Cerebral Revascularization for Aneurysm Treatment in the Era of Endovascular Flow Diversion

Background: With the advances in endovascular armamentarium, majority of giant, wide neck, or fusiform aneurysms are being treated with flow diversion rather than cerebral revascularization. The purpose of this study was to evaluate the indication and outcomes of cerebral revascularization for brain aneurysms in recent years when flow diversion is widely available as an option.

Methods: Among 132 patients who had undergone 148 cerebral revascularizations in our center over the past 10 years, 30 patients had the procedure for aneurysm treatment with at least 1 year follow-up. Indications for surgery were large aneurysms in 16, blister aneurysms in 3, fusiform aneurysms in 10, and a complex basilar tip aneurysm in 1 patient. Eight patients underwent combined endovascular treatment and surgical revascularization.

Results: Immediate aneurysm occlusion was achieved in 26 patients, and 4 were treated with retrograde flow strategy. Postoperative new deficit was observed in four patients (13.3%). Twenty-six patients were available for 1 year clinical and radiological follow-up. Bypass patency was confirmed in 24 cases (92.3%) in 1 year follow-up. The two patients with occluded bypass did not have new stroke. Two of the aneurysms needed additional treatment at follow-up. Clinical evaluations at 1 year showed that 21 patients were living independently (mRS 2 or less), while four patients had mRS 4 or higher. Eighteen patients had follow-up studies beyond 3 years with no evidence of stroke or aneurysm recurrence.

Conclusion: Despite advances in endovascular flow diverting technologies, there is still a small subset of patients with brain aneurysms who benefit from cerebral revascularization. Our results suggest that cerebral revascularization can be regarded as a viable and durable treatment option for these challenging aneurysms with acceptable morbidity.