Advertisement

Anterior Communicating Artery Aneurysm: Previously Ruptured and Clipped Anterior Communicating Artery Aneurysm; Incidental Aneurysm Recurrence or Remnant; Endovascular Treatment with a Pipeline Embolization Device and Long-Term Follow-Up

  • Pablo Albiña
  • Rene Viso
  • Ivan Lylyk
  • Jorge Chudyk
  • Pedro LylykEmail author
Living reference work entry
  • 26 Downloads

Abstract

A 42-year-old woman underwent microsurgical clipping of a previously ruptured anterior communicating artery (AcomA) aneurysm in another institution, and her follow-up was performed at our institution. Surgery was performed 8 months (after the first rupture) and 3 months (after the second hemorrhage) before being admitted to our clinic. DSA revealed an aneurysm sac remnant or recurrence, which was treated with a Pipeline Embolization Device (Medtronic) with no periprocedural complications. A good clinical outcome and a successfully obliterated aneurysm were confirmed with angiography. MRI ruled out cerebral ischemia. Incompletely treated aneurysms carry a significant risk of rupture and re-rupture, and several strategies for their diagnosis and treatment have been evaluated. Currently, three-dimensional digital subtraction angiography (3D DSA) is considered the imaging method of choice for failed aneurysm surgery evaluation, mainly when multiple clips have been applied or when the remnants are small (≤ 2 mm diameter). Clinical trials have demonstrated low rebleeding rates after microsurgical aneurysm clipping; however, aneurysm remnants and recurrent hemorrhage after clip ligation are well-recognized. If an AcomA aneurysm remnant or recurrence after surgery is identified, repeat microsurgical treatment is not always possible in this location. Retreatment of a previously clipped aneurysm by endovascular means is considered an example of a “hybrid” approach. Such combined treatment strategies bring many advantages to the field, and their origin dates back to the early days of endovascular therapy. Recently published experience with the use of flow diverters for the retreatment of AcomA aneurysms after microsurgical clipping has shown a >80% occlusion rate and a low incidence of complications. The feasibility of flow diversion treatment for remnants and recurrences of previously clipped AcomA aneurysms not amenable to conventional treatment methods is the main topic of this chapter.

Keywords

Anterior communicating artery Pipeline Embolization Device Failed aneurysm surgery Hybrid approach Aneurysm remnant Aneurysm recurrence 

