Combined One-Step Hybrid Treatment for a Pediatric Giant Internal Carotid Artery Aneurysm: A Case Report

Abstract

Background

Giant intracranial aneurysms require complex treatment strategies including clipping, coiling, stenting, parent artery occlusion, bypass, or combined procedures. Neurovascular hybrid operating rooms (h-OR) combine a conventional operating theatre with high-resolution digital subtraction angiography (DSA). We describe a one-step combined surgical and endovascular treatment in a h-OR for a pediatric internal carotid artery (ICA) giant aneurysm that can be an optimal solution to manage such challenging cases.

Case Description

An 11-year-old boy presented with rapid onset right hemiparesis and left eyelid ptosis. A 3-month history of headache associated with sporadic vomit was reported. A giant, unruptured, left ICA aneurysm was detected on imaging. The patient underwent surgical trapping of the aneurysm. Intraoperative DSA showed residual backflow from the posterior communicating artery and coils were placed to completely exclude the aneurysm. At 18-month follow-up, the patient showed a complete recovery and magnetic resonance imaging showed a progressive reduction of the sac aneurysm.

Conclusions

Due to their morphological variability, intracranial giant aneurysms may require a different procedural strategy instead of direct clipping or coiling. The introduction of h-OR allows combined treatments to be performed simultaneously in the same room setting. The present case shows that combined treatment in a neurovascular h-OR can be an optimal solution to manage challenging cases, such as giant aneurysms, reducing operative time with the added benefit of selecting an appropriate strategy adjustment in a multidisciplinary effort.

Keywords

coil embolization - combined neurovascular approach - hybrid operating room - microsurgical clipping - giant intracranial aneurysm

