Bypass combined with embolization via a venous graft in a patient with a giant aneurysm in the posterior communicating artery and bilateral idiopathic occlusion of the internal carotid artery in the neck

Case report

Restricted access

✓ The authors describe the case of a patient with a symptomatic giant aneurysm of the posterior communicating artery (PCoA) associated with bilateral idiopathic occlusion of the internal carotid artery (ICA). The presence of severe tortuosity of the vertebral arteries (VAs), both at their origin from the subclavian artery and at the level of the third segment, impeded navigation of the catheter for embolization of the aneurysm with Guglielmi detachable coils (GDCs).

A direct surgical approach was considered to be a high-risk procedure because of the bilateral occlusion of the ICAs and the size of the aneurysm. The following therapeutic strategy was therefore adopted: 1) balloon occlusion test of the left VA; 2) vertebro—vertebral bypass with saphenous vein graft to provide a pathway for subsequent embolization; 3) ICA—left middle cerebral artery bypass to ensure blood flow in the event that embolization resulted in closure of the PCoA; and 4) GDC embolization of the aneurysm via the posterior circulation graft to ensure complete exclusion of the lesion from the arterial circulation and preservation of the PCoA. At 3-month follow-up review the patient did not present with any neurological deficits; at 1-year control examination, magnetic resonance (MR) imaging and MR angiography both confirmed complete exclusion of the aneurysm and patency of the two bypasses.

Article Information

Address reprint requests to: Antonio Santoro, M.D., Neurochirurgia 1, Viale del Policlinico, 155, 00185 Roma, Italy. email: Santorant@libero.it.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Digital subtraction angiogram of the left VA, base view, demonstrating a saccular aneurysm that seems to originate from the posterior cerebral artery.

  • View in gallery

    Right VA angiogram demonstrating the increase in size of the aneurysm and the extreme tortuosity of the third VA segment.

  • View in gallery

    Upper: Angiogram of the left vertebro—vertebral bypass confirming its patency. Lower: Oblique base view angiogram obtained via catheterization of the venous graft, demonstrating the proximal marker of the microcatheter (arrow) in the right P1 segment, and the distal marker (curved arrow) through the right PCoA, inside the aneurysm.

  • View in gallery

    Follow-up angiogram of the left vertebro—vertebral bypass, oblique base view, demonstrating the BA (curved arrow), right and left PCoA (small arrows), right and left P1 segments (large arrows), and complete occlusion of the aneurysm with GDC (asterisk).

References

  • 1.

    Abd el-Bary THDujovny MAusman JI: Microsurgical anatomy of the atlantal part of the vertebral artery. Surg Neurol 44:3924011995Abd el-Bary TH Dujovny M Ausman JI: Microsurgical anatomy of the atlantal part of the vertebral artery. Surg Neurol 44:392–401 1995

    • Search Google Scholar
    • Export Citation
  • 2.

    Akimura TAbiko SIto H: True posterior communicating artery aneurysm. Acta Neurol Scand 84:2072091991Akimura T Abiko S Ito H: True posterior communicating artery aneurysm. Acta Neurol Scand 84:207–209 1991

    • Search Google Scholar
    • Export Citation
  • 3.

    Anegawa STorigoe RAikawa Yet al: [A case of bilateral absence of internal carotid with cerebral aneurysm.] No To Shinkei 39:5175251987 (Jpn)Anegawa S Torigoe R Aikawa Y et al: [A case of bilateral absence of internal carotid with cerebral aneurysm.] No To Shinkei 39:517–525 1987 (Jpn)

    • Search Google Scholar
    • Export Citation
  • 4.

    Borota LMarinkovic SBajic Ret al: Intracranial aneurysms associated with moyamoya disease. Neurol Med Chir 36:8608641996Borota L Marinkovic S Bajic R et al: Intracranial aneurysms associated with moyamoya disease. Neurol Med Chir 36:860–864 1996

    • Search Google Scholar
    • Export Citation
  • 5.

    Cantore GPSantoro A: Treatment of aneurysms unsuitable for clipping or endovascular therapy. J Neurosurg Sci 42 (Suppl 1):71751998Cantore GP Santoro A: Treatment of aneurysms unsuitable for clipping or endovascular therapy. J Neurosurg Sci 42 (Suppl 1):71–75 1998

    • Search Google Scholar
    • Export Citation
  • 6.

