Neurosurg Focus 17 (5):E11, 2004

Combined endovascular and microsurgical management

of giant and complex unruptured aneurysms

FRANCISCO A. PONCE, M.D., FELIPE C. ALBUQUERQUE, M.D.,

CAMERON G. MCDOUGALL, M.D., PATRICK P. HAN, M.D., JOSEPH M. ZABRAMSKI, M.D.,
AND ROBERT F. SPETZLER, M.D.

Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical
Center, Phoenix, Arizona

Object. The purpose of this study was to assess the efficacy and describe the technical features of combined endo-
vascular and microsurgical treatments for complex and giant unruptured intracranial aneurysms.
Methods. A prospectively maintained database was reviewed to identify all patients with unruptured intracranial an-
eurysms 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 par-
ent-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 proce-
dures. 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 asso-
ciated with the natural history of this subset of aneurysms.

KEY WORDS • endovascular technique • complex aneurysm • giant aneurysm •

revascularization • microneurosurgery

Combined microsurgical and endovascular strategies
have been used for more than a decade to treat complex
intracranial aneurysms.2,15,19 Ongoing advances in endo-
vascular techniques have increased the safety and efficacy
of this modality of treatment, making it more attractive,
especially for patients. As the field of endovascular neu-
rosurgery evolves, interest in combined neurovascular
teams has been renewed.1,6–10,13,14,17,18 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
Abbreviations used in this paper: ACA = anterior cerebral ar-
tery; ACoA = anterior communicating artery; BA = basilar artery;
EDH = epidural hematoma; GDC = Guglielmi detachable coil;
ICA = internal carotid artery; MCA = middle cerebral artery; OA =
occipital artery; PCA = posterior cerebral artery; PICA = posterior
inferior cerebellar artery; SCA = superior cerebellar artery; STA =
superficial temporal artery; VA = vertebral artery.
importantly, the combined management plan should im-
prove 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.
CLINICAL MATERIAL AND METHODS
The records of 21 patients who underwent combination
therapy for unruptured aneurysms between January 1997
and March 2003 were reviewed to determine aneurysm
location, type of endovascular and surgical intervention,
follow-up results of treatment, and associated complica-
tions. Only patients for whom a combined endovascular
and surgical intervention was planned at the start of treat-
ment were included in the study. Patients undergoing clip
placement for the recurrence of an aneurysm previously
treated with coil occlusion or coil occlusion for the recur-
rence of an aneurysm previously treated with clip place-
ment were excluded. All patients were followed for the
development of treatment-related sequelae by using a pro-
spectively maintained database.

Neurosurg. Focus / Volume 17 / November, 2004 1

 F. A. Ponce, et al.

Patient Characteristics Treatment Modalities

There were 21 patients (eight men and 13 women)
included in this study. Their mean age was 55.1
13.7
years (mean
standard deviation). Their median age was
55 years (range 22–73 years). Fourteen patients presented
with symptoms related to mass effect of the aneurysm,
two with headaches, and two with ischemia. Aneurysms
were diagnosed incidentally in two patients (Table 1).
Aneurysm Characteristics
Of the 21 aneurysms, 11 (52.4%) were located in the
anterior circulation and 10 (47.6%) were located in the
posterior circulation. In the posterior circulation, six an-
eurysms (28.5%) involved the PCA, and two each (9.5%)
the basilar apex and basilar trunk. In the anterior circula-
tion, seven lesions (33.3%) involved the cavernous ICA,
and one each (4.8%) the ACoA, the junction of the A2 and
A3 segments of the ACA, the petrous ICA, and the cer-
vical ICA. Factors contributing to the complexity of the
lesions were identified and included nine giant, four dis-
secting, and four dolichoectatic aneurysms; previous clip
occlusion of two lesions; a calcified neck in one; and sig-
nificant scarring in one.
Treatment decisions were made for all 21 patients after
the cases were reviewed by the neurovascular team, which
included two cerebrovascular surgeons (R.F.S., J.M.Z.)
and two endovascular neurosurgeons (C.G.M., F.C.A.).
Microvascular procedures included 17 extracranial–intra-
cranial bypasses, two intracranial–intracranial bypasses,
one arterial clip placement for flow redirection, and one
transposition of the cervical ICA to facilitate endovascu-
lar therapy (Table 2). All but one of the endovascular tech-
niques involved parent-vessel occlusion. One patient un-
derwent stent-assisted coil placement.
Extracranial–Intracranial Revascularization and Parent-
Vessel Occlusion
Eight patients harbored anterior circulation aneu-
rysms that were treated with microsurgical extracra-
nial–intracranial bypass followed by endovascular parent-
vessel occlusion. Among these patients, all eight under-
went an STA–MCA bypass for seven aneurysms
involving the cavernous ICA, including one pseudoa-
neurysm related to transsphenoidal surgery and one
involving the petrous ICA.
The six patients with PCA aneurysms were treated with

