Endovascular therapy for acute basilar artery occlusion caused by vertebral artery dissection: Case report

RATIONALE

The best endovascular therapy revascularization strategies for acute ischemic stroke caused by vertebral artery dissection (VAD) are unclear. We describes a case of basilar artery (BA) occlusion caused by extracranial VAD, in which we used a stent-retriever to achieve thrombectomy in the BA through the contralateral vertebral artery (VA).

PATIENT CONCERNS

A 32-year-old male presented with a sudden-onset headache accompanied by articulation disorder, left-sided weakness, and tinnitus in the left ear.

DIAGNOSIS

Digital subtraction angiography showed the V1 to V2 segment dissection of the left VA and occlusion of the BA.

INTERVENTIONS

Thrombectomy was performed through the thinner right VA with three passes of the Solitaire FR device 4 × 20 mm in the BA, and angiograms showed modified treatment in cerebral ischemia 3 reperfusion of BA and left VA V4 segment still occluded.

OUTCOMES

The patient had a modified Rankin Scale of 2 at 90 days, and re-established blood flow of the left VA and BA.

LESSONS

When extracranial VAD complicated with BA occlusion, choosing the clean-road path to perform a BA thrombectomy may be a fast and effective treatment strategy.

Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era

Background

Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported.

Methods

Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice.

Results

Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome.

Conclusions

Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.

Microvascular decompression for trigeminal neuralgia attributable to the vertebrobasilar artery: decompression technique and significance of separation from the nerve root

BACKGROUND

Separation of the vertebrobasilar artery (VBA) from the trigeminal nerve root in microvascular decompression (MVD) is technically challenging. This study aimed to review the clinical features of VBA involvement in trigeminal neuralgia and evaluate surgical decompression techniques in the long term.

METHODS

We retrospectively reviewed the surgical outcomes of 26 patients (4.4%) with VBA involvement in 585 consecutive MVDs for TGN using a Teflon roll for repositioning the VBA. The final operative status of the nerve decompression was categorized into two groups: the separation group and the contact group. Separation of the VBA from the nerve root was completed in 13 patients in the separation group, and slight vascular contact remained in the remaining 13 patients of the contact group. The clinical features of VBA-related TGN were investigated and the operative results were analyzed.

RESULTS

Multiple arteries are involved in neurovascular compression (NVC) in most cases. The anterior inferior cerebellar artery was the most common concomitant artery (69%). The site of the NVC varies from the root entry zone to the distal portion of the root. All patients were pain-free immediately after surgery and maintained medication-free status during the follow-up period, except for one patient (3.8%) who had recurrent facial pain 8 years after surgery. Postoperative facial numbness was observed in six patients (23%). Of these, one patient showed improvement within 3 months and the other five patients had persistent facial numbness (19.2%). Other neurological deficits include one dry eye, one diplopia due to trochlear nerve palsy, two decreased hearing (< 50 db), two facial weaknesses, and two cerebellar ataxia. Although most of them were transient, one dry eye, two hearing impairments, and one cerebellar ataxia became persistent deficits. Statistical analyses revealed no difference in surgical efficacy or complications in the long term between the two groups.

CONCLUSIONS

Slightly remaining vascular contact does not affect pain relief in the long term. Our study indicated that once the tense trigeminal nerve is loosened, further attempts to mobilize the VBA are not necessary.

Three-dimensional morphology of the superior cerebellar artery running in trigeminal neuralgia

The superior cerebellar artery (SCA) is the most frequent offending vessel in trigeminal neuralgia. This study aims to elucidate the patterns of the SCA running in 34 patients with typical trigeminal neuralgia using three-dimensional computer graphics. The SCA which runs in the medial aspect of the trigeminal nerve compressed predominantly the root entry zone at the distal segment of the caudal loop. Meanwhile, the SCA which runs in the cranial or lateral aspect of the trigeminal nerve compressed predominantly the mid-third portion at the proximal segment of the caudal loop. The site of neurovascular compression differed depending on the shape of the initial segment of SCA. Transposition methods could not be performed in several patients with arch-shaped SCA. Three-dimensional computer graphics revealed different characteristics of the SCA running in trigeminal neuralgia depending on the site of neurovascular compression and shape of the SCA. These differences might affect procedures for microvascular decompression.

