Complex brain aneurysm. Endovascular and open brain surgery. Clinical case. 4

Complex brain aneurysm. Endovascular and open brain surgery. Clinical case. 4

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Leading expert in cerebrovascular and endovascular neurosurgery, Dr. Peng Chen, MD, explains how a combined open and endovascular surgical approach successfully treated a teenager's two giant, complex brain aneurysms, highlighting the critical decision-making process for optimal patient outcomes.

Combined Surgical Approaches for Complex Brain Aneurysm Treatment

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Complex Aneurysm Case in a Teenager

Dr. Peng Chen, MD, describes a particularly illustrative case of a 16-year-old male patient who presented on his birthday with a severe headache. The patient had a complex congenital cerebrovascular structure associated with connective tissue issues, resulting in the development of two giant dissecting aneurysms. This case exemplifies the high-volume, complex caseload handled at a major neurosurgical center, where approximately half of the procedures involve such intricate pathologies.

Aneurysm Symptoms and Presentation

The teenager's symptoms, which began on Christmas Eve, were a direct result of the rapid enlargement of one of the aneurysms. Dr. Peng Chen, MD, identified the two aneurysms in critical locations: one on the left middle cerebral artery (MCA) and a second on the anterior communicating artery (ACom). The MCA aneurysm was exceptionally large, measuring approximately 7 centimeters in size, a dimension that signifies a high-risk, life-threatening condition requiring immediate and expert intervention.

Open Surgery Bypass for MCA Aneurysm

For the giant 7-cm MCA dissecting aneurysm, endovascular treatment was not a viable option because the entire vessel wall was compromised. Dr. Peng Chen, MD, explains that the only solution was to perform a surgical bypass, specifically a bypass anastomosis. This open microsurgical technique involves rerouting blood flow to the left side of the brain by connecting a donor artery to a recipient artery, effectively creating a new pathway that bypasses the diseased segment.

Endovascular Treatment and Coil Embolization

Following the successful bypass procedure, the next phase of treatment utilized endovascular techniques. After the blood flow was securely rerouted, the giant aneurysm itself was shut down. Dr. Peng Chen, MD, notes that this was achieved using endovascular methods, which typically involve guiding catheters through the blood vessels to the aneurysm site to deploy coils (coil embolization) or other devices to occlude the aneurysm and prevent rupture.

Second Surgery for ACom Aneurysm Reconstruction

After a successful recovery from the first procedures, which included a ski trip, the patient returned months later for treatment of the second aneurysm. Dr. Chen performed another open surgery to reconstruct the anterior communicating artery (ACom) aneurysm. This staged approach allowed for the safe and effective treatment of both complex vascular lesions, culminating in a successful overall outcome for the young patient.

Factors in Treatment Decision-Making

The decision to use open surgery, endovascular techniques, or a combination of both is based on a meticulous analysis of each aneurysm's specific structure and location. As Dr. Peng Chen, MD, emphasizes, the treatment plan is tailored to what offers the patient the best long-term outcome with the lowest surgical risk. Key factors include the aneurysm's size, whether it is dissecting or saccular, its proximity to critical branches, and the patient's overall health and anatomy.

Benefits of a Multimodal Surgical Approach

The combination of open microsurgical clipping and endovascular coil embolization or stenting provides a powerful toolkit for neurosurgeons. Dr. Chen concludes that this multimodal strategy allows for the treatment of multiple aneurysms in different parts of the brain in the safest manner possible. This personalized approach, which weighs long-term outcomes, procedural risks, and patient wishes, is fundamental to achieving excellent results without complications in complex cerebrovascular surgery.

Full Transcript

Dr. Anton Titov, MD: Last year you did about 700 operative cases and procedures. Is there any particular case you can think about as a good illustration of the combination of endovascular and open brain surgery skills that you apply here in Houston?

Dr. Peng Chen, MD: This place is a very busy one, and probably the busiest place in Texas. Fortunately, we are busy, but at the same time, obviously, not all neurosurgery cases we do are very complex. But about half of the cases we do are complex cases, including open surgery and endovascular treatment.

Some of the cases—I can give an example—they really benefit from the combination of surgery methods. I have this child, who I operated on about four years ago. It was his 16th birthday. Yeah, on his 16th birthday he had a bad headache around Christmas Eve. It turns out he had a very complicated cerebrovascular structure.

He was born with some congenital issues, with connective tissue issues. So he had two giant so-called dissecting aneurysms. One involved the left side of the middle cerebral artery, the other one involved the anterior communicating artery. So he had two giant aneurysms in different configurations.

Symptoms at the time he presented were due to a quick aneurysm enlargement, more on the left side. The middle cerebral artery dissecting aneurysm was large—about 7 centimeters, which is quite a large aneurysm in the brain. For that aneurysm, endovascular treatment was not an option because the entire vessel was giving way.

So the only way to fix it was to do a bypass, so-called bypass anastomosis, to replace the blood flow to the left side of the brain—to put anastomosis. That's what we did, and then we shut down the aneurysm with the endovascular technique.

He did well. He went on a ski trip and then came back a couple months later after recovery, and we did another surgery. We were able to reconstruct the ACom aneurysm successfully, which is open surgery. ACom stands for Anterior Communicating Artery.

So this is one example. I treated patients with multiple brain aneurysms in different parts of the brain, and these different parts structure-wise would determine whether the open surgical approach is easier or not, or how high the risk of treatment is.

Some patients with multiple aneurysms benefit more from endovascular techniques, called coil embolization, even putting stents in. In other aneurysms we do surgery, clipping, so the combination makes the patient have a great result and great outcome without any complications.

These kinds of things are what we do frequently. We analyze and assess the patient and give the best recommendation based on what is best for the patient treatment-wise for a long-term outcome, surgical risk, and the patient's wishes.