Combined open and endovascular surgery for complex cerebral aneurysms

In the treatment of cerebral aneurysms, a combination of open and endovascular surgeries may be necessary when simple clipping or coiling are difficult. The authors retrospectively analyzed such patients to clarify the current status and issues to be overcome. Between 2003 and 2012, clipping was selected as the first choice until 2007 and coiling thereafter. Five representative cases with the combination therapy are presented. Case 1:A giant internal carotid artery (IC) aneurysm at the cavernous portion was treated with a high flow bypass and parent artery occlusion, based on the finding of the preoperative balloon test occlusion which revealed severe reduction of cerebral blood flow upon IC occlusion. Case 2: A ruptured vertebral artery dissection involving the posterior inferior cerebellar artery (PICA) was treated with the occipital artery (OA) - PICA bypass followed by internal trapping of the dissection and the parent artery with a coil. Wallenberg syndrome developed, but the patient became independent. Case 3: A giant basilar artery- superior cerebellar artery (SCA) aneurysm was treated with a superficial temporal artery- SCA bypass followed by coil embolization of the aneurysm sac, because the SCA originated from the dome of the aneurysm. Case 4: Clipping was intended for so-called kissing aneurysms, comprising IC-posterior communicating artery (Pcom) and anterior choroidal aneurysms; however, adhesion between the aneurysms and with the Pcom itself was too tight to dissect. After discussion with the endovascular surgeons, the clipping was abandoned and coil embolization was successfully performed one month later. Case 5: A case of a subarachnoid hemorrhage with IC-PC and basilar tip aneurysms. Coiling was intended for both aneurysms in the acute stage. It was revealed during the coiling procedure for the basilar tip aneurysm that one of the two humps of the aneurysm was difficult to occlude completely. A perforating artery of the basilar tip was shown by microcatheter angiography. The surgical team was consulted and the basilar tip aneurysm was clipped successfully after coiling of the IC-PC aneurysm. For aneurysms which are difficult to treat with simple clipping or coiling, a combination of open and endovascular surgeries may play a valuable role after effective communication between the neurosurgeons and endovascular surgeons. There remain certain limitations in terms of completeness of the aneurysm occlusion and perforators which still need to be overcome.