Surgical Flow Alteration for the Treatment of Intracranial Aneurysms That Are Unclippable, Untrappable, and Uncoilable

Abstract

ObjectiveThe treatment of complex intracranial aneurysms remains challenging. One approach is the application of surgical flow alteration to treat aneurysms that are neither clippable, trappable, or coilable. The efficacy and limitations of surgical flow alteration have not yet been established.MethodsCases of complex aneurysms treated with surgical flow alteration (proximal occlusion with or without bypass, distal occlusion with or without bypass and bypass only) were included in this retrospective study.ResultsAmong a total of 16 cases, there were 7 giant aneurysms (≥25 mm diameter) and 9 large aneurysms (>10 mm diameter); 15 of 16 aneurysms were unruptured. There were 8 aneurysms located in the anterior circulation, while the other 8 were in the posterior circulation. Aneurysms were treated with proximal occlusion in 10 cases and distal occlusion in 5 cases; in 1 case, the aneurysm occluded spontaneously after bypass without parent artery occlusion. All but 2 cases underwent prior or concurrent bypass surgery. Complete obliteration of the aneurysm at the latest imaging follow-up was shown in 12 of 16 cases (75.0%). Bypass patency was confirmed in 13 of 15 cases (86.7%). Surgery-related morbidity developed in 3 cases (18.8%, Glasgow outcome scale of 4) and all were perforator infarctions. There were no mortalities.ConclusionSurgical flow alteration resulted in a high rate of aneurysmal obliteration with acceptable morbidity. Although several limitations remained, it could represent an alternative method for treating complex aneurysms.

Trapping and A4-A4 end-to-side anastomosis for the treatment of a ruptured A3 fusiform aneurysm: Potential risk of in-situ bypass

“…In our case, proximal and distal occlusion of the ACA at the side of the aneurysm was performed with distal IC-IC bypass. 4) According to Sanai et al, the advantages of IC-IC bypass over EC-IC bypass are as follows: similar diameter of donor-recipient arteries, decreased bypass lengths, and the lack of need to harvest additional donor arteries, reducing surgical durations. 7) These advantages were also evident in our case.…”

“…Although EC-IC bypass is the more commonly used bypass technique for complex aneurysms, IC-IC bypass can be used as a simpler, less time-consuming technique. In our case, proximal and distal occlusion of the ACA at the side of the aneurysm was performed with distal IC-IC bypass [ 4 ]. According to Sanai et al, the advantages of IC-IC bypass over EC-IC bypass are as follows: similar diameter of donor-recipient arteries, decreased bypass lengths, and the lack of need to harvest additional donor arteries, reducing surgical durations [ 7 ].…”

Development of a Cadaveric Multiport Model of Posterior Circulation Aneurysm Clipping for Neurosurgery and Otolaryngology Residents

“…While these techniques are successful in some cases, the widespread applicability is limited due to stark differences in patient anatomy and the difficult to access posterior location of the vessels. This has led to the increased use of flow diversion in aneurysms deemed unclippable, untrappable, and uncoilable 18 . While flow diversion can lead to some aneurysmal obliteration, some aneurysms remain patent and therefore have a risk of rupture.…”

Clinical Outcomes of Large (>10 mm) Unruptured Posterior Circulation Aneurysms and Their Predictors

“…In the case of large posterior circulation aneurysms that are unclippable and untrappable, a surgical flow alteration such as distal or proximal trapping of parent artery after EC-IC bypass surgery could be a feasible treatment option. Lee et al [ 8 ] reported favorable treatment outcomes for surgical flow diversion for intracranial aneurysms that were unclippable, untrappable, and uncoilable. They reported a 75% rate of complete obliteration after surgical flow diversion, although the complication rate of surgical flow diversion was 18% [ 8 ].…”

“…Lee et al [ 8 ] reported favorable treatment outcomes for surgical flow diversion for intracranial aneurysms that were unclippable, untrappable, and uncoilable. They reported a 75% rate of complete obliteration after surgical flow diversion, although the complication rate of surgical flow diversion was 18% [ 8 ]. The high morbidity of transcranial surgery remains a great challenge.…”