Tailoring the surgical corridor to the basilar apex in the pretemporal transcavernous approach: morphometric analyses of different neurovascular mobilization maneuvers

BACKGROUND

The pretemporal transcavernous approach (PTA) provides optimal exposure and access to the basilar artery (BA); however, the PTA can be invasive when vital neurovascular structures are mobilized. The goal of this study was to evaluate mobilization strategies to tailor approaches to the BA.

METHODS

After an orbitozygomatic craniotomy, 10 sides of 5 cadaveric heads were used to assess the surgical access to the BA via the opticocarotid triangle (OCT), carotid-oculomotor triangle (COT), and oculomotor-tentorial triangle (OTT). Measurements were obtained, and morphometric analyses were performed for natural neurovascular positions and after each stepwise expansion maneuver. An imaginary line connecting the midpoints of the limbus sphenoidale and dorsum sellae was used as a reference to normalize the measurements of BA exposure and to facilitate the clinical applicability of this technique.

RESULTS

In the OCT, the exposed BA segment ranged from - 1 ± 3.9 to + 6 ± 2.0 mm in length in its natural position. In the COT, the accessible BA segment ranged from - 4 ± 2.3 to - 2 ± 3.0 mm in length in its natural position. Via the OTT, the accessible BA segment ranged from - 7 ± 2.6 to - 5 ± 2.8 mm in length in its natural position. In the OCT, COT, and OTT, a posterior clinoidectomy extended the exposure down to - 6 ± 2.7, - 8 ± 2.5, and - 9 ± 2.9 mm, respectively.

CONCLUSIONS

This study quantitatively evaluated the need for the expansion maneuvers in the PTA to reach BA aneurysms according to the patient's anatomical characteristics.

Endovascular treatment combined with vertebral artery endarterectomy for patients with acute tandem vertebrobasilar artery occlusion

PURPOSE

To evaluate the safety and efficacy of endovascular treatment combined with vertebral artery endarterectomy in patients with acute tandem vertebrobasilar artery occlusion.

METHODS

From April 2017 to March 2019, three patients with acute basilar artery occlusion combined with ostial vertebral occlusion in our institution were enrolled in the study. They underwent endovascular treatment combined with vertebral artery endarterectomy. The clinical, technical and functional outcomes of the patients were retrospectively analysed.

RESULTS

All three patients in the study underwent complete recanalization. The modified Thrombolysis in Cerebral Infarction (mTICI) grade was 2b/3 in all patients. The modified Rankin Scale (mRS) score was 0-2 for the three patients at 3 months. Follow-up CT scans revealed no cerebral haemorrhage, and no patients died during follow-up. All patients achieved good clinical outcomes after the combined treatment.

CONCLUSION

Endovascular treatment combined with vertebral artery endarterectomy is a feasible method to treat patients with acute basilar artery occlusion combined with ostial vertebral occlusion, especially when the guidewire cannot pass through the ostium of the dominant vertebral artery occlusion.

Decision-making for endovascular treatment of a fusiform basilar trunk artery aneurysm with visualization of chronological blood mass distribution using computational fluid dynamics

Fusiform basilar trunk artery aneurysms are rare lesions, to which stent-assisted coil embolization or flow diversion have been generally applied. When a stent is placed from the distal basilar artery or the posterior cerebral artery to the vertebral artery (VA) through a fusiform basilar artery aneurysm, the side of the VA may be determined according to its size, shape, accessibility and aneurysm projection. In the present report, we constructed stent-placement models from the distal basilar artery to either VA across the aneurysm, and investigated blood mass distribution using computational fluid dynamics. The results revealed more stagnated blood flow in the aneurysm after stenting to the left VA. According to the simulation, stent-assisted coil embolization of the aneurysm was performed, resulting in sufficient obliteration. This visualization technique could be useful for decision-making for the treatment of complicated aneurysms and has a wide range of potential applications.

Mechanical Thrombectomy for Basilar Artery Occlusion Compared with Anterior Circulation Stroke

OBJECTIVE

To investigate the clinical effectiveness of mechanical thrombectomy (MT) for basilar artery occlusion (BAO) and to ascertain whether outcomes for patients with BAO were comparable to those with anterior circulation large vessel occlusion (ACS).

METHODS

A total of 345 patients who underwent MT between 2011 and 2018 were grouped by occlusion site (295 patients with ACS and 50 patients with BAO). Patients' baseline characteristics, procedural times, complications, symptomatic intracranial hemorrhage, modified Rankin Scale score, and mortality at 90 days were analyzed.

