Giant Intracranial Aneurysms: A Case-Based Atlas of Imaging and Treatment

170 Pages·2016·25.76 MB·English

by  Naci Kocer (auth.)

Naci Kocer
Giant Intracranial
Aneurysms
A Case-Based Atlas of
Imaging and Treatment
In collaboration with
Civan Islak
Osman Kizilkilic
Sedat Giray Kandemirli
Prabath Kumar Mondel
123
Giant Intracranial Aneurysms
Naci Kocer
Giant Intracranial
Aneurysms

A Case-Based Atlas of Imaging and Treatment
In collaboration with
Civan Islak
Osman Kizilkilic
Sedat Giray Kandemirli

Prabath Kumar Mondel
Naci Kocer
Department of Neuroradiology
Istanbul University Cerrahpasa
Medical School
Istanbul
Turkey
Collaborators
Civan I slak Sedat Giray Kandemirli
Department of Neuroradiology Department of Neuroradiology
Istanbul University Cerrahpasa Istanbul University Cerrahpasa
Medical School Medical School
Istanbul Istanbul
Turkey Turkey
Osman Kizilkilic Prabath Kumar Mondel
Department of Neuroradiology C onsultant in Interventional
Istanbul University Cerrahpasa Neuroradiology
Medical School Fortis Hospital
Istanbul Mumbai
Turkey India
ISBN 978-3-319-41786-8 ISBN 978-3-319-41788-2 (eBook)
DOI 10.1007/978-3-319-41788-2
Library of Congress Control Number: 2016954637
© Springer International Publishing Switzerland 2016
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The registered company address is Gewerbestrasse 11, 6330 Cham, Switzerland
To my wife Oya,
my children, Batuhan and Defne,
and my parents
VII
Foreword
Giant Intracranial A neurysms. A Case-Based Atlas proper analysis of the pathology, rationale of
of Imaging and Treatment is a superb atlas on the treatment, and with many cases the long-term
state of the art in the treatment of giant intracra- results. Th e case presentations, illustration of
nial aneurysms in general and the endovascular technical detail, and the methods of dealing with
treatment in particular. Th e author and his col- some of the complications add to the use of this
laborators are well recognized as experts and pio- excellent work for individual practitioners.
neers in the fi eld of endovascular surgery, with a I believe that this work will prove to be of tre-
long-term experience in the ever-expanding tech- mendous value also to those that are in the early
nical improvements in the minimally invasive stage of their career, as those of us with experi-
treatment of giant intracranial aneurysms, where ence, through its illustrations, discussions, and
we have evolved from endovascular coiling, which reviews of the complex approach to giant intra-
was seen as ineff ective, with a very high index of cranial aneurysms.
recanalization and compaction, diffi cult surgical I congratulate Dr. Kocer and his collaborators
techniques including bypass techniques, or the for an excellent book, written in a simple yet use-
requirement of cardiac standstill that presently ful format, and for demonstrating their skill and
belongs to the history of the treatment of giant dedication to the management of giant intracra-
intracranial aneurysms, thanks to innovation and nial aneurysms.
creativity so well illustrated in this atlas as case
presentations, studying the clinical presentation, Alejandro Berenstein, MD
the imaging, and the potential techniques needed Professor of Neurosurgery, Radiology and
for management. In addition, each case is accom- Pediatrics
panied with pertinent bibliography, illustrations, I cahn School of Medicine at Mount Sinai
relevant anatomy, and embryology. Health Systems
Th e atlas is very well illustrated, permitting New York, NY, USA
the reader to learn not only the techniques but the
IX
Pref ace
A s a reference center in our institution – Istanbul Cases— arranged to refl ect the changing manage-
University, Cerrahpasa Medical Faculty, Neurora- ment strategies based on the hemodynamic or
diology Section – we are regularly treating patients morphological characteristics of the giant aneu-
with large, giant, and complex aneurysms from the rysms. Additionally, a few relevant open surgi-
beginning of the modern endovascular era in the cal options are described. However, it is not our
early 1990s. aim to discuss in detail the open neurosurgical
A t Symposium Neuroradiologicum 2014, techniques involved in giant aneurysms.
Springer-Verlag approached us with the idea of
writing a textbook on giant intracranial aneu- All the cases are described with their dates of
rysms. I decided to write a case-based atlas instead treatment and their follow-up. Cases with rela-
of a didactic textbook on the subject. Th e aim was tively long follow-ups were given priority over
to illustrate neuroendovascular techniques and those with short-d uration follow-ups in their
their evolution over the last two decades in the selection for the book. Furthermore, a selection
management of this challenging disease. of a variety of techniques and materials was done
W e wanted to provoke the readers to deliberate to invoke the interest of readers. Figure legends
on the individual cases and their management are intentionally kept long and detailed with
strategies in that period and compare them with description including dates, techniques, and our
the present-day treatment. Th e time line for the underlying reasoning. A few animations and
cases is given in individual fi gure legends and also illustrations have also been included in the boxes
in a pullout excel sheet. and fi gures to help the reader better understand
Th e book refl ects our experience for the past the technical complexity of the cases. Addition-
25 years in treating giant aneurysms in a tertiary ally, a few videos are available online for inquisi-
care center in Turkey and various other institu- tive readers to better understand the 3D anatomy
tions throughout the world. Th e same group of and pre- and postprocedural angiograms in
authors treated all the cases selected in this book. selected cases.
Th e selection and arrangement of the cases follow I have tried to include and cover all the diff er-
a pattern that we believe will stimulate and engage ent aspects that are relevant to giant aneurysms
the minds of our readers. Th ough we have tried to and their management. However, the aim of an
move away from a theoretically intensive text- atlas is to illustrate by fi gures rather than words
book, readers looking for salient features and top- and stimulate thinking on the subject and indi-
ics of interest related to giant aneurysms will fi nd vidual cases among readers rather than a com-
them in purposely built boxes. Th ese boxes prehensive textbook on the subject. Finally,
describe either our thought process on a particular though there have been a few technical innova-
aspect of the case under review sometimes sup- tions and breakthroughs in the fi eld of giant
ported by illustrations (blue background) or more aneurysms and their management, we still have a
frequently a synopsis of the current literature per- long way to go before we make the management
taining to the topic or a sprinkling of anatomy and of giant aneurysms completely safe for all our
relevant embryology (gray background). patients.
Th e book is divided into two main sections:
Introduction— containing description, relevant Naci Kocer
history, diagnosis, classifi cation, and manage- Istanbul, Turkey
ment options for giant intracranial aneurysms.
XI
Commonly Mentioned Endovascular
Devices and Their Manufacturers
FRED® Microvention, Tustin, CA, USA