TABLE 1
Clinical summary of 21 patients with aneurysms who underwent a combined approach*
Case Age (yrs), Indication Location Complicating Neurological FU
No. Sex for Op of Lesion Factors Complications Sequelae (mos)

1 28, M ataxia rt PCA, P1/P2 dissecting EDH homonymous 25

junction hemianopia
2 51, M vision changes ACoA giant none none 37
3 68, F CN III palsy rt cavernous ICA none none none 48
4 52, M headache rt PCA, P2 fusiform EDH homonymous 38
hemianopia, mild
lt hemiparesis
5 51, M mass effect causing basilar tip giant none none 43
dysmetria
6 55, M brainstem compression basilar trunk giant, dolichoectatic intraop rupture, died of brainstem NA
causing coma EDH compression caused
by aneurysm
7 65, F CN III palsy  rt cavernous ICA none none none 33
retroorbital pain
8 61, M lower CN deficits basilar trunk giant, dolichoectatic EDH died 4
9 45, M headache lt PCA, P2 dissecting none none 6
10 68, M CN III palsy lt cavernous ICA pseudoaneurysm none none 27
11 71, F incidental finding cervical ICA tortuous none none 6
12 48, F headache lt PCA dissecting none none 27
13 51, F stroke basilar tip giant, thrombosed, none died of underlying 2
calcified malignancy
14 22, F incidental finding rt petrous ICA large none none 7
15 40, F blurred vision rt PCA, P3/P4 dissecting none none 17
16 65, F CN III palsy rt cavernous ICA giant none none 2
17 73, F CN III & V palsy rt cavernous ICA giant none none 17
18 59, F CN III palsy rt cavernous ICA growing pseudoaneurysm none 1
of FA
19 65, M hemiparesis, diplopia, lt PCA, P2 giant EDH, PCA homonymous 12
hearing loss infarction hemianopia
20 69, F mass effect causing lt cavernous ICA giant none none 12
CN VI palsy
21 51, F stroke rt ACA, A2–A3 large none none 5
junction
* CN = cranial nerve; FA = femoral artery; FU = follow up; NA = not applicable.

2 Neurosurg. Focus / Volume 17 / November, 2004

Combined management of complex aneurysms

TABLE 2
Location of lesion, treatment, and outcome in 21 patients with complex aneurysms
Outcome

Location Excellent Good Fair Poor Dead

of Lesion Treatment (71.4%) (14.3%) (0%) (0%) (14.3%)

cervical ICA op transposition, endovascular stent, coil placement 1

petrous ICA STA–MCA bypass, coil occlusion of aneurysm & parent vessel 1
cavernous ICA STA–MCA bypass, coil occlusion of aneurysm & parent vessel 2
STA–MCA bypass, balloon occlusion 4 1
ACoA A3–A3 bypass, coil occlusion of inflow, aneurysm debulking 1
A2/A3 A3–A3 bypass, coil occlusion of rt A1 1
basilar trunk STA–SCA bypass, coil occlusion of VAs 2
basilar tip STA–SCA bypass, coil occlusion of VAs 1
clip occlusion of P1, stent placement in BA to contralat P1, 1
coil placement
PCA OA–PCA bypass, coil occlusion of aneurysm & vessel 3 2
OA onlay, coil occlusion of aneurysm & vessel 1