References

  1. Ahn SS, Kim YD. Three-dimensional digital subtraction angiographic evaluation of aneurysm remnants after clip placement. J Korean Neurosurg Soc. 2010;47(3):185–90.  https://doi.org/10.3340/jkns.2010.47.3.185.CrossRefPubMedPubMedCentralGoogle Scholar
  2. Alderazi YJ, Shastri D, Kass-Hout T, Prestigiacomo CJ, Gandhi CD. Flow diverters for intracranial aneurysms. Stroke Res Treat. 2014;2014:415653.  https://doi.org/10.1155/2014/415653.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ, Woo HH, Lopes DK, Berez AL, Cher DJ, Siddiqui AH, Levy EI, Albuquerque FC, Fiorella DJ, Berentei Z, Marosfoi M, Cekirge SH, Nelson PK. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. 2013;267(3):858–68.  https://doi.org/10.1148/radiol.13120099.CrossRefPubMedGoogle Scholar
  4. CARAT Investigators. Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment. Stroke. 2006;37(6):1437–42.  https://doi.org/10.1161/01.STR.0000221331.01830.ce.CrossRefGoogle Scholar
  5. Colby GP, Bender MT, Lin LM, Beaty N, Huang J, Tamargo RJ, Coon AL. Endovascular flow diversion for treatment of anterior communicating artery region cerebral aneurysms: a single-center cohort of 50 cases. J Neurointerv Surg. 2017;9(7):679–85.  https://doi.org/10.1136/neurintsurg-2016-012946.CrossRefPubMedGoogle Scholar
  6. Dabus G, Grossberg JA, Cawley CM, Dion JE, Puri AS, Wakhloo AK, Gonsales D, Aguilar-Salinas P, Sauvageau E, Linfante I, Hanel RA. Treatment of complex anterior cerebral artery aneurysms with pipeline flow diversion: mid-term results. J Neurointerv Surg. 2017;9(2):147–51.  https://doi.org/10.1136/neurintsurg-2016-012519.CrossRefPubMedGoogle Scholar
  7. David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg. 1999;91(3):396–401.  https://doi.org/10.3171/jns.1999.91.3.0396.CrossRefPubMedGoogle Scholar
  8. Dawbarn RHM. The starvation operation for malignancy in the external carotid area. Its failures and successes. JAMA. 1904;XLIII(12):792–5.  https://doi.org/10.1001/jama.1904.92500120002g.CrossRefGoogle Scholar
  9. Dehdashti AR, Binaghi S, Uske A, Regli L. Comparison of multislice computerized tomography angiography and digital subtraction angiography in the postoperative evaluation of patients with clipped aneurysms. J Neurosurg. 2006;104(3):395–403.  https://doi.org/10.3171/jns.2006.104.3.395.CrossRefPubMedGoogle Scholar
  10. Drake CG, Vanderlinden RG. The late consequences of incomplete surgical treatment of cerebral aneurysms. J Neurosurg. 1967;27(3):226–38.  https://doi.org/10.3171/jns.1967.27.3.0226.CrossRefPubMedGoogle Scholar
  11. Griessenauer CJ, Ogilvy CS, Foreman PM, Chua MH, Harrigan MR, He L, Fusco MR, Mocco JD, Stapleton CJ, Patel AB, Sonig A, Siddiqui AH, Thomas AJ. Pipeline embolization device for small intracranial aneurysms: evaluation of safety and efficacy in a multicenter cohort. Neurosurgery. 2017;80(4):579–87.  https://doi.org/10.1227/NEU.0000000000001377.CrossRefPubMedGoogle Scholar
  12. Gross BA, Albuquerque FC, Moon K, Ducruet AF, McDougall CG. Endovascular treatment of previously clipped aneurysms: continued evolution of hybrid neurosurgery. J Neurointerv Surg. 2017;9(2):169–72.  https://doi.org/10.1136/neurintsurg-2016-012625.CrossRefPubMedGoogle Scholar
  13. Hayakawa M, Murayama Y, Duckwiler GR, Gobin YP, Guglielmi G, Viñuela F. Natural history of the neck remnant of a cerebral aneurysm treated with the Guglielmi detachable coil system. J Neurosurg. 2000;93(4):561–8.  https://doi.org/10.3171/jns.2000.93.4.0561.CrossRefPubMedGoogle Scholar
  14. Jabbarli R, Pierscianek D, Wrede K, Dammann P, Schlamann M, Forsting M, Müller O, Sure U. Aneurysm remnant after clipping: the risks and consequences. J Neurosurg. 2016;125(5):1249–55.  https://doi.org/10.3171/2015.10.JNS151536.CrossRefPubMedGoogle Scholar
  15. Johnston SC, Dowd CF, Higashida RT, Lawton MT, Duckwiler GR, Gress DR, CARAT Investigators. Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the cerebral aneurysm Rerupture after treatment (CARAT) study. Stroke. 2008;39(1):120–5.  https://doi.org/10.1161/STROKEAHA.107.495747.CrossRefPubMedGoogle Scholar
  16. Kang HS, Han MH, Kwon BJ, Jung SI, Oh CW, Han DH, Chang KH. Postoperative 3D angiography in intracranial aneurysms. AJNR Am J Neuroradiol. 2004;25(9):1463–9.PubMedGoogle Scholar
  17. Le Roux PD, Elliott JP, Eskridge JM, Cohen W, Winn HR. Risks and benefits of diagnostic angiography after aneurysm surgery: a retrospective analysis of 597 studies. Neurosurgery. 1998;42(6):1248–54; discussion 1254–5.  https://doi.org/10.1097/00006123-199806000-00026.CrossRefPubMedGoogle Scholar
