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Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long-standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs. The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru, during 2018–2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications. Seventeen patients (70.59% female; median age: 53 years) with 17 CIAs (64.7% saccular; 76.5% ruptured) were included. The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first-, second-, and third-generation bypass. In 47.1% of cases, an anastomosis between the superficial temporal artery and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), a superficial temporal artery-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). The intraoperative aneurysm rupture rate was 11.8%. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10–15). At the 6-month follow-up, 82.4% of patients had a modified Rankin Scale score ≤2, bypass patency was present in all cases, and the morbidity rate was 17.6%. CIAs represent a spectrum of defiant vascular lesions with a poor natural history. Bypass surgery offers the potential for definitive treatment. Our case series illustrated the predominant role of cerebral revascularization of CIAs with a critical case-by-case approach to provide optimal outcomes in a limited-resource setting. [ABSTRACT FROM AUTHOR]

We present the case of a 58-year-old male with a 3-day history of sudden onset headache, loss of consciousness, and uncontrolled vomiting. The patient had 3/5 quadriparesis and a Glasgow coma scale (GCS) score of 8, which merited neurocritical intensive care. Brain imaging suggested the presence of two lesions: (i) a fusiform aneurysm of 12 × 7 mm in an accessory A2 artery of the anterior cerebral artery and (ii) an unruptured saccular aneurysm of 3.3 × 2.8 mm in the distal segment of the basilar artery. He was deemed a candidate for microsurgical management. Postoperatively, he had 4/5 quadriparesis, paresis of the right oculomotor nerve, and a GCS score of 13. A 3-month follow-up showed a significant improvement in neurological function with a score of 2 on the modified Rankin scale. The presented case illustrates the relevance of a nuanced acquaintance to operate in diseased anatomical variants and complex pathologies of narrow corridors. [ABSTRACT FROM AUTHOR]

Over the last decades, minimally invasive techniques have revolutionized the endovascular treatment (EVT) of brain aneurysms. In parallel, the development of conscious sedation (CS), a potentially less harmful anesthetic protocol than general anesthesia (GA), has led to the course optimization of surgeries, patient outcomes, and healthcare costs. Nevertheless, the feasibility and safety of EVT of brain aneurysms under CS have yet to be assessed thoroughly. Herein, we systematically reviewed the medical literature about this procedure. In accordance with the PRISMA guidelines, four databases (PubMed, EMBASE, SCOPUS, and Cochrane Library) were queried to identify articles describing the EVT of brain aneurysms under CS. Successful procedural completion, complete aneurysm occlusion outcomes, intraoperative complications, clinical outcomes, and mortality rates assessed the feasibility and safety. Our search strategy yielded 567 records, of which 11 articles were included in the qualitative synthesis. These studies entailed a total of 1142 patients (40.7% females), 1183 intracranial aneurysms (78.4% in the anterior circulation and 60.9% unruptured at presentation), and 1391 endovascular procedures (91.9% performed under CS). EVT modalities under CS included coiling alone (63.2%), flow diversion (17.7%), stent-assisted coiling (10.6%), stenting alone (6.5%), onyx embolization alone (1.7%), onyx + stenting (0.2%), and onyx + coiling (0.2%). CS was achieved by combining two or more anesthetics, such as midazolam, fentanyl, and remifentanil. Selection criteria for CS were heterogenous and included patients' history of pulmonary and cardiovascular diseases, outweighing the benefits of CS versus GA, a Hunt and Hess score of I–II, a median score of 3 in the American Society of Anesthesiology scale, and patient's compliance with elective CS. Procedures were deemed successful or achieving complete aneurysm occlusion in 88.1% and 9.4% of reported cases, respectively. Good clinical outcomes were described in 90.4% of patients with available data at follow-up (mean time: 10.7 months). The procedural complication rate was 16%, and the mortality rate was 2.8%. No complications or mortality were explicitly attributed to CS. On the other hand, procedure abortion and conversion from CS to GA were deemed necessary in 5% and 1% of cases, respectively. The present study highlights the feasibility of performing EVT of brain aneurysms under CS as an alternative anesthetic protocol to GA. However, the limited nature of observational studies, methodological quality, the predominant absence of a comparative GA group, and clinical data during follow-up restrict a conclusive statement about the safety of EVT under CS. Accordingly, further research endeavors are warranted toward a higher level of evidence that can be translated into surgical practice. [ABSTRACT FROM AUTHOR]

Over the last decades, minimally invasive techniques have revolutionized the endovascular treatment (EVT) of brain aneurysms. In parallel, the development of conscious sedation (CS), a potentially less harmful anesthetic protocol than general anesthesia (GA), has led to the course optimization of surgeries, patient outcomes, and healthcare costs. Nevertheless, the feasibility and safety of EVT of brain aneurysms under CS have yet to be assessed thoroughly. Herein, we systematically reviewed the medical literature about this procedure. In accordance with the PRISMA guidelines, four databases (PubMed, EMBASE, SCOPUS, and Cochrane Library) were queried to identify articles describing the EVT of brain aneurysms under CS. Successful procedural completion, complete aneurysm occlusion outcomes, intraoperative complications, clinical outcomes, and mortality rates assessed the feasibility and safety. Our search strategy yielded 567 records, of which 11 articles were included in the qualitative synthesis. These studies entailed a total of 1142 patients (40.7% females), 1183 intracranial aneurysms (78.4% in the anterior circulation and 60.9% unruptured at presentation), and 1391 endovascular procedures (91.9% performed under CS). EVT modalities under CS included coiling alone (63.2%), flow diversion (17.7%), stent-assisted coiling (10.6%), stenting alone (6.5%), onyx embolization alone (1.7%), onyx + stenting (0.2%), and onyx + coiling (0.2%). CS was achieved by combining two or more anesthetics, such as midazolam, fentanyl, and remifentanil. Selection criteria for CS were heterogenous and included patients' history of pulmonary and cardiovascular diseases, outweighing the benefits of CS versus GA, a Hunt and Hess score of I–II, a median score of 3 in the American Society of Anesthesiology scale, and patient's compliance with elective CS. Procedures were deemed successful or achieving complete aneurysm occlusion in 88.1% and 9.4% of reported cases, respectively. Good clinical outcomes were described in 90.4% of patients with available data at follow-up (mean time: 10.7 months). The procedural complication rate was 16%, and the mortality rate was 2.8%. No complications or mortality were explicitly attributed to CS. On the other hand, procedure abortion and conversion from CS to GA were deemed necessary in 5% and 1% of cases, respectively. The present study highlights the feasibility of performing EVT of brain aneurysms under CS as an alternative anesthetic protocol to GA. However, the limited nature of observational studies, methodological quality, the predominant absence of a comparative GA group, and clinical data during follow-up restrict a conclusive statement about the safety of EVT under CS. Accordingly, further research endeavors are warranted toward a higher level of evidence that can be translated into surgical practice. [ABSTRACT FROM AUTHOR]