Proximal clipping and bypass between bilateral vertebral arteries using a radial arterial graft for the treatment of a dissecting aneurysm of the vertebral artery

Radical surgical treatment for recurrent giant fusiform thrombosed vertebral artery aneurysm previously coiled

Background:

Fusiform aneurysms are rare (<1%) and the underlying pathophysiology is not well known. Endovascular coiling is the standard of treatment; however, a surgical procedure with vascular reconstruction by excluding the pathological segment of the vessel and restoring the blood flow, seems to be the most effective and definitive treatment.

Case Description:

We report a patient who presented a fusiform vertebral artery aneurysm previously coiled which developed a giant enlargement and a new contralateral fusiform aneurysm. Hemodynamic changes resulting in the formation of contralateral aneurysm might be the result of aneurysm occlusion without revascularization. In addition, continued blood flow to the aneurysmal wall through the vasa vasorum might result in aneurysm recanalization or regrowth. In order to account for these possible sources of complications, we performed a vascular reconstruction with high and low flow bypasses after trapping the aneurysm.

Conclusions:

We hypothesize that, in this and similar cases, surgical vascular reconstruction should be the first and definitive treatment under experienced cerebrovascular surgeons.

Extracranial-intracranial bypass surgery using a radial artery interposition graft for cerebrovascular diseases

OBJECTIVE

To investigate the efficacy of extracranial-intracranial (EC-IC) bypass surgery using a radial artery interposition graft (RAIG) for surgical management of cerebrovascular diseases.

METHODS

The study involved a retrospective analysis of 13 patients who underwent EC-IC bypass surgery using RAIG at a single neurosurgical institute between 2003 and 2009. The diseases comprised intracranial aneurysm (n=10), carotid artery occlusive disease (n=2), and delayed stenosis in the donor superficial temporal artery (STA) following previous STA-middle cerebral artery bypass surgery (n=1). Patients were followed clinically and radiographically.

RESULTS

Bypass surgery was successful in all patients. At a mean follow-up of 53.4 months, the short-term patency rate was 100%, and the long-term rate was 92.3%. Twelve patients had an excellent clinical outcome of Glasgow Outcome Scale (GOS) 5, and one case had GOS 3. Procedure-related complications were a temporary dysthesia on the graft harvest hand (n=1) and a hematoma at the graft harvest site (n=1), and these were treated successfully with no permanent sequelae. In one case, spasm occurred which was relieved with the introduction of mechanical dilators.

CONCLUSION

EC-IC bypass using a RAIG appears to be an effective treatment for a variety of cerebrovascular diseases requiring proximal occlusion or trapping of the parent artery.

The Deep Inferior Epigastric Artery: Anatomy and Applicability as a Source of Microvascular Arterial Grafts

BACKGROUND

Arterial grafts are superior to venous grafts when used for microvascular grafting procedures. Advantages of arterial grafts include anatomical taper, improved size match, improved handling characteristics, and superior patency rates. The deep inferior epigastric artery may be used as a source of microvascular graft to replace damaged or diseased arterial segments. By studying cadaver dissections, it is possible to estimate the clinically usable length and caliber of the deep inferior epigastric artery.

METHODS

Thirty-four preserved cadavers were dissected and 63 deep inferior epigastric arterial systems were removed and measured. The deep inferior epigastric artery was used as an arterial conduit to bypass across nine wrists in eight patients.

RESULTS

The mean length from the external iliac artery to the point at which the vessel displayed an external diameter of 1 mm was 14.06 +/- 2.54 cm. The deep inferior epigastric artery has been used in nine clinical cases as an arterial conduit to bypass distal to the wrist. All nine bypasses were patent 1 year postoperatively, without donor-site complication.

CONCLUSION

The deep inferior epigastric artery is a morphologically reliable and clinically useful source of arterial grafts.

The Subscapular Arterial Tree as a Source of Microvascular Arterial Grafts

The subscapular arterial tree may be used as a source of microvascular grafts to replace damaged or diseased portions of arteries, particularly in the hand and forearm. By studying cadaver dissections, it is possible to estimate the number of branches that may be found at different arterial segment lengths from the origin of the subscapular artery. Fifty-five preserved cadaver subscapular arterial trees were dissected, and the branching patterns were documented. Three major arterial branching patterns of the subscapular artery were observed with one, two, and three major branches to the serratus anterior in 60 percent, 29 percent, and 9 percent of the cases, respectively. The authors determined the number of 1-mm-diameter, 1-cm-long branches arising from each of six 3-cm regions of the arterial tree measured from the origin of the subscapular artery to the end of the longest terminal branch. The probability of finding at least one usable terminal branch that is at least 12.0 cm in length was found to be 98 percent. Typically, there are two to five useful branches at this distance. Such information may help surgeons fine tune their process of selecting an appropriate arterial donor site for a particular arterial defect and supports the use of the subscapular arterial tree as a donor site for microvascular arterial grafts.

