- Department of Neurosurgery, Udine University-Hospital P. le S. Maria della Misericordia 15, 33100, Udine, Italy
- Department of Neuroradiology, Udine University-Hospital P. le S. Maria della Misericordia 15, 33100, Udine, Italy
Department of Neurosurgery, Udine University-Hospital P. le S. Maria della Misericordia 15, 33100, Udine, Italy
DOI:10.4103/2152-7806.155802Copyright: © 2015 Skrap M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Skrap M, Petralia B, Toniato G. The combined treatment of stenting and surgery in a giant unruptured aneurysm of the middle cerebral artery. Surg Neurol Int 24-Apr-2015;6:67
How to cite this URL: Skrap M, Petralia B, Toniato G. The combined treatment of stenting and surgery in a giant unruptured aneurysm of the middle cerebral artery. Surg Neurol Int 24-Apr-2015;6:67. Available from: http://sni.wpengine.com/surgicalint_articles/combined-treatment-stenting-surgery-giant-unruptured-aneurysm-middle-cerebral-artery/
Background:This case study reports on a combined therapy of stenting and surgery for a giant unruptured middle cerebral artery (MCA) aneurysm with the aim of preserving the patency of the vessel during surgery.
Case description:A 51-year-old male presented with a sudden onset of moderate left hemiparesis and dysarthria. Neuro-radiological evaluations showed a giant right unruptured MCA aneurysm without subarachnoid hemorrhage (SAH). The cerebral angiography confirmed the presence of such an aneurysm producing compression of both M2 branches with consequent slowing of the blood flow. Two weeks later, the patient underwent the positioning of an Enterprise stent and inside this, a flow diverter Silk stent. They were placed across the aneurysm and in one of the two M2 branches with the aim of protecting them during surgical manipulation. The patient went immediately to surgery, where the aneurysm was resected and both M2 branches decompressed.
Conclusion:The combined placement of the stents allowed safe and successful surgical dissection of the M2 branches and clipping of the aneurysm without interrupting the blood flow.
Keywords: Aneurysm, clip, combined treatment, stent
The endovascular treatment of intracranial aneurysms is well-defined in neurosurgery and its role is becoming increasingly preeminent, thanks to continuous technical improvements.[
Clinical history and baseline data
A 51-year-old male was hospitalized in our department following sudden onset of a left hemiparesis. The cerebral computed tomography (CT) and the computed tomographic angiogram (CTA) scans, carried out at admission, showed a right giant MCA aneurysm without subarachnoid hemorrhage (SAH) but with mass effect [
(a,b) The baseline cerebral angiography showed a giant right MCA aneurysm with the largest perpendicular diameters at the anteroposterior projection of about 20 × 30 mm. Note the delayed and reduced contrast opacification (a and b, black arrows) of the MCA distal to the aneurysm. (c) The slowing of the blood flow (c, black arrow) was well-evident in venous phase
Therapeutic strategy and clinical neuroradiological follow-up
With the aim of avoiding any interruption of the bood flow, we decided to perform a combined therapeutic strategy with stenting and surgery. The stenting would protect the MCA and its branches during the surgical maneuvers of dissection and clipping of the aneurysm.
