Progressive Growth of a Giant Dolichoectatic Vertebrobasilar Artery Aneurysm after Complete Hunterian Occlusion of the Posterior Circulation: Case Report

Petrous Carotid to Upper Posterior Circulation Bypass for the Treatment of Basilar Trunk Aneurysm: A Novel High-Flow Intracranial-Intracranial Skull Base Bypass for Posterior Circulation

BACKGROUND

Basilar trunk aneurysms are the most surgically challenging, and the spectrum covers small fusiform to dolichoectatic aneurysms and may lead to rupture, brain ischemia, or direct brainstem compression. The current strategy remains cerebral revascularization coupled with aneurysm trapping. Available bypass options for upper posterior circulation (UPC) are based on (1) different flow volumes from diverse blood supplies and (2) distinct modulation purposes for cerebral revascularization; however, the potential compromise of eloquent perforators of the basilar trunk and the occurrence of fatal brainstem infarcts remain unacceptable.

OBJECTIVE

To innovate a high-flow intracranial-intracranial skull base bypass for posterior circulation to afford robust retrograde flow and shorten the graft length.

METHODS

We retrospectively reviewed our experience in the treatment of a patient with basilar trunk aneurysm and reported a novel bypass alternative supplied by petrous internal carotid artery to augment blood flow to the UPC by a pretemporal approach.

RESULTS

The postoperative course was uneventful, and there was no pons or midbrain ischemia or other complications. Postoperative computed tomography angiogram revealed the patency of bypass. There was no further development or rerupture observed during follow-up.

CONCLUSION

Petrous internal carotid artery as a donor site is a reliable bypass modality for UPC. This approach provides the utmost retrograde flow to alleviate the development of dissecting aneurysms, preserves eloquent perforators of the basilar trunk, maintains bypass patency, and shortens the graft course. Therefore, this novel therapeutic alternative could be beneficial for improving the prognosis of basilar trunk aneurysms.

Prospects and Dilemmas of Endovascular Treatment for Vertebrobasilar Dolichoectasia

Vertebrobasilar dolichoectasia (VBD) is characterized by significant expansion, elongation, and tortuosity of the basilar artery and vertebral artery. Certain highly selected cases of VBD can require intervention. Recent advances in endovascular treatment (EVT) have renewed hope for patients with VBD. However, which cases of VBD can benefit from EVT still needs to be determined. Currently, little is known regarding this matter. Therefore, we performed a review of the literature from a PubMed search and cataloged our experience regarding the classification and natural history of VBD and the prospects, prognosis and complications of EVT. The findings can be summarized as follows: for asymptomatic VBD, “wait and see” or medical management may be a reasonable strategy. EVT may only be effective in certain patients. For saccular aneurysms in VBD, especially ruptured aneurysms, EVT is reasonable. For fusiform aneurysms in VBD, EVT can carry high complication rates and should be recommended with caution. For stenting reconstruction in VBD, the effect is uncertain. For the future of EVT of VBD, randomized controlled trials and the development of neurointerventional products are worth pursuing, but EVT in VBD still has a long way to go.

[Diagnosis and treatment of non-saccular vertebrobasilar aneurysms]

OBJECTIVE

To systematize the data on diagnosis and treatment of non-saccular vertebrobasilar aneurysms.

MATERIAL AND METHODS

We have analyzed modern and fundamental studies in the PubMed database for the period 1969-2020. The following keywords were used: non-saccular aneurysm, dolichoectasia, vertebrobasilar pool. Fifty-nine studies including 1 meta-analysis, 9 case reports, 24 reviews and 25 original articles were selected.

RESULTS

Analysis of literature data indicates various unresolved problems associated with difficult diagnosis and choice of treatment that results high rates of disability and mortality.

CONCLUSION

Data on anatomical features of non-saccular aneurysms, such as presence or absence of perforating arteries within the affected arterial segment, analysis of electrophysiological changes following brainstem compression by aneurysm can serve as factors that will improve treatment outcomes in these patients.

[Unfavorable outcome of giant vertebral artery aneurysm. Clinical case and literature review]

OBJECTIVE

To demonstrate the unfavorable natural course and prognosis of giant vertebral artery aneurysm, to analyze the literature, and to conduct a postmortem histopathological study of the features of this disease.

