COMPLEX INTRACRANIAL ANEURYSMS - COMBINED OPERATIVE AND ENDOVASCULAR APPROACHES

OBJECTIVE: Endovascular management of complex intracranial aneurysms i s increasingly being considered as an alternative to standard surgical clipping, However, little attention has been paid to the complementar y nature of surgery and endovascular therapy. METHODS: Between Septemb er 1992 and May 1997, 12 patients with complex intracranial aneurysms were treated with combined operative and endovascular methods. Seven p atients demonstrated subarachnoid hemorrhage (two of Grade II, two of Grade III, and three of Grade IV). Five patients demonstrated unruptur ed aneurysms, i.e., three giant aneurysms (one vertebrobasilar junctio n aneurysm, one middle cerebral artery bifurcation aneurysm, and one i nternal carotid artery-ophthalmic artery aneurysm), one large internal carotid artery-ophthalmic artery aneurysm, and one middle cerebral ar tery serpentine aneurysm. Management strategies involved either surger y followed by endovascular therapy (S-E; n = 5) or endovascular therap y followed by surgery (E-S; n = 7). S-E paradigms included aneurysm ex ploration followed by endovascular treatment (S-E1; n = 3), partial an eurysm clipping followed by endovascular aneurysm packing (S-E2; n = 1 ), and extracranial-to-intracranial bypass followed by endovascular pa rent vessel occlusion (S-E3; n = 1). E-S paradigms included superselec tive angiography followed by surgical clipping (E-S1; n = 2), Guglielm i detachable coil partial dome packing followed by delayed surgical cl ipping (E-S2; n = 2), proximal temporary vessel balloon occlusion foll owed by aneurysm clipping (E-S3; n = 2), and proximal permanent vessel occlusion followed by surgical aneurysm decompression for mass effect treatment (E-S4; n = 1), RESULTS: Eleven aneurysms (92%) were complet ely eliminated. The remaining aneurysm was 90% obliterated and remaine d quiescent at the 34-month follow-up examination, despite presenting with subarachnoid hemorrhage. No Patient experienced repeat bleeding ( follow-up period, 23 +/- 28 mo). There were no deaths. One patient ach ieved a fair outcome (Glasgow Outcome Scale score of III); all other p atients experienced excellent outcomes (Glasgow Outcome Scale score of I). In all cases, the aneurysm management paradigm chosen had a posit ive effect on definitive therapy. CONCLUSION: Several factors can cont ribute to the complexity of intracranial aneurysms. Management strateg ies that combine operative and endovascular techniques in a complement ary way, for the best possible outcomes for these patients, can be des igned accordingly.