Abstract 1122‐000071: Large and Giant Intracranial Aneurysms, Clinico‐Radiological Outcome and Predictors with Flow Diverter Stent

Introduction : Endovascular treatment for large and giant aneurysms has included either a reconstructive approach or a deconstructive approach by parent artery occlusion. 1,2 Stent‐assisted coiling and balloon‐assisted coiling were alternative techniques developed to deal with such complex aneurysms, but studies have shown less expected efficacy. This study aims to assess the safety and efficacy of the flow diverter stents for treating large and giant intracranial aneurysms and to examine possible predictors for radiological and clinical outcomes such as location and presence of branching artery, bifurcation, and adjuvant coiling. Methods : This study had been conducted on 65 consecutive patients with 65 large and giant aneurysms (size ≥ 10 mm) treated with flow diverters; Periprocedural complications were reported in all patients and clinical outcomes. Follow‐up angiography was done for 60 patients (92.3%) at 12 months. Results : The study included 65 patients who harbored 65 aneurysms. The median age was 55.5 years (IQR: 44.25 ‐ 62.75 years), the female represented 70.8 % of all patients. The clinical presentation had been reported (Headache, cranial nerve palsy, motor deficit, seizures, and visual field defect in 40 patients (61.5%), nine patients (13.8%), seven patients (10.8%), five patients (7.7%), and four patients (6.2%) respectively. The vascular risk factors had been reviewed (HTN, DM, smoking, and Hyperlipidemia in 25 patients (9.2%), Six patients (9.2%), sixteen (24.6%), and 10 patients (15.4%) respectively). The median size of aneurysms was 16.4 mm (IQR: 12.50 ‐ 23.85 mm) and the median neck width was 7.15 mm (IQR: 5.85‐10.24 mm). Fourteen aneurysms (21.4 %) had previous treatment, eleven aneurysms (16.9%) were treated by coils only, one case (1.5%) by assisted procedure, one case (1.5%) by previous FDS, and parent artery occlusion in one case (1.5%). Complete occlusion in 50 from 60 aneurysms (83.4%), neck remnant in 8 aneurysms (13.3%), and sac remnant in two aneurysms (3.3%). Periprocedural problems were encountered in 14 patients (21.5%) with morbidity in six patients (9.2%) and mortality in one patient (1.5%). Univariate and multivariate logistic regression analysis was used to discover possible predictors of combined mortality and morbidity and occlusion in Table (1). Conclusions : From this study, it could be concluded that Endovascular treatment of the large and giant aneurysms with flow diverters represents a safe method for treating this kind of complex intracranial aneurysms. Complex aneurysms with branching artery and bifurcation were associated with aneurysm persistence and complications respectively while the location of the aneurysm was the only predictor for clinical outcome.

Successful management of bilateral internal carotid artery fusiform giant aneurysms in a patient with intimal fibroplasia using multiple flow diverters: With long-term imaging follow up

The authors report a rare case of sequentially developed bilateral internal carotid artery (ICA) fusiform giant aneurysms in a patient with pathologically confirmed intimal fibroplasia. Both ICA fusiform aneurysms were treated with multiple flow diverter insertion and were well-managed over the past 5.5 years of follow-up. The development of aneurysms in this rare disease entity appears to be a lifelong process based on the authors’ observations in serial angiographic follow-up studies. Reconstruction therapy using flow-diverting stents in this unique condition may be a safe and effective treatment modality.

Therapeutic dilemmas regarding giant aneurysms of the intracranial vertebral artery causing medulla oblongata compression

Background Giant aneurysms of the intracranial vertebral artery are very rare cerebrovascular lesions. Due to the rarity of these aneurysms, we know little about them. Methods We performed a systematic review of the English literature by searching the PubMed database. The inclusion criteria were as follows: (a) the full text was available and (b) complete clinical data were available. Results A total of 45 articles were identified, containing 53 patients (53 aneurysms). The patients were aged from 5 to 77 years (48.8 ± 20.8 years). Four patients receiving conservative treatment died. The remaining 49 patients were divided into the aneurysm removal group ( n = 17) and the aneurysm reserve group ( n = 32). The outcomes of the 49 treated cases could be obtained in 45 cases, 31 of which (68.9%, 31/45) had a Glasgow outcome scale score of 4–5. Conclusions It is still difficult to treat intracranial giant vertebral artery aneurysms, regardless of the treatment selected. Because of the malignant natural history, aggressive treatment is still advocated.

A case of successful surgical treatment of a ruptured giant aneurysm of the infrarenal aorta in an elderly patient

Today, abdominal aortic aneurysm surgery is a fairly well-studied area of medicine. Nevertheless, some questions remain rather debatable. No clear criteria for giant aneurysms have been developed so far. The available foreign and domestic literature reports about 40 cases of surgical treatment of giant abdominal aortic aneurysms, 16 of which are cases of aneurysm rupture. Open surgery remains the method of choice in the treatment of giant aneurysms due to the pronounced technical difficulties of endovascular intervention. The authors present a case of successful surgical treatment of a giant aneurysm rupture in an elderly patient. The peculiarity of this patient's condition is the occurrence of aneurysm rupture after hospital admission. The patient refused surgical treatment for two years after aneurysm detection. On examination after admission, multispiral computed tomography revealed an aneurysm size of 101 mm. On the eve of surgery, pain syndrome in the left abdomen and tachycardia appeared. Aneurysm rupture was suspected and the patient was urgently admitted to the operating room. The surgery was performed under the conditions of machine reinfusion of autoblood. The patient underwent abdominal aortic aneurysm resection with linear prosthesis and retroperitoneal hematoma removal. The postoperative period had no peculiarities. On the 10th day after the operation the patient was discharged in satisfactory condition to the outpatient treatment. This clinical case demonstrates the possibility of successful surgical treatment of giant aneurysm rupture in elderly patients.

A Posterior Communicating Segment Aneurysm of the Supraclinoid Internal Carotid Artery Treated with an Extracranial to Intracranial Bypass and Trapping

Surgical treatment of giant aneurysms often poses significant challenges. Endovascular techniques have evolved exponentially over the last decades, and most of these complex aneurysms can be treated with flow-diverting techniques; however, successful obliteration of all giant aneurysms is not always possible with endovascular flow-diverting techniques. Although the need for microsurgical intervention has undoubtedly diminished, a versatile-thinking surgeon should keep in mind that obliteration of these aneurysms combined with revascularizing the distal circulation via extracranial–intracranial bypass techniques can provide a potentially life-long durable solution. The key to curing these pathologies is to utilize interdisciplinary decision making with a robust knowledge of the pros and cons of different treatment approaches. Herein, we present a case of a giant posterior communicating segment aneurysm of the left supraclinoid internal carotid artery (ICA), which was treated by obliteration (Fig. 1). Extradural anterior clinoidectomy was used to provide exposure of the supraclinoidal ICA proximal to the aneurysm, and revascularization of the distal circulation was achieved with a common carotid artery to M2-superior trunk bypass using a radial artery interposition graft (Fig. 2). The patient was a 62-year-old female who presented with vision loss in her left eye but was otherwise neurologically intact. She had a history of two unsuccessful flow-diverting stent placement attempts 2 months prior to this surgery. Postoperatively, the patient woke up without any deficits, with her left eye vision partially recovered and ultimately returning to normal at 1-year follow-up. Computed tomography (CT) angiography at a 1-year follow-up showed complete obliteration of the aneurysm and successful revascularization of the distal circulation.The link to the video can be found at: https://youtu.be/3Zz-ecvlDIc .