ABSTRACT
Complex intracranial aneurysms (CIAs) include those classified as giant, those located in brain regions of technically difficult access, or that involve arterial trunks/branches, and/or have complicated wall structure. We reviewed retrospectively our management of such lesions in a 12-year period. From 1997 to 2009, 192 patients were admitted with CIAs (133 females, 59 males; average age 55 years); 128 presented with subarachnoid hemorrhage (SAH) and 64 with unruptured, symptomatic CIAs. The SAH group had 73 anterior- and 55 posterior-circulation aneurysms. Most frequent location was middle cerebral artery. Treatment strategies included clipping (65.6%), coiling/stenting (28.1%), bypass (3.1%), no treatment (3.1%). Coiling/stenting was exclusively used for posterior-circulation aneurysms. Outcomes were good (modified Rankin Scale [mRS] 0 to 2) in 54 patients (42.2%), fair (mRS = 3 to 4) in 38 (29.7%), and poor (mRS = 5 to 6) in 36 (28.1%). Among unruptured CIAs, there were 47 anterior- and 17 posterior-circulation aneurysms. Most frequent location was ophthalmic. Thirty (46.9%) were clipped, 19 (29.7%) coiled, 6 (9.4%) by-passed, 2 (3.1%) wrapped, and 7 (10.9%) had no treatment. Outcomes were good in 57 patients (89%) and fair in 7 (11%). Good outcomes were obtained in unruptured CIAs using a multidisciplinary approach. Ruptured CIAs carry a significantly worse prognosis than overall SAH patients.
KEYWORDS
Cerebral aneurysm - clipping - coiling - cerebral revascularization
REFERENCES
-
1
Albanese E, Russo A, Ulm A J.
Fenestrated vertebrobasilar junction aneurysm: diagnostic and therapeutic considerations.
J Neurosurg.
2009;
110
(3)
525-529
-
2
Alexander B L, Riina H A.
The combined approach to intracranial aneurysm treatment.
Surg Neurol.
2009;
72
(6)
596-606
discussion 606
-
3
Barrow D L, Cawley C M.
Surgical management of complex intracranial aneurysms.
Neurol India.
2004;
52
(2)
156-162
-
4
Chen L, Kato Y, Sano H et al..
Management of complex, surgically intractable intracranial aneurysms: the option for intentional reconstruction of aneurysm neck followed by endovascular coiling.
Cerebrovasc Dis.
2007;
23
(5-6)
381-387
-
5
Hacein-Bey L, Connolly Jr E S, Mayer S A, Young W L, Pile-Spellman J, Solomon R A.
Complex intracranial aneurysms: combined operative and endovascular approaches.
Neurosurgery.
1998;
43
(6)
1304-1312
discussion 1312-1313
-
6
Hanel R A, Spetzler R F.
Surgical treatment of complex intracranial aneurysms.
Neurosurgery.
2008;
62
(6, Suppl 3)
1289-1297
discussion 1297-1299
-
7
Hauck E F, Wohlfeld B, Welch B G, White J A, Samson D.
Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study.
J Neurosurg.
2008;
109
(6)
1012-1018
-
8
Hoh B L, Carter B S, Putman C M, Ogilvy C S.
Important factors for a combined neurovascular team to consider in selecting a treatment modality for patients with previously clipped residual and recurrent intracranial aneurysms.
Neurosurgery.
2003;
52
(4)
732-738
discussion 738-739
-
9
Hoh B L, Putman C M, Budzik R F, Carter B S, Ogilvy C S.
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.
J Neurosurg.
2001;
95
(1)
24-35
-
10
Jin S C, Kwon H, Song Y, Kim H J, Ahn J S, Kwun B D.
Multimodal treatment for complex intracranial aneurysms: clinical research.
J Korean Neurosurg Soc.
2008;
44
(5)
314-319
-
11
Lawton M T, Quinones-Hinojosa A, Sanai N, Malek J Y, Dowd C F.
