Combined microsurgical and endovascular management of complex intracranial aneurysms

Michael T. Lawton, Alfredo Quinones-Hinojosa, Nader Sanai, Junaid Y. Malek, Christopher F. Dowd, Robert H. Rosenwasser, Robert A. Solomon, Bernard R. Bendok, L. Nelson Hopkins, H. Hunt Batjer

Research output: Contribution to journalArticle

72 Citations (Scopus)

Abstract

OBJECTIVE: The disciplines of microneurosurgery and cranial base surgery have reached maturity, and technical advances in the surgical management of aneurysms are limited. Although most aneurysms can be clipped microsurgically or coiled endovascularly, a subset of patients may require a combined approach. A consecutive series of patients with aneurysms in one surgeon's cerebrovascular practice was reviewed retrospectively to analyze strategies for integrating microsurgical and endovascular techniques in the management of complex aneurysms. METHODS: Between 1997 and 2001, 596 aneurysms in 491 patients were treated microsurgically by the senior author (MTL) at the University of California, San Francisco, and 77 of these patients (96 aneurysms) were managed with a multimodality approach comprising a total of eight different combinations: selective revascularization and aneurysm occlusion (n = 23), endovascular and surgical trapping (n = 1), clipping of the aneurysm after attempted or incomplete coiling (n = 22), coiling after attempted or incomplete clipping (n = 5), clipping of recurrent aneurysm after coiling (n = 6), coiling of recurrent aneurysm after clipping (n = 1), clipping and coiling of multiple remote aneurysms (n = 13), and coiling after previous surgery (n = 6). RESULTS: A total of 96 aneurysms were treated with combined therapy, of which 43% were large or giant in size and 34% had fusiform or dolichoectatic morphology. Complete angiographic obliteration was achieved in 91 aneurysms (95%). Overall, 66 patients (86%) had good outcomes (Glasgow Outcome Scale score of 4 or 5; mean follow-up, 9 mo). The treatment mortality rate was 9.1% (seven patients), and permanent treatment-associated neurological morbidity rate was 5.2% (four patients). CONCLUSION: Evolving endovascular technologies need to be integrated into the microsurgical management of aneurysms. Multimodality approaches are best used with complex aneurysms in which conventional therapy with a single modality has failed. Revascularization remains a unique surgical contribution to the overall management of aneurysms with which current endovascular techniques cannot be used. Multimodality management should be considered an elegant addition to the therapeutic armamentarium that, through simplification and increased safety, improves the treatment of complex aneurysms beyond what is achievable by performing clipping or coiling alone.

Original languageEnglish (US)
Pages (from-to)263-275
Number of pages13
JournalNeurosurgery
Volume52
Issue number2
StatePublished - Feb 1 2003

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Intracranial Aneurysm
Aneurysm
Endovascular Procedures
Therapeutics
Glasgow Outcome Scale
San Francisco
Skull Base

Keywords

  • Endovascular
  • Giant aneurysm
  • Intracranial aneurysm
  • Microsurgery
  • Revascularization
  • Subarachnoid hemorrhage

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Lawton, M. T., Quinones-Hinojosa, A., Sanai, N., Malek, J. Y., Dowd, C. F., Rosenwasser, R. H., ... Batjer, H. H. (2003). Combined microsurgical and endovascular management of complex intracranial aneurysms. Neurosurgery, 52(2), 263-275.

Combined microsurgical and endovascular management of complex intracranial aneurysms. / Lawton, Michael T.; Quinones-Hinojosa, Alfredo; Sanai, Nader; Malek, Junaid Y.; Dowd, Christopher F.; Rosenwasser, Robert H.; Solomon, Robert A.; Bendok, Bernard R.; Hopkins, L. Nelson; Batjer, H. Hunt.

In: Neurosurgery, Vol. 52, No. 2, 01.02.2003, p. 263-275.

Research output: Contribution to journalArticle

Lawton, MT, Quinones-Hinojosa, A, Sanai, N, Malek, JY, Dowd, CF, Rosenwasser, RH, Solomon, RA, Bendok, BR, Hopkins, LN & Batjer, HH 2003, 'Combined microsurgical and endovascular management of complex intracranial aneurysms', Neurosurgery, vol. 52, no. 2, pp. 263-275.
Lawton MT, Quinones-Hinojosa A, Sanai N, Malek JY, Dowd CF, Rosenwasser RH et al. Combined microsurgical and endovascular management of complex intracranial aneurysms. Neurosurgery. 2003 Feb 1;52(2):263-275.
Lawton, Michael T. ; Quinones-Hinojosa, Alfredo ; Sanai, Nader ; Malek, Junaid Y. ; Dowd, Christopher F. ; Rosenwasser, Robert H. ; Solomon, Robert A. ; Bendok, Bernard R. ; Hopkins, L. Nelson ; Batjer, H. Hunt. / Combined microsurgical and endovascular management of complex intracranial aneurysms. In: Neurosurgery. 2003 ; Vol. 52, No. 2. pp. 263-275.
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