dual antiplatelet therapy remain an unsolved problem (20).…”

Endovascular Modalities for the Treatment of Cavernous Sinus Arteriovenous Fistulas: A Single-Center Experience

“…18,19 The main technical difference between doing BOT for aneurysms or other vascular pathologies and TCCF is that the balloon must be positioned to cover the fistula rent, so as to prevent retrograde flow into the fistula that can elicit arterial steal and can lead to false interpretation of the test. 4 occlude the fistula.…”