RESULTS

Male preponderance (66.0% vs. 48.8%; P = 0.0316), younger age (72.5 years [interquartile range (IQR), 64.75-78.5 years] vs. 77 years [IQR 69-84 years]; P = 0.0297), higher National Institutes of Health Stroke Scale score (24.5 [IQR, 13-32] vs. 18 [IQR 13-22]; P = 0.0015) and higher reperfusion rate (100% vs. 84.7%; P = 0.0010) were observed in patients with BAO. We found no significant difference in favorable outcomes (modified Rankin Scale score ≤2) between patients with BAO and patients with ACS (64.3% vs. 49.3%; P = 0.0914). In multivariate analysis, Alberta Stroke Program Early Computed Tomography Score (odds ratio [OR], 1.282; 95% confidence interval [CI], 1.090-1.524; P = 0.0024), time from onset to reperfusion (OTR) (OR, 0.9950; 95% CI, 0.992-0.998; P = 0.0008), successful reperfusion (OR, 6.953; 95% CI, 1.576-48.729; P = 0.0092), and hemorrhagic complication (OR, 0.352; 95% CI, 0.151-0.797; P = 0.0122) were associated with a favorable outcome at 90 days in patients with ACS. In patients with BAO, only OTR (OR, 0.9879; 95% CI, 0.974-0.999; P = 0.0314) was associated with a favorable outcome at 90 days.

CONCLUSIONS

MT may be considered the standard care for patients with BAO. OTR was the only common significant predictor for favorable outcomes in both patient cohorts.

Posterior Cerebral Artery Reconstruction by In-Situ Bypass with Superior Cerebellar Artery via Occipital Transtentorial Approach

BACKGROUND

Posterior cerebral artery (PCA) aneurysms are relatively rare, and neck clipping is often difficult due to their fusiform shape. We report a case of a thrombosed aneurysm of the distal PCA for which curative trapping and parent artery reconstruction by in situ bypass were performed through an occipital transtentorial approach (OTA).

CASE DESCRIPTION

A 67-year-old woman had been suffering from numbness in the right face and limbs for 4 months. Radiologic imaging demonstrated a thrombosed aneurysm on a distal portion of the left PCA. Curative trapping of the aneurysm and in-situ bypass between the distal PCA and superior cerebellar artery were performed through the OTA. Before surgery, we had evaluated access to the PCA and feasibility of the bypass in a cadaveric simulation. The PCA was well exposed in the posterior half of the ambient cistern, and the proximity of the distal PCA to the superior cerebellar artery through a tentorial incision was confirmed.

CONCLUSIONS

This OTA could represent a useful option for definitive treatment of distal PCA aneurysms.

Microsurgical Clipping of Basilar Apex Aneurysms: A Systematic Historical Review of Approaches and their Results

OBJECTIVE

Neck clipping remains a valuable treatment option for basilar apex aneurysms, especially in those with complex morphology, such as incorporation of branching vessels or large size, and young patient age. Several approaches have proved to give effective exposure for various types of lesion morphologies. Our historic literature review from 1976 to the present systematically compares the outcomes and complications of the key surgical approaches in the treatment of basilar apex aneurysms.

METHODS

We searched PubMed for articles with at least 5 patients, data on neurologic outcome, and procedure-associated complications for the following approaches: pterional or orbitozygomatic transsylvian, subtemporal (with or without zygomatic osteotomy), pretemporal (with or without transcavernous extension), and transpetrous. n-Weighted averages for clinical outcome, aneurysm occlusion rates, morbidity, mortality, and aneurysm morphology were compared.

RESULTS

Of 35 articles selected, 2041 patients with 722 ruptured aneurysms underwent microsurgery, including 1131 transsylvian, 241 pretemporal, 375 subtemporal, and 17 transpetrous approaches. Comparing these 4 approaches in n-weighted averages, respectively, we noted good neurologic outcomes (81%, 85%, 81%, and 58%), surgical morbidity (14%, 10%, 34%, and 53%), surgical mortality (4%, 1%, 0, and 1%), and complete occlusion rates (95%, 94%, 86%, and 75%).

CONCLUSIONS

Transsylvian, pretemporal, and subtemporal approaches showed favorable neurologic outcomes at similar rates and were applied for aneurysms located between -1mm and +7mm in relation to the posterior clinoid process. The pretemporal approach was preferably applied to large and giant aneurysms with good outcome; the transsylvian approach was most frequently used for ruptured aneurysms.