Combined Microsurgical, Endovascular, and Endoscopic Approach to the Treatment of a Giant Vertebrobasilar Aneurysm

BACKGROUND

Dolichoectasia is defined as elongation and dilatation of a blood vessel. In the intracranial circulation, the basilar artery is affected in 80% of cases. These are challenging lesions with an aggressive natural history, and treatment carries a relatively high rate of morbidity and mortality. We describe a case of multimodal treatment including endovascular, open microsurgical, and endoscopic endonasal approach (EEA) for management.

OBJECTIVE

To describe the technical nuance of the addition of the EEA for management of posterior circulation dolichoectasia.

METHODS

A 44-yr-old Hispanic woman with a 2-mo history of progressive headaches, gait disturbance, and lower cranial nerve dysfunction presented with acute neurologic decline. MRI demonstrated a dolichoectatic vertebrobasilar system with a giant 4.5-cm fusiform basilar aneurysm.

RESULTS

She underwent concomitant endovascular bilateral vertebral artery sacrifice with suction decompression and trapping by clip ligation distal to the lesion. Postoperatively, she developed symptomatic pontine compression. She was then taken for a transclival EEA for intra-aneurysmal thrombectomy. Thereafter, she made a significant functional recovery.

CONCLUSION

The addition of endoscopic reconstruction to the treatment of a dolichoectatic basilar aneurysm is an operative nuance that can be employed in treating these highly morbid lesions. This case describing a multimodal treatment paradigm including EEA reconstruction can serve as an example for the future of treatment select cases of dolichoectasia of the vertebrobasilar complex.

Delayed extensive brain edema caused by the growth of a giant basilar apex aneurysm treated with basilar artery obliteration: a case report

Background

Partially thrombosed giant aneurysms at the basilar apex (BA) artery are challenging lesions with a poor prognosis if left untreated. Here we describe a rare case of extensive brain edema after growth of a surgically treated and thrombosed giant basilar apex aneurysm.

Case presentation

We performed a proximal surgical basilar artery occlusion on a 64-year-old female with a partially thrombosed giant BA aneurysm. MRI showed no ischemic lesions but showed marked edema adjacent to the aneurysm. She had a good recovery, but 3 months after surgical occlusion, her gait deteriorated together with urinary incontinence and worsening right hemiparesis. MRI showed that the aneurysm had grown and developed intramural hemorrhage, which caused extensive brain edema and obstructive hydrocephalus. She was treated by a ventriculoperitoneal shunt placement. Follow-up MRI showed progressive brain edema resolution, complete thrombosis of the lumen and shrinkage of the aneurysm. At 5 years follow-up the patient had an excellent functional outcome.

Conclusions

Delayed growth of a surgically treated and thrombosed giant aneurysm from wall dissection demonstrates that discontinuity with the initial parent artery does not always prevent progressive enlargement. The development of transmural vascular connections between the intraluminal thrombus and adventitial neovascularization by the vasa vasorum on the apex of the BA seems to be a key event in delayed aneurysm growth. Extensive brain edema might translate an inflammatory edematous reaction to an abrupt enlargement of the aneurysm.

The safety and efficacy of using large woven stents to treat vertebrobasilar dolichoectasia

OBJECTIVES

To characterize the safety and efficacy of large woven stents in the treatment of vertebrobasilar dolichoectasia (VBD).

METHODS

We retrospectively reviewed 19 consecutive patients with VBD treated with large woven intracranial stent (Leo stents) between January 2016 and December 2018. The clinical symptoms and angiograms of all the patients were recorded.

RESULTS

The patients were treated with 1-3 large Leo stents (5.5 mm x 75 mm, 5.5 mm x 50 mm, or 4.5 mm x 40 mm), with or without coiling. They had follow-up angiography and MRI between 3 months and 1 year. Digital subtraction angiography showed 16 patients with complete reconstruction of the target vessels, one patient with almost complete reconstruction, and two patients with partial reconstruction. All patients had symptomatic improvement shortly after treatment, but two patients developed recurrent dysphagia at 8 and 18 months, respectively.

