Giant cavernous aneurysms occluded by aneurysmal thrombosis,calcification,parent artery occlusion:A case report and review of literature

BACKGROUND Patients with giant intracranial aneurysms(GIAs)are at a high risk of rupture,morbidity,and mortality even after surgical or endovascular treatment.We described a case of a spontaneously occluded GIA secondary to gradual growth of the GIA,continuously progressed aneurysmal thrombosis,complete aneurysmal calcification and complete occlusion of the parent artery-the right internal carotid artery(RICA).CASE SUMMARY A 72-year-old female patient complained of sudden pain in her right eye upon admission to our hospital.She had been diagnosed with a GIA[30 mm(axial)×38 mm(coronal)×28 mm(sagittal)]containing an aneurysmal thrombus located in the cavernous sinus segment of RICA diagnosed by magnetic resonance imaging(MRI),enhanced MRI,and magnetic resonance angiography more than 14 years ago.Later,with slow growth of the cavernous carotid GIA,aneurysmal thrombosis progressed continuously,spontaneous occlusion of the RICA,complete aneurysmal calcification,and occlusion of the GIA occurred gradually.She had no history of subarachnoid hemorrhage but missed the chance for endovascular therapy at an early stage.As a result,she was left with severe permanent sequelae from the injuries to the right cranial nerves Ⅱ,Ⅲ,Ⅳ,V1/V2,and Ⅴ.CONCLUSION The risk of rupture of the cavernous carotid GIAs was relatively low and possibly further be reduced by the stasis flow and spontaneous occlusion of the parent artery internal carotid artery(ICA)induced by the mass effect of the cavernous carotid GIAs and the extremely rare aneurysmal calcification.However,nowadays,it is advisable to recommend early endovascular treatment for the cavernous carotid GIAs to prevent injuries to the surrounding intracranial nerves and occlusion of the ICA,mainly caused by the mass effect of the cavernous carotid GIAs.

Application of hybrid operating rooms for clipping large or giant intracranial carotid-ophthalmic aneurysms

BACKGROUND A hybrid operating room(Hybrid-OR)is a surgical theatre that combines a conventional operating room with advanced medical imaging devices.There are still plenty of limitations when endovascular treatment or microsurgical treatment is used individually to treat large or giant carotid-ophthalmic aneurysms.AIM To explore and summarize the technical features and effectiveness of the application of a Hybrid-OR in managing major intracranial carotid-ophthalmic aneurysms.METHODS The Department of Neurosurgery treated 12 cases of large or giant intracranial carotid-ophthalmic aneurysms between March 2013 and December 2019 in a Hybrid-OR.All cases were treated with clipping and parent vessel reconstruction.RESULTS With the assistance of the Hybrid-OR,the rate of incomplete intraoperative aneurysm clipping decreased from 25%(3/12)to 0%,while the rate of vessel stenosis decreased from 16.7%(2/12)to 8.35%(1/12).In terms of thromboembolic events,ischemic infarction complication occurred in only one patient,and none of the patients experienced embolic infarction complications.All 12 patients were followed for an average of 3 years,and no aneurysms recurred.The postoperative recovery was evaluated with the modified Rankin Scale(mRS):11 patients showed no symptoms(mRS=0),1 patient showed slight disability(mRS 1-2),and none of the patients had severe disability(mRS=5)or died(mRS=6).CONCLUSION The Hybrid-OR provides new ideas for the surgical clipping of large or giant intracranial carotid-ophthalmic aneurysms and decreases the rate of intraoperative vessel stenosis and unsuccessful clipping.

More to it than meets the eye: a case report of incomitant esotropia in a child caused by a giant basilar aneurysm

Background:Esotropia is a common concern in pediatric ophthalmology consultations.While most cases stem from strabismus,it is crucial for physicians to differentiate atypical features that might indicate underlying organic causes,such as VI nerve palsy,hinting at the presence of intracranial spaceoccupying lesions.Although the occurrence of cerebral aneurysms in children is rare,they can have severe consequences.Case Description:Here,we described an extremely rare case of giant basilar fusiform aneurysm measuring 4.0 cm×3.9 cm×3.9 cm in an otherwise healthy 8-year-old child,and analyzed its atypical features that suggested an intracranial etiology.We further described an endovascular approach,performed by interventional radiologists,and discussed its advantages over the conventional neurosurgery.The patient continued to be followed by our multidisciplinary team.He had a stable post-operative course and made an excellent recovery neurologically.At the 1-year follow-up,he was orthophoria with excellent vision and stereopsis.Conclusions:To our knowledge,this is the first pediatric case in Canada where a giant intracranial aneurysm was treated endovascularly.The salient red flags—progressive incomitant esotropia and diplopia,the presence of myopia(rather than hyperopia),nystagmus and abnormal saccadic movements—should be astutely recognized by clinicians as intracranial giant aneurysms carry a poor prognosis.A multidisciplinary approach is essential for the management of such cases.

