الفهرس 
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Abstract
Eighty patients with 83 complex intracranial aneurysms were collected over a period of 4 years from 2013-2017, from both
Ain-Shams university hospital in Cairo (53.75%) and Alexandria university hospital in Alexandria (46.25%). Males dominated the study group (56.3%) and the commonest age group was 40-60 years.
All patients were classified and assessed according to their initial presentation into ruptured aneurysms (28 patients) and unruptured aneurysms (52 patients). The commonest symptoms for ruptured aneurysms were those presenting with coma 23 (82.1%) patients, seizures 3 (10.9%) while for unruptured patients was cranial nerve palsies 24 (46.1%) patients, headaches 20 (38.4%) patients and recurrent TIAs 5 (9.6%) patients.
CT scan was done to all patients immediately on admission to diagnose blood in the basal cisterns or subarachnoid spaces, it showed 28 (35%) patients with SAH, 12 (15%) patients with hydrocephalus, 10 (12.5%) patients with intra-cerebral hemorrhage and 5 (6.3%) with wall calcification and 25 (31.3%) of patient had unremarkable study.
Regarding the commonest site of the aneurysms, in this study, 74 (89%) aneurysms were in the anterior circulation while 9 (11%) aneurysms were in the posterior circulation.
The ICA aneurysms were further classified according to their relation to the ophthalmic artery into:
- Infra-ophthalmic segment; which constituted 34 aneurysms.
- Ophthalmic segment; which constituted 16 aneurysms.
- Supra-ophthalmic segment; which included 15 aneurysms, this group was the most challenging due to the presence of vital arteries such as the P-com, A-chord.
As for the posterior circulation aneurysms, the same concept was adopted according to the origin of the posterior inferior cerebellar artery PICA
- Infra-PICA segment; there were 3 aneurysms.
- PICA segment; which included only one aneurysm.
- Supra-PICA segment; where five aneurysms were included and the challenge here was the preservation of the perforators and major vessels as the AICA and SCA.
Balloon occlusion test BTO was performed to all 80 patients prior to the management to decide the most suitable line of treatment weather surgical, endovascular or combined. Forty-five patients were tolerant to BTO.
Surgical treatment was done for 22 (26.5%) patients. The surgical intervention varied from bypass, vessel wall reconstruction by clips and proximal ICA ligation (PVO). The commonest procedure done was proximal ICA ligation (54.5%) followed by aneurysm multiple clipping 7 (31.8%) patients.
Endovascular treatment was done for 61 (76.2%) aneurysms with 78 endovascular procedures, which included direct coiling of the aneurysms 32 (41%) aneurysms, PVO by balloon 13 (16.6%), flow diversion 12 (15.4%) PVO by coils 8 (10.2%), stent assisted coiling 7 (8.95%), telescoping stents 3 (3.8%), and balloon assisted coiling1 (1.3%).
A protocol for the management of carotid artery complex aneurysms was proposed according to the origin of the ophthalmic artery and hence the carotid artery was divided into three subgroups; the infra ophthalmic group was successfully treated by proximal ICA occlusion either by surgical ligation or by endovascular occlusion. The ophthalmic and supra ophthalmic groups required direct aneurysm treatment or diseased segment harboring the aneurysm with or without added bypass or through endovascular proximal ligation and direct coiling.
Again for the vertebro-basilar complex aneurysms a proposed classification was concluded, for the infra-PICA segment PVO was safely done and had a great success rate while for the PICA segment a combined PVO and flow reversal or flow diversion was done. As for the supra-PICA segment the challenge would be preservation of the perforators and major arteries such as the AICA and SCA and so direct coiling or assisted coiling was the procedure of choice with or without bypass.
The combined surgical and endovascular therapy or the multi-modality approaches is best when chosen for complex aneurysms on a case-by-case basis.