title: Combined endovascular and microsurgical management of complex cerebral aneurysms.
abstract: 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.
authors: Department of Neurosurgery, Stanford Stroke Center, Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine , Stanford, CA , USA.
authors: Omar
authors: O
authors: Choudhri
authors: Nitin
authors: N
authors: Mukerji
authors: Gary K
authors: GK
authors: Steinberg
keywords: coil embolization; combined therapy; complex aneurysms; microsurgical clipping; revascularization bypass; vessel sacrifice
references: AJNR Am J Neuroradiol. 2013 May;34(5):1022-7
references: 23124637
references: AJNR Am J Neuroradiol. 2012 Jan;33(1):159-63
references: 22033717
references: J Neurosurg. 2004 Jul;101(1):154-8
references: 15255267
references: N Engl J Med. 2012 Jun 28;366(26):2474-82
references: 22738097
references: Lancet. 2003 Jul 12;362(9378):103-10
references: 12867109
references: Neurosurg Clin N Am. 2005 Jul;16(3):475-85, v
references: 15990039
references: Neurosurgery. 1998 Dec;43(6):1304-12; discussion 1312-3
references: 9848843
references: J Clin Neurosci. 2008 Nov;15(11):1276-9
references: 18842411
references: Clin Neuroradiol. 2012 Dec;22(4):295-303
references: 23124329
references: Skull Base Surg. 1995;5(1):21-6
references: 17171153
references: Interv Neuroradiol. 2007 Mar 15;13 Suppl 1:68-72
references: 20566080
references: J Neurosurg. 1991 Jul;75(1):8-14
references: 2045924
references: Neurosurgery. 2011 Sep;69(3):677-88; discussion 688
references: 21471845
references: Neurosurg Clin N Am. 2005 Apr;16(2):223-9, vii
references: 15694154
references: World Neurosurg. 2012 Jan;77(1):76-7
references: 22405389
references: Surg Neurol. 1998 Oct;50(4):363-6
references: 9817461
references: Surg Neurol. 2009 Dec;72(6):596-606; discussion 606
references: 19818994
references: Neurosurgery. 2008 Jun;62(6):1236-49; discussion 1249-53
references: 18824990
references: Neurosurgery. 1997 Mar;40(3):442-50; discussion 450-1
references: 9055282
references: Lancet. 2002 Oct 26;360(9342):1267-74
references: 12414200
references: J Neuroradiol. 2011 Mar;38(1):40-6
references: 21257202
references: Interv Neuroradiol. 2000 Mar 30;6(1):61-4
references: 20667182
references: J Neurosurg. 2001 Jul;95(1):24-35
references: 11453395
references: Interv Neuroradiol. 1997 Mar 30;3(1):21-35
references: 20678369
references: Neurology. 2013 Jan 29;80(5):e56-9
references: 23359381
references: Neurosurgery. 2003 Feb;52(2):263-74; discussion 274-5
references: 12535354
references: Neurosurg Clin N Am. 2010 Apr;21(2):221-33
references: 20380965
references: J Neurosurg Sci. 2011 Sep;55(3):211-31
references: 21968585
references: J Neurosurg. 1990 Aug;73(2):305-6
references: 2366090
references: Neurosurgery. 2010 Jun;66(6):1128-33; discussion 1133
references: 20495427
references: Neurosurgery. 2009 May;64(5 Suppl 2):301-15; discussion 315-7
references: 19404109
references: Neurosurg Clin N Am. 2010 Apr;21(2):247-61
references: 20380967
references: J Neurosurg. 2003 Feb;98(2):319-25
references: 12593618
references: Neurosurgery. 2010 Aug;67(2):E521
references: 20644387
references: Neurosurgery. 2000 Jan;46(1):226-30; discussion 230-1
references: 10626956
references: J Endovasc Ther. 2002 Apr;9(2):160-4
references: 12010094
references: Neurosurgery. 2011 Dec;69(6):1261-70; discussion 1270-1
references: 21734614
references: Stroke. 2008 Oct;39(10):2720-6
references: 18669898
references: Clin Neurol Neurosurg. 2013 Aug;115(8):1343-9
references: 23352715
references: J Neurosurg. 2012 Jan;116(1):135-44
references: 22054213
references: J Korean Neurosurg Soc. 2008 Jan;43(1):21-5
references: 19096540
references: Acta Neurochir Suppl. 2013;115:113-7
references: 22890656
references: J Neurosurg. 2011 Jun;114(6):1768-77
references: 21314274
references: AJNR Am J Neuroradiol. 1995 Jan;16(1):15-8
references: 7900585
references: Neurosurgery. 1996 May;38(5):955-60; discussion 960-1
references: 8727821
references: J Neurosurg. 2013 Jul;119(1):146-57
references: 23621600
references: Neurosurg Focus. 2006 Jun 15;20(6):E3
references: 16819811
references: AJNR Am J Neuroradiol. 2001 Feb;22(2):345-51
references: 11156781