Surgical repair of an emergent giant hepatic aneurysm with an abdominal aortic dissection:A case report

BACKGROUND Hepatic artery aneurysm(HAA)is the second most common visceral aneurysm.A significant number of hepatic aneurysms are found accidentally on examination.However,their natural history is characterized by their propensity to rupture,which is very serious and requires urgent treatment.An emergent giant hepatic aneurysm with an abdominal aortic dissection is less commonly reported.CASE SUMMARY We report the complicated case of a giant hepatic aneurysm with an abdominal aortic dissection.A 66-year-old female presented with the complaint of sudden upper abdominal pain accompanied by vomiting.Physical examination showed that her blood pressure was 214/113 mmHg.Her other vital signs were stable.Computed tomography found a giant hepatic proper aneurysm and dissection of the lower segment of the abdominal aorta.Furthermore,angiography showed a HAA with the maximum diameter of approximately 56 mm originating from the proper hepatic artery and located approximately 15 mm from the involved bifurcation of the left and right hepatic arteries with no collateral circulation.Therefore,we decided to use a stent to isolate the abdominal aortic dissection first,and then performed open repair.After the operation,the patient recovered well without complications,and her 3-month follow-up checkup did not reveal any late complications.CONCLUSION Open surgery is a proven method for treating giant hepatic aneurysms.If the patient's condition is complex,staged surgery is an option.

Cerebellar Syndrome Revealing a Giant Postero Inferior Cerebellar Artery Aneurysm: A Case Report and a Review of Literature

Context: Cerebellar syndrome caused by disturbances of balance and coordination is not an uncommon neurological disorder. It has varied etiologies usually caused by tumor processes or suppurative collections. Vascular causes remain very rare, especially when it is a giant aneurysm of PICA representing 1% of intracranial aneurysms. Treating giant PICA aneurysms is a very difficult task for neurosurgeons because the surgical dissection can lead to severe damage due to the intimate relationship of PICA with the brainstem or nerve structures. We report a case of giant PICA aneurysm responsible for cerebellar syndrome successfully treated with surgery. The objective of this work is to draw the attention of practitioners to this unusual cause which can lead to diagnosis wandering and a lack of planning at the time of management. Case report: A 65 years old hypertensive patient was seen for a progressive disturbance of balance and walking disorder, but worsened in the last three months with no notion of fever. On admission, the patient was lucid, oriented in time and space and presented with static and kinetic cerebellar syndrome. Brain CT-scan without and with contrast revealed a tissular mass in the posterior fossa suggesting a tumor process, however, CT angiography showed a giant aneurysm of the PICA after reconstruction. A careful microdissection by a sub-occipital approach was decided. Opening the large cistern made it possible to visualize the aneurysm sack surrounded by a yellowish gliosis. The reclining and microdissection revealed the neck of the aneurysm, which was clipped to exclude the giant aneurysm in block. Postoperative follow-up was simple with progressive improvement in the cerebellar syndrome and walking over three months. Conclusion: Giant aneurysm of the PICA is rare. The localization in the posterior cerebral fossa can be confusing. Microsurgery gives a good result.

Risk factors and outcomes of postoperative stroke in surgical treatment for giant intracranial aneurysms

Background:Giant intracranial aneurysms(GIAs)are challenges for surgical treatment.Risk factors of postoperative stroke remain unclear.This study aims to investigate the predictors of postoperative stroke in GIAs and the impact of stroke on outcomes.Methods:We performed a retrospective medical record review of patients with GIAs who received microsurgery at our institution between 2011 and 2018.Multivariate logistic regression analyses were carried out to identify risk factors for postoperative stroke.The clinical and angiographic outcomes were compared between patients with and without stroke.Results:A total of 97 patients were included in this study.Surgical modalities included direct aneurysm neck clipping in 85 patients(87.7%),trapping with the bypass in 8(8.2%),proximal artery ligation in 1(1%),and bypass alone in 3(3.1%).Postoperative stroke was found in 26 patients(26.8%).Independent factors that affect postoperative stroke were recurrent aneurysm(OR,10.982;95%CI,1.976-61.045;P=0.006)and size≥3.5 cm(OR,3.420;95%CI,1.133-10.327;P=0.029).Combined perioperative mortality and morbidity was 26.8%.Follow-up was achieved from 89 patients(91.8%),with a mean follow-up period of 39 months(range 19 to 94 months).Good outcomes were observed in 75 patients(84.3%)and poor outcomes were observed in 14 patients(15.7%).Conclusions:Postoperative stroke was significantly associated with clinical outcome.Favorable outcomes can be achieved in most patients with GIAs after appropriate microsurgical modality.Recurrent aneurysm and size≥3.5 cm are risk factors of postoperative stroke.

