Treatment Strategies for Complex Internal Carotid Artery (ICA) Aneurysms: Direct ICA Sacrifice or Combined with Extracranial-to-Intracranial Bypass

ObjectiveDirect surgery for complex internal carotid artery (ICA) aneurysms can be difficult. In certain situations, sacrificing the parent artery is a unique way to obliterate the aneurysm and extracranial-to-intracranial (EC-IC) bypass is indispensable to prevent postoperative cerebral ischemia. This article discusses the indications for direct ICA occlusion, and the strategies, techniques, and outcomes in a series of patients treated for complex ICA aneurysms in a single institution.MethodsDuring a 7-year period, 49 patients with complex ICA aneurysms underwent direct ICA sacrifice, or ICA sacrifice combined with EC-IC bypass. The appropriate type of bypass was determined by the results of balloon occlusion test and computed tomographic perfusion. The technique of ICA sacrifice used was selected based on the evaluation of retrograde filling of the aneurysm during balloon occlusion test.ResultsTen patients underwent direct ICA sacrifice and no ischemia-related complications were evident during the 5–12 months of follow-up. A total of 39 patients were treated by ICA sacrifice combined with EC-IC bypass, including 21 cases of superficial temporal artery–radial artery–middle cerebral artery and 18 cases of external carotid artery–radial artery–middle cerebral artery. ICA sacrifice was achieved in 38 patients by using prolonged occlusion (25 cases) or acute occlusion (13 cases). Five patients presented with minor ischemia after surgery, but four patients recovered completely. Two patients developed brain swelling postoperatively and one developed intracranial hemorrhage, which required evacuation of the hematoma.ConclusionBalloon occlusion test combined with computed tomographic perfusion can be an efficient way to evaluate the compromised cerebrovascular reserve in patients with complex ICA aneurysms after ICA occlusion. In conjunction with EC-IC bypass, ICA proximal occlusion or trapping can be an effective treatment strategy.