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Background: The main treatment of cerebral aneurysms is direct surgical clipping or endovascular coil embolization. However, some cerebral aneurysms that we reviewed in the literature are still not susceptible to a single treatment approach. These aneurysms can be referred to as complex aneurysms. Objective: We aim to report these aneurysms and share our clinical experience with their treatment and diagnosis. Methods: All cases of cerebral aneurysms treated in New York University and in Mansoura University from 2010-2021 were retrospectively reviewed. Results: 18 patients with 21 cerebral aneurysms were treated by combined surgical and endovascular modalities. Aneurysms associated with arteriovenous malformations (AVMs) in 3 patients, associated with vasospasm in 7 patients, and 3 patients had double aneurysms. A total of 18 patients with aneurysms were treated with combined endovascular and microsurgical therapy. Early angiogram (< 1 week) revealed; complete obliteration of 19 aneurysms (90%) out of a total of 21 aneurysms, residual filling was observed in 2 aneurysms (10%). Late radiological follow up (> 3 months- 2 years) revealed; a stable residual filling in one and the other case underwent retreatment. Conclusions: The recalcitrant or complex cerebral aneurysms can be better referred to as diseases rather than lesions as many clinical and anatomical factors make their treatment difficult. Endovascular and microsurgery could be complementary to each other and create a multimodal approach for treating them.

Background: Giant intracranial artery aneurysms (GIAAs) are often not amenable to neurosurgical clipping or endovascular coiling. Extracranial-intracranial (EC-IC) bypass, a procedure that has been essentially abandoned for the treatment of intracranial ischemic disease, followed by parent vessel occlusion, is often successful in treating these aneurysms. Vascular surgeons should be familiar with this operation, especially in centers with neurosurgical capability., Methods: A retrospective review of patients treated from 1990 to 2010 at New York University Medical Center was performed. Office and hospital records of all patients identified were reviewed with attention to the age and sex of the patient, presenting symptoms, preoperative testing, procedure performed, type of bypass conduit, graft patency, intraoperative and postoperative complications, length of follow-up, and overall outcome. EC-IC bypass was performed using a graft of great saphenous vein (GSV) or radial artery (RA). The vascular surgeon harvested the vascular conduit, tunneled the graft, and performed the extracranial anastomosis, and the intracranial anastomosis was performed by the neurosurgeon., Results: A total of 36 patients (14 men, 22 women) underwent 37 EC-IC bypasses with 34 GSV and three RA grafts. The median age was 57 years (interquartile range, 49-66 years), and the median follow-up was 53 months (interquartile range, 29-77 months). Aneurysm location was the internal carotid artery in 30 patients, the basilar artery in three, and the middle cerebral artery in four. All 37 aneurysms were excluded from the cerebral circulation, with 33 grafts remaining patent at follow-up, as determined by serial cerebral or magnetic resonance angiogram. At follow-up, 33 of 34 of the GSV grafts (88%) and three of three (100%) of the RA grafts were patent. There were two deaths (5.6%), despite patent grafts. Postoperative graft occlusion led to homonymous hemianopsia in one patient and temporary hemiparesis in another (5.6%). Graft occlusions were asymptomatic in two patients., Conclusions: EC-IC bypass is a safe and effective treatment for GIAAs, with acceptable rates of morbidity (5.6%), mortality (5.6%), and graft patency (89.2%). We suggest that the technique described in this report should be routinely used for treatment of GIAAs in centers where neurosurgery and vascular surgery services are available and should be considered a standard procedure in the armamentarium of the vascular surgeon., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Pituitary adenoma may present with neuro-ophthalmic manifestations and, typically, rapid tumor expansion is the result of apoplexy. Herein, we present the first case of an isolated sixth cranial nerve palsy as initial feature of a rapidly expanding ACTH positive silent tumor without apoplexy., Case Presentation: A 44 year old female with a history of sarcoidosis presented with an isolated sixth cranial nerve palsy as the initial clinical feature of a rapidly expanding ACTH positive silent pituitary adenoma. The patient underwent emergent transsphenoidal hypophysectomy for this rapidly progressive tumor and subsequently regained complete vision and ocular motility. Despite tumor extension into the cavernous sinus, the other cranial nerves were spared during the initial presentation., Conclusions: This case illustrates the need to consider a rapidly growing pituitary tumor as a possibility when presented with a rapidly progressive ophthalmoplegia.