Abstract
Background. Surgical treatment of complex aneurysms often requires the execution of a revascularization procedure. Even if avoiding the concomitant trapping of the aneurysm during the bypass procedure (waiting for the subsequent endovascular or spontaneous closure) permits one to verify the graft’s patency and patient’s adaptation to increased flow, the hemodynamic changes induced by the bypass may cause the aneurysmal rupture. Whether or not to perform the concomitant trapping of the aneurysm still remains a dilemma. Here we illustrate our management protocol through the critical analysis of some illustrative cases of our series.
Materials and methods. Between 1990 and 2016, 48 of 157 patients affected by complex aneurysms underwent a revascularization procedure. In 19 cases (1990–1997) only a bypass procedure was performed. Spontaneous or endovascular closure was obtained within the first postoperative week once the graft patency had been verified (staged revascularization strategy). In the remaining 29 cases (1997–2016) the revascularization procedure and the closure of the aneurysm were performed simultaneously during the same surgical procedure (single-stage strategy).
Results. In the staged revascularization era, one patient died because of the rupture of the aneurysm before its closure.
In the single-stage era no further cases of rebleeding were observed. Neurologic status of this group was unvaried or improved.
Conclusions. Given the unpredictable response of complex aneurysms to the hemodynamic changes induced by the revascularization, in our opinion it is always preferable to perform complete or at least incomplete trapping of the aneurysm during the bypass procedure.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Hanel RA, Spetzler RF. Surgical treatment of complex intracranial aneurysms. Neurosurgery. 2008;62(6 suppl 3):1289–97.
Mohit AA, Sekhar LN, Natarajan SK, Britz GW, Ghodke B. High-flow bypass grafts in the management of complex intracranial aneurysms. Neurosurgery. 2007;60(2 Suppl 1):ONS105–22.
Scott RM, Liu HC, Yuan R, Adelman L. Rupture of a previously unruptured giant middle cerebral artery aneurysm after extracranial-intracranial bypass surgery. Neurosurgery. 1982;10(5):600–3.
Benashvili GM, Alexander LF, Zubkov YN. Thrombosis of a giant aneurysm after extracranial-intracranial bypass. Neurosurgery. 1992;31(2):360–4.
Cantore G, Santoro A, Da Pian R. Spontaneous occlusion of supraclinoid aneurysms after the creation of extra-intracranial by passes using long grafts: report of two cases. Neurosurgery. 1999;44(1):216–9.
Haque R, Kellner C, Solomon RA. Spontaneous thrombosis of a giant fusiform aneurysm following extracranial-intracranial bypasssurgery. J Neurosurg. 2009;110(3):469–674.
Anson JA, Stone JL, Crowell RM. Rupture of a giant carotid aneurysm after extracranial-to-intracranial bypass surgery. Neurosurgery. 1991;28(1):142–7.
Heros RC, Ameri AM. Rupture of a giant basilar aneurysm after saphenous vein interposition graft to the posterior cerebral artery. Case report. J Neurosurg. 1984;61(2):387–90.
Hopkins LN, Grand W. Extracranial-intracranial arterial bypass in the treatment of aneurysms of the carotid and middle cerebralarteries. Neurosurgery. 1979;5(1 Pt 1):21–31.
Cantore G, Santoro A, Guidetti G, Delfinis CP, Colonnese C, Passacantilli E. Surgical treatment of giant intracranial aneurysms: current viewpoint. Neurosurgery. 2008;63(4 Suppl 2):279–89.
Kawaguchi T, Nishimura S, Kanamori M, Takazawa H, Omodaka S, Sato K, Maeda N, Yokoyama Y, Midorikawa H, Sasaki T, Nishijima M. Distinctive flow pattern of wall shear stress and oscillatory shear index: similarity and dissimilarity in ruptured and unruptured cerebral aneurysm blebs. J Neurosurg. 2012;117(4):774–80.
Yeh H, Tomsick TA. Obliteration of a giant carotid aneurysm after extracranial-to-intracranial bypass surgery: case report. Surg Neurol. 1997;48(5):473–6.
Meng H, Tutino VM, Xiang J, Siddiqui A. High WSS or low WSS? Complex interactions of hemodynamics with intracranial aneurysm initiation, growth, and rupture: toward a unifying hypothesis. AJNR Am J Neuroradiol. 2014;35(7):1254–62.
Omodaka S, Sugiyama S, Inoue T, Funamoto K, Fujimura M, Shimizu H, Hayase T, Takahashi A, Tominaga T. Local hemodynamics at the rupture point of cerebral aneurysms determined by computational fluiddynamics analysis. Cerebrovasc Dis. 2012;34(2):121–9.
Russin J, Babiker H, Ryan J, Rangel-Castilla L, Frakes D, Nakaji P. Computational fluid dynamics to evaluate the management of a giant internal carotid artery aneurysm. World Neurosurg. 2015;83(6):1057–65.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG, part of Springer Nature
About this paper
Cite this paper
Pescatori, L., Tropeano, M.P., Santoro, A. (2018). Complex Aneurysm: The Unpredictable Pathological Entity. In: Esposito, G., Regli, L., Kaku, Y., Tsukahara, T. (eds) Trends in the Management of Cerebrovascular Diseases. Acta Neurochirurgica Supplement, vol 129. Springer, Cham. https://doi.org/10.1007/978-3-319-73739-3_9
Download citation
DOI: https://doi.org/10.1007/978-3-319-73739-3_9
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-73738-6
Online ISBN: 978-3-319-73739-3
eBook Packages: MedicineMedicine (R0)