✓Partially thrombosed giant aneurysms that are located at the basilar artery (BA) bifurcation and are not amenable to clip application are among the most challenging lesions for neurosurgeons. They compress vital structures such as the brainstem and the thalamus, and the prognosis is extremely poor when they are left untreated. Although obliteration of the upper BA is a promising approach for these aneurysms, some lesions are refractory to this treatment, and effective additional strategies have not been clearly established. The authors report a case treated by placement of clips in the unilateral posterior cerebral artery (PCA) and posterior communicating artery as well as by superficial temporal artery–PCA bypass after unsuccessful upper BA obliteration. Complete thrombosis and dramatic shrinkage of the aneurysm were obtained.
Jun C. Takahashi, Kenichi Murao, Koji Iihara, Yuko Nonaka, Junya Taki, Izumi Nagata and Susumu Miyamoto
Koji Iihara, Kenichi Murao, Nobuyuki Sakai, Naoaki Yamada, Izumi Nagata and Susumu Miyamoto
The authors of this study prospectively compared periprocedural neurological morbidity and the appearance of lesions on diffusion-weighted (DW) magnetic resonance (MR) imaging in patients who had undergone carotid endarterectomy (CEA) or carotid artery stent placement (CASP) with distal balloon protection, based on a CEA risk grading scale.
Patients undergoing CEA (139 patients) and CASP (92 patients) were classified into Grades I to IV, based on the presence of angiographic (Grade II), medical (Grade III), and neurological (Grade IV) risks. Although not randomized, the CEA and CASP groups were well matched in terms of the graded risk factors except for a greater proportion of neurologically unstable patients in the CEA group (11 compared with 3%, p = 0.037). There were greater proportions of asymptomatic (64 compared with 34%, p = 0.006) and North American Symptomatic Carotid Endarterectomy Trial–ineligible patients (29 compared with 14%, p < 0.0001) in the CASP group. The overall rates of neurological morbidity with ischemic origin and the appearance of lesions on DW MR imaging after CEA were 2.2 and 9.3%, and those after CASP were 7.6 and 35.9% (nondisabling stroke only), respectively. The only disabling stroke was caused by an intracerebral hemorrhage attributable to hyperperfusion in one case (0.7%) of CEA. There were no deaths. There was no significant association between neurological morbidity and the risk grade in patients who had undergone CEA, although the incidence of lesions on DW imaging was significantly greater in the Grade IV risk group compared with that in the other risk groups combined (42.1 compared with 4.2%, p < 0.0001). After CASP, a higher incidence of neurological morbidity and lesions on DW imaging was noted for the Grade II and III risk groups combined as compared with that in the Grade I risk group, regardless of a symptomatic or an asymptomatic presentation (neurological morbidity: 10.5 compared with 3.1%, respectively, p = 0.41; and DW imaging lesions: 47.4 compared with 19.4%, p = 0.01). The incidence of lesions on DW imaging after CEA was significantly lower than that after CASP except for the Grade IV risk groups.
Despite a higher incidence of DW imaging–demonstrated lesions in the Grade IV risk group, there was no significant association between the risk group and neurological morbidity rates after CEA. The presence of vascular and medical risk profiles conferred higher rates of neurological morbidity and an increased incidence of lesions on DW imaging after CASP. Considering that no serious nonneurological complications were noted, CEA and CASP appear to be complementary methods of revascularization for carotid artery stenosis with various risk profiles.
Koji Iihara, Nobuyuki Sakai, Kenichi Murao, Hideki Sakai, Toshio Higashi, Shuji Kogure, Jun C. Takahashi and Izumi Nagata
Object. The authors present a retrospective analysis of their experience in the treatment of vertebral artery (VA) dissecting aneurysms and propose a management strategy for such aneurysms, with special emphasis on the most formidable VA dissecting aneurysms, which involve the origin of the posterior inferior cerebellar artery (PICA).
Methods. Since 1998, 18 patients with VA dissecting aneurysms, 11 of whom presented with subarachnoid hemorrhage (SAH), have been treated by endovascular surgery at the authors' institution. Obliteration of the entire segment of the dissected site with coils (internal trapping) was performed for aneurysms without involvement of the origin of the PICA (12 cases; among these the treatment-related morbidity rate was 16.7%). The treatment strategy applied to PICA-involved VA dissecting aneurysms presenting with SAH (three cases) included proximal occlusion of the parent artery followed by internal trapping of the aneurysm (one case), proximal occlusion of the parent artery followed by occipital artery (OA)—PICA bypass (one case), and two-staged internal trapping of the aneurysm involving double PICAs (one case). For PICA-involved VA dissecting aneurysms that were not associated with SAH at presentation (three cases), OA—PICA bypass was performed and followed by internal trapping of the aneurysm (two cases). In the remaining case in which a fetal-type posterior communicating artery was present, internal trapping was performed following successful balloon test occlusion (BTO). Overall, there was no sign of infarction in the PICA territory, despite complete occlusion of aneurysms involving the PICA. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. The overall treatment-related morbidity rate for the VA dissecting aneurysms involving the PICA was 16.7%.
