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Vol. 31. Issue 4.
Pages 173-183 (July - August 2020)
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Vol. 31. Issue 4.
Pages 173-183 (July - August 2020)
Clinical Research
DOI: 10.1016/j.neucie.2019.10.002
Treatment of complex intracranial pathologies with transcirculation endovascular approaches
Tratamiento de enfermedades intracraneales complejas con enfoques endovasculares de transcirculación
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Michael A. Silvaa, Alfred P. Seeb,
Corresponding author
alfredpsee@gmail.com

Corresponding author.
, Samir Sura, Mohammad A. Aziz-Sultanb
a Department of Neurosurgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA
b Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Article information
Abstract
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Abstract
Object

The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques.

Methods

A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated.

Results

Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma.

Conclusions

Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients.

Keywords:
Endovascular
Aneurysms
Transcirculation
Coiling
Pipeline
Flow diversion
Abbreviations:
MCA
ICA
AVM
ACA
A1
PICA
AICA
SCA
PCoA
CSF
PED
MRI
CT
SAH
tPA
ACoA
VA
Resumen
Objetivo

La variedad y la complejidad de las enfermedades neurovasculares tratadas con neurocirugía endovascular ha aumentado drásticamente en los últimos años. Muchos aneurismas continúan siendo difíciles de tratar de forma segura. Los enfoques de transcirculación (contralateral y/o retrógrada) a través del círculo de Willis son alternativas útiles para el tratamiento endovascular de lesiones difíciles. Presentamos una serie de casos de pacientes tratados con técnicas de transcirculación no convencionales.

Métodos

Se trató a un total de 6 pacientes que inicialmente se creía que no eran aptos para el tratamiento endovascular: 4 pacientes con 5 aneurismas, un paciente con un ictus de la arteria cerebral media (ACM) y un paciente con un meningioma que requería embolización preoperatoria. Se tomó la decisión de tratar a estos pacientes con métodos de transcirculación. Todos los pacientes fueron tratados por un solo especialista. Se localizaron y trataron un aneurisma en el segmento cavernoso de la arteria carótida interna (ACI), otro en la arteria vertebral, 2 en el segmento paraclinoideo de la ACI y otro en una malformación arteriovenosa cerebelosa de un vaso nutriente.

Resultados

Cinco de los 6 pacientes (83%) alcanzaron una recuperación neurológica completa. Se trataron 3 aneurismas hasta una oclusión completa, un aneurisma se dejó con un pequeño relleno de cuello residual y otro aneurisma no pudo ser tratado. Un paciente fue sometido a una trombectomía mecánica de un émbolo en la ACM y el relleno de la ACM se restauró después del tratamiento. Un paciente se sometió a embolización completa del riego vascular profundo de un meningioma.

Conclusiones

Aunque muchas enfermedades neurovasculares siguen sin ser adecuadas para el tratamiento endovascular, los enfoques de transcirculación pueden permitir el tratamiento seguro y exitoso de lesiones difíciles en pacientes seleccionados.

Palabras clave:
Endovascular
Aneurismas
Transcirculación
Helicoidal
Pipeline
Diversión de flujo

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