    Cantore GSantoro ADa Pian R: Spontaneous occlusion of a supraclinoid aneurysm after the creation of extra-intracranial bypasses using long grafts: report of two cases. Neurosurgery 44:2162201999Cantore G Santoro A Da Pian R: Spontaneous occlusion of a supraclinoid aneurysm after the creation of extra-intracranial bypasses using long grafts: report of two cases. Neurosurgery 44:216–220 1999

    • Search Google Scholar
    • Export Citation
  • 7.

    Civit TAuque JMarchal JCet al: Aneurysm clipping after endovascular treatment with coils: a report of eight patients. Neurosurgery 38:9559611996Civit T Auque J Marchal JC et al: Aneurysm clipping after endovascular treatment with coils: a report of eight patients. Neurosurgery 38:955–961 1996

    • Search Google Scholar
    • Export Citation
  • 8.

    Fukui M: Guidelines for the diagnosis and treatment of spontaneous occlusion of the circle of Willis (moyamoya disease). Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) of the Ministry of Health and Welfare, Japan. Clin Neurol Neurosurg 99 (Suppl 2):S238S2401997Fukui M: Guidelines for the diagnosis and treatment of spontaneous occlusion of the circle of Willis (moyamoya disease). Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) of the Ministry of Health and Welfare Japan. Clin Neurol Neurosurg 99 (Suppl 2):S238–S240 1997

    • Search Google Scholar
    • Export Citation
  • 9.

    George BLaurian C: Surgical approach to the whole length of the vertebral artery with special reference to the third portion. Acta Neurochir 51:2592721980George B Laurian C: Surgical approach to the whole length of the vertebral artery with special reference to the third portion. Acta Neurochir 51:259–272 1980

    • Search Google Scholar
    • Export Citation
  • 10.

    George BLaurian C: Surgical possibilities in the third portion of the vertebral artery (above C2). Anatomical study and report of a case of anastomosis between subclavian artery and vertebral artery at C1–C2 level. Acta Neurochir Suppl 28:2632691979George B Laurian C: Surgical possibilities in the third portion of the vertebral artery (above C2). Anatomical study and report of a case of anastomosis between subclavian artery and vertebral artery at C1–C2 level. Acta Neurochir Suppl 28:263–269 1979

    • Search Google Scholar
    • Export Citation
  • 11.

    Gewirtz RJAwad IA: Giant aneurysms of the anterior circle of Willis: management outcome of open microsurgical treatment. Surg Neurol 45:4094211996Gewirtz RJ Awad IA: Giant aneurysms of the anterior circle of Willis: management outcome of open microsurgical treatment. Surg Neurol 45:409–421 1996

    • Search Google Scholar
    • Export Citation
  • 12.

    Giuffrè RSherkat S: The vertebral artery: developmental pathology. J Neurosurg Sci 43:1751891999Giuffrè R Sherkat S: The vertebral artery: developmental pathology. J Neurosurg Sci 43:175–189 1999

    • Search Google Scholar
    • Export Citation
  • 13.

    Guglielmi GVinuela FDion Jet al: Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience. J Neurosurg 75:8141991Guglielmi G Vinuela F Dion J et al: Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience. J Neurosurg 75:8–14 1991

    • Search Google Scholar
    • Export Citation
  • 14.

    Guglielmi GViñuela FDuckwiler Get al: Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 77:5155241992Guglielmi G Viñuela F Duckwiler G et al: Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 77:515–524 1992

    • Search Google Scholar
    • Export Citation
  • 15.

    Guglielmi GViñuela FSepekta Iet al: Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: Electrochemical basis, technique, and experimental results. J Neurosurg 75:171991Guglielmi G Viñuela F Sepekta I et al: Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: Electrochemical basis technique and experimental results. J Neurosurg 75:1–7 1991

    • Search Google Scholar
    • Export Citation
  • 16.

    Gurian JHMartin NAKing WAet al: Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization. J Neurosurg 83:8438531995Gurian JH Martin NA King WA et al: Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization. J Neurosurg 83:843–853 1995

    • Search Google Scholar
    • Export Citation
  • 17.

    Ide MJimbo MYamamoto Met al: Posterior cerebral artery aneurysm associated with unilateral internal carotid artery agenesis—case report. Neurol Med Chir 35:8258291995Ide M Jimbo M Yamamoto M et al: Posterior cerebral artery aneurysm associated with unilateral internal carotid artery agenesis—case report. Neurol Med Chir 35:825–829 1995

    • Search Google Scholar
    • Export Citation
  • 18.

    Iwama TTodaka THashimoto N: Direct surgery for major artery aneurysm associated with moyamoya disease. Clin Neurol Neurosurg 99 (Suppl 2):S191S1931997Iwama T Todaka T Hashimoto N: Direct surgery for major artery aneurysm associated with moyamoya disease. Clin Neurol Neurosurg 99 (Suppl 2):S191–S193 1997

    • Search Google Scholar
    • Export Citation
  • 19.

