Combined Endovascular and Microsurgical Management
Object: The purpose of this study was to assess the efficacy and describe the technical features of combined endovascular and microsurgical treatments for complex and giant unruptured intracranial aneurysms.
Methods: A prospectively maintained database was reviewed to identify all patients with unruptured intracranial aneurysms who were treated with combined techniques. Twenty-one lesions were treated in as many patients: six lesions involved the posterior cerebral artery (PCA); seven the cavernous portion of the internal carotid artery (ICA); two the basilar apex; two the basilar trunk; and one each the anterior communicating artery, anterior cerebral artery, petrous ICA, and cervical ICA. Aneurysms were treated with combined extracranial-intracranial bypass procedures and parent-vessel occlusion, flow redirection, or arterial transposition. Aneurysm occlusion was achieved in 20 patients. In the remaining patient the aneurysm recurred, requiring stent-assisted repeated coil placement. Three patients suffered permanent neurological deficits related to treatment, and three died, two of whom had basilar trunk aneurysms.
Conclusions: Certain complex aneurysms may be treated optimally by combining endovascular and surgical procedures. A low incidence of complications follows treatment of anterior circulation aneurysms. Treatment of complex posterior circulation aneurysms is associated with a higher incidence of complications, although this likely reflects the more complex nature of these lesions. The risks of this combined treatment strategy are likely lower than the risks associated with the natural history of this subset of aneurysms.

Combined microsurgical and endovascular strategies have been used for more than a decade to treat complex intracranial aneurysms. Ongoing advances in endovascular techniques have increased the safety and efficacy of this modality of treatment, making it more attractive, especially for patients. As the field of endovascular neurosurgery evolves, interest in combined neurovascular teams has been renewed. Such teams select the optimal management strategy for aneurysms on a case-by-case basis.

A subset of intracranial aneurysms requires combined microsurgical and endovascular management. Ideally, a combined treatment strategy offers better results and leads to fewer complications than either treatment alone. Most importantly, the combined management plan should improve on the natural history of the untreated lesion. In this report we present our series of patients who were treated with a combined approach. Our goal was to identify the types of complex aneurysms for which such an approach is indicated.