Extracranial-intracranial vein graft bypass for giant intracranial aneurysm surgery for pediatric patients: two technical case reports

OBJECTIVE AND IMPORTANCE

Herein we describe two cases of extracranial-intracranial vein graft bypasses for the treatment of giant intracranial aneurysms in prepubertal pediatric patients. One patient is, we think, the youngest patient reported in the literature to have been successfully treated in such a manner, with a good long-term outcome. Such grafts seem to enlarge longitudinally during the growth spurt, making such techniques reasonable long-term therapeutic options for the management of complex intracranial aneurysms in pediatric patients.

CLINICAL PRESENTATION

Patient 1, a 13-year-old boy, presented with headaches and rapidly progressive right cavernous sinus syndrome. Computed tomography and cerebral angiography revealed a giant, fusiform, right intracavernous internal carotid artery aneurysm. Patient 2, a 23-month-old girl, was discovered to harbor an asymptomatic, recurrent, giant, fusiform, left M1 middle cerebral artery aneurysm 1 year after presenting with seizures related to subarachnoid hemorrhage from the aneurysm, for which she had been treated with clipping and an M2-M2 anastomosis.

INTERVENTION

Both patients underwent craniotomies, with sacrifice of the proximal parent vessel (the distal cervical internal carotid artery and the proximal middle cerebral artery, respectively), combined with cerebral revascularization through extracranial-intracranial saphenous vein bypass grafts. Both patients experienced excellent long-term clinical outcomes, have undergone significant growth, and exhibit excellent long-term graft patency and aneurysm obliteration.

CONCLUSION

These two cases highlight the safety and efficacy of extracranial-intracranial vein graft bypasses among prepubertal pediatric patients. The indications for bypass procedures to treat giant intracranial aneurysms are discussed, and the technical aspects of maximizing vein bypass graft patency are reviewed.

Multiple "mirror" aneurysms involving intracavernous carotid arteries and vertebral arteries: case report

BACKGROUND

Bilateral intracavernous carotid artery aneurysms are rare. Moreover, the proportion of vertebrobasilar aneurysms in association with multiple aneurysms is extremely low. We describe a rare case of "mirror" aneurysms on the bilateral intracavernous carotid and bilateral vertebral arteries.

CASE DESCRIPTION

A 54-year-old male suffered from ophthalmic pain and oculomotor palsy on the left side. Cerebral angiography disclosed a giant left cavernous aneurysm and large asymptomatic aneurysms on the right intracavernous carotid artery and bilateral vertebral arteries. The cavernous sinus syndrome on the left side was successfully treated by left carotid artery ligation. However, 2 years later, severe subarachnoid hemorrhage (SAH) occurred. Computed tomography revealed thick clots densely distributed in the basal cisterns and third and fourth ventricles, indicating that the SAH originated from one of the vertebral artery aneurysms. Consciousness disturbance progressed rapidly, leading to cardiopulmonary arrest.

CONCLUSION

The literature contains no case of mirror intracranial aneurysms involving both intracavernous carotid and vertebral arteries. Multi-staged surgical techniques with optimal combinations of direct clipping, ligation or trapping, and endovascular embolization may be essential for patients with multiple aneurysms to avoid SAH.

Transcranial bypass for spontaneous intracranial carotid artery dissection--a case report

A case of spontaneous intracranial artery dissection (IAD) of the anterior circulation is reported. A 32-year-old man developed left hemiparesis with headache. Angiographies (AGs) showed progressive occlusion of the distal end of the right internal carotid artery. He underwent a superficial temporal artery-middle cerebral artery anastomosis 20 days after his initial symptoms. He improved gradually after operation. The prognosis and treatment of IAD are discussed. The authors conclude that cases with IADs of the anterior circulation should be followed up by cerebral AG or magnetic resonance angiography and that early bypass surgery should be considered to prevent massive cerebral infarction in some cases.