    Kudo T: An operative complication in a patient with a true posterior communicating artery aneurysm: case report and review of the literature. Neurosurgery 27:6506531990Kudo T: An operative complication in a patient with a true posterior communicating artery aneurysm: case report and review of the literature. Neurosurgery 27:650–653 1990

    • Search Google Scholar
    • Export Citation
  • 20.

    Marks MPSteinberg GKLane B: Combined use of endovascular coils and surgical clipping for intracranial aneurysms. AJNR 16:15181995Marks MP Steinberg GK Lane B: Combined use of endovascular coils and surgical clipping for intracranial aneurysms. AJNR 16:15–18 1995

    • Search Google Scholar
    • Export Citation
  • 21.

    Matsumoto KKuriyama MTamiya Tet al: Direct clip obliteration of a ruptured giant aneurysm of the posterior communicating artery: case report. Neurosurgery 41:9399431997Matsumoto K Kuriyama M Tamiya T et al: Direct clip obliteration of a ruptured giant aneurysm of the posterior communicating artery: case report. Neurosurgery 41:939–943 1997

    • Search Google Scholar
    • Export Citation
  • 22.

    Mizoi KYoshimoto TTakahashi Aet al: A pitfall in the surgery of a recurrent aneurysms after coil embolization and its histological observations: technical case report. Neurosurgery 39:1651691996Mizoi K Yoshimoto T Takahashi A et al: A pitfall in the surgery of a recurrent aneurysms after coil embolization and its histological observations: technical case report. Neurosurgery 39:165–169 1996

    • Search Google Scholar
    • Export Citation
  • 23.

    Ogawa TOkudera TNoguchi Ket al: Cerebral aneurysms: evaluation with three-dimensional CT angiography. AJNR 17:4474541996Ogawa T Okudera T Noguchi K et al: Cerebral aneurysms: evaluation with three-dimensional CT angiography. AJNR 17:447–454 1996

    • Search Google Scholar
    • Export Citation
  • 24.

    Okuno TNishiguchi THayashi Set al: [A case of carotid superior cerebellar artery anastomosis associated with bilateral hypoplasia of the internal carotid artery represented as the rupture of posterior cerebral artery-posterior communicating artery aneurysm.] No Shinkei Geka 16:121112171988 (Jpn)Okuno T Nishiguchi T Hayashi S et al: [A case of carotid superior cerebellar artery anastomosis associated with bilateral hypoplasia of the internal carotid artery represented as the rupture of posterior cerebral artery-posterior communicating artery aneurysm.] No Shinkei Geka 16:1211–1217 1988 (Jpn)

    • Search Google Scholar
    • Export Citation
  • 25.

    Pedroza ADujovny MArtero JCet al: Microanatomy of the posterior communicating artery. Neurosurgery 20:2282351987Pedroza A Dujovny M Artero JC et al: Microanatomy of the posterior communicating artery. Neurosurgery 20:228–235 1987

    • Search Google Scholar
    • Export Citation
  • 26.

    Pelz DMViñuela FFox AJet al: Vertebrobasilar occlusion therapy of giant aneurysms. Significance of angiographic morphology of the posterior communicating arteries. J Neurosurg 60:5605651984Pelz DM Viñuela F Fox AJ et al: Vertebrobasilar occlusion therapy of giant aneurysms. Significance of angiographic morphology of the posterior communicating arteries. J Neurosurg 60:560–565 1984

    • Search Google Scholar
    • Export Citation
  • 27.

    Santoro AGuidetti GDazzi Met al: Long saphenous-vein grafts for extracranial and intracranial internal carotid artery aneurysms amenable neither to clipping nor to endovascular treatment. J Neurosurg Sci 43:2372511999Santoro A Guidetti G Dazzi M et al: Long saphenous-vein grafts for extracranial and intracranial internal carotid artery aneurysms amenable neither to clipping nor to endovascular treatment. J Neurosurg Sci 43:237–251 1999

    • Search Google Scholar
    • Export Citation
  • 28.

    Scott RMLiu HCYuan Ret al: Rupture of a previously unruptured giant middle cerebral artery aneurysm after extracranialintracranial bypass surgery. Neurosurgery 10:6006031980Scott RM Liu HC Yuan R et al: Rupture of a previously unruptured giant middle cerebral artery aneurysm after extracranialintracranial bypass surgery. Neurosurgery 10:600–603 1980

    • Search Google Scholar
    • Export Citation
  • 29.

