J Neurosurg Pediatr Volume 23 • February 2019 259 J Neurosurg Pediatr 23:259, 2019 LETTERS TO THE EDITOR Neurosurgical Forum Hybrid approaches in pediatric neurovascular surgery TO THE EDITOR: We read with interest the article by Ocal et al. 2 describing their interesting case of a cervi- cal carotid artery aneurysm in a pediatric patient treated with combined surgical and endovascular therapy (Ocal O, Yilmaz M, Peynircioglu B, et al: Hybrid vascular in- tervention for a giant cervical carotid artery aneurysm in a clopidogrel-hyporesponsive child. J Neurosurg Pediatr 22:265–269, September 2018). The authors describe a cre- ative approach to treating this challenging lesion. We recently published a similar case experience in Cu- reus , describing a hybrid approach for the surgical recon- struction of the carotid artery to enable eventual endovas- cular treatment. 3 Ocal et al. discuss the challenges involved with pri- mary endovascular treatment of this lesion, highlighting diffculty with access and tracking a stiff stent through the tortuosity. In our case, we encountered the same diffculty with a loop associated with 3 pseudoaneurysms. Resec- tion of this redundant loop allowed for eventual guide catheter traversal for fow diversion (FD) treatment of an intracranial aneurysm. Sacrifce of the vessel could have also been considered, either surgically or endovascularly. We considered such a Hunterian strategy in our case af- ter the patient passed a balloon test occlusion but opted against this approach. In a young patient, if there are other viable options, we favor a reconstructive approach over a deconstructive one. Finally, we wish to discuss the use of antiplatelet ac- tivity monitoring that was so well applied in this case. Monitoring P2Y12 or other assays prior to endovascular therapy is controversial. We have discussed our standard protocol as applied to FD cases. 4 Even if it may be an inex- act science, monitoring a patient’s response to antiplatelet medications is important to avoid potential complications, especially when the exposed bare metal burden is quite high, as in the case described. The use of these assays in pediatric FD has been a particular topic of interest as this treatment becomes more common in that population. 1 Ocal et al. have one of the foremost single-center experi- ences with these situations. The standard doses used in adults likely do not apply in children, and weight-based dosing for these medications is not available based on cur- rent formulations. Thus, we must rely on objective guid- ance to determine if patients are receiving appropriate therapy. As more neurointerventionalists foray into using FD in children, they should be encouraged to follow the experience already gained by these authors. It is fortunate that the patient described did not suffer adverse events despite abrupt cessation of antiplatelet ther- apy. This may likely be due to progressive stenosis leading to occlusion in a “tourniquet” effect, as we have previously described. 4 In some of the cases in which we encountered this effect, it occurred after reduction of antiplatelet thera- py. We commend the authors for sharing their experience with this interesting case and encourage others to consider a similar hybrid approach in such cases. Visish M. Srinivasan, MD Peter Kan, MD, MPH Baylor College of Medicine, Houston, TX Edward A. M. Duckworth, MD, MS Northwest Neurosurgical Associates, Boise, ID References 1. Barburoglu M, Arat A: Flow diverters in the treatment of pe- diatric cerebrovascular diseases. AJNR Am J Neuroradiol 38: 113–118, 2017 2. Ocal O, Yilmaz M, Peynircioglu B, Bilginer B, Peker A, Arat A: Hybrid vascular intervention for a giant cervical carotid artery aneurysm in a clopidogrel-hyporesponsive child. J Neurosurg Pediatr 22:265–269, 2018 3. Srinivasan VM, Kaufmann A, Kan P, Duckworth EA: Surgi- cal reconstruction to allow endovascular access for fow di- version of giant cavernous aneurysm: a combined approach. Cureus 10:e2381, 2018 4. Srinivasan VM, Mokin M, Duckworth EAM, Chen S, Puri A, Kan P: Tourniquet parent artery occlusion after fow diversion. J Neurointerv Surg 10: 122–126, 2018 Disclosures The authors report no conflict of interest. Correspondence Visish M. Srinivasan: vsriniva@bcm.edu. INCLUDE WHEN CITING Published online November 9, 2018; DOI: 10.3171/2018.8.PEDS18488. Response No response was received from the authors of the origi- nal article. ©AANS 2019, except where prohibited by US copyright law Unauthenticated | Downloaded 07/02/20 02:54 PM UTC