[Surgical treatment of large and giant vertebrobasilar aneurysms manifested by brainstem compression symptoms]

The study aim was to analyze the results of surgical treatment of vertebrobasilar (VB) aneurysms manifested by brainstem compression symptoms.

MATERIAL AND METHODS

The study included 8 patients operated on in the period between 2014 and 2017. All patients underwent intravascular intervention; two patients had open surgery at the second stage.

RESULTS AND CONCLUSION

Intravascular intervention, both alone and in combination with open surgery, is effective treatment of VB aneurysms whose clinical picture is manifested by brainstem compression symptoms. The use of flow-diverting stents in most cases has provided good radicalness in the long-term period, without worsening the functional outcome. Treatment of fusiform aneurysms of the basilar artery trunk requires separate consideration and an individual approach due to a high risk of thrombosis of short branches feeding the brainstem.

Microsurgical treatment of carotid-ophthalmic aneurysm associated with multiple anterior and posterior circulation aneurysms: A case report

BACKGROUND

The clipping of multiple intracranial aneurysms in 1 stage is uncommon. In this case, we report clipping of an ophthalmic aneurysm associated with multiple anterior and posterior circulation aneurysms via the Dolenc approach.

METHODS

The main symptoms of the patient are headache, along with nausea and vomiting. The patient's arteriogram revealed a wide-necked aneurysm of the right ophthalmic artery, an irregular aneurysm of the anterior communicating artery, and a basilar artery aneurysm. The surgical intervention for these aneurysms is a challenge because of the complex anatomical relationship with the surrounding structures. The 3 aneurysms, which were not amenable to a single intervention, were successfully clipped in 1 incision.

RESULTS

After surgery, the patient reported feeling well. One year after surgery, the patient had no SAH recurrence.

CONCLUSIONS

Occasionally, surgical treatment was used even for aneurysms of the carotid-ophthalmic artery with aneurysms of anterior communicating artery and basilar artery, which are contraindicated for interventional therapy.

Giant Basilar Artery Aneurysm Involving the Origin of Bilateral Posterior Cerebral and Superior Cerebellar Arteries: Neck Reconstruction with pCONus-Assisted Coiling

Giant aneurysms of the basilar artery are rare and are frequently associated with obstructive hydrocephalus and brainstem compression. Treatment still remains a challenge both for neurosurgeons and for interventional neuroradiologists. Cases reported in the literature are anecdotal and, overall, their outcomes are poor. We present the case of a patient with a giant aneurysm of the basilar artery tip, involving the origin of both the posterior cerebral and superior cerebellar arteries, who underwent coiling and ventriculoperitoneal shunting for associated obstructive hydrocephalus. A pCONus ® stent (Phenox; Bochum, Germany) was detached with its petals opened over the ostia of the parent vessels, with the aim being to reconstruct the neck of the aneurysm and to preserve the flow in the parent vessel. Moreover, the presence of the stent was useful to maintain the coils within the dome of the aneurysm. The pCONus is a new neurovascular device that is also useful for treating cases of complex basilar artery aneurysms when the ostia of the parent vessel origin is at the level of the aneurysm neck.

Long-Term Follow-Up for a Giant Basilar Trunk Aneurysm Surgically Treated by Proximal Occlusion and External Carotid Artery to Posterior Cerebral Artery Bypass Using a Saphenous Vein Graft

The authors describe a case of a basilar trunk aneurysm with long-term follow-up after successful bypass and proximal occlusion. A 64-year-old woman had a giant aneurysm of the basilar trunk and underwent external carotid artery-to-posterior cerebral artery vein graft bypass surgery and proximal clipping of the basilar artery, which was followed by low-dose aspirin (100 mg/d) treatment. No ischemic symptoms and lesions developed and the thrombosed aneurysm was stable during 11 years of follow-up. An extracranial-intracranial high flow bypass combined with immediate proximal occlusion and aspirin administration may be an acceptable treatment option for patients with giant posterior circulation aneurysms.

Prospective Evaluation of Factors Associated with Early Failure of Arteriovenous Fistulae in Hemodialysis Patients

Recent guidelines have recommended performing native arteriovenous fistulae (AVF) in hemodialysis patients rather than synthetic grafts whenever possible. However, early failure of AVF may reach up to 50%. The purpose of this study was to assess the factors associated with early failure of such procedures in hemodialysis patients.