extracranial–intracranial revascularization and endovas-
cular parent-vessel occlusion. Six patients harbored an-
eurysms of the PCA (one giant, four dissecting, one fu-
siform; four of the P1–P2 junction; one of the P2 segment;
and one of the P3/P4 junction), five of whom underwent
an OA–PCA anastomosis followed by endovascular coil
placement and occlusion of the aneurysm and PCA. The
other patient underwent an OA onlay. The patient with a
dissecting aneurysm at the P3–P4 junction of the PCA un-
derwent an OA onlay, followed by endovascular balloon
occlusion of the parent vessel. A patient with a giant basi-
lar apex aneurysm was treated with coil embolization fol-
lowed by an STA–SCA bypass.
Flow Redirection
Four patients underwent flow redirection procedures. A
patient with a giant basilar tip aneurysm underwent clip
placement on P1 away from the aneurysm to redirect flow.
She later underwent endovascular stent placement in the
BA and contralateral PCA and stent-assisted coil place-
ment in the basilar trunk aneurysm. A patient with a large
right A2 aneurysm underwent a pericallosal artery micro-
surgical bypass followed by endovascular parent-vessel
occlusion of the right A1 to redirect flow through the an-
eurysm. Two patients underwent STA–SCA anastomosis
followed by endovascular occlusion of the VAs to reverse
flow through the BA.
Additional Combined Techniques
A patient with the giant ACoA aneurysm underwent an
A3–A3 bypass followed by clip occlusion of the aneurysm.
One day later, this patient underwent endovascular coil
placement in the inflow into the giant ACA. Another pa-
tient with a high cervical ICA aneurysm was found to
have a tortuous cervical carotid artery. To render the artery
amenable to stent placement, the ICA was transposed sur-
gically, thus straightening the portion of the artery that
harbored the aneurysm. The aneurysm was then treated
with stent placement and coil occlusion.
RESULTS
Clinical Outcomes
Fifteen patients (71.4%) had excellent outcomes, three
(14.3%) had good outcomes, and three (14.3%) died
(Table 2). One patient (Case 13) died of an underlying pul-
monary malignancy. Another (Case 6) presented with ex-
tensor posturing after intraoperative rupture of his giant
basilar trunk aneurysm. He suffered a postoperative EDH
and died of brainstem compression caused by the aneu-
rysm. The third patient who died (Case 8) had experienced
a brainstem stroke 6 years earlier. His giant basilar trunk
aneurysm was treated with an STA–SCA bypass, followed
by coil occlusion of the right VA distal to the PICA. Three
months later, BA thrombosis developed on the morning
that he was scheduled to undergo endovascular occlusion
of the contralateral VA, and he died.
The mean follow-up duration for the 18 surviving pa-
tients was 20 months (range 1–48 months). Eleven pa-
tients were symptom and disease free at follow-up review.
Four patients’ symptoms were unchanged from presenta-
tion, including three who presented with mass effect and
one who continued to suffer headaches. Three patients
suffered mild strokes that resulted in a homonymous
hemianopia after occlusion of their bypass graft.
Aneurysm Obliteration
Immediate postoperative angiography confirmed oblit-
eration of the lesion in 20 patients and demonstrated resid-
ual aneurysm in the other one. Angiographic follow-up
studies were obtained in 14 of the 18 surviving patients
and demonstrated complete occlusion or stable residual
aneurysm in 13 and a 1-cm enlarging residual lesion in
one. The latter patient underwent stent-assisted coil place-
ment in the residual aneurysm.
Postoperative Complications
Procedure-related complications occurred in eight cas-
es. One patient had an occlusion of an OA–PCA bypass
graft and a homonymous hemianopia developed; no treat-
ment was given, and the deficit was permanent. Five pa-
tients suffered EDHs, all of which occurred after heparin-
ization and endovascular treatment (Cases 1, 4, 6, 8, and
19). Among these, one patient (Case 6) presented in a
coma and died shortly after evacuation of the EDH. An-
other patient (Case 8) died 3 months later of a brainstem
stroke.

