A Retrospective Study in Microsurgical Procedures of Large and Giant Intracranial Aneurysms: An Outcome Analysis

Abstract

Objective: Intracranial aneurysms are considered large if >10 mm and giant if >25 mm. The risk of aneurysmal rupture compounds with increase in size of the aneurysm, thus, warranting appropriate intervention. In this study, we have analyzed the outcome and effectiveness of microsurgical procedures in large and giant aneurysms.

Methods: A retrospective analysis of all the patients who underwent microsurgical procedures for large and giant cerebral aneurysms from 2014-2018 in our institute was conducted. There were a total of 52 patients, in which direct clipping was performed in 42 (80.7%) patients, proximal trapping in 3 (5.7%) patients, trapping with bypass in 3 (5.7%) patients, suction decompression in 3 (5.7%) patients, and 1 (1.9%) patient underwent surgical reconstruction.

Results: Among the 52 patients, in the postoperative period, 1 (1.9%) patient became comatose, 1 (1.9%) patient developed hemiplegia, 1 (1.9%) patient had a transient hemiparesis, and 1 (1.9%) patient had transient lower cranial nerve palsy. Two (3.8%) patients had chronic subdural hematoma during the 3-month follow-up. There was no mortality in our series.

Conclusions: There are several treatment strategies available to manage large and giant cerebral aneurysms. In this study, we had minimal morbidity (3.8%), favorable outcome (96.1%), and no mortality. Therefore, we would like to conclude that appropriate microsurgical procedures, in experienced hands, can be considered as first line in the management for large and giant intracranial aneurysms, especially those with complex anatomy, wide neck, mass effect, partial thrombosis, and the presence of critical perforating vessels from the aneurysm wall.

Keywords: 3D, 3-Dimensional; BTO, Balloon test occlusion; Bypass; CFD, Computational fluid dynamics; CTA, Computed tomography angiogram; Clipping; DIVA; DIVA, Dual image video angiography; DSA, Digital subtraction angiography; GOS, Glasgow Outcome Scale; Giant; ICA, Internal cerebral artery; ICG, Indo-cyanine green; Intracranial aneurysm; MEP, Motor evoked potential; MRI, Magnetic resonance imaging; OA, Occipital artery; Outcome; PICA, Posterior inferior cerebellar artery; RSD, Retrograde suction decompression; Trapping; VA, Vertebral artery.

Figure 1

(A) Left vertebral artery, posterior inferior cerebellar artery (PICA) segment aneurysm. (B) PICA originating just proximal to the aneurysm. VA, vertebral artery.

Figure 2

(A and B) Computational fluid dynamics showing increased wall pressure and a spiral streamline flow.

Figure 3

(A) Dual image video angiography (DIVA) showing filling of the aneurysm, occipital artery (OA)-posterior inferior cerebellar artery (PICA) bypass completed. (B) Post-trapping DIVA shows no flow in the aneurysm and good flow in the OA-PICA. VA, vertebral artery.

Figure 4

(A) Left transcondylar approach. (B) Postoperative image with clips in situ and complete exclusion of the aneurysm from the circulation.

Figure 5

(A and B) Magnetic resonance imaging-computed tomography angiogram fusion image showing left internal carotid artery-ophthalmic segment large aneurysm.

Figure 6

(A) Catheterization of the carotid artery with suction catheter. (B) Suction decompression of the large aneurysm with temporary clips in situ. (C) Postclipping dual image video angiography shows complete occlusion of the aneurysm. CC, common carotid artery; EC, external carotid artery; ICA, internal cerebral artery.

Figure 7

(A) Magnetic resonance imaging of the brain shows a large partially thrombosed aneurysm in the left vertebral artery (VA). (B) Computed tomography angiogram shows a large fusiform aneurysm of the left VA involving the posterior inferior cerebellar artery segment.

Figure 8

(A) Giant vertebral artery aneurysm with dilated vasa vasorum (circled), (B) neuroendoscopic view of the aneurysm, (C) retrieval of the intra-aneurysmal coil, (D) reconstruction of the aneurysmal wall and clipping. An, aneurysm; LCN, lower cranial nerves; PICA, posterior inferior cerebellar artery; VA, vertebral artery.

Figure 9

Postclipping computed tomography angiogram shows exclusion of the aneurysm from the circulation.

Figure 10

Right internal carotid artery giant cavernous segment aneurysm. R.ICA, right internal carotid artery.

Figure 11

Intraoperative images. (A) Low flow superficial temporal artery M4 bypass. (B) High flow external carotid artery M2 bypass and postanastomosis dual image video angiography with good flow. EC, external carotid artery; M2/M4, segments of the middle cerebral artery; STA, superficial temporal artery.