Combined microsurgical and endovascular management of complex intracranial aneurysms.
Neurosurgery.
2008;
62
(6, Suppl 3)
1503-1515
-
12
Mack W J, Ducruet A F, Angevine P D et al..
Deep hypothermic circulatory arrest for complex cerebral aneurysms: lessons learned.
Neurosurgery.
2007;
60
(5)
815-827
discussion 815-827
-
13
Mohit A A, Sekhar L N, Natarajan S K, Britz G W, Ghodke B.
High-flow bypass grafts in the management of complex intracranial aneurysms.
Neurosurgery.
2007;
60
(2, Suppl 1)
ONS105-ONS122
discussion ONS122-ONS123
-
14
Murakami K, Shimizu H, Matsumoto Y, Tominaga T.
Acute ischemic complications after therapeutic parent artery occlusion with revascularization for complex internal carotid artery aneurysms.
Surg Neurol.
2009;
71
(4)
434-441
discussion 441
-
15
Park E K, Ahn J S, Kwon H, Kwun B D.
Result of extracranial-intracranial bypass surgery in the treatment of complex intracranial aneurysms : outcomes in 15 cases.
J Korean Neurosurg Soc.
2008;
44
(4)
228-233
-
16
Quiñones-Hinojosa A, Lawton M T.
In situ bypass in the management of complex intracranial aneurysms: technique application in 13 patients.
Neurosurgery.
2008;
62
(6, Suppl 3)
1442-1449
-
17
Sanai N, Zador Z, Lawton M T.
Bypass surgery for complex brain aneurysms: an assessment of intracranial-intracranial bypass.
Neurosurgery.
2009;
65
(4)
670-683
discussion 683
-
18
Scamoni C, Dario A, Castelli P, Caronno R, Picano M, Tomei G.
Extracranial-intracranial bypass for giant aneurysms and complex vascular lesions: a clinical series of 10 patients.
J Neurosurg Sci.
2008;
52
(1)
1-9
discussion 9-10
-
19
Seo B R, Kim T S, Joo S P et al..
Surgical strategies using cerebral revascularization in complex middle cerebral artery aneurysms.
Clin Neurol Neurosurg.
2009;
111
(8)
670-675
-
20
Surdell D L, Hage Z A, Eddleman C S, Gupta D K, Bendok B R, Batjer H H.
Revascularization for complex intracranial aneurysms.
Neurosurg Focus.
2008;
24
(2)
E21
-
21
van Doormaal T P, van der Zwan A, Verweij B H, Langer D J, Tulleken C A.
Treatment of giant and large internal carotid artery aneurysms with a high-flow replacement bypass using the excimer laser-assisted nonocclusive anastomosis technique.
Neurosurgery.
2008;
62
(6, Suppl 3)
1411-1418
-
22
Yang I, Lawton M T.
Clipping of complex aneurysms with fenestration tubes: application and assessment of three types of clip techniques.
Neurosurgery.
2008;
62
(5, Suppl 2)
ONS371-ONS378
discussion 378-379
-
23
Beretta F, Andaluz N, Zuccarello M.
Aneurysms of the ophthalmic (C6) segment of the internal carotid artery: treatment options and strategies based on a clinical series.
J Neurosurg Sci.
2004;
48
(4)
149-156
-
24
Proust F, Debono B, Hannequin D et al..
Treatment of anterior communicating artery aneurysms: complementary aspects of microsurgical and endovascular procedures.
J Neurosurg.
2003;
99
(1)
3-14
-
25
Andaluz N, Beretta F, Keller J T, Zuccarello M.
Aneurysms of the ophthalmic (C6) segment of the internal carotid artery: clinical experience, treatment options, and strategies (Part 2).
Neurosurg Q.
2005;
15
91-102
-
26
Andaluz N, Zuccarello M.
Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database.
J Neurosurg.
2008;
108
(6)
1163-1169
-
27
Cowan Jr J A, Ziewacz J, Dimick J B, Upchurch Jr G R, Thompson B G.
Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms.
J Neurosurg.
2007;
107
(3)
530-535
-
28
Johnston S C.
Effect of endovascular services and hospital volume on cerebral aneurysm treatment outcomes.
Stroke.
2000;
31
(1)
111-117
-
29
Qureshi A I, Suri M F, Nasar A et al..
Trends in hospitalization and mortality for subarachnoid hemorrhage and unruptured aneurysms in the United States.
Neurosurgery.
2005;
57
(1)
1-8
discussion 1-8
-
30
Kocaeli H, Andaluz N, Choutka O, Zuccarello M.
Use of radial artery grafts in extracranial-intracranial revascularization procedures.
Neurosurg Focus.
2008;
24
(2)
E5
-
31
Abdel Aziz K M, Andaluz N, Zuccarello M.
Basilar bifurcation aneurysms: Strategies for surgical approach selection.
Neurosurg Q.
2007;
17
101-112
-
32
Andaluz N, Van Loveren H R, Keller J T, Zuccarello M.
Anatomic and clinical study of the orbitopterional approach to anterior communicating artery aneurysms.
Neurosurgery.
2003;
52
(5)
1140-1148
discussion 1148-1149
-
33
Andaluz N, Romano A, Reddy L V, Zuccarello M.
Eyelid approach to the anterior cranial base.
J Neurosurg.
2008;
109
(2)
341-346
-
34
Beretta F, Andaluz N, Chalaala C, Bernucci C, Salud L, Zuccarello M.
Image-guided anatomical and morphometric study of supraorbital and transorbital minicraniotomies to the sellar and perisellar regions: comparison with standard techniques.
J Neurosurg.
2010;
113
(5)
975-981
-
35
Ponce F A, Spetzler R F, Han P P et al..
Cardiac standstill for cerebral aneurysms in 103 patients: an update on the experience at the Barrow Neurological Institute. Clinical article.
J Neurosurg.
2011;
114
(3)
877-884
-
36
Vendrell J F, Costalat V, Brunel H, Riquelme C, Bonafe A.
Stent-assisted coiling of complex middle cerebral artery aneurysms: initial and midterm results.
AJNR Am J Neuroradiol.
2011;
32
(2)
259-263
-
37
Xu B N, Sun Z H, Romani R et al..
Microsurgical management of large and giant paraclinoid aneurysms.
World Neurosurg.
2010;
73
(3)
137-146
discussion e17, e19
-
38
Cunha e Sá M.
The use of deep hypothermia and cardiac arrest in the surgical treatment of large and complex intracranial circulation aneurysms.
Acta Neurochir (Wien).
2010;
152
(6)
1089-1090
-
39
Patel H C, Teo M, Higgins N, Kirkpatrick P J.
High flow extra-cranial to intra-cranial bypass for complex internal carotid aneurysms.
Br J Neurosurg.
2010;
24
(2)
173-178
-
40
Schebesch K M, Proescholdt M, Ullrich O W et al..
Circulatory arrest and deep hypothermia for the treatment of complex intracranial aneurysms—results from a single European center.
Acta Neurochir (Wien).
2010;
152
(5)
783-792
-
41
Sano H.
Treatment of complex intracranial aneurysms of anterior circulation using multiple clips.
Acta Neurochir Suppl (Wien).
2010;
107
27-31
-
42
Connolly Jr E S, Hoh B L, Selden N R et al..
Clipping versus coiling for ruptured intracranial aneurysms: integrated medical learning at CNS 2007.
Neurosurgery.
2010;
66
(1)
19-34
discussion 34
-
43
Shimizu H, Matsumoto Y, Tominaga T.
Parent artery occlusion with bypass surgery for the treatment of internal carotid artery aneurysms: clinical and hemodynamic results.
Clin Neurol Neurosurg.
2010;
112
(1)
32-39
-
44
Xu F, Qin X, Tian Y, Gu Y, Leng B, Song D.