Neurosurg. Focus / Volume 17 / November, 2004 3


Homonymous hemianopia developed in three patients
treated with OA–PCA revascularization (Cases 1, 4, and
19). In one (Case 1) the complication resolved complete-
ly, in one (Case 19) an occlusion of the graft developed
and this patient was found to have a left PCA infarct, and
in one (Case 4) a mild permanent visual field deficit was
found. In one patient (Case 18) a pseudoaneurysm devel-
oped at the femoral artery after a cavernous ICA aneu-
rysm was treated with coils. One patient (Case 2) required
placement of a ventriculoperitoneal shunt after surgery to
control increased intracranial pressure.
ILLUSTRATIVE CASES
Case 16
This 65-year-old woman had a 3-month history of pro-
gressive proptosis, double vision, and intermittent head-
aches. Magnetic resonance imaging and magnetic reso-
nance angiography revealed a mesial right temporal mass,
and four-vessel angiography demonstrated a giant cav-
ernous ICA aneurysm (Fig. 1A).
A right STA–MCA bypass was performed, and patency
was documented using intraoperative angiography. Three
days later the patient tolerated temporary test occlusion of
the right ICA. Seven GDCs were inserted into the petrous
and high cervical segments of the right ICA (Fig. 1B and
C). Complete occlusion of the vessel was documented,
and a right external carotid artery injection demonstrated
excellent filling of the distal MCA branches through the
bypass graft. At her 6-month follow-up examination, the
patient reported resolution of her symptoms. Angiography
confirmed obliteration of the aneurysm and patency of the
bypass graft.
Case 13
This 51-year-old woman with a history of lung cancer
presented with the sudden onset of slurred speech and
weakness of the right arm. Imaging studies revealed a cal-
cified basilar apex aneurysm extending into the third ven-
tricle (Fig. 2A) and an infarction of the left temporal lobe
and posterior aspect of the left subinsular cortex. A three-
stage approach, including clip placement, endovascular
stent insertion, and embolization was recommended.
Fig. 1. Case 16. Cerebral angiograms and artist’s rendering depicting the anterior circulation. Left: Preoperative lat-
eral view of the right ICA demonstrating a giant cavernous carotid artery aneurysm. Center: Lateral view obtained after
bypass and coil occlusion confirming obliteration of the aneurysm and occlusion of the ICA. Right: Illustration depict-
ing the combined technique.
4 Neurosurg. Focus / Volume 17 / November, 2004
F. A. Ponce, et al.
During surgery, the neck of the aneurysm could not be
clipped satisfactorily because of the extensive thrombosis
and calcification at its base. Therefore, the P1 segment of
the right PCA was clipped as it emerged from the base of
the aneurysm. The posterior communicating artery recon-
stituted the distal right PCA (Fig. 2B). The second stage
of treatment was stent placement. After the initial angio-
grams were obtained a 3  14–mm stent (Radius; Bos-
ton Scientific, Watertown, MA) was placed, extending
from the left PCA down to the BA proximal to the SCAs.
Three weeks later, the residual aneurysm was embolized
with seven GDCs, which were placed without incident
(Fig. 2C and D). The patient later died of her underlying
malignancy.
Case 19
This 65-year-old man had received a diagnosis of a
giant left PCA aneurysm 3 years earlier and had been told
that the lesion was inoperable. He presented to us with
progressive decline, including dizziness, right hemipare-
sis, and intermittent diplopia. Angiography confirmed the
presence of the aneurysm (Fig. 3A), and an OA–distal
PCA bypass followed by coil embolization of the distal P2
segment of the PCA was recommended.
Initially, the patient underwent a bioccipital craniotomy
and microsurgical anastomosis of the right OA to the dis-
tal PCA. Two days later angiography demonstrated paten-
cy of the bypass, and the patient underwent coil emboliza-
tion and occlusion of the aneurysm and parent artery (Fig.
3B and C). Seven GDCs were deposited within the an-
eurysm. Subsequent angiography demonstrated filling of
the PCA through the bypass graft but no filling of the an-
eurysm from the VA injections.
The patient’s postoperative course was complicated
by an occipital EDH, which caused right homonymous
hemianopia. The hematoma was evacuated and the pa-
tient’s left visual field cut resolved. At 1-year follow-up
examination, the patient had resumed all activities of daily
living.
DISCUSSION
Combined endovascular and surgical therapy has been
practiced since 1987.19 Early applications of endovascular
Combined management of complex aneurysms

Fig. 2. Case 13. Cerebral angiograms and artist’s rendering depicting the posterior circulation. A: Anteroposterior
view demonstrating a large basilar apex aneurysm. B: Anteroposterior view of the aneurysm after microsurgical clip-
ping of the right P1 segment of the PCA. Subsequently, a stent was placed extending from the distal BA to the left P1 seg-
ment of the PCA. C: Angiogram obtained when the patient returned for further endovascular obliteration of the an-
eurysm with seven GDCs 3 weeks after placement of the stent. D: Illustration depicting the combined technique.

