Aneurysm Strategy – management beyond ego

Vipul GuptaNeurointerventional Surgery(Interventional Neuroradiology)Institute of Neurosciences Medanta the Medicity

Aneurysm Strategy – management beyond ego

Large – giant aneurysms ISUIA Trial

Flow diverters (stents)-

Giant fusiform, no collateral, mass effect

Thrombosed after a week Decompression Independent, mild UL weakness

Giant/large aneurysms Stent-assisted coiling – safe,

follow-up and possible repeat treatment

Flow diverters - evolving, paraclinoidal aneurysms, ?risk

(Parent vessel occlusion – may be the ideal treatment for cavernous aneurysms)

Fusiform giant ICA with no collaterals– need bypass

Fusiform dissecting aneurysm…

56 yr old, ischaemic stroke

Fusiform-dissecting aneurysms & blister aneurysms

Extremely difficult to treat Overlapping stents with coils as much

as possible to buy time/promote thrombosis

Continued growth common- early check Flow diverter

However , Distal fusiform dissecting

aneurysms.. Stent/FD not possible ---

bypass/surgical reconstruction..

Small Blister/dissecting Friable, continued growth, re-rupture

F

A

Very small berry aneurysms

Near the neck rupture

Catheter reposition

1-mm coil

A B C

DYSPLASTIC BIFURCATION ANEURYSMS

• 64 year old lady• History of blurring of

vision• Left temporal

hemianopia

Most probably partially thrombosed Will need stent…. Will recur

Dysplastic bifurcation aneurysms- Needing complicated stenting- Partially thrombosed

Branch from aneurysm- balloon overinflation

A B

Hemtoma – not conscious

Hematoma ….M6

Dysplastic aneurysm- high chance of recurrence

Progressive intraaneurysmal partial thrombosis starts

8th DAY POST COILING

10th DAY POST COILING , sudden clinical deterioration

Referred for surgeryGiant fusiform needing bypass Dysplastic bifurcation needing

stenting/angulated vesselsDistal dissecting, partially

thrombosed aneurysmAneurysm with symptomatic

hematomaMass effect Cost/follow-up/re-treatment

issues

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