Conclusions. Dissecting VA aneurysms that do not involve the PICA can be safely treated by internal trapping. For those lesions that do involve the PICA, a decision-making algorithm is advocated to maximize the efficacy of the treatment as well as to minimize the risks of treatment-related morbidity based on BTO.
Koji Iihara, Kenichi Murao, Nobuyuki Sakai, Akio Soeda, Hatsue Ishibashi-Ueda, Chikao Yutani, Naoaki Yamada and Izumi Nagata
✓ A 58-year-old woman harboring a partially thrombosed giant aneurysm of the vertebral artery (VA) presented with lower cranial nerve palsies and cerebellar ataxia. The authors initially attempted to reduce the mass effect by obliterating the lumen of the aneurysm as well as by trapping of the parent artery with coils. Although there was no angiographically demonstrated evidence of filling, the aneurysm continued to enlarge. Magnetic resonance imaging revealed a marked enhancement around the packed coils close to the neck of the aneurysm. Aneurysmectomy and removal of the coils were performed and resulted in an almost complete cure of the patient's symptoms. Interestingly, at the time of resection, a marked development of vasa vasorum on the occluded VA and the neck of the aneurysm was noted. When the occluded VA was cut, there was blood oozing through the coils packed within its lumen on the side where the aneurysm lay. Histological examination showed the presence of inflammatory cells and neovascularization of a partially organized thrombus around the packed coils in both the aneurysm and occluded VA. The proliferation of vasa vasorum was also recognized histologically. This unique case provides insight into the growth mechanisms of a partially thrombosed giant aneurysm after an apparently complete occlusion by endovascular treatment, especially the role of vaso vasorum on the occluded parent artery in the dynamic process of neovascularization in the incomplete organization of thrombus around the packed coils.
Koji Iihara, Kenichi Murao, Nobuyuki Sakai, Atsushi Shindo, Hideki Sakai, Toshio Higashi, Shuji Kogure, Jun C. Takahashi, Katsuhiko Hayashi, Toshihiro Ishibashi and Izumi Nagata
Object. To elucidate an optimal management strategy for unruptured paraclinoid aneurysms, the authors retrospectively reviewed their experience in the treatment of 100 patients who underwent 112 procedures for 111 paraclinoid aneurysms performed using direct surgery and/or endovascular treatment.
Methods. Between 1997 and 2002, 111 unruptured paraclinoid aneurysms categorized according to a modified al-Rodhan classification (Group Ia, 30 anterior wall lesions; Group Ib, 25 ventral paraclinoid lesions; Group II, 18 true ophthalmic artery lesions; Group III, 37 carotid cave lesions; and Group IV, one transitional lesion) were treated by direct surgery (35 lesions) and/or endovascular treatment (77 lesions) (one aneurysm was treated by both procedures). In lesions in Groups Ia, Ib, II, and III that were treated by endovascular treatment, complete aneurysm obliteration was achieved in 50, 65, 50, and 78%, respectively, and the combined transient and permanent morbidity rates due to cerebral embolic events were 20, 25, 20, and 13.9%, respectively. Overall, the transient morbidity rate after endovascular treatment was 14.3% and the permanent morbidity rate was 6.5%. Notably, permanent visual deficits caused by retinal embolism occurred after endovascular treatment in two patients with Group II aneurysms. Direct surgery was mainly performed in Groups Ia (20 lesions), Ib (five lesions), and II (eight lesions), with complete neck clip occlusion achieved in 80, 80, and 71.4%, respectively; the transient and permanent morbidity rates associated with aneurysms treated by surgery were 8.6 and 2.9%, respectively.
Conclusions. Endovascular therapy for superiorly projecting paraclinoid aneurysms (Groups Ia and II) is associated with lower rates of complete obliteration than direct surgery, and with rates of cerebral embolic events comparable to those of endovascular treatment in the other groups. Furthermore, endovascular treatment for Group II aneurysms entails additional risks of retinal embolism. Therefore, direct surgery is recommended for the treatment of paraclinoid aneurysms projecting superiorly. For other groups, especially for Group III, endovascular treatment is the acceptable first line of therapy.