Tailored flow sequestration treatment using high-flow and low-flow bypass for partially thrombosed giant internal carotid artery aneurysm-a technical case report.
Direct clipping of giant partially thrombosed intracranial internal carotid artery (ICA) aneurysms is challenging, especially when important perforating arteries are involved. Proximal occlusion with bypass represents a possible alternative approach. An 80-year-old female presented with worsening visual acuity and severe headache caused by partially thrombosed giant (38 mm in diameter) aneurysms of the right ICA, suggestive of impending rupture. Direct clipping in conjunction with temporary occlusion of the lesion involving the anterior choroidal artery (AChA) was considered too risky. Thus, we sequestrated the ipsilateral ICA flow into a low-flow and a high-flow system using two external carotid artery (ECA)-ICA bypasses and one in situ bypass with cervical ICA ligation. As a result, the low-flow system by the superficial temporal artery-middle cerebral artery (MCA) bypass perfused mainly the proximal MCA lesions and aneurysm, whereas the high-flow system by ECA-radial artery-M2 bypass exclusively supplied the residual distal MCA area. This tailored flow sequestration successfully interrupted intra-aneurysmal flow and accelerated near-complete thrombosis of the aneurysm while preserving the AChA and avoiding any significant neurological deterioration. We conclude that this method is effective for the management of giant partially thrombosed aneurysms of the ICA, especially when direct clipping is difficult.
Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya-shi, Shizuoka, 418-0021, Japan. hirohasegawa-tky@umin.ac.jp.
Hirotaka
H
Hasegawa
Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya-shi, Shizuoka, 418-0021, Japan.
Tomohiro
T
Inoue
Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya-shi, Shizuoka, 418-0021, Japan.
Akira
A
Tamura
Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya-shi, Shizuoka, 418-0021, Japan.
Isamu
I
Saito
D000369:Aged, 80 and over; D002340:Carotid Artery Diseases / Q000473:pathology / Q000601:surgery; D002343:Carotid Artery, Internal / Q000601:surgery*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D020768:Middle Cerebral Artery / Q000601:surgery*; D013927:Thrombosis / Q000473:pathology / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000379:methods
Extracranial-intracranial arterial bypass; Flow sequestration; Giant intracranial aneurysm; In situ arterial bypass; Radial artery graft