Proximal Clipping and Distal High-Flow Bypass in the Treatment of Giant/Complex Intracranial Aneurysm: An Opportunity or a Risk from a Fluid-Structural Interaction Analysis

Objectives Conventional clipping and endovascular treatment are difficult to apply for some giant intracranial aneurysms (GIAs), and sometimes extracranial-to-intracranial (EC-IC) bypass becomes the optional choice. However, not all GIA patients can benefit from it. This study aims to recognize the underlying problems.Methods We included eligible patients in our care. Then, we researched from three levels: a retrospective review of clinical data, fluid-structural analysis from two representative patient-specific models, and fluid-structural interaction analysis for idealized models to investigate the hemodynamic and biomechanical mechanisms.Results In this article, we report nine patients with GIA who underwent EC-IC surgery. Of them, three experienced dangerous postoperative hemorrhage, and one patient died. Among these three patients, two lacked the A1 segment of the anterior cerebral artery (ACA). The numerical simulation showed that after surgery, for the patient with an unruptured aneurysm and existence of ACA, the wall deformation, wall stress, pressure, and area of the oscillatory shear index (OSI) > 0.2 were decreased by 43%, 39%, 33%, and 13%, while the patient without A1 segment having postoperative hemorrhage showed 36%, 45%, 13%, and 55% increased, respectively. Thus, we postulated a dangerous "stump phenomenon" in such conditions and further demonstrated it from idealized models with different sizes of ACA. Finally, we found a larger anastomosis angle and smaller diameter of the graft can alleviate this effect.Conclusions Neurosurgeon should cautiously evaluate the opportunity and risk for such patients who have aplasia of the A1 segment of ACA when making clinical decisions.