Hisashi Kubota1, Rokuya Tanikawa2, Makoto Katsuno1, Naoto Izumi1, Kosumo Noda1, Nakao Ota1, Yohei Ishishita1, Takanori Miyazaki1, Shinichi Okabe3, Sumio Endo4, Mika Niemelä5, Masaaki Hashimoto1. 1. Far East Neurosurgical Institute Abashiri Neurological Hospital, Hokkaido, Japan. 2. Far East Neurosurgical Institute Abashiri Neurological Hospital, Hokkaido, Japan. Electronic address: taniroku@gmail.com. 3. Department of Neurosurgery, Seirei Memorial Hospital, Ibaraki, Japan. 4. Department of Neurosurgery, Yokohama Shin-midori General Hospital, Kanagawa, Japan. 5. Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
Abstract
BACKGROUND: The treatment of unclippable vertebral artery (VA) aneurysms incorporating the posterior inferior cerebellar artery with parent artery preservation is among one of the most formidable challenges for cerebrovascular microsurgery and endovascular surgery. We propose that intracranial VA reconstruction using an extracranial VA-to-intracranial VA (VA-VA) bypass with a radial artery graft or an occipital artery graft may be an additional technique in the armamentarium to treat these formidable lesions. The rationale, surgical technique, and complications are discussed. METHODS: Three illustrative cases are described, in which the lesions were a VA dissecting aneurysm with ischemic lesions, bilateral asymptomatic unruptured VA aneurysms, and a VA giant aneurysm with subarachnoid hemorrhage. RESULTS: The partial extreme lateral infrajugular transcondylar approach was used. Computed tomographic angiography was useful for preoperative evaluation of the depth of the distal aneurysmal neck. A VA-VA bypass was performed in two patients. Because there was another ipsilateral aneurysm at the V2 segment in one patient, an external carotid artery-VA bypass was performed. Although two patients were discharged with good clinical results, one patient with subarachnoid hemorrhage died because of brainstem infarction. CONCLUSIONS: The VA-VA bypass using a radial artery graft or an occipital artery graft is an option that can be considered in the strategy for treating VA aneurysms to preserve the normal anatomic vascular configuration in the posterior circulation.
BACKGROUND: The treatment of unclippable vertebral artery (VA) aneurysms incorporating the posterior inferior cerebellar artery with parent artery preservation is among one of the most formidable challenges for cerebrovascular microsurgery and endovascular surgery. We propose that intracranial VA reconstruction using an extracranial VA-to-intracranial VA (VA-VA) bypass with a radial artery graft or an occipital artery graft may be an additional technique in the armamentarium to treat these formidable lesions. The rationale, surgical technique, and complications are discussed. METHODS: Three illustrative cases are described, in which the lesions were a VA dissecting aneurysm with ischemic lesions, bilateral asymptomatic unruptured VA aneurysms, and a VA giant aneurysm with subarachnoid hemorrhage. RESULTS: The partial extreme lateral infrajugular transcondylar approach was used. Computed tomographic angiography was useful for preoperative evaluation of the depth of the distal aneurysmal neck. A VA-VA bypass was performed in two patients. Because there was another ipsilateral aneurysm at the V2 segment in one patient, an external carotid artery-VA bypass was performed. Although two patients were discharged with good clinical results, one patient with subarachnoid hemorrhage died because of brainstem infarction. CONCLUSIONS: The VA-VA bypass using a radial artery graft or an occipital artery graft is an option that can be considered in the strategy for treating VA aneurysms to preserve the normal anatomic vascular configuration in the posterior circulation.