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J Stroke Cerebrovasc Dis. 2017 Jun;26(6):e114-e118. doi: 10.1016/j.jstrokecerebrovasdis.2017.03.028. Epub 2017 Apr 13.

Clipping in Awake Surgery as End-Stage in a Complex Internal Carotid Artery Aneurysm After Failure of Multimodal Endovascular and Extracranial-Intracranial Bypass Treatment.

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Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy.
Department of Neurology and Psychiatry, Endovascular Neurosurgery, "Sapienza" University of Rome, Rome, Italy. Electronic address:
Department of Neurology and Psychiatry, Neuroradiology, "Sapienza" University of Rome, Rome, Italy.



Intracranial carotid artery aneurysm can be treated via microsurgical or endovascular techniques. The optimal planning is the result of the careful patient selection through clinical, anatomic, and angiographic analysis.


We present a case of ruptured internal carotid artery (ICA) aneurysm that became a complex aneurysm after failure of multi-endovascular and surgery treatment. We describe complete trapping in awake craniotomy after failure of coiling, stenting, and bypassing.


ICA aneurysms could become complex aneurysms following multi-treatment failure. Endovascular approaches to treat ICA aneurysms include coiling, stenting, flow diverter stenting, and stenting-assisted coiling technique. The role of surgery remains relevant. To avoid severe neurologic deficits, recurrence, and the need of retreatment, a multidisciplinary discussion with experienced endovascular and vascular neurosurgeons is mandatory in such complex cases.


Extracranial-intracranial bypass; flow diverter stent; intracranial aneurysm; intracranial stent; subarachnoid hemorrhage; surgical clip

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