A prospective study was performed on all patients with end-stage renal disease who had an AVF between June 2003 and March 2005. Data including patient characteristics and the type of AVF were recorded. The internal diameter of the vein and artery and intraoperative blood flow were measured. Patients were followed up for 3 months.

One hundred twenty-six AVF were included in this study. Early failure was in 14 (9%) patients. The internal diameter of the vein and artery and intraoperative blood flow were significantly lower in the failure group than in the patent group. The failure rate was not significantly related to other parameters.

Our data showed that intraoperative blood flow is a reliable parameter that determines the early failure of an AVF. Careful selection of the vein and the artery may reduce the rate of failure.

Deconstructive and Reconstructive Techniques in Treatment of Vertebrobasilar Dissecting Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Various endovascular techniques have been applied to the treatment of vertebrobasilar dissecting aneurysms, including parent artery preservation with coiling, stent placement or flow diverter placement, and trapping and proximal occlusion. We performed a systematic review and meta-analysis to study clinical and angiographic outcomes of patients undergoing endovascular treatment of vertebrobasilar dissecting aneurysms.

MATERIALS AND METHODS

We performed a comprehensive literature search for studies on the endovascular treatment of vertebrobasilar dissecting aneurysms. From each study we abstracted the following data: immediate occlusion, long-term occlusion, long-term good neurologic outcome, perioperative morbidity, perioperative mortality, rebleed (ruptured only), recurrence, and retreatment. We performed subgroup analyses of patients undergoing deconstructive-versus-reconstructive techniques. Meta-analysis was performed by using a random effects model.

RESULTS

Seventeen studies with 478 patients were included in this analysis. Sixteen studies had at least 6 months of clinical/angiographic follow-up. Endovascular treatment was associated with high rates of long-term occlusion (87.0%; 95% CI, 74.0%-94.0%) and low recurrence (7.0%; 95% CI, 5.0%-10.0%) and retreatment rates (3.0%; 95% CI, 2.0%-6.0%). Long-term good neurologic outcome was 84.0% (95% CI, 65.0%-94.0%). Deconstructive techniques were associated with higher rates of long-term complete occlusion compared with reconstructive techniques (88.0%; 95% CI, 35.0%-99.0% versus 81.0%; 95% CI, 64.0%-91.0%; P < .0001). Deconstructive and reconstructive techniques were both associated with high rates of good neurologic outcome (86.0%; 95% CI, 68.0%-95.0% versus 92.0%; 95% CI, 86.0%-95.0%; P = .10).

CONCLUSIONS

Endovascular treatment of vertebrobasilar dissecting aneurysms is associated with high rates of complete occlusion and good long-term neurologic outcomes. Deconstructive techniques are associated with higher occlusion rates. There was no statistical difference in neurologic outcomes between groups, possibly due to low power.

Combined intraoperative monitoring of abnormal muscle response and Z-L response for hemifacial spasm with tandem compression type

BACKGROUND

Multiple neurovascular compression is present in about 38 % cases of hemifacial spasm (HFS). In these cases, the vertebral artery (VA) compresses another vessel, which in turn compresses the nerve. This type was named as "the tandem type". In the tandem type, the real offending vessel is often concealed by the VA. It is sometimes neglected by the surgeons. In this study, we report our experience in using abnormal muscle response (AMR) and ZL-Response (ZLR) simultaneously as intraoperative monitoring for MVD surgery of HFS with "the tandem type" vascular compression involving VA.

METHODS

Fourteen "tandem type" patients treated with microvascular decompression surgery (MVD) surgery were included. ZLR and AMR were recorded simultaneously to identify the offending vessels in operation.

RESULTS

After MVD surgery, 13 patients achieved excellent resolution of spasm. In one case, the patient failed to attain resolution in the first operation, underwent early reoperation and had good resolution. There were no operative deaths or serious operative complications. In all 14 cases, we found that VA compressed the anterior inferior cerebellar artery (AICA) or posterior inferior cerebellar artery (PICA), which in turn compressed the root exit zone (REZ). A typical ZLR was identified from the AICA or PICA but not from the VA. AMR was absent in one case and persisted in one case. After the VA was transposed, the typical AMR was unchanged, unstable or disappeared, and ZLR from the AICA/PICA also existed. AMR and ZLR did not disappear until AICA/PICA was sufficiently decompressed.