CONCLUSIONS

Deployment of woven stents with or without supportive coiling may offer symptom relief and reconstruction in patients with VBD.

Outcomes in Symptomatic Patients With Vertebrobasilar Dolichoectasia Following Endovascular Treatment

Objective: To evaluate whether the presenting symptoms of VBD predict outcomes following endovascular treatment. Methods: We retrospectively reviewed our institutional clinical database and identified 22 patients (all men; mean age: 52.6 years, range: 11-73 years) with a diagnosis of VBD, who underwent endovascular treatment from January 2010 to December 2017. Results: After analyzing the clinical and imaging data, we evaluated data for 22 symptomatic patients with VBD. At the time of VBD diagnosis, 13 patients (59%) had compressive symptoms, four (18%) had hemorrhagic symptoms, and five (23%) had ischemic symptoms. Nine of the 22 patients (41%), who presented with hemorrhagic and ischemic symptoms, achieved a satisfactory clinical and/or digital subtraction angiography imaging outcome after endovascular treatment. However, of the 13 patients who presented with compressive symptoms, seven (54%, 7/13) died from severe brainstem compression during follow-up; furthermore, magnetic resonance imaging showed worsening of the mass effect in eight patients with compressive symptoms (62%, 8/13). Conclusions: VBD is considered a challenging lesion without an ideal treatment modality. Endovascular treatment of VBD in patients presenting with compressive symptoms at diagnosis may not be beneficial. However, long-term outcomes following endovascular treatment may be acceptable in patients with non-compressive symptoms at diagnosis compared with those with compressive symptoms.

Successive occurrence of vertebrobasilar dolichectasia induced trigeminal neuralgia, vestibular paroxysmia and hemifacial spasm: A case report

RATIONALE

Study reported an extremely rare case of trigeminal neuralgia, vestibular paroxysmia, and hemifacial spasm successively occurring in a patient with vertebrobasilar dolichoectasia (VBD).

PATIENT CONCERNS

A 66-year-old female patient presented with episodic vertigo for 20 days before she was admitted to our hospital. Vertigo suddenly occurred when the patient rotated her head 20 days ago, the symptoms of vertigo were improved after continuous 1 to 3 seconds, and similar symptoms were repeated in sleep and rest, with a frequency of 30 to 40 times per day. The patient had a history of hypertension with poor blood pressure control for more than 20 years.

DIAGNOSES

The final diagnosis was vertebrobasilar dolichectasia, right trigeminal neuralgia, and vestibular paroxysmia.

INTERVENTIONS

Vitamin B1 (10 mg), methylcobalamin (0.5 mg), and carbamazepine (0.1 g) were given orally 3 times a day to relieve the symptoms.

OUTCOMES

On the seventh day of drug treatment, the symptoms of paroxysmal vertigo and trigeminal neuralgia were completely relieved, but occasional episodes occurred during the follow-up period. Five months after discharge, right hemifacial spasm appeared in the patient, which did not affect the quality of life of the patient, so the patient did not choose further treatment. Six months after discharge, the patient was lost to follow-up.

LESSONS

Comprehensive treatment to control VBD risk factors, delay the progression of VBD, and improve clinical symptoms may have a better effect on such patients. However, further research is needed.

[Giant partially thrombosed aneurysm of the vertebral artery: a case report and literature review]

INTRODUCTION

Giant partially thrombosed aneurysms of the vertebral artery are recalcitrant to treatment by microsurgical trapping and thrombectomy. Application of endovascular interventions is limited due to substantial brainstem compression and cranial nerve neuropathy. Combined endovascular exclusion and microsurgical excision provides an approach to treatment of these lesions.

CLINICAL CASE

A 48-year-old female patient presented with progressive complaints of ataxia, diplopia in left lateral gaze, and dysphagia. Imaging studies (CT, MRI, angiography) revealed a giant partially thrombosed aneurysm of the right vertebral artery and pronounced brainstem compression.