Clinical characteristics and surgical treatment of patients with giant intracranial aneurysms

Background Compared with smaller aneurysms, giant intracranial aneurysms （GICAs） have a poorer prognosis and require more meticulous surgical planning and techniques to exclude them from the circulation. GICAs continue to challenge the limits of neurosurgical techniques. A series of 170 patients with GICAs were reviewed for understanding the clinical characteristics, surgical treatment and outcomes of patients with GICAs.Methods Collected data of 170 consecutive patients with GICAs from January 1995 to July 2007 were analyzed. The clinical characteristics in this study included age, sex, intracranial aneurysms size, the first presentations, locations and Hunt ＆ Hess grade. Surgical methods included direct clipping of the aneurysm neck, parent artery reconstruction, proximal artery ligation, trapping and wrapping. Surgical results were evaluated postoperatively by the Glasgow Outcome Scale （GOS）.Results GICAs were more commonly diagnosed at age 30 to 50 years with a mean age of 39.3 years and without obvious gender preponderance in our study （88 male and 82 female patients）. The size of the GICAs ranged from 2.5 cm to 8.0 cm （mean, 2.9 cm）. Hemorrhage （41%）, mass effect （34%） and headache （12%） were the first 3 most common presentations. Regarding the Hunt ＆ Hess classification, at admission there were 100 cases in grade 0. 24 in grade 1,21 in grade 2, 16 in grade 3, 8 in grade 4 and 1 in grade 5. There were 84 cases of GICAs treated by direct neck-clipping, 47 by parent artery reconstruction, 19 by proximal artery occlusion （with 4 combined with revascularization）, 18 by trapping and 2 by wrapping. The follow-up study （ranging from 6 to 115 months, mean 32 months） showed good results in 108 cases, moderate disability in 26 and severe disability in 15 accordina to GOS. Six cases died. Conclusions Surgical treatment is an effective treatment for GICAs. Surgical strategies should be made carefully and individually. Doppler ultrasonography, neuroendoscope and intraoperative angiography are useful to perfect surgical results.

Surgical management of large and giant intracavernous and paraclinoid aneurysms

Background Due to their location, large and giant intracavernous and paraclinoid aneurysms remain a challenge for vascular neurosurgeons, We identified characteristics, surgical indications and treatment strategies of large and giant intracavernous and paraclinoid aneurysms in 36 patients.Methods The pterional approach was routinely used. The cervical internal carotid artery was exposed for proximal control of parent vessel and retrograde suction decompression. Paraclinoid aneurysms were directly clipped, intracavernous pseudoaneurysm was repaired and the intracavernous aneurysms were trapped with extracranial-intracranial bypass of saphenous vein graft. Intraoperative electroencephalogram （EEG） and somatosensory evoked potential （SSEP） monitoring were used to detect cerebral ischemia during the temporary occlusion of parent arteries. Microvascular Doppler ultrasonography was used to assess blood flow of the parent and branch vessels. Endoscopy was helpful particularly in dealing with internal carotid artery posterior wall aneurysms. Postoperative digital subtraction angiography （DSA） was performed in 33 of the 36 patients.Results Thirty-two paraclinoid aneurysms were directly clipped, 1 intracavernous pseudoaneurysm was repaired and the other 3 intracavernous aneurysms were trapped with revascularization. Except for two patients who died in the early postoperative stage, 34 patients＇ follow-up was 6-65 months （mean 10 months） and a Glasgow Outcome Scale score of 4 to 5 at discharge. At the 6-month follow-up examination, Rankin Outcome Scale scores were 0 to 2 in 32 patients. EEG and SSEP monitoring changed in six patients. Twelve clips were readjusted when insufficient blood flow in parent and branch vessels was detected. Three posterior wall aneurysms were clipped.Conclusions Intracavernous aneurysms not amenable to endovascular treatment should be treated surgically and surgical treatment is the first option for paraclinoid aneurysms. The temporary parent vessel occlusion, retrograde suction decompression, endoaneurysmectomy, parent vessel reconstruction, vascular anastomosis, electrophysiological monitoring, Doppler ultrasonography and endoscopy are essential techniques in the treatment of the large and giant intracavernous and paraclinoid aneurysms.