Publikationsverlauf

Eingereicht: 21. Juni 2024

Angenommen: 19. November 2024

Accepted Manuscript online:
25. November 2024

Artikel online veröffentlicht:
14. November 2025

• References

• 1 Fandino J, Taussky P, Marbacher S. et al. The concept of a hybrid operating room: applications in cerebrovascular surgery. Acta Neurochir Suppl (Wien) 2013; 115: 113-117
• 2 Kassell NF, Torner JC, Haley Jr EC, Jane JA, Adams HP, Kongable GL. The international cooperative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 1990; 73 (01) 18-36
• 3 Lawton MT, Spetzler RF. Surgical management of giant intracranial aneurysms: experience with 171 patients. Clin Neurosurg 1995; 42: 245-266
• 4 Morita A, Kirino T, Hashi K. et al; UCAS Japan Investigators. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med 2012; 366 (26) 2474-2482
• 5 Onuma T, Suzuki J. Surgical treatment of giant intracranial aneurysms. J Neurosurg 1979; 51 (01) 33-36
• 6 Huang J, McGirt MJ, Gailloud P, Tamargo RJ. Intracranial aneurysms in the pediatric population: case series and literature review. Surg Neurol 2005; 63 (05) 424-432 , discussion 432–433
• 7 Choi IS, David C. Giant intracranial aneurysms: development, clinical presentation and treatment. Eur J Radiol 2003; 46 (03) 178-194
• 8 Choudhri O, Mukerji N, Steinberg GK. Combined endovascular and microsurgical management of complex cerebral aneurysms. Front Neurol 2013; 4 (August): 108
• 9 Kotowski M, Sarrafzadeh A, Schatlo B. et al. Intraoperative angiography reloaded: a new hybrid operating theater for combined endovascular and surgical treatment of cerebral arteriovenous malformations: a pilot study on 25 patients. Acta Neurochir (Wien) 2013; 155 (11) 2071-2078
• 10 Schaller K, Kotowski M, Pereira V, Rüfenacht D, Bijlenga P. From intraoperative angiography to advanced intraoperative imaging: the geneva experience. Acta Neurochir Suppl (Wien) 2011; 109: 111-115
• 11 Shen SC, Tsuei YS, Chen WH, Shen CC. Hybrid surgery for dural arteriovenous fistula in the neurosurgical hybrid operating suite. J Neurointerv Surg 2015; 7 (02) e6
• 12 Pruvot AS, Curey S, Derrey S, Castel H, Proust F. Giant intracranial aneurysms in the paediatric population: suggested management and a review of the literature. Neurochirurgie 2016; 62 (01) 20-24
• 13 Murayama Y, Saguchi T, Ishibashi T. et al. Endovascular operating suite: future directions for treating neurovascular disease. J Neurosurg 2006; 104 (06) 925-930
• 14 Jin H, Liu J. Application of the hybrid operating room in surgery: a systematic review. J Invest Surg 2022; 35 (02) 378-389
• 15 Greve T, Stoecklein VM, Dorn F. et al. Introduction of intraoperative neuromonitoring does not necessarily improve overall long-term outcome in elective aneurysm clipping. J Neurosurg 2019; 132 (04) 1188-1196
• 16 Macdonald DB, Skinner S, Shils J, Yingling C. American Society of Neurophysiological Monitoring. Intraoperative motor evoked potential monitoring - a position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol 2013; 124 (12) 2291-2316
• 17 Szelényi A, Kothbauer K, de Camargo AB, Langer D, Flamm ES, Deletis V. Motor evoked potential monitoring during cerebral aneurysm surgery: technical aspects and comparison of transcranial and direct cortical stimulation. Neurosurgery 2005; 57 (4, Suppl): 331-338 , discussion 331–338
• 18 Szelényi A, Langer D, Kothbauer K, De Camargo AB, Flamm ES, Deletis V. Monitoring of muscle motor evoked potentials during cerebral aneurysm surgery: intraoperative changes and postoperative outcome. J Neurosurg 2006; 105 (05) 675-681
• 19 Banna M, Lasjaunias P. Intracavernous carotid aneurysm associated with proptosis in a 13-month-old girl. AJNR Am J Neuroradiol 1991; 12 (05) 969-970
• 20 Herman JM, Rekate HL, Spetzler RF. Pediatric intracranial aneurysms: simple and complex cases. Pediatr Neurosurg 1991; -1992 17 (02) 66-72 , discussion 73
• 21 Linskey ME, Sekhar LN, Horton JA, Hirsch Jr WL, Yonas H. Aneurysms of the intracavernous carotid artery: a multidisciplinary approach to treatment. J Neurosurg 1991; 75 (04) 525-534
• 22 Swamy NKS, Pope FM, Coakham HB. Giant aneurysm of internal carotid artery in a four-year-old child: a case report. Surg Neurol 1993; 40 (02) 138-141
• 23 Maggi G, Ruggiero C, Petrone G, Aliberti F. Giant intracavernous carotid aneurysm in a child. Case report. J Neurosurg Sci 1997; 41 (04) 349-351
• 24 Cekirge S, Saatci I, Firat MM. et al. Bilateral cavernous carotid artery aneurysms in a 4-year-old child: endovascular treatment with mechanically detachable coils. Neuroradiology 1997; 39 (05) 367-370
