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Hayashi T, Endo H, Kanoke A, Kawaguchi T, Tominaga T. Bypass surgery for ruptured dissecting aneurysms of the proximal posterior cerebral artery: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22341. [PMID: 36461837 PMCID: PMC9552679 DOI: 10.3171/case22341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/29/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Posterior cerebral artery (PCA) dissecting aneurysms commonly occur in the proximal PCA and are considered rare. The treatment of proximal PCA dissecting aneurysms is challenging because of the existence of perforators supplying the vital neural structures. Recently, endovascular intervention has been used; however, concerns for ischemic or hemorrhagic complications exist. OBSERVATIONS A 54-year-old woman presented with subarachnoid hemorrhage due to dissecting aneurysm rupture at the P1-P2 junction of the PCA. The thalamoperforating artery (TPA) and medial posterior choroidal artery (MPchA) originated from the proximal end and the distal end of the aneurysm, respectively. Additionally, the posterior communicating artery (PcomA) connected with the dissected segment. To preserve these perforators, we performed surgical trapping combined with superficial temporal artery (STA) PCA anastomosis. Clips were applied for trapping the proximal and distal end of the aneurysm, with preservation of the TPA and MPchA origin. PcomA was left open for blood flow preservation to the perforators directly arising from the aneurysm. The postoperative course was uneventful, and the patient was discharged. LESSONS Surgical trapping using STA-PCA bypass could be a treatment of choice for proximal PCA dissecting aneurysms, considering its potential for cure and prevention of ischemic complications.
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Affiliation(s)
- Tetsuya Hayashi
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan; and
| | - Hidenori Endo
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
- Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Atsushi Kanoke
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | | | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan; and
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Kugai M, Suyama T, Kitano M, Tominaga Y, Tominaga S. A Recurrent Large Posterior Cerebral Artery Aneurysm Successfully Treated with Parent Artery Occlusion Using Somatosensory-Evoked Potential: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2022; 16:556-564. [PMID: 37501735 PMCID: PMC10370874 DOI: 10.5797/jnet.cr.2022-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 07/19/2022] [Indexed: 07/29/2023]
Abstract
Objective Treatment of large posterior cerebral artery (PCA) aneurysm involving the P1-P2 segment is difficult by both neurosurgery and endovascular treatment. Balloon occlusion test (BOT) to identify precise peripheral collateral flow is difficult prior to parent artery occlusion (PAO). Besides, PAO at the aneurysm at this location can cause peripheral cortical infarction of the occipital and temporal lobes and/or perforator infarction involving the midbrain and thalamus perfused by the perforating artery arising from the P1-P2 segment. However, detection of the perforator during PAO is difficult. Case Presentation The patient was a 49-year-old woman. At the age of 43 years, a right large PCA aneurysm was discovered in the right P1-P2 segment. A simple technique coiling was performed. As recurrence was identified 1 year later, embolization was performed using a same procedure. Since further recurrences were later found, a third round of treatment was planned. Somatosensory-evoked potential (SEP) was recorded as intraoperative electrophysiological monitoring. Tortuosity of the right PCA was observed at the aneurysm neck and the distal right PCA could not be secured. We could neither perform stent-assisted coil embolization nor BOT in the right PCA. Hence, we inflated the balloon in the basilar artery and checked the collateral circulation routes retrograde into the right PCA from the right middle cerebral artery via a leptomeningeal anastomosis. PAO was performed on the right P1-P2 segment at the aneurysm neck. The signal of the SEP was not decreased, and the aneurysm was not visualized. Another coil was added to strengthen the PAO to the right P1 segment, which decreased the SEP amplitude in the extremities by 3 minutes after. As the last coil was thought to be occluding the perforator branching from the right P1 segment, it was removed without detaching. The SEP amplitude began to improve and recovered by 9 minutes after. There was no postoperative deficit. No recurrence of aneurysm was observed on MRA 9 months postoperatively. Conclusion During PAO at the P1 segment of large PCA aneurysm involving the P1-P2 segment, SEP may be helpful to prevent perforator infarction, even if perforating artery originating from the proximal portion of the aneurysm was not detected by angiography.