TREATMENT

The initial phase of treatment involved endovascular occlusion of the vertebral artery and aneurysm trapping that did not lead to changes in the postoperative patient's neurological status. MRI demonstrated complete aneurysm thrombosis and a weak TOF signal in the vertebral artery near the proximal aneurysm neck region. Because of persistent brainstem compression, the patient underwent right suboccipital craniectomy and hemilaminectomy of the CI arch for aneurysm excision one week after endovascular occlusion. After isolating the aneurysmal sac, the vertebral artery was transected, and two small branches extending from the aneurysm neck to the brainstem were also coagulated and transected, followed by aneurysm excision. Numerous vasa vasorum in the wall of the proximal vertebral artery and aneurysm neck were coagulated to stop bleeding. After surgery, the patient developed neurological symptoms (right leg ataxia and dysphagia worsening) due to lateral medullary infarction (confirmed by MRI) that presumably resulted from coagulation of two small perforating branches coming from the aneurysm neck to the brainstem. Recovery of the patient's neurological functions was observed during conservative treatment. The patient was discharged with mild right leg ataxia and preoperative left-sided abducens paresis.

CONCLUSION

Medulla oblongata compression associated with a giant thrombosed aneurysm of the vertebral artery can be eliminated by endovascular trapping followed by surgical excision of the aneurysm. Preserving the vasa vasorum feeding the brainstem is crucial for prevention of ischemic complications.

Endovascular treatment of the extracranial carotid pseudoaneurysms resulting from stab penetrating injury using overlapping bare stents

Injury pertaining to the common carotid artery may result in complete or partial arterial transection, pseudoaneurysms, or arteriovenous connections. Endovascular treatment option of the pseudoaneurysm has already been established with favorable success rate and minimal morbidity. Our purpose is to report one 18-year-old male patient having 2 traumatic pseudoaneurysms as a result of penetrating stab injury in the extracranial common carotid. The patient was successfully treated using 2 overlapping bare-metal stents. The 2 common carotid pseudoaneurysms had different degree inflow angles defined as the space between the lines indicating the direction of blood flow from the parent artery and through the aneurysmal neck to the dome. Computed tomography angiography was utilized to follow the evolution of the pseudoaneurysms until total occlusion was demonstrated. The treatment modality used in this report represents an alternative approach of the endovascular treatment for the extracranial carotid pseudoaneurysm.

Research progress on vertebrobasilar dolichoectasia

Vertebrobasilar dolichoectasia (VBD) is a rare disease characterized by significant expansion, elongation, and tortuosity of the vertebrobasilar arteries. Current data regarding VBD are very limited. Here we systematically review VBD incidence, etiology, characteristics, clinical manifestations, treatment strategies, and prognosis. The exact incidence rate of VBD remains unclear, but is estimated to be 1.3% of the population. The occurrence of VBD is thought to be due to the cooperation of multiple factors, including congenital factors, infections and immune status, and degenerative diseases. The VBD clinical manifestations are complex with ischemic stroke as the most common, followed by progressive compression of cranial nerves and the brain stem, cerebral hemorrhage, and hydrocephalus. Treatment of VBD remains difficult. Currently, there are no precise and effective treatments, and available treatments mainly target the complications of VBD. With the development of stent technology, however, it may become an effective treatment for VBD.

Bypass and flow reduction for complex basilar and vertebrobasilar junction aneurysms

BACKGROUND

Giant aneurysms of the vertebral and basilar arteries are formidable lesions to treat.

OBJECTIVE

To evaluate the long-term outcomes of patients with vertebrobasilar aneurysms treated with extracranial-intracranial bypass and flow reduction.

METHODS

We retrospectively reviewed a prospective database of aneurysms cases treated between December 1993 and August 2011.