• 25 Dörfler A, Wanke I, Wiedemayer H, Weber J, Forsting M. Endovascular treatment of a giant aneurysm of the internal carotid artery in a child with visual loss: case report. Neuropediatrics 2000; 31 (03) 151-154
• 26 Proust F, Toussaint P, Garniéri J. et al. Pediatric cerebral aneurysms. J Neurosurg 2001; 94 (05) 733-739
• 27 Otsuka G, Miyachi S, Handa T. et al. Endovascular trapping of giant serpentine aneurysms by using Guglielmi detachable coils: successful reduction of mass effect. Report of two cases. J Neurosurg 2001; 94 (05) 836-840
• 28 Zhang YJ, Barrow DL, Day AL, Sutton LN, Scott RM. Extracranial-intracranial vein graft bypass for giant intracranial aneurysm surgery for pediatric patients: two technical case reports. Neurosurgery 2002; 50 (03) 663-668
• 29 Jurkiewicz E, Jóźwiak S. Giant intracranial aneurysm in a 9-year-old boy with tuberous sclerosis. Pediatr Radiol 2006; 36 (05) 463
• 30 Goedee HS, Depauw PRAM, vd Zwam B, Temmink AH. Superficial temporal artery-middle cerebral artery bypass surgery in a pediatric giant intracranial aneurysm presenting as migraine-like episodes. Childs Nerv Syst 2009; 25 (02) 257-261
• 31 Rehman T, Ali R, Taylor C, Yonas H. Bilateral giant cavernous carotid artery aneurysms in a child with juvenile Paget's disease. World Neurosurg 2010; 73 (06) 691-693
• 32 Sanai N, Auguste KI, Lawton MT. Microsurgical management of pediatric intracranial aneurysms. Childs Nerv Syst 2010; 26 (10) 1319-1327
• 33 Gatto L, Barro A, Tacla R, Demartini Z, Koppe G. Endovascular treatment of a giant dissecting aneurysm in an infant. Arq Bras Neurocir Brazilian Neurosurg. 2018; 37 (03) 217-222
• 34 Buño II BO, Cruz FM. Neuro-ophthalmological presentation of giant intracavernous carotid artery aneurysm in a child. BMJ Case Rep 2018; 11 (01) 10-12
• 35 Nam SM, Jang D, Wang KC. et al. Characteristics and treatment outcome of intracranial aneurysms in children and adolescents. J Korean Neurosurg Soc 2019; 62 (05) 551-560
• 36 Kumaria A, McConachie NS, Macarthur DC. Successful treatment of giant cavernous carotid artery aneurysm in a child using a flow diverter stent. Br J Neurosurg 2021; 35 (01) 122-124
• 37 de Aguiar GB, Ozanne A, Elawady A. et al. Intracranial aneurysm in pediatric population: a single-center experience. Pediatr Neurosurg 2022; 57 (04) 270-278
• 38 Malikov A, Secen AE, Daglioglu E, Belen AD. A pediatric case of completely thrombosed giant cavernous carotid aneurysm with ipsilateral ICA occlusion mimicking an intra-axial cystic lesion: a case report and review of the literature. Childs Nerv Syst 2022; 38 (09) 1809-1812
• 39 Nathal E, Degollado-García J, Bonilla-Suastegui A, Rodríguez-Rubio HA, Ferrufino-Mejia BR, Casas-Martínez MR. Microsurgical treatment of a giant intracavernous carotid artery aneurysm in a pediatric patient: case report and literature review. Cureus 2023; 15 (01) e34010
• 40 Cockroft KM, Marks MP, Steinberg GK. Planned direct dual-modality treatment of complex broad-necked intracranial aneurysms: four technical case reports. Neurosurgery 2000; 46 (01) 226-230 , discussion 230–231
• 41 Tajima H, Araki Y, Izumi T, Nishihori M, Okamoto S, Wakabayashi T. Coiling of a ruptured large internal carotid artery aneurysm via extracranial-intracranial saphenous vein bypass graft just after proximal ligation of the internal carotid artery. World Neurosurg 2017; 98: 879.e1-879.e4
• 42 Liao CH, Chen WH, Lee CH, Shen SC, Tsuei YS. Treating cerebrovascular diseases in hybrid operating room equipped with a robotic angiographic fluoroscopy system: level of necessity and 5-year experiences. Acta Neurochir (Wien) 2019; 161 (03) 611-619
• 43 Zhang N, Xin WQ. Application of hybrid operating rooms for clipping large or giant intracranial carotid-ophthalmic aneurysms. World J Clin Cases 2020; 8 (21) 5149-5158
• 44 Choi E, Lee JY, Jeon HJ, Cho B-M, Yoon DY. A hybrid operating room for combined surgical and endovascular procedures for cerebrovascular diseases: a clinical experience at a single centre. Br J Neurosurg 2019; 33 (05) 490-494
• 45 Lee MC, Macdonald RL, Satow T. et al. Intraoperative cerebral angiography: superficial temporal artery method and results. Neurosurgery 2003; 53 (05) 1067-1074 , discussion 1074–1075
• 46 Nasi D, Meletti S, Tramontano V, Pavesi G. Intraoperative neurophysiological monitoring in aneurysm clipping: does it make a difference? A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 196: 105954
• 47 Pavesi G, Dimitriadis S, Baroni S. et al. Intraoperative functional and perfusion monitoring during surgery for giant serpentine middle cerebral artery aneurysms. World Neurosurg 2015; 84 (02) 592.e15-592.e21