Combined endovascular and microsurgical management of complex cerebral aneurysms
- Department of Neurosurgery, Stanford Stroke Center, Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, CA, USA
Cerebral aneurysms are associated with a 50% mortality rate after rupture and patients can suffer significant morbidity during subsequent treatment. Neurosurgical management of both ruptured and unruptured aneurysms has evolved over the years. The historical practice of using microsurgical clipping to treat aneurysms has benefited in the last two decades from tremendous improvement in endovascular technology. Microsurgery and endovascular therapies are often viewed as competing treatments but it is important to recognize their individual limitations. Some aneurysms are considered complex, due to several factors such as aneurysm anatomy and a patient’s clinical condition. A complex aneurysm often cannot be completely excluded with a single approach and its successful treatment requires a combination of microsurgical and endovascular techniques. Planning such an approach relies on understanding aneurysm anatomy and thus should routinely include 3D angiographic imaging. In patients with ruptured aneurysms, endovascular coiling is a well-tolerated early treatment and residual aneurysms can be treated with intervals of definitive clipping. Microsurgical clipping also can be used to reconstruct the neck of a complex aneurysm, allowing successful placement of coils across a narrow neck. Endovascular techniques are assisted by balloons, which can be used in coiling and testing parent vessel occlusion before sacrifice. In some cases microsurgical bypasses can provide alternate flow for planned vessel sacrifice. We present current paradigms for combining endovascular and microsurgical approaches to treat complex aneurysms and share our experience in 67 such cases. A dual microsurgical–endovascular approach addresses the challenge of intracranial aneurysms. This combination can be performed safely and produces excellent rates of aneurysm obliteration. Hybrid angiographic operating-room suites can foster seamless and efficient complementary application of these two modalities.
Keywords: coil embolization, combined therapy, complex aneurysms, microsurgical clipping, revascularization bypass, vessel sacrifice
Citation: Choudhri O, Mukerji N and Steinberg GK (2013) Combined endovascular and microsurgical management of complex cerebral aneurysms. Front. Neurol. 4:108. doi: 10.3389/fneur.2013.00108
Received: 13 June 2013; Accepted: 19 July 2013;
Published online: 08 August 2013.
Edited by:Christopher Sean Eddleman, UT Southwestern Medical Center at Dallas, USA
Reviewed by:Elias A. Giraldo, Drexel University College of Medicine, USA
Ashish Nanda, University of Missouri, USA
Copyright: © 2013 Choudhri, Mukerji and Steinberg. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Gary K. Steinberg, Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive R281, Stanford, CA 94305-5327, USA e-mail: email@example.com