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Affiliation(s)
- Miyahito Kugai
- Department of Neurosurgery, Tominaga Hospital, Osaka, Osaka, Japan
| | - Takehiro Suyama
- Department of Neurosurgery, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Masahiko Kitano
- Department of Neurosurgery, Tominaga Hospital, Osaka, Osaka, Japan
| | - Yoshiko Tominaga
- Department of Neurosurgery, Tominaga Hospital, Osaka, Osaka, Japan
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Demartini Z, Gatto LAM, Francisco AN, Koppe GL. Endovascular treatment of P3 segment of posterior cerebral artery aneurysm with stent and coils. Neurochirurgie 2021; 68:437-442. [PMID: 34499946 DOI: 10.1016/j.neuchi.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 02/12/2019] [Accepted: 08/24/2021] [Indexed: 11/27/2022]
Abstract
Posterior cerebral artery (PCA) aneurysms are rare and usually arise from proximal portion of the artery. The distal location is even less frequent, and aneurysms in this location tend to be larger and dissecting. Although they can be treated by direct surgery, recently endovascular procedures have been preferred in some centers. We report a case of large aneurysm of the posterior cerebral artery in a 45-year-old female presenting with headache. An uneventful endovascular treatment was performed with stent and platinum coils achieving total occlusion of the aneurysm, and the patient had good recovery. The findings are compared to earlier reports and literature regarding the issue is discussed.
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Affiliation(s)
- Z Demartini
- Neurosurgeon, Neuroradiologist, Hemodynamics Division, Federal University of Parana - UFPR, Curitiba, PR, Brazil; Neurosurgeon, Neuroradiologist, Department of Neurosurgery - Cajuru University Hospital, Pontifical University Catholic of Parana - PUCPR, Curitiba, PR, Brazil.
| | - L A M Gatto
- Neurosurgeon, Neuroradiologist, Department of Neurosurgery - Cajuru University Hospital, Pontifical University Catholic of Parana - PUCPR, Curitiba, PR, Brazil
| | - A N Francisco
- Neurosurgeon, Department of Neurosurgery - Cajuru University Hospital, Pontifical University Catholic of Parana - PUCPR, Curitiba, PR, Brazil
| | - G L Koppe
- Interventional Radiologist, Department of Neurosurgery-Hospital Vita Curitiba, Curitiba, PR, Brazil
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Mitsuhashi T, Oishi H, Makino K, Tokugawa J, Fuse A, Hishii M. Stent-Assisted Coil Embolization for Acute Ruptured Dissecting Aneurysm at the P2 Segment of the Posterior Cerebral Artery: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 16:157-162. [PMID: 37502277 PMCID: PMC10370781 DOI: 10.5797/jnet.cr.2021-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/08/2021] [Indexed: 07/29/2023]
Abstract
Objective We report a case of ruptured posterior cerebral artery (PCA) dissecting aneurysm treated with stent-assisted coil embolization in the acute phase of ruptured aneurysm. Case Presentation A 60-year-old woman presented with sudden onset of severe headache followed by unconsciousness. CT showed severe subarachnoid hemorrhage. Digital subtraction angiography showed a dissecting aneurysm at the P2 segment of the right PCA. Stent-assisted coil embolization was performed for the ruptured dissecting aneurysm. Since thrombus was observed in the stent, ozagrel was administered intravenously, and the thrombus gradually disappeared during the follow-up period. She was discharged without neurological deficit. Conclusion Parent artery occlusion is widely performed for acute ruptured PCA dissecting aneurysm, but reconstruction with stent-assisted coiling is considered to be an effective therapeutic strategy.
