{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,6]],"date-time":"2026-11-06T09:35:29Z","timestamp":1793957729405,"version":"4.8.0"},"reference-count":50,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,4,21]],"date-time":"2023-04-21T00:00:00Z","timestamp":1682035200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec><jats:title>Background and purpose<\/jats:title><jats:p>The treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and methods<\/jats:title><jats:p>Retrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization\/occlusion for complex intracranial aneurysms from 1\/2016 to 6\/2022.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Ten patients (4 male [40%]; mean age 51.9\u2009\u00b1\u20098.7\u2009years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9\/10 (90%), were ruptured and 8\/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8\/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery\/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7\/10 [70%]) and extracranial-to-intracranial (EC-IC; 3\/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm\/vessel sacrifice in 9\/10 patients) were performed early after surgery (0.7\u2009\u00b1\u20091.5\u2009days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3\/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4\u201372 months). Good outcomes (defined as a Glasgow Outcomes Scale \u22654 and modified Rankin Scale \u22642) occurred in 6\/10 patients (60%).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>A variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fneur.2023.1102496","type":"journal-article","created":{"date-parts":[[2023,4,21]],"date-time":"2023-04-21T04:50:43Z","timestamp":1682052643000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":19,"title":["Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series"],"prefix":"10.3389","volume":"14","author":[{"given":"Robert C.","family":"Rennert","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincent N.","family":"Nguyen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aidin","family":"Abedi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nadia A.","family":"Atai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph N.","family":"Carey","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Tenser","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arun","family":"Amar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William J.","family":"Mack","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan J.","family":"Russin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2023,4,21]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"134","DOI":"10.3174\/ajnr.A6352","article-title":"Flow-diversion treatment for Unruptured nonsaccular intracranial aneurysms of the posterior and distal anterior circulation: a meta-analysis","volume":"41","author":"Cagnazzo","year":"2020","journal-title":"AJNR Am J Neuroradiol"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"924","DOI":"10.1136\/neurintsurg-2019-014815","article-title":"The safety and effectiveness of the woven EndoBridge (WEB) system for the treatment of wide-necked bifurcation aneurysms: final 12-month results of the pivotal WEB Intrasaccular therapy (WEB-IT) study","volume":"11","author":"Arthur","year":"2019","journal-title":"J Neurointerv Surg"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"1891","DOI":"10.1007\/s00234-021-02727-6","article-title":"The woven EndoBridge device for ruptured intracranial aneurysms: international multicenter experience and updated meta-analysis","volume":"63","author":"Harker","year":"2021","journal-title":"Neuroradiology"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"675917","DOI":"10.3389\/fneur.2021.675917","article-title":"Pipeline embolization device for the treatment of ruptured intracerebral aneurysms: a multicenter retrospective study","volume":"12","author":"Zhong","year":"2021","journal-title":"Front Neurol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"694","DOI":"10.1136\/neurintsurg-2018-014363","article-title":"Pipeline shield with single antiplatelet therapy in aneurysmal subarachnoid haemorrhage: multicentre experience","volume":"11","author":"Manning","year":"2019","journal-title":"J Neurointerv Surg"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"403","DOI":"10.1016\/j.nec.2022.05.004","article-title":"Rethinking cerebral bypass surgery","volume":"33","author":"Rennert","year":"2022","journal-title":"Neurosurg Clin N Am"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"E50","DOI":"10.1093\/ons\/opy057","article-title":"Occipital artery to posterior cerebral artery bypass using descending branch of the lateral circumflex femoral artery