RESULTS

Eleven patients (8 male, 3 female) with 12 aneurysms were treated. There were 3 basilar apex aneurysms, 2 aneurysms of the basilar trunk, and 7 vertebrobasilar junction aneurysms. There were 5 saccular and 7 fusiform aneurysms. All patients underwent extracranial-intracranial bypass and vessel occlusion. Flow was reversed or reduced by complete (n = 6) or partial occlusion of the basilar artery (n = 3) or by occlusion of the vertebral arteries distal to the posterior inferior cerebellar artery (n = 3). Postoperatively (mean follow-up, 71.6 months; range, 4-228; median, 49 months), the bypass patency rate was 92.3% (12/13). The perioperative mortality rate for the initial treatment was 18.2% (2/11). In 4 cases, the aneurysms continued to grow and required further treatment; after re-treatment, 3 of these patients died. Of the initial 11 patients, 6 were treated successfully and 5 died. The mean preoperative modified Rankin Scale score was 2.1 (range, 1-3; median, 2). At last follow-up for all patients, the mean modified Rankin Scale score was 3.45 (range, 1-6; median, 3) and 2.5 (range, 1-4; median, 2.5) for the 6 long-term survivors.

CONCLUSION

Vertebrobasilar aneurysms are challenging lesions with limited microsurgical or endovascular options. Despite aggressive surgical treatment, the long-term outcome remains poor for most patients.

Endovascular reconstruction for treatment of vertebrobasilar dolichoectasia: long-term outcomes

BACKGROUND AND PURPOSE

VBD can trigger various clinical symptoms, especially ischemic stroke in the posterior circulation, but there is no effective treatment for their prevention. We aimed to validate the feasibility of coil-assisted stent reconstruction in the vascular lumen for the treatment of VBD and to evaluate its long-term effectiveness in preventing ischemic events.

MATERIALS AND METHODS

Clinical and imaging data of 9 patients with unruptured VBD were reviewed retrospectively. Depending on the length and diameter of the diseased target vessel, multiple LEO and/or Solitaire stents were implanted, assisted by coils.

RESULTS

Stent reconstruction in the vascular lumen was successful in all patients. Procedure-related complications occurred in 1 patient who developed brain stem and cerebellar infarction 8 days after endovascular treatment and died in 4 months. Coil embolization of the nondominant side of the vertebral artery was performed 1 month after the operation in 1 patient who developed partial brain stem and cerebellar infarction leading to hemiplegia. The mean follow-up time of the 8 surviving patients was 20.75 ± 6.90 months. Of the 4 patients with dolichoectasia in the anterior circulation, 2 experienced ischemic events in the anterior circulation. Another patient had sudden death at home 26 months after the operation. The conditions of the remaining 5 patients were stable without deterioration, and in 4, DSA/CTA/MRA suggested improved morphology of the vertebral artery compared with that before the operation.

CONCLUSIONS

Endovascular reconstruction with coil-assisted stent placement or stent placement alone in the vascular lumen for the treatment of VBD is technically feasible and can prevent ischemic events in the territory of stented vessels compared with the natural course, though further studies in larger samples are needed.

Successful endovascular treatment of a growing megadolichoectasic vertebrobasilar artery aneurysm by flow diversion using the "diverter-in-stent" technique

Giant dolichoectatic and fusiform aneurysms of the vertebrobasilar artery are among the most difficult and dangerous aneurysms to treat. Conservative management may be reasonable in asymptomatic elderly patients. Nevertheless, due to the frequent presence of mass effect on the brainstem and the risks of thromboembolic events and rupture, these aneurysms often demand treatment rather than observation. With the advancement of endovascular techniques some of these lesions have become treatable without the high morbidity and mortality rates associated with open surgical treatment. When dealing with giant, progressively enlarging symptomatic aneurysms, more limited therapeutic alternatives are available. The authors present a case of a growing megadolichoectatic vertebrobasilar artery aneurysm causing major disability due to increasing mass effect in a 51-year-old man. The aneurysm was treated with flow diversion by placing multiple telescoped stents and diverters ("diverter-in-stent" technique), achieving thrombosis of the aneurysm and reduction of the mass effect on the brainstem, with neurological improvement. The successful clinical and angiographic results observed in our case of giant dolichoectasic vertebrobasilar aneurysm contribute to the literature on giant aneurysms treated by means of flow diversion.