Venous and arterial bypass grafts for difficult tumors, aneurysms, and occlusive vascular lesions: evolution of surgical treatment and improved graft results

OBJECTIVE: In the treatment of patients with cranial base tumors, unclippable aneurysms, or medically intractable ischemia, it may be necessary to use high-flow bypass grafts. The indications, surgical techniques and complications are discussed. METHODS: During a 10-year period, 99 saphenous vein grafts and 3 radial artery grafts were performed for 101 patients, i.e., 72 with neoplasms, 23 with aneurysms, and 6 with ischemia. Clinical follow-up monitoring of the patients was by direct examination or telephone interview, with a mean follow-up period of 41.2 months (range, 5-147 mo). Radiological follow-up monitoring was by magnetic resonance imaging, magnetic resonance angiography, or three-dimensional computed tomographic angiography, with a mean follow-up period of 32 months (range, 1-120 mo). During the follow-up period, there was one late graft occlusion and one graft stenosis. RESULTS: The use of intraoperative angiography improved the patency rate from 90 to 98% and reduced the incidence of perioperative stroke from 13 to 9.5%. Ninety-two percent of the patients were in excellent or good neurological condition at the time of discharge from the hospital, compared with 95% before surgery. The perioperative mortality rate was 2%. Other complications included three intracranial hematomas, rupture of a vein graft in a patient with Marfan's syndrome, and five tumor resection-related problems. The long-term survival rates for patients who received grafts were excellent for patients with benign tumors, fair to poor for patients with malignant tumors, good for patients with aneurysms, and excellent for patients with ischemia. CONCLUSION: The results of saphenous vein and radial artery grafting have been greatly improved by the use of intraoperative angiography, improvements in surgical techniques, and improved perioperative treatment.

Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation

STUDY DESIGN

Potential precipitating events and risk factors for vertebrobasilar artery dissection were reviewed in an analysis of the English language literature published before 1993.

OBJECTIVES

To assess the literature pertaining to precipitating neck movements and risk factors for vertebrobasilar artery dissection in an attempt to determine whether the incidence of these complications can be minimized.

SUMMARY OF BACKGROUND DATA

Vertebrobasilar artery dissection and occlusion leading to brain stem and cerebellar ischemia and infarction are rare but often devastating complications of cervical, manipulation and neck trauma. Although various investigators have suggested potential risk factors and precipitating events, the basis for these suggestions remains unclear.

METHODS

A detailed search of the literature using three computerized bibliographic databases was performed to identify English language articles from 1966 to 1993. Literature before 1966 was identified through a hand search of Index Medicus. References of articles obtained by database search were reviewed to identify additional relevant articles. Data presented in all articles meeting the inclusion criteria were summarized.

RESULTS

The 367 case reports included in this study describe 160 cases of spontaneous onset, 115 cases of onset after spinal manipulation, 58 cases associated with trivial trauma, and 37 cases caused by major trauma (3 cases were classified in two categories). The nature of the precipitating trauma, neck movement, or type of manipulation that was performed was poorly defined in the literature, and it was not possible to identify a specific neck movement or trauma that would be considered the offending activity in the majority of cases. There were 208 (57%) men and 158 (43%) women (gender data not reported in one case) with an average age of 39.3 +/- 12.9 years. There was an overall prevalence of 13.4% hypertension, 6.5% migraines, 18% use of oral contraception (percent of female patients), and 4.9% smoking. In only isolated cases was specific vascular disease such as fibromuscular hyperplasia noted.

CONCLUSIONS

The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.

Long-term patency of radial artery graft bypass for reconstruction of the internal carotid artery. Technical note

Reconstruction of the carotid artery by using a radial artery graft is a useful option that can produce reliable long-term patency for the surgical treatment of giant and/or large aneurysms of the cavernous and paraclinoid internal carotid artery (ICA). During the past 10 years, 43 patients with intracavernous and paraclinoid giant aneurysms of the ICA have been treated by reconstruction of the ICA with radial artery grafts after ligation of the cervical ICA. The long-term patency of the grafted radial artery was evaluated over more than a 5-year period (mean 7.2 years) in 20 of these patients by using magnetic resonance angiography or conventional angiography. There was no late occlusion of the graft in any of these cases. Stenotic graft changes were observed in two cases.

Vascular reconstruction using interposed small vessels

OBJECTIVE

This study presents the relationship between the patency of short-vessel graft bypasses and their diameter/length.