therapy as a surgical adjunct included embolization of
vascular lesions before resection.4,18,20 This approach made
it possible to obliterate extensive portions of vascular mal-
formations and tumors and thus enhanced the feasibili-
ty of resection. Combined techniques have also been ap-
plied to the treatment of intracranial dural fistulas6,12,17
and vascular occlusion.11,16,21 The classic application of
the combined technique is an extracranial–intracranial by-
pass combined with endovascular parent-vessel occlusion.
First attempted in 1987, Serbinenko, et al.,19 described this
technique in 1990 after treating nine patients with giant
ICA aneurysms for whom direct clip occlu- sion was
deemed to be associated with an unjustifiably high risk.
Early combined treatment strategies also included en-
dovascular retrograde suction decompression of paracli-
noid aneurysms to facilitate dissection and direct clip oc-
clusion.3 The use of balloon occlusion of the ICA before
dissection of unruptured aneurysms allowed proximal
artery control for temporary occlusion without requiring
neck dissection for proximal control of the ICA.15
The overwhelmingly poor prognosis associated with
untreated giant and complex aneurysms mandates aggres-
sive treatment in which both microsurgical and endovas-
cular techniques are used. In this series, combination ther-
apy was performed safely and aneurysms were obliterated
successfully in most cases. The use of such techniques
significantly alters the natural history of these lesions.5
The combined endovascular and surgical treatment
paradigms typically fall within one of four categories, as
follows: 1) endovascular or surgical treatment after un-
successful prior surgical or endovascular treatment, re-
spectively; 2) endovascular treatment of the remote sec-
ond aneurysm; 3) endovascular proximal parent artery
control during surgery for clip occlusion/decompression;
and 4) combined surgical and endovascular treatment for
complex intracranial aneurysms (for example, microsurgi-
cal revascularization followed by endovascular parent-
artery occlusion and flow-redirection techniques).
Barnett, et al.,2 Lawton, et al.,13 and Hacein-Bey, et al.,7
published large contemporary series of patients treated
with a combined modality. In this report, we reviewed on-
ly the subset of patients who received the aforementioned
fourth treatment paradigm. Specifically, endovascular and
surgical modalities were combined in the initial treatment
plan. Broadly, these patients may be categorized in the fol-
lowing subgroups: 1) those with aneurysms involving the
petrous, cavernous, or paraclinoid ICA that are not ame-
nable to direct surgical clip occlusion and that require

Fig. 3. Case 19. Cerebral angiograms and artist’s rendering depicting the posterior circulation. Left: Anteroposterior
view demonstrating a large right-sided P1/P2 junction aneurysm. Center: Anteroposterior view of the aneurysm after
OA–PCA bypass and coil embolization and occlusion of the lesion and parent artery. Right: Illustration depicting the
combined technique.

