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Carotid artery occlusion for the treatment of symptomatic giant carotid aneurysms: a proposal of classification and surgical protocol

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Abstract

Giant intracranial aneurysms are rare disorders that represent only 5 % of all intracranial aneurysms; they have a wide variety of presentations including rupture, embolic effects, and mass effect symptoms that can mislead the diagnosis to tumors rather than aneurysms. Their treatment is difficult and carries higher morbidity and mortality than usual aneurysms due to their complex nature. This study involved retrospective analysis of data of 28 patients, managed between 2006 and 2012, suffering from giant internal carotid artery (ICA) aneurysms with various presenting symptoms, none of which was hemorrhage. They were all evaluated by BOT prior to any intervention; they were subjected to various treatment strategies including selective coiling, parent artery occlusion with or without bypass, aneurysm trapping with or without bypass, and patients were followed for a period ranging from 6 months to 5 years. Out of 26 patients with giant aneurysms with mass effects, 16 patients showed full recovery (61.5 %), 5 showed partial improvement (19.2 %), and 5 showed no change in mass effect symptoms (19.2 %). One patient died (3.5 %). Symptoms such as TIA or epistaxis showed complete recovery. This study shows that a well-designed protocol aiming at parent artery sacrifice will yield good to excellent results in managing ICA giant aneurysms, and it also shows that parent artery sacrifice is superior to other forms of treatment of these lesions regarding recurrence rates, morbidity, and mortality.

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Abbreviations

A-com:

Anterior communicating artery

BOT:

Balloon occlusion test

ECA:

External carotid artery

ICA:

Internal carotid artery

MCA:

Middle cerebral artery

OA:

Ophthalmic artery

P-com:

Posterior communicating artery

PAO:

Parent artery occlusion

SAH:

Subarachnoid hemorrhage

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Authors and Affiliations

  1. Department of Neurosurgery, Alexandria University School of Medicine, Alexandria, Egypt

    Sherif Rashad, Tamer Hassan, Waseem Aziz & Ahmed Marei

Authors
  1. Sherif Rashad
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  2. Tamer Hassan
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  3. Waseem Aziz
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  4. Ahmed Marei
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Corresponding author

Correspondence to Tamer Hassan.

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Comments

Kenichi Sato, Teiji Tominaga, Sendai, Japan

Authors in this study proposed a protocol for therapeutic carotid artery occlusion in the management of symptomatic giant carotid artery aneurysms based on their six-year experience with 28 patients. Authors divided these patients into three groups according to arterial sites which aneurysms originated from: infraophthalmic (group A), ophthalmic (group B), and supraophthalmic (group C). Aneurysms of group A were successfully treated with proximal internal carotid artery occlusion by endovascular procedures as well as surgical ligation. Aneurysms of groups B and C were required to trap the segment of the internal carotid artery harboring aneurysm. In patients in group C, however, the clinical outcomes were obviously worse than those in group B primarily because of ischemic complications in the anterior choroidal artery territory. Authors performed balloon test occlusion of the internal carotid artery with induced hypotension and evaluated the tolerance against the internal carotid artery occlusion for all patients preoperatively. IC-EC bypass was performed, if needed.

The treatment for symptomatic giant carotid aneurysms remains challenging of all times. It is required to decide the treatment strategy carefully taking a side view of their pathophysiology in individual cases. For this, it is necessary to estimate patients’ ischemic tolerance against the occlusion of the internal carotid artery, the risk of the future recanalization in treated aneurysms, and the invasiveness of the treatment procedures. Nowadays, parent artery occlusion, endovascularly or surgically, with or without IC-EC bypass is the primary way for the treatment of symptomatic giant carotid aneurysms, while selective coiling into the aneurysms or the placement of flow diverter devices is the alternative because of less information on their long-term clinical outcome.

Finally, we congratulate authors on this well-designed study and good clinical results despite social and economical limitations in their country as they mentioned.

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Rashad, S., Hassan, T., Aziz, W. et al. Carotid artery occlusion for the treatment of symptomatic giant carotid aneurysms: a proposal of classification and surgical protocol. Neurosurg Rev 37, 501–511 (2014). https://doi.org/10.1007/s10143-014-0533-y

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  • DOI: https://doi.org/10.1007/s10143-014-0533-y

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