Incomplete Kawasaki disease complicated with acute abdomen: A case report

Kawasaki disease(KD)is an acute systemic vasculitis characterized by unknown etiology.CASE SUMMARY A 4.5-year-old boy developed an acute abdomen during the onset of incomplete KD.He still had persistent abdominal pain after undergoing exploratory laparotomy and appendectomy.Ultrasound examination at early onset revealed a giant coronary artery aneurysm.The patient developed a myocardial infarction and heart failure accompanied by respiratory and cardiac arrest.He underwent coronary artery revascularization and coronary artery bypass graft using an autologous internal mammary artery.After the operation,the cardiac output increased,and the symptoms of heart failure resolved.Follow-up evaluation at 1 mo after operation showed that the patient's cardiac function had restored to New York Heart Association standard Grade I heart failure,and normal growth was obtained.CONCLUSION Coronary artery revascularization and coronary artery bypass graft is an effective method for treating myocardial ischemia in children with KD complicated with giant coronary artery aneurysm.Nevertheless,some issues still need specific attention.

CEREBRAL ARTERY RECONSTRUCTION IN THE TREATMENT OF LARGE AND GIANT INTRACRANIAL ANEURYSMS

From 1978 to 1988, 14 giant intracranial aneurysms(more than 2.4 cm in diameter) and one large aneurysm (1.5cm in diameter) were treated by extracranial/intracranial(EC/IC) bypass or cerebral artery reconstruction. Of theaneurysms, 10 were located at the intracavernous carotid ar-tery (CCA). One of the 10 anourysms was posttraumatic andlocated at both the carotid-ophthalmic artery segment and thebifurcation of the internal carotid artery (ICA). Three wereseen at the middle cerebral artery (MCA) trunk.Theaneurysms were demonstrated by angiography and CTscanning. They were treated with trapping of the aneurysm andsuperficial temporal artery (STA)/middle cerebral artery(STA-MCA) bypass with/without a graft (6 cases), cervicalICA ligation and STA-MCA bypass with / without a graft (6)aneurysm excision with an end-to-end anastomosis of theMCA and a STA-MCA bypass with a graft (1), proximal

Giant serpentine aneurysm of the internal cerebral artery and mandibular aneurysm: a case report

Background:Giant serpentine aneurysms(GSA)originate from saccular or spindle aneurysm,dissimilar from dissected aneurysm,that are defined as partially thrombosed giant aneurysms with tortuous internal vascular channel.The clinical and neuroradiologic characteristics are clarified and the mechanism of formation and the efficacy of double stent implantation in GSA are discussed.Case presentation:An 18-year-old man presented himself with a GSA arising from the internal cerebral artery(ICA).In addition,a mandibular aneurysm(MA)arose from the external cerebral artery(ECA).Success was achieved in treating GSA through endovascular treatment with double stents implanted in the parent artery,which were LEO stent and Tubridge flow diverter.After 1 year of follow-up,three-dimensional reconstruction of blood vessels revealed the disappearance of the serpentine access of GSA,which was found to be replaced with a roughly normal vascular structure.Conclusions:Double stent implantation has provided a feasible treatment option for giant serpentine internal carotid aneurysms and eliminated the possibility of causing collateral circulation occlusion.Therefore,it represents a simple and suitable treatment method for anatomical structure and operation.

Case report of a rare giant left anterior descending coronary artery aneurysm

Giant coronary artery aneurysm(CAA)is a rare condition,reportedly seen in 0.02-0.2%of patients undergoing coronary angiography.Asymptomatic in most cases,patients may present with angina pectoris,myocardial infarction,cardiac tamponade or sudden death.Given that the natural history of the CAA is still not predictable,the optimal treatment remains still debatable.In this case report,we present a male patient with a sudden non-exertional dyspnea and angina in a context of obesity,multiple large and medium vessels aneurysms and chronic kidney disease(CKD).A contrast CT detected a giant left anterior descending artery(LAD)CAA measuring 73 mm×47 mm,apparently compressing the circumflex(CX)and the pulmonary artery(PA).After undergoing a full(etiologic and aneurysm extension)panel of exams,the patient underwent a surgical exclusion of the giant CAA and a coronary artery bypass grafting(CABG)by using the left thoracic mammary artery(LITA).The hospitalization was uneventful,and the patient left the hospital completely asymptomatic.In conclusion,even in cases of giant coronary aneurysms,the treatment is surgical by excluding the aneurismatic sac and performing a surgical revascularization.