On the day of surgery under general anesthesia in the radiology unit, an Enterprise stent (4.5 × 37 mm) (Cordis Neurovascolar, Miami Lakes, Florida, USA) was first placed from the right carotid dichotomy to the proximal M2 segment of the inferior trunk. Afterwards a flow diverter Silk stent (2.5 × 15 mm) (Balt, Montmorency, France) from the distal M1 segment to the proximal M2 segment of the inferior trunk was placed to complete the coverage of the aneurysmal neck. No stent was placed in the M2 superior thinner trunk of the right MCA. At the end of the endovascular procedure, an angiogram was performed, which showed a major staunching of blood within the sac, patency of the MCA, and the correct position of both stents [
(a,b) The M2 inferior branch was sharply dissected from the wall of the giant aneurysm with a microblade, the vessel kept his steadiness facilitating the dissection and the branch of the MCA maintained the shape thanks to the Silk stent (b, black continued arrow) and the Enterprise stent (b, black interrupted arrow). (c) The dissection of the M2 superior branch with the exposure of adequate working-space around neck aneurysm for clipping. (d) Note the clipping of the aneurysm with three clips and patency of the protected neck
After surgery the patient remained in the intensive care unit for 2 days. Upon awakening, he showed a moderate left hemiparesis, which improved 3 weeks after surgery. A postoperative CT showed hypodensity around the surgical field [
Cerebral angiography monitoring at 1-year showed the complete exclusion of the aneurysmal sac, no delay in the venous phase was seen while optimal flow through both M2 branches was noted [
Anticoagulant and antiplatelet therapy management
An important issue is the management of the anticoagulant/antiplatelet therapy. We use a standard protocol for stenting alone or with coiling as follows: 5 days of double antiplatelet theraphy before the procedure with acetylsalicylic acid (100 mg once daily) and clopidrogel (75 mg once daily), a bolus of 5000 UI of heparin at benning of the treatment followed by 1000 UI of heparin hourly during the procedure. After that, we administer both antiplatelet drugs for the first 3 months and then only acetylsalicylic acid for the following 2 months after the procedure at dosages reported in the pretreatment regimen.
In this case, we decided to modify the standard therapy on the days before and on the day of combined treatment.
Three days before the combined treatment, prophylaxis with heparin, started at admission, was interrupted and antiplatelet therapy only with acetylsalicylic acid (100 mg once daily) was administered orally. On the day of combined treatment, a double pharmacological antiplatelet therapy was administered. Acetylsalicylic acid (100 mg once daily) was administered before the stenting and clopidrogel (75 mg once daily) just after closing the duramater. No bolus of heparin was administered at the beginning of endovascular procedure. However, as in all endovascular procedures, all pressure washing systems were fully heparinized. One day after surgery, the patient started with the standard therapy with both antiplatelet drugs for the first 3 months and then with acetylsalicylic acid only for the following 2 months at the usual dosages. No particular problems of immediate or later bleeding with the wound was managed in this case.
Intracranial giant aneurysms are severe neurovascular lesions, which should be treated aggressively considering their poor natural history.[
Moreover, among different surgical strategies documented in the literature, direct clipping[
In our case, the main problem was insufficient vascular blood flow distally to the giant MCA aneurysm due to the aneurysmal mass effect on M2 branches. The situation was clear with the CTA at admission, and later it was confirmed by the angiogram. Esteban et al.[
In the reported case, the aneurysmal compression on the M1 tract-M2 branches was persistent and likely also affected the lenticulostriate arteries around the MCA bifurcation. For this reason we have considered at risk any strategy that would accept any form of even temporary proximal occlusion of MCA. Consequently, despite the devolopment of endovascular technology,[
In this case, we also retained that direct clipping of the aneurysm would also create the risk of spasm and damage to the M2 branches during their dissection. Furthermore, the clipping itself, due to the thickness of the wall, would increase the risk of losing the patency of MCA at the level of the neck during the surgical maneuvers. We did not trust the possibility of a compensatory blood pressure augmentation and burst suppression as we would probably need them for a longer period.
Evaluating then the strategy of revascularization with high-flow bypass, the compressed recipient M2 vessels, partially hidden by the aneurysmal sac, would be too thin to build a safe and patent bypass, apart from the usual well known problem of the temporary occlusion of a M2 branch. Neither did we consider a low-flow bypass sufficient. The low-flow bypass could be anyway inadequate or, in any case, would need a longer time to become functionally helpful, while the clinical situation required more urgent therapeutical management.
We decided finally to adopt a combined strategy that would keep the vascularization during the entire procedure. In the literature, a combined treatment approach for the same aneurysm has been described in the following different situations: (i) Delayed endovascular[
Another issue in this case was the antiplatelet and heparinic anticoagulant drug therapy before, during, and after the combined treatment. According to several authors,[
The combined treatment of a giant aneurysm with stenting, followed by immediate clipping, may be taken into consideration, whenever it is necessary to protect and strengthen the arterial walls during surgical maneuvers. Selected neoplastic lesions might also benefit from this strategy.
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