METHODS

The authors performed interposed graft bypass operations using small vessels for four patients with moyamoya disease, six patients with cerebral thrombosis, and one patient with aortitis syndrome. The donor artery was the superficial temporal artery (10 patients) or the occipital artery (1 patient), and the recipient artery was the cortical branch of the middle cerebral artery (8 patients) or the cortical branch of the anterior cerebral artery (3 patients). The interposed graft used between these donor and recipient vessels was the superficial temporal vein (seven patients), the superficial temporal artery (three patients), or the epigastric artery (one patient).

RESULTS

Good patency of the graft was confirmed for 7 of these 11 patients. Regarding the relationship between the diameter/length and the patency, we found that long-term patency could not be expected when the discriminant function of y = (15.39 x diameter) - (0.35 x length) - 14.37 was below zero.

CONCLUSION

Short-vessel graft bypass is a practical option for cerebral revascularization surgery when short large vessels are used.

Thrombosed growing giant aneurysms of the vertebral artery: growth mechanism and management

Results in three patients with thrombosed giant aneurysms of the vertebral artery are reported. Each of the aneurysms presented as a mass lesion. On postcontrast computerized tomography and magnetic resonance imaging, each aneurysm demonstrated a patent lumen and intrathrombotic vascular channels. Two patients died and were autopsied, and the other patient was successfully treated. Pathological examination revealed that the aneurysms had staged clots, an open lumen, intrathrombotic channels with endothelial lining, and aneurysmal walls with intimal thickening. The authors suggest that the development of the intrathrombotic capillary channels may be an important factor in the growth of thrombosed giant aneurysm of the vertebral artery. Trapping of the aneurysm followed by aneurysmectomy appears to be the best treatment for this type of aneurysm.

Spontaneous vertebral artery dissection as a complication of autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) may be associated with a variety of cardiovascular complications, including intracranial saccular aneurysms. In ADPKD, intracranial saccular aneurysms tend to rupture more frequently and earlier than the sporadic variety with a tendency to cluster in families. In contrast, dissecting intracranial aneurysms are rarely associated with either intracranial saccular aneurysms or ADPKD. We describe an ADPKD-1 patient whose course was complicated by a spontaneous dissection of a vertebral artery aneurysm. This particular patient had previously experienced three episodes of ascending aortic dissection with cystic medial necrosis. Intracranial vascular and aneurysmal dissection may occur in select ADPKD patients with familial clusters.

Dissection of the vertebral arteries: case report and discussion

Vertebral artery dissection is an unusual condition with potentially protean neurologic presentations. It may occur spontaneously or follow apparently minor neck trauma. Ischemic symptoms related to the posterior circulation ensue and may be due to obstruction or embolization. The ensuing stroke is ischemic, although subarachnoid hemorrhage may be a complication as well. A case of vertebral artery dissection in a young woman who developed symptoms approximately one week after mild neck injury is reported, and the topic is reviewed.

Vein graft replacement of the distal vertebral artery

Vein graft reconstruction of the cervical portion of the vertebral artery has been commonly used for the treatment of atherosclerotic arterial disease. In this article, we describe two instances of vein graft replacement of the distal portion of the vertebral artery. In the first case, the vein graft was placed from C2 transverse foramen to the intradural portion of the vertebral artery to replace an artery abnormally encased and involved by meningioma. The grafting was done in this case to preserve the cerebrovascular reserve in a young patient. In the second case, a vein graft was placed from the extradural C1 portion to the intradural artery beyond the posterior inferior cerebellar artery. This was done to replace a segment of the artery involved by a giant aneurysm, which could not be clipped without occluding the parent artery. In this case, the vein graft replacement was necessitated by changes of somatosensory evoked potentials after the aneurysm was clipped, demonstrating the need to preserve the patency of the artery. Vein graft replacement of the proximal intradural vertebral artery is feasible by the combination of standard cerebro-vascular techniques and the exposures afforded by skull base surgery.

Dissecting aneurysm of the anterior cerebral artery: report of two cases

Two cases of spontaneous dissecting aneurysm localized to the anterior cerebral artery are reported. Both patients experienced severe headaches, followed by symptoms of cerebral ischemia. In the first case, the dissecting aneurysm showed an angiographic appearance resembling a saccular aneurysm of the anterior communicating artery, and the diagnosis of dissecting aneurysm was confirmed at operation. The second case was treated conservatively, and the diagnosis was reached by repeat angiographic studies.