graft for treatment of fusiform, Unruptured posterior cerebral artery aneurysm: 3-dimensional operative video","volume":"15","author":"Ravina","year":"2018","journal-title":"Oper Neurosurg (Hagerstown)"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"247","DOI":"10.1093\/ons\/opy334","article-title":"A3-A3 anastomosis in the Management of Complex Anterior Cerebral Artery Aneurysms: experience with in situ bypass and lessons learned from Pseudoaneurysm cases","volume":"17","author":"Ravina","year":"2019","journal-title":"Oper Neurosurg (Hagerstown)"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"395","DOI":"10.1093\/ons\/opx277","article-title":"Efficacy and outcomes of posterior inferior cerebellar artery (PICA) bypass for proximal PICA and vertebral artery-PICA aneurysms: a case series","volume":"15","author":"Rennert","year":"2018","journal-title":"Oper Neurosurg (Hagerstown)"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1093\/ons\/opx241","article-title":"Descending branch of the lateral circumflex femoral artery graft for posterior inferior cerebellar artery revascularization","volume":"15","author":"Strickland","year":"2018","journal-title":"Oper Neurosurg (Hagerstown)"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1227\/ons.0000000000000144","article-title":"Cerebral bypass using the descending branch of the lateral circumflex femoral artery: a case series","volume":"22","author":"Wolfswinkel","year":"2022","journal-title":"Oper Neurosurg (Hagerstown)"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1136\/svn-2019-000304","article-title":"Multimodal management of giant cerebral aneurysms: review of literature and case presentation","volume":"5","author":"Campos","year":"2020","journal-title":"Stroke Vasc Neurol"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"108","DOI":"10.3389\/fneur.2013.00108","article-title":"Combined endovascular and microsurgical management of complex cerebral aneurysms","volume":"4","author":"Choudhri","year":"2013","journal-title":"Front Neurol"},{"key":"ref14","first-page":"E6","article-title":"Combined surgical and endovascular treatment of a recurrent A3-A3 junction aneurysm unsuitable for stand-alone clip ligation or coil occlusion","volume":"18","author":"Kim","year":"2005","journal-title":"Tech Note Neurosurg Focus"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"444","DOI":"10.1016\/j.wneu.2019.05.146","article-title":"Staged, combined Management of Ruptured Vertebral Artery Dissecting Aneurysms Involving the posterior inferior cerebellar artery: report of 4 cases and review of the literature","volume":"128","author":"Kim","year":"2019","journal-title":"World Neurosurg"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"1503","DOI":"10.1227\/01.neu.0000333814.02649.a0","article-title":"Combined microsurgical and endovascular management of complex intracranial aneurysms","volume":"62","author":"Lawton","year":"2008","journal-title":"Neurosurgery"},{"key":"ref17","doi-asserted-by":"crossref","first-page":"E11","DOI":"10.3171\/foc.2004.17.5.11","article-title":"Combined endovascular and microsurgical management of giant and complex unruptured aneurysms","volume":"17","author":"Ponce","year":"2004","journal-title":"Neurosurg Focus"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"55522","DOI":"10.3791\/55522","article-title":"Comprehensive endovascular and open surgical Management of Cerebral Arteriovenous Malformations","volume":"128","author":"Rennert","year":"2017","journal-title":"J Vis Exp"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"57","DOI":"10.3171\/jns.1990.73.1.0057","article-title":"Management of giant intracranial ICA aneurysms with combined extracranial-intracranial anastomosis and endovascular occlusion","volume":"73","author":"Serbinenko","year":"1990","journal-title":"J Neurosurg"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"283","DOI":"10.1016\/j.jstrokecerebrovasdis.2010.08.009","article-title":"Combined surgical and endovascular approach to a complex dural arteriovenous fistula involving the superior sagittal sinus and torcula","volume":"21","author":"Spiotta","year":"2012","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"614601","DOI":"10.3389\/fneur.2020.614601","article-title":"A hybrid strategy for patients with complex cerebral aneurysm: STA-MCA bypass in combination with endovascular embolization","volume":"11","author":"Wang","year":"2020","journal-title":"Front Neurol"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"1018","DOI":"10.1177\/0963689719845366","article-title":"Combined microsurgery and endovascular intervention in one-stop for treatment of cerebral arteriovenous malformation: the efficacy of a hybrid