    Sen CSekhar LN: Direct vein graft recostruction of the cavernous, petrous, and upper cervical internal carotid artery: lessons learned from 30 cases. Neurosurgery 30:7327431992Sen C Sekhar LN: Direct vein graft recostruction of the cavernous petrous and upper cervical internal carotid artery: lessons learned from 30 cases. Neurosurgery 30:732–743 1992

    • Search Google Scholar
    • Export Citation
  • 30.

    Shibuya THayashi N: A case of posterior cerebral artery aneurysm associated with idiopathic bilateral internal carotid artery occlusion: case report. Surg Neurol 52:6176221999Shibuya T Hayashi N: A case of posterior cerebral artery aneurysm associated with idiopathic bilateral internal carotid artery occlusion: case report. Surg Neurol 52:617–622 1999

    • Search Google Scholar
    • Export Citation
  • 31.

    Smith KAKraus GEJohnson BAet al: Giant posterior communicating artery aneurysm presenting as third ventricle mass with obstructive hydrocephalus. Case report. J Neurosurg 81:2993031994Smith KA Kraus GE Johnson BA et al: Giant posterior communicating artery aneurysm presenting as third ventricle mass with obstructive hydrocephalus. Case report. J Neurosurg 81:299–303 1994

    • Search Google Scholar
    • Export Citation
  • 32.

    Sundt TM Jr: Occlusive Cerebrovascular Disease. Diagnosis and Surgical Management. Philadelphia: WB Saunders1987 pp 429438Sundt TM Jr: Occlusive Cerebrovascular Disease. Diagnosis and Surgical Management. Philadelphia: WB Saunders 1987 pp 429–438

    • Search Google Scholar
    • Export Citation
  • 33.

    Sundt TM Jr: Occlusive Cerebrovascular Disease. Diagnosis and Surgical Management. Philadelphia: WB Saunders1987 pp 439464Sundt TM Jr: Occlusive Cerebrovascular Disease. Diagnosis and Surgical Management. Philadelphia: WB Saunders 1987 pp 439–464

    • Search Google Scholar
    • Export Citation
  • 34.

    Sundt TM JrPiepgras DGHouser OWet al: Interposition saphenous vein grafts for advanced occlusive disease and large aneurysms in the posterior circulation. J Neurosurg 56:2052151982Sundt TM Jr Piepgras DG Houser OW et al: Interposition saphenous vein grafts for advanced occlusive disease and large aneurysms in the posterior circulation. J Neurosurg 56:205–215 1982

    • Search Google Scholar
    • Export Citation
  • 35.

    Takahashi AKamiyama HImamura Het al: “True” posterior communicating artery aneurysm—report of two cases. Neurol Med Chir 32:3383411992Takahashi A Kamiyama H Imamura H et al: “True” posterior communicating artery aneurysm—report of two cases. Neurol Med Chir 32:338–341 1992

    • Search Google Scholar
    • Export Citation
  • 36.

    Tanaka YTakeuchi KAkai K: Intracranial ruptured aneurysm accompanying moyamoya phenomenon. Acta Neurochir 52:35431980Tanaka Y Takeuchi K Akai K: Intracranial ruptured aneurysm accompanying moyamoya phenomenon. Acta Neurochir 52:35–43 1980

    • Search Google Scholar
    • Export Citation
  • 37.

    Vincentelli FCaruso GGrisoli Fet al: Microsurgical anatomy of the cisternal course of the perforating branches of the posterior communicating artery. Neurosurgery 26:8248311990Vincentelli F Caruso G Grisoli F et al: Microsurgical anatomy of the cisternal course of the perforating branches of the posterior communicating artery. Neurosurgery 26:824–831 1990

    • Search Google Scholar
    • Export Citation
  • 38.

    Yabumoto MFunahashi KFujii Tet al: Moyamoya disease associated with intracranial aneurysms. Surg Neurol 20:20241983Yabumoto M Funahashi K Fujii T et al: Moyamoya disease associated with intracranial aneurysms. Surg Neurol 20:20–24 1983

    • Search Google Scholar
    • Export Citation
  • 39.

    Yoshida MWatanabe MKuramoto S: “True” posterior communicating artery aneurysm. Surg Neurol 11:3793811979Yoshida M Watanabe M Kuramoto S: “True” posterior communicating artery aneurysm. Surg Neurol 11:379–381 1979

    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 69 70 23
Full Text Views 129 129 0
PDF Downloads 60 60 0
EPUB Downloads 0 0 0

PubMed

Google Scholar