Vertebrobasilar occlusion therapy of giant aneurysms

Significance of angiographic morphology of the posterior communicating arteries

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✓ The clinical and angiographic records were reviewed for 71 patients with giant aneurysms of the posterior circulation, who underwent therapeutic occlusion of the basilar artery or both vertebral arteries. This treatment is used when the aneurysm neck cannot be surgically clipped, and occlusion of the parent artery is performed to initiate thrombosis within the lumen. In these cases, collateral blood flow to the brain stem is supplied mainly by the posterior communicating arteries. Consequently, their angiographic morphology (patency, size, and number) is demonstrated as a preoperative indicator of whether the patient will be able to tolerate vertebrobasilar occlusion. Vertebral angiograms with carotid artery compression (the Allcock test) will often be needed to provide this information.

The data relating posterior communicating artery morphology to clinical outcome in 71 cases of attempted vertebrobasilar occlusion are presented. The use and accuracy of carotid artery compression studies are also discussed. It is essential for the radiologist to supply the neurosurgeon with this valuable information in every case of giant posterior circulation aneurysm.

Article Information

Address reprint requests to: David M. Pelz, M.D., Department of Diagnostic Radiology, University Hospital, 339 Windermere Road, London, Ontario N6A 5A5, Canada.

© AANS, except where prohibited by US copyright law.

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Figures

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    Serial arteriograms in a patient with a giant basilar bifurcation aneurysm. A: Preoperative left vertebral arteriogram, lateral projection. B: Left vertebral arteriogram, lateral projection, following basilar artery tourniquet placement just distal to the origin of the superior cerebellar artery. The distal end of the tourniquet is indicated by a metallic clip (black arrow). The tourniquet has been closed, causing complete occlusion of the basilar artery. The superior cerebellar arteries fill retrogradely from the posterior inferior cerebellar artery (open arrows). C: Right carotid arteriogram, lateral projection, following tourniquet closure. There is virtually complete thrombosis of the aneurysm (white arrow) with good filling of the right posterior cerebral artery from the right posterior communicating artery (black arrow). D: Left carotid arteriogram, lateral projection, following tourniquet closure. There is good filling of the left posterior cerebral artery with no visualization of the aneurysm.

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    Serial arteriograms in a patient with a giant basilar bifurcation aneurysm. A: Preoperative left vertebral arteriogram, anteroposterior projection. B: Left vertebral arteriogram, anteroposterior projection, following tourniquet placement. The tourniquet has been closed, causing complete occlusion of the basilar artery proximal to the origins of the superior cerebellar arteries (black arrow). C: Left carotid arteriogram, anteroposterior projection, following tourniquet closure. The basilar bifurcation aneurysm (white arrow) continues to fill via the large left posterior communicating and posterior cerebral arteries, and is unchanged in size.

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    Serial arteriograms in a patient with a giant basilar bifurcation aneurysm. A: Preoperative right vertebral arteriogram, lateral projection. B: Right vertebral arteriogram, anteroposterior projection. The basilar artery has been clipped just proximal to the origin of the superior cerebellar arteries. C: Left carotid arteriogram, lateral projection, following basilar artery clipping. There has been incomplete thrombosis of the aneurysm, and the base continues to fill (large arrow). The superior cerebellar arteries fill antegradely (small arrows).

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    A: Left vertebral arteriogram, lateral projection with right carotid compression, showing good filling of a large right posterior communicating artery (arrow). B: Left vertebral arteriogram, lateral projection with left carotid compression in the same patient, showing good filling of a small left posterior communicating artery (arrow).

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