Endovascular treatment of ruptured and unruptured vertebral artery aneurysms

This paper analyzes the success of endovascular management of ruptured and unruptured vertebral artery aneurysms. Sixty-three patients with 65 vertebral (both acute dissection and chronic larger aneurysms are included) treated at our hospital form the basis of the analysis. Clinical outcome was evaluated using the modified Rankin Scale. Angiographic follow-up data was obtained for 44 patients (69.8%) for periods ranging from three to 16 months (mean, eight months). Based on the Hunt and Hess grading scale, the patient population included 34 patients (54.0%) with unruptured aneurysms, 28 (44.4%) with Grade 1 aneurysms, one (1.6%) with Grade 2 aneurysms. The locations of the aneurysms included 25 (38.5%) at the distal to posterior inferior cerebellar artery (PICA), 22 (33.8%) at the proximal to PICA and 18 (27.7%) at the vertebral artery-posterior inferior cerebellar artery (VA-PICA). Of the 63 patients, 12 (19%) were women and 51 (81%) were men. The mean age at treatment was 41.7 years (range, six-77 yrs). Follow-up angiograms were obtained in 44 (69.8%) out of 63 patients. Complete or virtually complete thrombosis was confirmed on early posttreatment angiography in 39 (88.6%) out of 44 patients. A slight reduction in the size of the lesion was noted in three patients and there was a significant residual lesion in two (4.5%) patients. Clinical follow-up revealed 90.5% patients in the mRS 0-2 category, 4.8% patients in the mRS>2 category, and 4.8% patients had died (mRS 6). Three patients died of rebleeding (n=1) or progressive mass effect/brainstem ischemia (n=2). Ruptured and unruptured aneurysms of the vertebral artery can be well treated using endovascular techniques, overall long-term results were good in 90.5% of patients.

Ruptured peripheral aneurysms in a collateral pathway associated with stenosis of a major cerebral artery: Report of two cases

Background

While hemodynamic stress can result in aneurysm formation, it rarely contributes to the development of peripheral aneurysms in collateral pathways. We report two patients with ruptured distal aneurysms in a collateral pathway associated with stenosis of a major cerebral artery.

Case Description

A 67-year-old man presented with intracerebral hemorrhage in the right frontal lobe. Digital subtraction angiography (DSA) revealed severe stenosis of the right middle cerebral artery and two aneurysms in the collateral pathway of the right anterior cerebral artery. The ruptured aneurysm was trapped and resected; histologically, it was a true saccular aneurysm. The unruptured aneurysm was clipped and the patient was discharged without additional neurological deficits. The second patient was a 73-year-old woman with subarachnoid hemorrhage. DSA revealed three arterial dilations. On the 7^th day of hospitalization, one of the aneurysms in a posterior inferior cerebellar artery–anterior inferior cerebellar artery anastomosis that functioned as a collateral pathway in the presence of severe basilar artery stenosis was found to be enlarged. It was treated by selective aneurysmal coil embolization with parent artery preservation. Her postoperative course was uneventful and she was discharged without any neurological deficits.

Conclusion

We document the successful treatment of two patients with ruptured aneurysms in the peripheral portion of a collateral pathway. We discuss the histology of peripheral aneurysms and present a review of the literature.

Successful obliteration and shrinkage of giant partially thrombosed basilar artery aneurysms through a tailored flow reduction strategy with bypass surgery

Object

The authors evaluated the efficacy of a new flow reduction strategy for giant partially thrombosed upper basilar artery (BA) aneurysms, for which proximal parent artery occlusion is not always effective.

Methods

Eight consecutive patients with severely symptomatic, partially thrombosed, giant upper BA aneurysms were treated with a tailored flow reduction strategy, or received conservative therapies. The flow reduction strategy comprised isolation of several branches from the upper BA at their origins with bypasses in addition to parent artery occlusion.

Results

The median follow-up period of all 8 patients was 15.0 months (range 4–31 months). In 6 patients treated with flow reduction, the mean decrease in residual blood lumen was −10.7 mm (95% CI −19.7 to −1.7 mm; p = 0.029) and the mean decrease in diameter of the aneurysms was −11.5 mm (95% CI −25.1 to 2.1 mm; p = 0.082). Complete or virtually complete thrombosis was achieved in all but 1 aneurysm (83%) and shrinkage was observed in 4 (67%). In those in whom complete or virtually complete thrombosis was achieved, significant shrinkage of the aneurysm was observed (mean decrease in diameter −14.8 mm; 95% CI −28.8 to −0.8 mm; p = 0.043). Improvement or stabilization of symptoms occurred in 67% of the patients who received flow reduction treatment. Both patients who received conservative treatment had unfavorable outcomes.