Neurosurg. Focus / Volume 17 / November, 2004 5


an STA–MCA bypass or a cervical carotid artery–MCA
saphenous vein bypass graft followed by parent-vessel
occlusion; 2) those with aneurysms in the posterior circu-
lation that require an STA–SCA or OA–PCA bypass; and
3) those with complex aneurysms that cannot be eliminat-
ed from the circulation and that require flow-redirection
techniques. In our series, the most common aneurysms for
which a combined technique was required were those in-
volving the cavernous ICA and PCA. Of the latter, most
were dissecting aneurysms.
Treatment of ICA Aneurysms
The technique for combining endovascular and surgical
approaches to treat ICA aneurysms (Fig. 1C) has been
well described.1,2,8,10,13–15 We treated 12 patients by using an
STA–MCA bypass or cervical ICA–MCA saphenous vein
bypass graft, and all had excellent outcomes.
Treatment of PCA Aneurysms
Revascularization followed by parent-vessel occlusion
was the modality used to treat PCA aneurysms. The PCA
aneurysms were difficult to access and their morphology
was complex; four were dissecting aneurysms, one was
fusiform, and one was a giant lesion. These patients un-
derwent OA–PCA microanastomosis followed by emboli-
zation and occlusion of the aneurysm and parent vessel
(Fig. 3C). One patient underwent an OA onlay instead of
a bypass because of a poor-quality recipient artery.
The technical difficulty involved in the performance
of an OA–PCA bypass may be greater than that for
STA–MCA, as evidenced by the fact that homonymous
hemianopia developed in four patients after PCA occlu-
sion. Nevertheless, this deficit improved or resolved in
two patients and was permanent in only one. The postop-
erative course in three patients treated for PCA aneurysms
was complicated by EDH, underscoring the frequent but
unfortunately necessary risk associated with hepariniza-
tion during the endovascular treatment stage.
Flow Redirection
Flow-redirection techniques were used for aneurysms
involving the BA and the ACAs. When an aneurysm can-
not be removed from the circulation, the goal is to alter the
hemodynamics at the lesion by changing the direction of
blood flow.
The two patients with complex aneurysms involving
the trunk of the BA were treated using flow reversal. The
first procedure consisted of revascularization through an
STA–SCA bypass, followed by a two-stage endovascular
treatment. The second patient underwent procedures con-
sisting of unilateral occlusion of the VA proximal to the
PICA, followed by contralateral VA occlusion distal to the
PICA. The goal in delaying occlusion of the second VA
was to provide the graft with time to mature. Ultimately,
one PICA depends on backflow from the BA, and this
demand is thought to help prevent basilar thrombosis, thus
maintaining flow from the bypass to the BA and the brain-
stem perforating vessels.
In both patients for whom this strategy was selected,
postoperative EDHs developed, and neither individual
survived long enough for the second endovascular proce-
dure to be performed. One patient required a decompres-
6 Neurosurg. Focus / Volume 17 / November, 2004
F. A. Ponce, et al.
sive craniectomy and recovered from this procedure dur-
ing his prolonged hospitalization. He died 3 months later
of a posterior fossa stroke caused by BA thrombosis suf-
fered on the day he was scheduled to undergo the second
stage of endovascular treatment. One patient with a basi-
lar apex aneurysm was treated with flow redirection en-
tailing surgical clip occlusion of the right P1 segment of
the PCA, followed by stent placement in the distal BA and
left PCA, followed in turn by stent-assisted coil emboliza-
tion of the aneurysm (Fig. 2D). This patient eventually
died of an underlying malignancy, although her postoper-
ative course was excellent.
Two patients underwent flow-reversal techniques for
ACA aneurysms. One had an A2–A3 aneurysm and the
other had an ACoA aneurysm. Both patients underwent
A3–A3 bypass followed by endovascular occlusion of the
aneurysm and feeding artery.
Arterial Transposition for Stent Placement
A combined technique also may be indicated when an
aneurysm is amenable to endovascular treatment but the
tortuosity of the feeding artery renders access to the lesion
impossible. One patient underwent transposition of a tor-
tuous ICA to straighten the segment containing the an-
eurysm. Stent placement in the parent vessel and coil oc-
clusion of the aneurysm were then possible.
CONCLUSIONS
Certain complex aneurysms may be treated optimally
by combining endovascular and surgical techniques. Ca-
vernous ICA aneurysms are classic examples, wherein
treatment consists of an extracranial–intracranial bypass
and endovascular parent-vessel occlusion. A similar strat-
egy may be indicated for complex PCA aneurysms. In this
case an OA–PCA bypass is performed, and the PCA is
occluded endovascularly at the location of the aneurysm.
