Combined endovascular and microsurgical approach in the treatment of giant paraclinoid and vertebrobasilar aneurysms

Aim. The aim of this study is to present the application of endovascular intraoperative occlusion of the parent artery during the microsurgical treatment of giant paraclinoidal internal carotid artery aneurysms (ICA) and of complex vertebrobasilar junction aneurysms . Methods. Five cases of giant paraclinoidal ICA aneurysms were treated by direct surgical approach. In the operatory room any patient underwent angiography and balloon occlusion test using a mobile digital subtraction angiograph. Thereafter the catheter was left in the aortic arch. Through an extended pterional craniotomy, it was possible to evidentiate the aneurismal sac. The proximal control of the vessel was achieved inflating a double-lumen balloon; clipping of the aneurysm was achieved, because of pressure lowering inside the aneurysm. Also a giant vertebrobasilar junction aneurysm was treated by this combined technique: using a posterolateral approach the control of the omolateral vertebral artery was obtained by temporary clipping above PICA's origin; the control of controlateral artery was obtained inflating a balloon introduced through the femoral artery. These combined manoeuvres determined sac deflation, allowing an easier clipping. Results. Aneurysm obliteration was achieved with preservation of the circulation without complications in all cases. Conclusion. The endovascular procedure allows safer and reliable proximal control of paraclinoidal ICA and vertebral artery during the microsurgical treatment of paraclinoid and vertebrobasilar junction aneurysms.