Conclusions

The flow reduction strategy is effective at promoting complete thrombosis of the aneurysm. This strategy can also induce shrinkage of the aneurysm if successful thrombosis is achieved. Although the neurological outcome of the treatment appears favorable considering its intractable nature, further study of the treatment is necessary to confirm its clinical efficacy and safety.

Visual failure and recovery after thrombosis of a giant carotid ophthalmic aneurysm following vascular bypass and carotid artery ligation

Thrombosis via Hunterian ligation, with or without high-flow bypass, is the definitive treatment for unclippable giant aneurysms; however, secondary deterioration may occur. We present a 67-year-old woman with an unclippable giant (33mm) carotid ophthalmic aneurysm. High-flow external carotid artery to middle cerebral artery bypass and proximal cervical internal carotid artery Hunterian ligation achieved complete thrombosis. Subsequent expansion of the thrombosed aneurysm created mass effect with hydrocephalus, leading to marked cognitive and visual decline. Aneurysmal decompression led to improved vision and near-normal neurological function.

Is an angiographically obliterated aneurysm always secure?

OBJECTIVE

Conventional cerebral angiography is the standard examination used to confirm aneurysm obliteration. Intraoperative indocyanine green (ICG) video angiography has recently been introduced as a valuable tool that is comparable to catheter intraoperative angiography. Intraoperative imaging evaluation is especially useful when complex aneurysm features are present, making direct clipping challenging. The aim of these angiographic evaluations is to assess parent vessel patency and to confirm lesion obliteration. However, there have been recent reports of growth or even rupture of angiographically obliterated aneurysms.

CLINICAL PRESENTATION

We report two patients in whom ICG video angiography falsely indicated that a clipped aneurysm was secure.

INTERVENTION

Both patients underwent direct clipping of unruptured aneurysms. ICG video angiography was performed, showing absence of residual filling of the sac. After incising the aneurysm dome, slow but significant dye extravasation was demonstrated. In the first patient, this occurred as a result of incomplete clipping of a wide aneurysm neck that was difficult to visualize; in the second patient, it occurred as a result of atheroma at the neck not allowing complete closure of the clip blades. This finding prompted clip readjustment and placement of an additional reinforcing clip in the two patients, respectively.

CONCLUSION

We demonstrate false indication of aneurysm obliteration by intraoperative video angiographic evaluation using ICG. It is possible that this limitation would also apply to catheter angiography. If certainty of complete exclusion of the aneurysm through opening the dome is not achieved, long-term follow-up angiographic evaluation would be strongly advised.

Surgical and endovascular management of symptomatic posterior circulation fusiform aneurysms

Object

Patients with fusiform aneurysms can present with subarachnoid hemorrhage (SAH), mass effect, ischemia, or unrelated symptoms. The absence of an aneurysm neck impedes the direct application of a clip and endovascular coil deployment. To evaluate the effects of their treatments, the authors retrospectively analyzed a consecutive series of patients with posterior circulation fusiform aneurysms treated at Stanford University Medical Center between 1991 and 2005.

Methods

Forty-nine patients (mean age 53 years, male/female ratio 1.2:1) treated at the authors' medical center form the basis of the analysis. Twenty-nine patients presented with an SAH. The patients presenting without SAH had cranial nerve dysfunction (five patients), symptoms of mass effect (eight patients), ischemia (six patients), or unrelated symptoms (one patient). The aneurysms were located on the vertebral artery (VA) or posterior inferior cerebellar artery (PICA) (21 patients); vertebrobasilar junction (VBJ) or basilar artery (BA) (18 patients); and posterior cerebral artery (PCA) (10 patients). Pretreatment clinical grades were determined using the Hunt and Hess scale; for patients with un-ruptured aneurysms (Hunt and Hess Grade 0) functional subgrades were added. Outcome was evaluated using the Glasgow Outcome Scale (GOS) score during a mean follow-up period of 33 months.