operation","volume":"28","author":"Wen","year":"2019","journal-title":"Cell Transplant"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"365","DOI":"10.3171\/2012.8.PEDS12101","article-title":"High-flow bypass and tandem microsurgical-endovascular occlusion of recurrent proximal middle cerebral artery aneurysms in a pediatric patient","volume":"10","author":"Abla","year":"2012","journal-title":"J Neurosurg Pediatr"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"36","DOI":"10.3340\/jkns.2014.55.1.36","article-title":"A case of endovascular treatment for followed by side to side bypass for vertebral artery dissecting aneurysms involved posterior inferior cerebellar artery","volume":"55","author":"Chung","year":"2014","journal-title":"J Korean Neurosurg Soc"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"259","DOI":"10.3171\/jns.2002.97.2.0259","article-title":"Dissecting aneurysms of the vertebral artery: a management strategy","volume":"97","author":"Iihara","year":"2002","journal-title":"J Neurosurg"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"Video3","DOI":"10.3171\/2015.V1.FOCUS14526","article-title":"Combined microsurgical PICA-PICA bypass and endovascular parent artery occlusion for a ruptured dissecting vertebral artery aneurysm","volume":"38","author":"Starke","year":"2015","journal-title":"Neurosurg Focus"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"E359","DOI":"10.1093\/ons\/opaa426","article-title":"External carotid artery-to-middle cerebral artery bypass using a saphenous vein graft with 3-vessel anastomosis for the treatment of a large, ruptured middle cerebral artery aneurysm: 2-dimensional operative video","volume":"20","author":"Ravina","year":"2021","journal-title":"Oper Neurosurg (Hagerstown)"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"496","DOI":"10.1016\/j.wneu.2019.03.164","article-title":"Complex revascularization for idiopathic intracranial occlusive disease with Unruptured, fusiform anterior cerebral artery and middle cerebral artery aneurysms: 3-dimensional operative video","volume":"126","author":"Ravina","year":"2019","journal-title":"World Neurosurg"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"e971","DOI":"10.1016\/j.wneu.2019.07.053","article-title":"Orphaned middle cerebral artery side-to-side in situ bypass as a favorable alternative approach for complex middle cerebral artery aneurysm treatment: a case series","volume":"130","author":"Ravina","year":"2019","journal-title":"World Neurosurg"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"209","DOI":"10.1016\/j.jocn.2017.01.026","article-title":"The arborization bypass: sequential intracranial-intracranial bypasses for an unruptured fusiform MCA aneurysm","volume":"39","author":"Russin","year":"2017","journal-title":"J Clin Neurosci"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"e417","DOI":"10.1016\/j.wneu.2018.06.046","article-title":"Extracranial-intracranial bypass for treatment of blister aneurysms: efficacy and analysis of complications compared with alternative treatment strategies","volume":"117","author":"Strickland","year":"2018","journal-title":"World Neurosurg"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"1364","DOI":"10.3171\/2014.3.JNS132219","article-title":"Anterior cerebral artery bypass for complex aneurysms: an experience with intracranial-intracranial reconstruction and review of bypass options","volume":"120","author":"Abla","year":"2014","journal-title":"J Neurosurg"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"1275","DOI":"10.3171\/2015.5.JNS15368","article-title":"Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients","volume":"124","author":"Abla","year":"2016","journal-title":"J Neurosurg"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"e122","DOI":"10.1016\/j.wneu.2020.10.056","article-title":"Comparative assessment of extracranial-to-intracranial and intracranial-to-intracranial in situ bypass for complex intracranial aneurysm treatment based on rupture status: a case series","volume":"146","author":"Ravina","year":"2021","journal-title":"World Neurosurg"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1016\/j.wneu.2019.01.259","article-title":"Intracranial-intracranial bypass with a graft vessel: a comprehensive review of technical characteristics and surgical experience","volume":"125","author":"Wang","year":"2019","journal-title":"World Neurosurg"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"80","DOI":"10.3171\/2018.3.JNS172158","article-title":"Long-term patency in cerebral revascularization surgery: an analysis of a consecutive series of 430 bypasses","volume":"131","author":"Yoon","year":"2018","journal-title":"J