CONCLUSIONS

The combination of AMR and ZLR provides more useful information than does the AMR alone, and ZLR may be the only useful intraoperative monitoring for MVD surgery in times when AMR is absent or persists. ZLR played a crucial role in finding the real offending vessel, which was often concealed by the VA in tandem type.

Microvascular decompression for trigeminal neuralgia using the 'Stitched Sling Retraction' technique in recurrent cases after previous microvascular decompression

BACKGROUND

Microvascular decompression is a well-known therapeutic option for trigeminal neuralgia. It is considered safe and effective, and is the surgical treatment of choice for the malady. However, there is no standard technique for it and different authors have proposed different techniques of performing it. In this study, we observe the clinical results of the so-called 'stitched sling retraction' technique for recurrent cases of trigeminal neuralgia.

METHODS

Twelve consecutive patients with recurrent trigeminal neuralgia after previous microvascular decompression(s) were admitted to our institution form February 2009 to February 2011 and underwent microvascular decompression of the trigeminal nerve using the 'stitched sling retraction' technique. In this technique, the offending loop of the superior cerebellar artery is retracted from the nerve and, using a silk thread loop around it, is suspended to the adjacent tentorium.

RESULTS

All patients experienced pain resolution during the immediate post-operative period or within the first 6 months after surgery. They were followed for 24 to 38 months. No recurrence occurred.

CONCLUSIONS

The 'stitched sling retraction' technique shows promising preliminary results in recurrent cases of trigeminal neuralgia after previous microvascular decompression(s). Since it is a 'transposing' technique, it might be associated with less recurrence rates (due to resuming of the neurovascular conflict) than the classic interposing technique, which uses a prosthesis between the offending vessel and the trigeminal nerve.

Microvascular decompression in patients with coexistent trigeminal neuralgia, hemifacial spasm and glossopharyngeal neuralgia

BACKGROUND

Trigeminal neuralgia(TN), hemifacial spasm (HFS) and glossopharyngeal neuralgia (GPN) were referred to hyperactive dysfunction syndromes (HDSs) of the cranial nerves. These symptoms may occur synchronously or metachronously, but the combination of three diseases is extremely rare.

METHODS

From 2007 through 2013, six patients with coexistent GPN-HFS-TN were treated in our department. The combined symptoms occurred on the same side in three and on both sides in three. These patients underwent nine microvascular decompression (MVD) procedures in total. The clinical data including operative findings were respectively analyzed, and the etiological factors as well as treatment strategies were discussed.

RESULTS

Intraoperatively, in all the cases a small posterior fossa was found, which was crowded with cranial nerve roots and cerbellar vesels. Postoperatively, spasm was stopped immediately in four and within 3 months in two; the symptom of TN disappeared immediately in four and within 2 weeks in two; the symptom of GPN was relieved immediately in four and improved with medication in two. During the up to 77 months' follow-up, no changes, recurrence or any dysfunctions of cranial nerves were observed in any of the patients.

CONCLUSIONS

The combination of HFS-TN-GPN is extremely rare and is often associated with a looped VBA and a smaller posterior fossa. However, MVD is still a good choice for treatment. To achieve a safe and effective outcome, dissection of the caudal cranial nerves and proximal transposition of the vertebral artery before decompression of the affected nerve roots are strongly recommended.

[Rescue treatment in acute thrombosis of intracranial stents]

INTRODUCTION

Acute intrastent thrombosis is a potentially serious complication in intracranial stenting. It is essential to determine which therapy is the most suitable in intrastent thromboses.

CASE REPORT

Female aged 58, the first case of acute thrombosis of an intracranial stent to be treated successfully by fibrinolysis after the implantation of a flow diverter device (Silk) in a fusiform basilar aneurysm.

CONCLUSION

The administration of abciximab as a rescue treatment seems safe in cases involving the formation of acute intrastent thromboses.