Finally, flow-redirection techniques may alter the hemo-
dynamics of aneurysms that are not amenable to removal
from the circulation. This treatment may be indicated for
giant dolichoectatic lesions of the posterior circulation. Al-
though the surgical and endovascular procedures empha-
sized in this combined paradigm are associated with well-
known complications, the high-risk nature of the primary
lesion mandates an aggressive approach. The risks of this
combined treatment strategy are likely lower than those
associated with the natural history of this subset of an-
eurysms.
Acknowledgment
We thank R. Spencer Phippen for the drawings depicting the cir-
culatory anatomy involved in the combined technique.
References
1. Arnautović KI, Al-Mefty O, Angtuaco E: A combined micro-
surgical skull-base and endovascular approach to giant and
large paraclinoid aneurysms. Surg Neurol 50:504–520, 1998
2. Barnett DW, Barrow DL, Joseph GJ: Combined extracranial-
intracranial bypass and intraoperative balloon occlusion for the
treatment of intracavernous and proximal carotid artery aneu-
rysms. Neurosurgery 35:92–98, 1994
Combined management of complex aneurysms
3. Batjer HH, Samson DS: Retrograde suction decompression
of giant paraclinoidal aneurysms. Technical note. J Neurosurg
73:305–306, 1990
4. Deruty R, Pelissou-Guyotat I, Amat D, Mottolese C, Bascou-
lergue Y, Turjman F, et al: Multidisciplinary treatment of ce-
rebral arteriovenous malformations. Neurol Res 17:169–177,
1995
5. Ferguson GG, Peerless SJ, Drake CG: Natural history of intra-
cranial aneurysms. N Engl J Med 305:99, 1981
6. Goto K, Sidipratomo P, Ogata N, et al: Combining endovascu-
lar and neurosurgical treatments of high-risk dural arteriove-
nous fistulas in the lateral sinus and the confluence of the sinus-
es. J Neurosurg 90:289–299, 1999
7. Hacein-Bey L, Connolly ES Jr, Mayer SA, et al: Complex in-
tracranial aneurysms: combined operative and endovascular
approaches. Neurosurgery 43:1304–1313, 1998
8. Hoh BL, Carter BS, Budzik RF, et al: Results after surgical and
endovascular treatment of paraclinoid aneurysms by a com-
bined neurovascular team. Neurosurgery 48:78–90, 2001
9. Hoh BL, Ogilvy CS, Butler WE, et al: Multimodality treatment
of nongalenic arteriovenous malformations in pediatric pa-
tients. Neurosurgery 47:346–358, 2000
10. Hoh BL, Putman CM, Budzik RF, et al: Combined surgical and
endovascular techniques of flow alteration to treat fusiform and
complex wide-necked intracranial aneurysms that are unsuit-
able for clipping or coil embolization. J Neurosurg 95:24–35,
2001
11. Konishi Y, Sato E, Shiokawa Y, et al: A combined surgical and
endovascular treatment for a case with five vertebro-basilar
aneurysms and bilateral internal carotid artery occlusions. Surg
Neurol 50:363–366, 1998
12. Krisht AF, Burson T: Combined pretemporal and endovascular
approach to the cavernous sinus for the treatment of carotid-
cavernous dural fistulae: technical case report. Neurosurgery
44:415–418, 1999
13. Lawton MT, Quinones-Hinojosa A, Sanai N, et al: Combined
Neurosurg. Focus / Volume 17 / November, 2004
microsurgical and endovascular management of complex in-
tracranial aneurysms. Neurosurgery 52:263–275, 2003
14. Martin NA: The combination of endovascular and surgical tech-
niques for the treatment of intracranial aneurysms. Neurosurg
Clin N Am 9:897, 1998
15. Mizoi K, Takahashi A, Yoshimoto T, et al: Combined endovas-
cular and neurosurgical approach for paraclinoid internal ca-
rotid artery aneurysms. Neurosurgery 33:986–992, 1993
16. Pappada G, Marina R, Fiori L, et al: Surgery and stenting as
combined treatment of a symptomatic tandem stenosis of the
carotid artery. Acta Neurochir 141:1177–1181, 1999
17. Pierot L, Visot A, Boulin A, et al: Combined neurosurgical and
neuroradiological treatment of a complex superior sagittal sinus
dural fistula: technical note. Neurosurgery 42:194–197, 1998
18. Rosenblatt S, Lewis AI, Tew JM: Combined interventional and
surgical treatment of arteriovenous malformations. Neuroim-
aging Clin N Am 8:469–482, 1998
19. Serbinenko FA, Filatov JM, Spallone A, et al: Management of
giant intracranial ICA aneurysms with combined extracranial-
intracranial anastomosis and endovascular occlusion. J Neuro-
surg 73:57–63, 1990
20. Shaffrey ME, Persing JA, Ferguson RD, et al: Vascular lesions
involving the cranial base: combined surgical and intervention-
al radiologic approach. J Craniofac Surg 1:106–111, 1990
21. Terada T, Nakai E, Tsuura M, et al: Combined surgery and en-
dovascular stenting for basilar artery stenosis refractory to bal-
loon angioplasty: technical case report. Acta Neurochir 143:
511–516, 2001
Manuscript received September 17, 2004.
Accepted in final form October 5, 2004.
Address reprint requests to: Felipe C. Albuquerque, M.D., Neu-
roscience Publications; Barrow Neurological Institute, 350 West
Thomas Road, Phoenix, Arizona 85013. email: neuropub@
chw.edu.
7