LEO® Balt Extrusion, Montmorency, France
Onyx® and Onyx HD-500 ® Onyx Liquid Embolic System, MTI, Irvine, CA, USA
PED® ev3, Plymouth, Minnesota, USA
SILK® and SILK + ® SFD; Balt Extrusion, Montmorency, France
VasoCT® Philips Healthcare, The Netherlands
XIII
Abbreviations
ACA Anterior cerebral artery
ACoM Anterior communicating artery
AICA Anterior inferior cerebellar artery
BTO Balloon test occlusion
CCA Common carotid artery
CE MRA C ontrast-enhanced magnetic resonance
angiogram
CECT Contrast-enhanced computed tomography
CTA Computed tomography angiography
DSA Digital subtraction angiography
FD F low diverter
FDCT Flat panel detector computed tomography
FDCTA Flat panel detector computed tomography
angiography
GFAs Giant fusiform aneurysms
GIA G iant intracranial aneurysm
GSaAs Giant saccular aneurysms
GSeAs Giant serpentine aneurysms
I AFDCTA Intra-arterial fl at panel detector computed
tomography angiography
ICA Internal carotid artery
IEL Internal elastic lamina
ISS In-stent stenosis
IVFDCTA Intravenous fl at panel detector computed
tomography angiography
MCA Middle cerebral artery
MDCT Multi-detector computed tomography
MRA Magnetic resonance angiography
MRI Magnetic resonance imaging
NECT Non-enhanced computed tomography
PCA Posterior cerebral artery
P CoM Posterior communicating artery
PICA Posterior inferior cerebellar artery
PTA Persistent trigeminal artery
PVO Parent vessel occlusion
SAH Subarachnoid hemorrhage
SCA Superior cerebellar artery
TOF MRA Time-of-fl ight magnetic resonance
angiogram
XV
Contents
Introduction ...................................................................................................................................................... xvii
History, Evolution, Defi nition and Epidemiology ................................................................................ xvii
What’s Diff erent About Giant Intracranial Aneurysms? .................................................................... xvii
Therapeutic Options ....................................................................................................................................... xviii
Genetics ............................................................................................................................................................... xviii
Types of Giant Intracranial Aneurysms .................................................................................................... xix
Pathophysiology of Giant Intracranial Aneurysms ............................................................................. xix
Imaging Features of Giant Intracranial Aneurysms ............................................................................ xx
References .......................................................................................................................................................... xxii
Case 1 ................................................................................................................................................................... 1
Flow Computational Studies in Basilar Fusiform GIA Treated with Scaff olding
Technique ............................................................................................................................................................ 2
Case 2 ................................................................................................................................................................... 7
In-Stent Stenosis (ISS) ..................................................................................................................................... 8
Case 3 ................................................................................................................................................................... 13
Side-Branch and Perforator Occlusion Post-FD Therapy ................................................................ 14
Scaff olding Technique ................................................................................................................................ 15
Case 4 ................................................................................................................................................................... 21
Cavernous ICA GIAs ..................................................................................................................................... 22
Case 5 ................................................................................................................................................................... 27
Antiplatelet Regimen for FD Therapy of Ruptured and Unruptured Aneurysms ................ 28
Case 6 ................................................................................................................................................................... 33
Looping and Anchoring Technique ....................................................................................................... 34
Case 7 ................................................................................................................................................................... 39
Telescopic Multiple FD Technique ......................................................................................................... 40
Case 8 ................................................................................................................................................................... 45
Troubleshooting FDs .................................................................................................................................. 46
Case 9 ................................................................................................................................................................... 51
Cerebral Edema in Cavernous GIAs ....................................................................................................... 52
Case 10 ................................................................................................................................................................ 57
Late Rupture After FD Therapy ............................................................................................................... 58
Case 11 ................................................................................................................................................................ 61
Theories of Late Rupture and Flow Studies ....................................................................................... 62
Case 12 ................................................................................................................................................................ 67
Evolution in Serpentine Aneurysms ..................................................................................................... 68
Case 13 ................................................................................................................................................................ 71
Posterior Cerebral Artery and Parent Vessel Occlusion................................................................. 72
Case 14 ................................................................................................................................................................ 77
Onyx® (Liquid Embolic Agents) in Intracranial Aneurysms .......................................................... 78