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Vertebrobasilar occlusion therapy of giant aneurysms

Significance of angiographic morphology of the posterior communicating arteries

David M. Pelz, Fernando Viñuela, Allan J. Fox and Charles G. Drake

✓ 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.

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Failed aneurysm surgery

Reoperation in 115 cases

Charles G. Drake, Allen H. Friedman and Sydney J. Peerless

previously and the other was clipped although no communication existed); posterior cerebral artery occlusion in four; basilar artery occlusion in five; and vertebral artery occlusion in four (bilateral in three). One giant posterior circulation aneurysm was rewrapped in gauze and plastic, and one carotid sac was merely evacuated of thrombus to restore vision. Surgical Approach When the reexploration was done within a few weeks, usually there was no difficulty in reexposing the sac and its neck. Where scar tissue existed, the dissection toward the sac was begun in

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Shiro Kashiwagi, John M. Tew Jr., Harry R. van Loveren and Geoffrey Thomas

circulation include occlusion of the proximal basilar or vertebral artery to induce its thrombosis, or trapping the involved segment of the basilar artery. Drake 2 reported that, in his initial experience with direct basilar artery occlusion in seven patients with giant posterior circulation aneurysms, three patients benefited from the procedure, two worsened, and two died. Drake has since modified his procedure, utilizing a tourniquet around the parent vessel which is tightened after the patient has awakened, with clinical monitoring and angiographic control (Hunterian

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these aneurysms represent some of the most difficult lesions to treat surgically. Few neurosurgeons would argue that some of the most difficult aneurysms to treat are giant lesions (greater than 2.5 cm) involving the posterior circulation. In the series of Higashida, et al. , seven patients with giant posterior circulation aneurysms were treated, resulting in immediate or delayed death in three (42.86%) of these patients ( Table 2 ). Peerless and Drake 1 reported a death rate of 12% ( Table 2 ). Less than 50% of the patients with giant posterior circulation

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Gary K. Steinberg, Charles G. Drake and Sydney J. Peerless

these patients is still lacking. 18 Future developments in endovascular balloon occlusion methods or coil thrombosis techniques may broaden the indications for their use. Presently, we recommend operative exploration of most giant posterior circulation aneurysms, except in nonsurgical candidates, since direct aneurysmal neck clipping is sometimes possible and is still the preferred treatment. Direct aneurysmal neck occlusion using deep hypothermia and complete circulatory arrest under cardiopulmonary bypass conditions also appears to be a useful technique in selected

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Robert A. Solomon, Matthew E. Fink and John Pile-Spellman

least risk. Approximately 5% of patients do not undergo surgical treatment, 20% are selected for GDC endovascular treatment, and 75% are treated with conventional surgery. The criteria for declining to treat a patient with an unruptured aneurysm are generally as follows: a patient over the age of 70 years (or younger with a limited life expectancy) with a small asymptomatic aneurysm; a minimally symptomatic patient over the age of 70 years with a giant posterior circulation aneurysm considered unsuitable for GDC embolization; and a patient unwilling to accept the risk

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Rohit K. Khanna, Ghaus M. Malik and Nuzhat Qureshi

similarly found aneurysm size to have an important influence on surgical outcome. The morbidity and mortality of unruptured aneurysms was 0% for aneurysms less than or equal to 10 mm in size, 6% for aneurysms between 10 and 25 mm, and 20% for aneurysms greater than 25 mm. 27 Drake 6 reported a 15% morbidity and mortality in nongiant posterior circulation aneurysms compared to 39% for giant posterior circulation aneurysms, although ruptured aneurysms were also included in his series. Clearly, aneurysm size influences surgical outcome, regardless of the location. In our

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John A. Anson, Michael T. Lawton and Robert F. Spetzler

directed toward decompression, either directly or by proximal vessel ligation. Drake 15 reported success with proximal occlusion in selected giant posterior circulation aneurysms but has stressed that morbidity and mortality rates may be substantial with this technique. We prefer a direct approach initially and to achieve decompression by thrombectomy of the aneurysm with either clipping or reconstruction of the aneurysm neck. Our usual technique for aneurysm thrombectomy was to open the aneurysm dome after either local or global circulatory arrest and to remove

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Masatou Kawashima, Albert L. Rhoton Jr., Necmettin Tanriover, Arthur J. Ulm, Alexandre Yasuda and Kiyotaka Fujii

intracranial aneurysms. 25, 27, 31, 32, 34, 47, 53, 57, 60, 61 At present, endovascular techniques, with or without combined bypass surgery, offer an alternative therapy for the treatment of patients with complex and giant posterior circulation aneurysms. 13, 19, 20 Nevertheless, there are contraindications for endovascular treatment, including a partially thrombosed aneurysm and a wide aneurysm neck. Most of these aneurysms present treatment challenges with the use of the direct clipping procedure. Cerebral revascularization procedures are then applied to the treatment of

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Sid Chandela, Juan Alzate, Chandranath Sen, Joon Song, Yasunari Nimi, Alejandro Berenstein and David Langer

a setting of insufficient collateral supply. Thus cerebral revascularization is often indicated to treat these types of aneurysms. 13 Various bypass techniques have been reported, namely occipital artery–PICA anastomosis, 5 VA–PICA anastomosis with the superficial temporal artery 3 , 11 or radial artery graft, 4 side-to-side PICA anastomosis of bilateral PICAs, 2 , 13 , 16 and end-to-side reimplantation of the PICA into the VA without a graft. 9 Addressing giant posterior circulation aneurysms remains challenging given that they often require both open and