Provocative Testing Prior to Anterior Cerebral Artery Fusiform Aneurysm Embolization

We report 2 cases of parent artery occlusion (PAO) for anterior cerebral artery (ACA) fusiform aneurysm embolization after superselective provocative testing was performed to confirm distal territory viability. The first case involves a patient in the second decade of life who presented with subarachnoid hemorrhage and underwent PAO after a balloon test occlusion in the distal ACA revealed no neurophysiology changes. The second case involves another patient in the forth decade of life who presented with an enlarging pseudoaneurysm and underwent PAO after a sodium amobarbital infusion in the distal ACA revealed no clinical change. Both patients tolerated PAO without clinical compromise. PAO after provocative testing may be a safe and effective strategy in the management of fusiform aneurysm treatment. Key Messages: Provocative testing with superselective balloon test occlusion and sodium amobarbital infusion are both viable options for clinical and physiological interrogation of brain tissue prior to parent vessel occlusion. Neurophysiological monitoring may be a useful surrogate for clinical examination after provocative testing, particularly if patients were treated under general anesthesia.

Endovascular treatment of intracranial infectious aneurysms in eloquent cortex with super-selective provocative testing: Case series and literature review

Intracranial infectious aneurysms (IIAs) are a rare subgroup of intracranial aneurysms. Often erroneously termed mycotic aneurysms, these lesions most often result from infectious endocarditis and involve the distal anterior cortical circulation. Diagnosis typically follows headaches or septic infarcts, although increasing numbers of lesions are found incidentally, during screening protocols for infectious endocarditis. Open surgical treatment was previously the mainstay of treatment; however, these IIAs are often fusiform and quite fragile, making open surgical obliteration difficult and typically requiring lesion trapping. Current treatment techniques more commonly involve endovascular coil embolization or parent vessel occlusion. Many of these lesions occur distally, in or around the eloquent cortex, making embolization potentially dangerous. We present cases that highlight the use of super-selective provocative testing with sodium amobarbital and lidocaine, to help clarify and predict the risk of parent vessel occlusion in IIAs located in the eloquent cortex.