Endovascular treatment of complex intracranial aneurysms using intra/extra-aneurysmal stent.
Acta Neurochir (Wien).
2011;
153
(4)
923-930
-
45
Albuquerque F C, Gonzalez L F, Hu Y C, Newman C B, McDougall C G.
Transcirculation endovascular treatment of complex cerebral aneurysms: technical considerations and preliminary results.
Neurosurgery.
2011;
68
(3)
820-829
discussion 829-830
-
46
Saatci I, Geyik S, Yavuz K, Cekirge S.
X–Configured Stent-Assisted Coiling in the Endovascular Treatment of Complex Anterior Communicating Artery Aneurysms: A Novel Reconstructive Technique.
AJNR Am J Neuroradiol.
2010;
November 24 (Epub ahead of print]
-
47
Lv X, Jiang C, Li Y, Wu Z.
Clinical outcomes of ruptured and unruptured vertebral artery-posterior inferior cerebellar artery complex dissecting aneurysms after endovascular embolization.
AJNR Am J Neuroradiol.
2010;
31
(7)
1232-1235
-
48
Lot G, Houdart E, Cophignon J, Casasco A, George B.
Combined management of intracranial aneurysms by surgical and endovascular treatment. Modalities and results from a series of 395 cases.
Acta Neurochir (Wien).
1999;
141
(6)
557-562
-
49
Natarajan S K, Sekhar L N, Ghodke B, Britz G W, Bhagawati D, Temkin N.
Outcomes of ruptured intracranial aneurysms treated by microsurgical clipping and endovascular coiling in a high-volume center.
AJNR Am J Neuroradiol.
2008;
29
(4)
753-759
-
50
Hoh B L, Chi Y Y, Dermott M A, Lipori P J, Lewis S B.
The effect of coiling versus clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the university of Florida.
Neurosurgery.
2009;
64
(4)
614-619
discussion 619-621
-
51
Jahromi B S, Mocco J, Bang J A et al..
Clinical and angiographic outcome after endovascular management of giant intracranial aneurysms.
Neurosurgery.
2008;
63
(4)
662-674
discussion 674-675
-
52
Krisht A F, Krayenbühl N, Sercl D, Bikmaz K, Kadri P A.
Results of microsurgical clipping of 50 high complexity basilar apex aneurysms.
Neurosurgery.
2007;
60
(2)
242-250
discussion 250-252
-
53
Collice M, Arena O, D'Aliberti G et al..
Aneurysms of the vertebro-basilar junction area: preliminary experience in endovascular and surgical management.
Acta Neurochir (Wien).
1997;
139
(2)
124-133
-
54
de Oliveira J G, Borba L A, Rassi-Neto A et al..
Intracranial aneurysms presenting with mass effect over the anterior optic pathways: neurosurgical management and outcomes.
Neurosurg Focus.
2009;
26
(5)
E3
-
55
Vendrell J F, Menjot N, Costalat V et al..
Endovascular treatment of 174 middle cerebral artery aneurysms: clinical outcome and radiologic results at long-term follow-up.
Radiology.
2009;
253
(1)
191-198
-
56
Sedat J, Chau Y, Mondot L, Vargas J, Szapiro J, Lonjon M.
Endovascular occlusion of intracranial wide-necked aneurysms with stenting (Neuroform) and coiling: mid-term and long-term results.
Neuroradiology.
2009;
51
(6)
401-409
-
57
Porter P J, Mazighi M, Rodesch G et al..
Endovascular and Surgical Management of Multiple Intradural Aneurysms. Review of 122 Patients Managed between 1993 and 1999.
Interv Neuroradiol.
2001;
7
(4)
291-302
Norberto AndaluzM.D.
c/o Editorial Office, Department of Neurosurgery, University of Cincinnati College of Medicine
ML 0515, Cincinnati, OH 45267-0515
eMail: andalun@uc.edu
