Giant intracranial aneurysms bervini
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Transcript of Giant intracranial aneurysms bervini
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EBS presentation 1
JCApril 19th 2012
D. Bervini
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EBS presentation 2
INTRODUCTION
1. Morbidity and mortality of surgery: 20-30%– Inherent treatment risks– Anatomy
• Wide neck• Complex arterial branches• Intraluminal thrombus• Atherosclerotic degeneration• Adherent perforating arteries
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EBS presentation 3
2. Increase in use of endovascular treatment– Coiling (Guglielmi 1990)– Flow diversion and Endoluminal reconstruction
(petrocavernous and paraclinoid ICA and BT)
3. Old surgical series
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EBS presentation 4
4. Improved radiological imaging and earlier diagnosis of large aneurysm
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EBS presentation 5
Older publications do not reflect the current practice environment
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EBS presentation 6
OBJECTIVE
• Examine specific changes in surgical management
• Examine the role of microsurgery in management strategy
• Quantify surgical results for comparison with evolving endovascular therapies
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EBS presentation 7
METHODS
• Retrospective study
• Single center
• Patients with ≥ 25mm aneurysms (thrombus included)
• 13 y period
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EBS presentation 8
Patients• 140 patients• 141 GA• 64% F, 36% M• mean age 54y• 16% (33) SHA
• HH I 5• HH II 5• HH III 6• HH IV 7
• 6 recurrent aneurysms after coiling
• 1 recurrent aneurysm after clipping
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EBS presentation 9
Aneurysms
• mean diameter 29mm
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EBS presentation 10
Surgical managment
• surgery VS coil on individual basis• Exclusion:
– HH V – aneurysm calcifications– location on the basilar trunk or vertebrobasilar
junction– advanced age– significant anesthetic risk– patient and family preferences
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EBS presentation 11
• primary strategy: direct aneurysm clipping
• alternative strategy = indirect occlusion:
• clipping parent artery
• bypass with clipping parent artery
• bypass with endovascular occlusion
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EBS presentation 12
Balloon test occlusion (BTO)
• 26 patients• Cavernous or supraclinoid ICA aneurysms• Failed
– 10 with BTO inflation alone high-flow bypass– 16 with additional hypotensive challenge low-
flow bypass
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EBS presentation 13
Outcomes
• Aneurysm occlusion (angiography)– Complete– Minimal residual aneurysm (dog-ear)– Incomplete (>5%)
• Aneurysm treatment failure = growth of residual aneurysm or rupture
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EBS presentation 14
• Neurological outcome = GOS
• Improved VS unchanged VS worse VS dead
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EBS presentation 15
Results
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EBS presentation 16
Bypass
• 38%
– ECA-MCA 26%
– STA-MCA 20%
– Intracranial-intracranial 28%
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EBS presentation 17
Outcome
Aneurysms• 77% complete occluded (79% clip / 72%
indirect)• 10% minimal residual (clip)• 11 % incompletely occluded (parent artery
clip with/without bypass)
• 3.5% retreatment
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EBS presentation 18
Post-operative durability of GA control
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EBS presentation 19
Outcome
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EBS presentation 20
• Posterior circulation aneurysms = more complications = independent risk factor.
• SAH patients had worse outcomes, mortality 39% (8% for no-SAH)
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EBS presentation 21
Discussion
• Dolichoectatic morphology• Aberrant branch anatomy• Atherosclerotic neck bypass• Intraluminal thrombus 47% clipping• Previous coil
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EBS presentation 22
• Heavy reliance on bypass techniques (38%)
OR
• adjuncts that facilitate direct clipping, like deep hypothermic circulatory arrest
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EBS presentation 23
Deep hypothermic circulatory arrest
• Eliminate risk of aneurysm rupture
• Permits clip collapse
• Permits manipulation (remove thrombus, create supple neck)
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EBS presentation 24
BUT
• Significant operation morbidity
– Compromise of distal circulation by cannulation– Cerebral ischemic injury– Postoperative bleeding complications– Cumulative mortality-morbidity 32%
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EBS presentation 25
Complications of bypass and indirect aneurysm occlusion
• Thrombotic occlusion of perforators or branch arteries (7%)
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EBS presentation 26
FIGURE 3 . Case 15. A, axial T2-weighted MR imaging revealed a giant left ICA bifurcation aneurysm and a large anterior communicating artery aneurysm in this 51-year-old woman. B, 3D reconstructed angiogram (left ICA injection) demonstrated its dolichoectatic morphology. An end-to-side anastomosis between radial artery and the efferent MCA was part of an ECA-MCA bypass. C, supraclinoid ICA was occluded with a clip as it entered the aneurysm, distal to PCoA. Indocyanine green videoangiography demonstrated patency of the bypass graft, filling of distal MCA branches, filling of the supraclinoid ICA up to the clip, and faint flow of dye within the aneurysm. Postoperative CT angiography showed a thin layer of new intra-aneurysmal thrombus anteriorly, posteriorly, and inferiorly on axial (D) and coronal (E) views. F, subsequent digital subtraction angiography demonstrated bypass patency and progressive intraluminal thrombosis (left ICA injection, anteroposterior view). CTA on postoperative day 5 revealed further intraluminal thrombosis with 2 serpentine channels connecting the bypass with the A1 segment on the opposite side of the aneurysm, as seen on axial (G) and coronal (H) views. Postsurgical thrombosis occluded the anterior choroidal artery, and she experienced a capsular infarct. This case demonstrates that postsurgical aneurysm thrombosis after proximal clip occlusion can occlude small branch arteries. ICA, internal carotid artery; MCA, middle cerebral artery; PCA, posterior cerebral artery; ECA, external carotid artery; PCoA, posterior communicating artery; CTA, computed tomographic angiography.
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EBS presentation 27
Computational fluid dynamic
• Preferred treatment:– maintain robust flow in regions where branch
arteries originate– accepting stagnation in perforator-free zones
(dome and fundus)
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EBS presentation 28
Conclusion
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EBS presentation 29
Superiority of Surgical Managment• Good results
– GOS 4-5 in 81%– Improved/unchanged in 78%
• Mortality 13% (vs 29%)• Morbidity 9% (vs 32%)• Complete occlusion 77% (vs 36%)• endovascular treatment: multiple treatments,
repeat risks exposure and relapsing clinical course.
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EBS presentation 30
Weakness of the article
• Retrospecive view• Lack of control group• Short follow-up duration (2y), especially for
indirect treatment (bypass)• Selection biais (chose for surgical treatment
because it was felt to offer better outcome)• Indirect treatment is not completely protective• No entirely surgical series (23 pts
endovascular)
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EBS presentation 31