[Ruptured aneurysm at the anomalous arterial wall of the distal anterior inferior cerebellar artery: a case report]

Distal anterior inferior cerebellar artery(AICA)aneurysms are rare, so its pathogenesis and treatment remain controversial. Here, we report the unique pathogenesis of a ruptured aneurysm in this area that was based on anomalous components as well as partial dissection of the arterial wall. A 61-year-old woman presented to our hospital with sudden headache and nausea. On admission, neurological examination revealed slight consciousness disturbance. Computed tomography(CT)of the head showed a clotted subarachnoid hemorrhage(SAH)that was dominant in the right cerebellopontine and prepontine cistern. Three-dimensional CT angiography detected an irregular fusiform aneurysm 4.5×3.2mm in size in the distal portion of the AICA. The patient underwent trapping without distal vascular reconstruction by the lateral suboccipital approach. After surgery, she experienced right hearing disturbance and ipsilateral facial palsy that were considered to be caused by vasogenic edema at the cerebellar peduncle that resulted from the initial SAH damage. Pathology revealed an aneurysmal wall with anomalous components and arterial dissection in the arterial wall. To our knowledge, only one article has reported the histological findings of a distal AICA aneurysm. Based on the pathology of this case, these findings may suggest a useful treatment strategy for this rare aneurysm.

[Subarachnoid hemorrhage caused by dissection of the basilar artery: a case report]

We report a case of subarachnoid hemorrhage, which was caused by dissection of the basilar artery during treatment for diabetes mellitus. The patient was a 60-year-old male who consulted our hospital complaining of sudden-onset of a severe headache. Head CT scan showed subarachnoid hemorrhage around the basilar artery, but 3D-CT angiography revealed no abnormality. The basilar artery was shown to be normal during cerebral angiography on Day 1. However, in retrospect pseudolumen of the basilar artery was suspected in the proximal portion of the branching point of the anterior inferior cerebellar artery. During a second cerebral angiography on Day 17, blood pressure elevated to 185/83mmHg and 30 minutes later this patient's consciousness deteriorated to 10 points of the GCS(E4, V2, M4). The double lumen in the basilar artery was identified around the branching point of the anterior inferior cerebellar artery. Head MRI on the same day showed intramural hemorrhage of the basilar artery as a high intensity lesion. Head MRI on Day 18 revealed multiple cerebellar infarctions in the region of the bilateral anterior inferior cerebellar arteries. His consciousness recovered to almost normal by reducing the blood pressure. Transient gait disturbance also recovered thereafter. Head MRI on Day 90 indicated disappearance of the intramural hemorrhage in the basilar artery. It was important to reduce the blood pressure to prevent recurrence of the arterial dissection.

[Endovascular treatment of basilar artery aneurysms associated with fenestration]

Aneurysms at the vertebrobasilar junction are often found with basilar artery(BA)fenestration. We encountered 10 consecutive cases of aneurysms associated with BA fenestration. The purpose of this study is to describe the frequency, clinical features, and outcome of these aneurysms treated by endovascular procedure. The incidence of these aneurysms in our series was 1.9%. All aneurysms were successfully treated by coil embolization. Half of them were treated by using simple technique, and the other half were treated by using adjunctive techniques such as balloon remodeling technique. 70% of these cases were ruptured, and all except one case showed good recovery at the time of discharge. We found 63 reported cases of this aneurysm in the literature between 2000 and 2012. 57 out of 63 aneurysms were treated by endovascular means with good clinical results. The usefulness of endovascular procedure is reported to be superior to surgical clipping because of their anatomical complexity and the difficulty of surgical exposure for clipping. We conclude that outcome of these aneurysms is favorable and endovascular procedure has become their standard treatment for these aneurysms.

Surgical management of vertebral and basilar artery aneurysms: a single center experience in 41 patients

OBJECTIVE

To study an effective method for surgical management of vertebral and basilar artery aneurysms.

METHODS

Forty-one patients with 43 aneurysms of the vertebral and basilar arteries were managed by microsurgical clipping. Cerebral angiography revealed basilar apex aneurysms in 17 patients, basilar trunk in six patients, vertebrobasilar (VB) junction aneurysms in three patients and vertebral aneurysms in 15 patients. One patient had two basilar aneurysms, and another had bilateral vertebral artery aneurysm.

SURGICAL TECHNIQUE

We used a pterional approach in basilar apex aneurysms (n = 17 patients), orbitozygomatic and its variants in upper basilar trunk aneurysms (n = 2 patients), combined petrosal and far-lateral approach in mid basilar trunk aneurysms (n = 4 patients), far-lateral and transcondylar approach for the aneurysms at VB junction (n = 3 patients) and transcondylar approach for the vertebral aneurysms (n = 15 patients). Bypass graft was performed in 14 patients with fusiform and wide neck aneurysms, to prevent potential cerebral ischemia due to prolonged temporary occlusion or possibility of intraoperative parent artery sacrifice.