Overall long-term outcome was good (GOS Score 4 or 5) in 59%, poor (GOS Score 2 or 3) in 16%, and fatal (GOS Score 1) in 24% of the patients. In a univariate analysis, poor outcome was predicted by age greater than 55 years, VBJ location, pretreatment Hunt and Hess grade in patients presenting with SAH, and incomplete aneurysm thrombosis after endovascular treatment. In a multivariate analysis, age greater than 55 years was the confounding factor predicting poor outcome. Stratification by aneurysm location removed the effect of age. Of 13 patients with residual aneurysm after treatment, five (38%) subsequently died of SAH (three patients) or progressive mass effect/brainstem ischemia (two patients).

Conclusions

Certain posterior circulation aneurysm locations (PCA, VA–PICA, and BA–VBJ) represent separate disease entities affecting patients at different ages with distinct patterns of presentation, treatment options, and outcomes. Favorable overall long-term outcome can be achieved in 90% of patients with PCA aneurysms, in 60% of those with VA–PICA aneurysms, and in 39% of those with BA–VBJ aneurysms when using endovascular and surgical techniques. The natural history of the disease was poor in patients with incomplete aneurysm thrombosis after treatment.

Ruptured Giant Basilar Artery Aneurysm in a Comatose Adolescent: Successful Obliteration Using Intraoperative SSEP, BAER, and MEP Monitoring. A Case Report

SUMMARY

Giant basilar aneurysms are infrequently seen in children. We present the endovascular management of an adolescent who presented comatose with pinpoint pupils due to a ruptured giant basilar trunk aneurysm. A noncontrast head CT disclosed a large prepontine lesion with brainstem hemorrhage. Catheter angiography showed a 4.5 cm irregular, fusiform basilar trunk aneurysm. With SSEP, BAER, and MEP monitoring, the patient underwent bilateral temporary vertebral artery occlusion, followed by GDC embolization of the aneurysm. Postprocedure internal carotid angiograms showed adequate blood supply to the basilar apex via patent posterior communicating arteries. On postprocedure day two, the patient was following commands. The remainder of his hospital course was uneventful. Postoperative angiograms showed no residual filling of the aneurysm. At 12 months the patient was neurologically intact and at baseline function as an honor student and follow-up angiogram showed persistent occlusion of the aneurysm from the circulation. Successful endovascular treatment has been considered a less invasive and safer alternative to surgical management of some complex vascular lesions. While most reports on reversing basilar artery flow have been carried out in awake patients with neurological examinations, this is not possible in a patient presenting in a comatose state. This report suggests that SSEPs, BAERs and MEP may be of use in such patients in safely carrying out basilar artery occlusion.

Angiographically occult, progressively expanding, giant vertebral artery aneurysm

✓Hunterian ligation is a well-known treatment for complex aneurysms not amenable to direct microsurgical clip application. After proximal parent vessel occlusion, cerebral angiography is typically used to confirm aneurysm thrombosis. The authors report on a vertebral artery (VA) aneurysm that had progressively expanded and caused brainstem compression after hunterian ligation, despite nondiagnostic findings on both conventional and computed tomography (CT) angiography at multiple time points.

This 64-year-old woman underwent hunterian ligation of a 1.8-cm VA aneurysm at the origin of the right posterior inferior cerebellar artery. An immediately postoperative conventional angiogram and follow-up CT angiograms obtained 5 and 6 years postligation confirmed complete obliteration of the lesion. Nine years after the initial surgery, however, the patient experienced neurological deterioration. Although CTs showed substantial aneurysm enlargement together with pontine compression, angiograms once again demonstrated complete right VA occlusion with no retrograde filling of the aneurysm. On reexploration, the aneurysm was effectively debulked, clipped, and obliterated. Arterial bleeding was found in the lesion neck, as was evidence of microrecanalization.

Hunterian ligation for complex aneurysms carries the risk of microrecanalization and lesion expansion despite non-diagnostic angiography. Although this ligation procedure remains a viable treatment option in carefully selected patients, an extended follow-up evaluation period may be required even when imaging suggests aneurysm obliteration.