Proximal Internal Carotid Artery Occlusion and Extracranial-Intracranial Bypass for Treatment of Fusiform and Giant Internal Carotid Artery Aneurysms

Sophie M Peeters; Geoffrey P Colby; Wi Jin Kim; Whi Inh Bae; Hiro Sparks; Kara Reitz; Satoshi Tateshima; Reza Jahan; Viktor Szeder; May Nour; Gary R Duckwiler; Fernando Vinuela; Neil A Martin; Anthony C Wang

doi:10.1016/j.wneu.2023.09.097

Proximal Internal Carotid Artery Occlusion and Extracranial-Intracranial Bypass for Treatment of Fusiform and Giant Internal Carotid Artery Aneurysms

World Neurosurg. 2023 Dec:180:e494-e505. doi: 10.1016/j.wneu.2023.09.097. Epub 2023 Sep 27.

Authors

Affiliations

¹ Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
² Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
³ David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
⁴ Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
⁵ Pacific Neuroscience Institute, Santa Monica, California, USA.
⁶ Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA. Electronic address: ACWang@mednet.ucla.edu.

PMID: 37774787
DOI: 10.1016/j.wneu.2023.09.097

Abstract

Objective: To discuss the treatment of intracranial fusiform and giant internal carotid artery (ICA) aneurysms via revascularization based on our institutional experience.

Methods: An institutional review board-approved retrospective analysis was performed of patients with unruptured fusiform and giant intracranial ICA aneurysms treated from November 1991 to May 2020. All patients were evaluated for extracranial-intracranial (EC-IC) bypass and ICA occlusion.

Results: Thirty-eight patients were identified. Initially, patients failing preoperative balloon test occlusion were treated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and concurrent proximal ICA ligation. We then treated them with STA-MCA bypass, followed by staged balloon test occlusion, and, if they passed, endovascular ICA coil occlusion. We treat all surgical medically uncomplicated patients with double-barrel STA-MCA bypass and concurrent proximal ICA ligation. The mean length of follow-up was 99 months. Symptom stability or improvement was noted in 85% of patients. Bypass graft patency was 92.1%, and all surviving patients had patent bypasses at their last angiogram. Aneurysm occlusion was complete in 90.9% of patients completing proximal ICA ligation. Three patients experienced ischemic complications and 4 patients experienced hemorrhagic complications.

Conclusions: Not all fusiform intracranial ICA aneurysms require intervention, except when life-threatening rupture risk is high or symptomatic management is necessary to preserve function and quality of life. EC-IC bypass can augment the safety of proximal ICA occlusion. The rate of complete aneurysm occlusion with this treatment is 90.9%, and long-term bypass graft-related complications are rare. Perioperative stroke is a major risk, and continued evolution of treatment is required.

Keywords: Cerebral aneurysm; Extracranial-intracranial bypass; Fusiform aneurysm; Giant aneurysm; Revascularization; STA-MCA bypass.

MeSH terms

Carotid Artery Diseases* / diagnostic imaging
Carotid Artery Diseases* / surgery
Carotid Artery, Internal / diagnostic imaging
Carotid Artery, Internal / surgery
Cerebral Revascularization*
Humans
Intracranial Aneurysm* / diagnostic imaging
Intracranial Aneurysm* / surgery
Postoperative Complications
Quality of Life
Retrospective Studies
Thrombosis*