RESULTS

Neurological outcomes were measured on the basis of Glasgow Outcome Score (GOS). The rate of back-to-normal life after surgery in basilar tip aneurysm, basilar trunk aneurysms, VB junction aneurysms and vertebral artery aneurysms was 15/17 (82.5 %), 5/6 (83 %), 3/3 (100 %) and 14/15 (93.3 %), respectively. Thirty-six (87.8 %) patients had uneventful postoperative courses. Two patient with basilar apex aneurysm suffered severe neurological deficits related to midbrain ischemia, two patient with occipital artery (OA) graft bypass had postoperative partial lower cranial nerve palsy, and one death with basilar trunk aneurysm occurred after the 20th day of surgery. Thirty-nine patients accepted postoperative digital subtraction angiography (DSA) and eight patients accepted computed tomography (CT) angiogram, whereas two patient denied either one. All the images demonstrated afferent and efferent vessels without aneurysm in situ. Out of 14 patients with graft bypass, 11 patients on cerebral angiographies disclosed the aneurysm clip and the graft bypass patency, one patient on angiography had unidentified graft bypass patency but no symptom related to the graft bypass patency, and two patients denied the postoperative cerebral angiographies. In 40 patients with a mean follow-up of 3.4 years, 37 patients had good outcome, two patients needed assistance for daily living, and one death occurred due to brainstem infarction related to surgery.

CONCLUSION

Selection of proper cranial base approach with adequate exposure is effective in clipping VB aneurysms, minimizing the postoperative complications. Graft bypass may avoid parent artery sacrifice and its branches occlusion in patients with fusiform and wide neck aneurysms.

Surgical management of vertebral and basilar artery aneurysms: a single center experience in 41 patients

OBJECTIVE

To study an effective method for surgical management of vertebral and basilar artery aneurysms.

METHODS

Forty-one patients with 43 aneurysms of the vertebral and basilar arteries were managed by microsurgical clipping. Cerebral angiography revealed basilar apex aneurysms in 17 patients, basilar trunk in six patients, vertebrobasilar (VB) junction aneurysms in three patients and vertebral aneurysms in 15 patients. One patient had two basilar aneurysms, and another had bilateral vertebral artery aneurysm.

SURGICAL TECHNIQUE

We used a pterional approach in basilar apex aneurysms (n = 17 patients), orbitozygomatic and its variants in upper basilar trunk aneurysms (n = 2 patients), combined petrosal and far-lateral approach in mid basilar trunk aneurysms (n = 4 patients), far-lateral and transcondylar approach for the aneurysms at VB junction (n = 3 patients) and transcondylar approach for the vertebral aneurysms (n = 15 patients). Bypass graft was performed in 14 patients with fusiform and wide neck aneurysms, to prevent potential cerebral ischemia due to prolonged temporary occlusion or possibility of intraoperative parent artery sacrifice.

RESULTS

Neurological outcomes were measured on the basis of Glasgow Outcome Score (GOS). The rate of back-to-normal life after surgery in basilar tip aneurysm, basilar trunk aneurysms, VB junction aneurysms and vertebral artery aneurysms was 15/17 (82.5 %), 5/6 (83 %), 3/3 (100 %) and 14/15 (93.3 %), respectively. Thirty-six (87.8 %) patients had uneventful postoperative courses. Two patient with basilar apex aneurysm suffered severe neurological deficits related to midbrain ischemia, two patient with occipital artery (OA) graft bypass had postoperative partial lower cranial nerve palsy, and one death with basilar trunk aneurysm occurred after the 20th day of surgery. Thirty-nine patients accepted postoperative digital subtraction angiography (DSA) and eight patients accepted computed tomography (CT) angiogram, whereas two patient denied either one. All the images demonstrated afferent and efferent vessels without aneurysm in situ. Out of 14 patients with graft bypass, 11 patients on cerebral angiographies disclosed the aneurysm clip and the graft bypass patency, one patient on angiography had unidentified graft bypass patency but no symptom related to the graft bypass patency, and two patients denied the postoperative cerebral angiographies. In 40 patients with a mean follow-up of 3.4 years, 37 patients had good outcome, two patients needed assistance for daily living, and one death occurred due to brainstem infarction related to surgery.

CONCLUSION

Selection of proper cranial base approach with adequate exposure is effective in clipping VB aneurysms, minimizing the postoperative complications. Graft bypass may avoid parent artery sacrifice and its branches occlusion in patients with fusiform and wide neck aneurysms.