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Affiliation(s)
- Takashi Mitsuhashi
- Department of Neurosurgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kensaku Makino
- Department of Neurosurgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Joji Tokugawa
- Department of Neurosurgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Atsuhito Fuse
- Department of Neurology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Makoto Hishii
- Department of Neurosurgery, Juntendo University Nerima Hospital, Tokyo, Japan
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Selvamurugan V, Prasad SN, Singh V, Neyaz Z. Traumatic dissecting pathology of posterior cerebral artery: a report of two cases-aneurysm and pial arteriovenous fistula. BMJ Case Rep 2021; 14:14/5/e237722. [PMID: 34016624 DOI: 10.1136/bcr-2020-237722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present two cases of 17-year-old man and 10-year-old boy presenting with subarachnoid haemorrhage and a history of road traffic accident. One patient had dissecting aneurysm of the posterior cerebral artery (PCA), and the other patient had partially thrombosed aneurysm on CT angiography. On digital subtraction angiography of the second patient, there was formation of PCA pontomesencephalic vein pial arteriovenous fistula (PAVF). Both the patients underwent endovascular treatment: stent-assisted coiling for aneurysm and coiling with parent vessel occlusion for PAVF. There were no procedural complications. Follow-up angiography showed no residual aneurysm or fistula. Trauma is one of the recognised causes of dissection, and intracranial dissections can present as stenotic lesions, aneurysms or fistulas, depending on the pathology. Traumatic dissecting PCA aneurysm has been reported in only two case reports previously, and post-traumatic PAVF in PCA has not been reported.
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Affiliation(s)
- Vignesh Selvamurugan
- Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Surya Nandan Prasad
- Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vivek Singh
- Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Zafar Neyaz
- Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Jabeen S, Pendharkar HS, Prasad C, Hr A, Saini J, Gupta AK, Shukla D. Dissecting aneurysms of the posterior cerebral artery - A retrospective review of imaging, angiographic characteristics, endovascular management and outcome. Interv Neuroradiol 2020; 27:152-162. [PMID: 33115298 DOI: 10.1177/1591019920967572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To review management, clinical and imaging outcomes of dissecting posterior cerebral artery (PCA) aneurysms with emphasis on endovascular management in the form of parent vessel occlusion (PVO) at a tertiary care center. METHODS Thirty-six dissecting PCA aneurysms (19 ruptured) encountered at our center between January 2013 and November 2019 were reviewed for aneurysm location/size/presence of fetal PCA/management. Postprocedural imaging of patients who underwent endovascular intervention was reviewed for PCA territory infarcts and clinical records assessed for presence of neuro-deficits and outcome. None of the patients underwent a balloon test occlusion (BTO) prior to PVO. RESULTS The location of the aneurysms was as follows-P1 = 8/P1-P2 = 11/P2 = 5/P2-P3 = 10/P3 = 2. The mean size was 11.7x6.8 mm. Endovascular intervention was carried out in 20 patients in the form of PVO with coiling in 16 patients, coiling alone in 3 patients, and reconstruction of the left PCA with flow diverter deployment in one patient. Postprocedural PCA territory infarct was seen in 5 cases of PVO out of which 4 had a good functional recovery. Overall, 15/16 patients (93.7%) who underwent PVO had mRS ≤ 2 on follow-up. The single case with flow diverter also developed an infarct and had adverse outcome on follow up. CONCLUSION Among the various management strategies for dissecting PCA aneurysms, PVO is feasible and relatively safe even in absence of BTO in scenarios like critically ill patients with ruptured aneurysms, difficult access and financial constraints. Thromboembolic complications and antiplatelet therapy is a concern in reconstructive strategies.
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Affiliation(s)
- Shumyla Jabeen
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Hima S Pendharkar
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Chandrajit Prasad
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Arvinda Hr
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Jitender Saini
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Arun Kumar Gupta
- Department of Vascular and Interventional Radiology, Paras Hospital, Gurgaon, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
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P1 segment dissection mimicking pre-truncal subarachnoid hemorrhage with spontaneous resolution. J Neuroradiol 2020; 48:456-457. [PMID: 32430104 DOI: 10.1016/j.neurad.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 11/23/2022]
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