Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization

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Object. Certain intracranial aneurysms, because of their fusiform or complex wide-necked structure, giant size, or involvement with critical perforating or branch vessels, are unamenable to direct surgical clipping or endovascular coil treatment. Management of such lesions requires alternative or novel treatment strategies. Proximal and distal occlusion (trapping) is the most effective strategy. In lesions that cannot be trapped, alteration in blood flow to the “inflow zone,” the site most vulnerable to aneurysm growth and rupture, is used.

Methods. From 1991 to 1999 the combined neurosurgical—neuroendovascular team at the Massachusetts General Hospital (MGH) managed 48 intracranial aneurysms that could not be clipped or occluded. Intracavernous internal carotid artery aneurysms were excluded from this analysis. By applying a previously described aneurysm rupture risk classification system (MGH Grades 0–5) based on the age of the patient, aneurysm size, Hunt and Hess grade, Fisher grade, and whether the aneurysm was a giant lesion located in the posterior circulation, the authors found that a significant number of patients were at moderate risk (MGH Grade 2; 31.3% of patients) and at high risk (MGH Grades 3 or 4; 22.9%) for treatment-related morbidity. The lesions were treated using a variety of strategies—surgical, endovascular, or a combination of modalities. Aneurysms that could not be trapped or occluded were treated using a paradigm of flow alteration, with flow redirected from either native collateral networks or from a surgically performed vascular bypass. Overall clinical outcomes were determined using the Glasgow Outcome Scale (GOS). A GOS score of 5 or 4 was achieved in 77.1%, a GOS score of 3 or 2 in 8.3%, and death (GOS 1) occurred in 14.6% of the patients. Procedure-related complications occurred in 27.1% of cases; the major morbidity rate was 6.3% and the mortality rate was 10.4%. Three patients experienced aneurysmal hemorrhage posttreatment; in two patients this event proved to be fatal. Aneurysms with MGH Grades 0, 1, 2, 3, and 4 were associated with favorable outcomes (GOS scores of 5 or 4) in 100%, 92.8%, 71.4%, 50%, and 0% of instances, respectively.

Conclusions. Despite a high incidence of transient complications, intracranial aneurysms that cannot be clipped or occluded require alternative surgical and endovascular treatment strategies. In those aneurysms that cannot safely be trapped or occluded, one approach is the treatment strategy of flow alteration.

Article Information

Address reprint requests to: Christopher S. Ogilvy, M.D., Cerebrovascular Surgery, Massachusetts General Hospital, VBK 710, Fruit Street, Boston, Massachusetts 02114. email: ogilvy@helix.mgh.harvard.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Schematic drawings depicting the normal flow pattern and inflow zone of an aneurysm and a treatment strategy of flow alteration. Upper: The inflow zone is the site of maximal shear stress and, thus, the site most vulnerable to aneurysm growth and rupture. It resides at the distal neck of the aneurysm. Lower: Flow alteration (in this instance, proximal occlusion with associated retrograde flow into the aneurysm) protects the inflow zone to the aneurysm but still preserves flow to vital perforating arteries incorporated into the aneurysm.

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    Schematic illustrations of the combined surgical and endovascular treatment strategies used in 48 fusiform and complex wide-necked intracranial aneurysms that were unamenable to clipping or coil embolization. A: Internal carotid artery aneurysms. B: Proximal (M1) MCA aneurysms. C: Distal MCA and distal ACA aneurysms. D: Basilar artery aneurysms.

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    E: Vertebrobasilar junction and VA aneurysms. F: Distal PICA, PCA, and AICA aneurysms. interposition = interpositional; occip = occipital artery.

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    Bar graph demonstrating the relationship between MGH grade and clinical outcome in 48 fusiform and complex wide-necked aneurysms unamenable to clipping or coil embolization. The MGH aneurysm classification system was used, in which a point is assigned for patient age (> 50 years), Hunt and Hess grade (IV or V), Fisher grade (3 or 4), aneurysm size (> 10 mm), and giant aneurysm in posterior circulation location. The points are added to generate a 0 to 5 grading system. Clinical outcome was determined by an independent nurse practitioner using the GOS, in which a GOS score of 5 is good recovery (hatched section), 4 is moderate disability (dotted section), 3 is severe disability (gray section), 2 is persistent vegetative state (section not shown; no patient in that group), and 1 is death (black section).

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    Angiograms demonstrating flow alteration used to treat an unclippable intracranial aneurysm. Upper Left: A small MCA aneurysm ruptured and was clipped at an outside institution. Upper Right: Five years later, a fusiform MCA aneurysm was found to incorporate the M1 segment of the MCA as well as the distal ICA. Lower Left: After common CA—saphenous vein—MCA bypass, intraoperative angiography revealed complete cessation of flow to the aneurysm at the distal MCA location because the antegrade flow from the ipsilateral ICA was balanced by opposing flow from the surgically created bypass. Lower Right: The remaining aneurysm segment was later occluded by GDC embolization.

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