Planned dual-modality treatment of complex intracranial aneurysms

Treatment of complex intracranial aneurysms with a single modality is sometimes impossible. In this study we report the planned combined endovascular and microsurgical treatment of four complex aneurysms in four separate patients. Patients in whom clipping or coiling simply failed were not included in this series as therapy was not planned. Mean age at presentation was 38.5 years (range 29-47 years). The majority of patients (three of four) presented with subarachnoid hemorrhage (one with Grade II and two with Grade III). The fourth patient presented with a progressive neurological deficit secondary to an associated arteriovenous malformation. Three of the aneurysms were located in the posterior circulation (two broad-necked basilar apex aneurysms and one bilobed vertebrobasilar junction aneurysm). The other was a broad-based paraclinoid-cavernous carotid lesion. In two of the patients with broad-necked aneurysms surgery was performed initially to create a narrow neck that would be amenable to future coiling. In the patient with the bilobed vertebrobasilar junction aneurysm surgery was performed initially to treat the ventral lobe, whereas the dorsal lobe, with the neck partially buried in the brainstem, was treated endovascularly. When endovascular therapy was performed first, the goal was to reduce the risk of rebleeding in an acutely ruptured broadbased aneurysm prior to surgery. Angiographic follow-up review documented the complete obliteration of all four aneurysms. Clinically all patients had good to excellent outcomes at 6 months follow-up review. These results demonstrate that complex aneurysms, which may be difficult to treat with a single mode of therapy, can be successfully treated with a combination of endovascular and microsurgical techniques.