  18. Li H, Pan R, Wang H, Rong X, Yin Z, Milgrom DP, Shi X, Tang Y, Peng Y. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke. 2013;44(1):29–37.  https://doi.org/10.1161/STROKEAHA.112.663559.CrossRefPubMedGoogle Scholar
  19. Lin LM, Iyer RR, Bender MT, Monarch T, Colby GP, Huang J, Tamargo RJ, Coon AL. Rescue treatment with pipeline embolization for postsurgical clipping recurrences of anterior communicating artery region aneurysms. Interv Neurol. 2017;6(3–4):135–46.  https://doi.org/10.1159/000460264.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Mira JM, Costa FA, Horta BL, Fabião OM. Risk of rupture in unruptured anterior communicating artery aneurysms: meta-analysis of natural history studies. Surg Neurol. 2006;66(Suppl 3):S12–9; discussion S19.  https://doi.org/10.1016/j.surneu.2006.06.025.CrossRefPubMedGoogle Scholar
  21. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):1267–74.  https://doi.org/10.1016/s0140-6736(02)11314-6.CrossRefPubMedGoogle Scholar
  22. Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol. 2011;32(1):34–40.  https://doi.org/10.3174/ajnr.A2421.CrossRefPubMedGoogle Scholar
  23. Patel PD, Chalouhi N, Atallah E, Tjoumakaris S, Hasan D, Zarzour H, Rosenwasser R, Jabbour P. Off-label uses of the pipeline embolization device: a review of the literature. Neurosurg Focus. 2017;42(6):E4.  https://doi.org/10.3171/2017.3.FOCUS1742.CrossRefPubMedGoogle Scholar
  24. Proust F, Hannequin D, Langlois O, Freger P, Creissard P. Causes of morbidity and mortality after ruptured aneurysm surgery in a series of 230 patients. The importance of control angiography. Stroke. 1995;26(9):1553–7.CrossRefGoogle Scholar
  25. Rauzzino MJ, Quinn CM, Fisher WS 3rd. Angiography after aneurysm surgery: indications for “selective” angiography. Surg Neurol. 1998;49(1):32–40; discussion 40-1CrossRefGoogle Scholar
  26. Saleme S, Iosif C, Ponomarjova S, Mendes G, Camilleri Y, Caire F, Boncoeur MP, Mounayer C. Flow-diverting stents for intracranial bifurcation aneurysm treatment. Neurosurgery. 2014;75(6):623–31. quiz 631.  https://doi.org/10.1227/NEU.0000000000000522.CrossRefPubMedGoogle Scholar
  27. Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. 1974. J Neurosurg. 2007;107(3):684–705.  https://doi.org/10.3171/JNS-07/09/0684.CrossRefPubMedGoogle Scholar
  28. Sindou M, Acevedo JC, Turjman F. Aneurysmal remnants after microsurgical clipping: classification and results from a prospective angiographic study (in a consecutive series of 305 operated intracranial aneurysms). Acta Neurochir. 1998;140(11):1153–9.CrossRefGoogle Scholar
  29. Sultan-Qurraie A, Sattar A, Wazni W, Noufal M, Zaidat O. Anterior communicating artery aneurysm treatment with the pipeline embolization device: a single-center experience with long-term follow-up. Interv Neurol. 2017;6(3–4):126–34.  https://doi.org/10.1159/000456552.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Suzuki J, Kwak R, Katakura R. Review of incompletely occluded surgically treated cerebral aneurysms. Surg Neurol. 1980;13(4):306–10.PubMedGoogle Scholar
  31. Tsutsumi K, Ueki K, Morita A, Usui M, Kirino T. Risk of aneurysm recurrence in patients with clipped cerebral aneurysms: results of long-term follow-up angiography. Stroke. 2001;32(5):1191–4.CrossRefGoogle Scholar
  32. van Rooij WJ, Sluzewski M. Perforator infarction after placement of a pipeline flow-diverting stent for an unruptured A1 aneurysm. AJNR Am J Neuroradiol. 2010;31(4):E43–4.  https://doi.org/10.3174/ajnr.A2034.CrossRefPubMedGoogle Scholar
  33. Werner SC, Blakemore AH, King BG. Aneurysm of the internal carotid artery within the skull: wiring and electrothermic coagulation. JAMA. 1941;116(7):578–82.  https://doi.org/10.1001/jama.1941.02820070028006.CrossRefGoogle Scholar
  34. Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O’Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC. International study of unruptured intracranial aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362(9378):103–10.  https://doi.org/10.1016/s0140-6736(03)13860-3.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Pablo Albiña
    • 1
    • 2
  • Rene Viso
    • 1
  • Ivan Lylyk
    • 1
  • Jorge Chudyk
    • 1
  • Pedro Lylyk
    • 1
    Email author
  1. 1.Clinica La Sagrada Familia, ENERIBuenos AiresArgentina
  2. 2.Neurosurgery DivisionHospital Barros Luco TrudeauSantiagoChile

Personalised recommendations