Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion.
Pipeline Embolization Devices (PEDs) have been shown to be effective for intracranial internal carotid artery (ICA) aneurysms, and are now approved by the FDA specifically for this use. Potential pitfalls, however, have not yet been described in the pediatric neurosurgical literature. The authors report on a 10-year-old boy who presented to the Barrow Neurological Institute after progressive visual decline. He had undergone placement of a total of 7 telescoping PEDs at another facility for a large ICA aneurysm. Residual filling of the aneurysm and significant expansion of intraaneurysmal thrombus with chiasmal compression on admission images were causes for concern. The patient underwent a surgical bailout with a superficial temporal artery-middle cerebral artery bypass, with parent artery occlusion. Postoperative vascular imaging was notable for successful occlusion of the parent vessel, with no evidence of filling of the aneurysm. Reports on the pitfalls of PEDs in the neurosurgical literature are scarce. To the authors' knowledge this represents the first paper describing a successful open surgical bailout for residual aneurysmal filling and expansion of thrombus after placement of a PED.
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
Adib A
AA
Abla
Hasan A
HA
Zaidi
R Webster
RW
Crowley
Gavin W
GW
Britz
Cameron G
CG
McDougall
Felipe C
FC
Albuquerque
Robert F
RF
Spetzler
D002340:Carotid Artery Diseases / Q000628:therapy*; D002343:Carotid Artery, Internal / Q000473:pathology / Q000601:surgery*; D002533:Cerebral Angiography; D002548:Cerebral Revascularization / Q000379:methods*; D002648:Child; D003251:Constriction, Pathologic / Q000209:etiology; D003399:Craniotomy; D004621:Embolization, Therapeutic / Q000295:instrumentation*; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery; D008279:Magnetic Resonance Imaging; D008297:Male; D020768:Middle Cerebral Artery / Q000601:surgery*; D009897:Optic Chiasm / Q000473:pathology* / Q000601:surgery*; D013699:Temporal Arteries / Q000601:surgery*; D013927:Thrombosis / Q000209:etiology / Q000601:surgery*; D017211:Treatment Failure; D016896:Treatment Outcome
AP = anteroposterior; ICA = internal carotid artery; MCA = middle cerebral artery; MRA = MR angiography; PED = Pipeline Embolization Device; Parry-Romberg syndrome; Pipeline Embolization Device; RA = radial artery; STA = superficial temporal artery; aneurysm; bypass; chiasmopathy; optic chiasm; parent vessel occlusion; vascular disorders