Neurosurg"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"796","DOI":"10.1136\/neurintsurg-2015-011732","article-title":"Endovascular parent vessel sacrifice in ruptured dissecting vertebral and posterior inferior cerebellar artery aneurysms: clinical outcomes and review of the literature","volume":"8","author":"Madaelil","year":"2016","journal-title":"J Neurointerv Surg"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"777","DOI":"10.1136\/neurintsurg-2020-016261","article-title":"Endovascular sacrifice of the proximal posterior inferior cerebellar artery for treatment of ruptured intracranial aneurysms","volume":"12","author":"Malcolm","year":"2020","journal-title":"J Neurointerv Surg"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"160","DOI":"10.3340\/jkns.2012.51.3.160","article-title":"A case of lateral medullary infarction after endovascular trapping of the vertebral artery dissecting aneurysm","volume":"51","author":"Cho","year":"2012","journal-title":"J Korean Neurosurg Soc"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"189","DOI":"10.1007\/BF02346126","article-title":"Origin of the anterior spinal artery","volume":"18","author":"G\u00f6vsa","year":"1996","journal-title":"Surg Radiol Anat"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"190","DOI":"10.1016\/S0090-3019(03)00577-9","article-title":"Microsurgical anatomy of the perforating branches of the vertebral artery","volume":"61","author":"Marinkovi\u0107","year":"2004","journal-title":"Surg Neurol"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"107","DOI":"10.3171\/2017.2.JNS162916","article-title":"Predictive factors of medullary infarction after endovascular internal trapping using coils for vertebral artery dissecting aneurysms","volume":"129","author":"Aihara","year":"2018","journal-title":"J Neurosurg"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3171\/2018.5.JNS18681","article-title":"Fusiform vertebral artery aneurysms involving the posterior inferior cerebellar artery origin associated with the sole angiographic anterior spinal artery origin: technical case report and treatment paradigm proposal","author":"Ravina","year":"2018","journal-title":"J Neurosurg"},{"key":"ref44","article-title":"Neuroanatomy, posterior cerebral arteries","volume-title":"StatPearls [Internet]","author":"Javed","year":"2022"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"279","DOI":"10.18999\/nagjms.80.2.279","article-title":"High-resolution cone beam CT for evaluation of vascular channel in intracranial partial thrombosed aneurysm","volume":"80","author":"Shintai","year":"2018","journal-title":"Nagoya J Med Sci"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"1117","DOI":"10.1097\/00006123-199905000-00101","article-title":"Recanalization and rupture of a giant vertebral artery aneurysm after hunterian ligation: case report","volume":"44","author":"Chang","year":"1999","journal-title":"Neurosurgery"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"622457","DOI":"10.3389\/fneur.2021.622457","article-title":"Treatment of Unruptured vertebral artery aneurysm involving posterior inferior cerebellar artery with pipeline embolization device","volume":"12","author":"Fu","year":"2021","journal-title":"Front Neurol"},{"key":"ref48","doi-asserted-by":"publisher","first-page":"e22","DOI":"10.1016\/j.wneu.2018.08.184","article-title":"Comparison of clinical and radiologic outcomes of diverse endovascular treatments in vertebral artery dissecting aneurysm involving the origin of PICA","volume":"121","author":"Cho","year":"2019","journal-title":"World Neurosurg"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"435","DOI":"10.3171\/2018.3.JNS172199","article-title":"Safety of coiling with stent placement for the treatment of ruptured wide-necked intracranial aneurysms: a contemporary cohort study in a high-volume center after improvement of skills and strategy","volume":"131","author":"Zuo","year":"2018","journal-title":"J Neurosurg"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3171\/2021.9.JNS21397","article-title":"Vertebrobasilar dissecting aneurysms: microsurgical management in 42 patients","author":"Frisoli","year":"2021","journal-title":"J Neurosurg"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2023.1102496\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,4,21]],"date-time":"2023-04-21T04:50:51Z","timestamp":1682052651000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2023.1102496\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,4,21]]},"references-count":50,"alternative-id":["10.3389\/fneur.2023.1102496"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2023.1102496","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,4,21]]},"article-number":"1102496"}}