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Microsurgery of Cerebral Aneurysms Not Amenable to Endovascular Therapy

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Endovascular Surgery of Cerebral Aneurysms

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Abstract

Over the last decade, there has been refinement in both microsurgical techniques as well as endovascular therapy (EVT) for the management of giant intracranial aneurysms (GIAs) and blood blister-like aneurysms (BBAs). Both of them come with their own set of problems in there management. GIAs are treacherous lesions with grave prognosis, and their management is problematic because of the wide atheromatous neck, involved branches, thrombus within, calcified wall, and complex anatomy resulting in a combined surgical morbidity and mortality that remains in the range of 20–30%. Posterior circulation aneurysms have a higher rupture risk (RR) over anterior circulation. While small saccular aneurysms are optimally excluded from circulation by EVT, there is a high failure rate after EVT of GIAs. Failures of EVT are often related to aneurysm morphology, a broad aneurysm neck (high neck: dome ratio), large and giant-size outflow arteries arising from the aneurysm base or walls, and fusiform/dolichoectatic morphology. An aneurysm with a broad neck can result in the herniation of coils into the parent artery lumen. Balloon- and stent-assisted coiling techniques are useful but are associated with the additional risk of parent artery ischemia, perforation, distal thromboembolism, and occlusion of adjacent perforators and branch arteries by the lattice of the stent. The rate of recurrence is also higher in broad neck aneurysms because the hemodynamics at the inflow zone is more complex. The other reasons for failure are incomplete initial obliteration, thrombus within the lumen, poor radiographic visualization of the aneurysm anatomy and its adjacent branches, and tortuosity of the feeding vessel, making catheterization difficult. Flow diverters are exciting, but it is still early days for prime time. Improvements in instrumentation and hardware, application of skull base surgical techniques, revascularization procedures, advances in anesthetic techniques like cerebral protection, adenosine-induced cardiac standstill, rapid ventricular pacing and hypothermic circulatory arrest, and intraoperative indocyanine green (ICG) angiography have made microsurgery a relatively safe and also a cost-effective option over EVT. Treatment of complex aneurysms like GIAs and BBAs is challenging. The modalities of treatment, microsurgery, EVT, or combined should be individualized taking into consideration the patient and pathological factors and available expertise. Although EVT is an attractive option, the high incidence of incomplete treatment, delayed complications, recurrence, and inadequate long-term follow-up data makes microsurgery relevant.

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  1. Department of Neurosurgery & Gamma Knife Radiosurgery, P.D. Hinduja Hospital & MRC, Mahim, Mumbai, India

    Abhijit G. Warade & Basant K. Misra

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Correspondence to Basant K. Misra .

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  1. Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China

    Xianli Lv

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Warade, A.G., Misra, B.K. (2022). Microsurgery of Cerebral Aneurysms Not Amenable to Endovascular Therapy. In: Lv, X. (eds) Endovascular Surgery of Cerebral Aneurysms. Springer, Singapore. https://doi.org/10.1007/978-981-16-7102-9_15

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