Patient 1

This 72-year-old woman presented with a subarachnoid hemorrhage (Hunt and Hess 4) secondary to a ruptured basilar tip aneurysm and was initially treated by endovascular coiling. She had various strokes during the hospitalization, and sustained permanent right third nerve palsy, but recovered to be independent for all daily living activities. Follow-up angiograms showed aneurysm recurrence due to coil compaction with the entire aneurysm mass measuring 21 × 19 × 25 mm, causing significant brainstem compression. She had four additional coiling procedures over the previous 5-year follow-up period (see Figures 27–1, 27–2A and 27–2B). Her examination indicated a right third nerve palsy, memory difficulties, and mild gait ataxia, and no other deficits. Her functional status was graded as modified Rankin score (mRS) 2.

During the clipping procedure, with a frontotemporal craniotomy and orbitozygotomy approach because of the coil mass, it was felt that the clip blades might slide onto the right PCA, or both PCAs during the clipping procedure. A RAG bypass surgery was performed from the right middle cerebral artery to the right PCA-P2 segment, under propofol-induced burst suppression, moderate induced hypertension, and mild anticoagulation. Following the bypass, the aneurysm could be clipped, albeit with significant narrowing of the right PCA by the clip due to the “funnel effect” caused by the coils.

The patient suffered a transient neurological decline postoperatively, but recovered significantly with fluid administration. She recuperated in a rehabilitation facility, with recovery to her baseline at about 3 months. An angiogram immediately after the operation showed excellent flow through the bypass into the PCA, and occlusion of the aneurysm (Figure 27–3 and Figures 27–4A and 27–4B). Delayed angiography at 3 months showed sluggish flow through the bypass. Angiography at 18 months postoperatively demonstrated the complete occlusion of the bypass and the aneurysm, but good filling of the right PCA from the BA and through the right PCOM artery (Figures 27–4C and 27–4D). At this time, and at 4 years postoperatively, the patient was independent for activities of daily life. Her gait ataxia was worse than her preoperative baseline, with the patient needing a cane, and not driving. But she was mentally alert with a good memory, and able to go out to restaurants, exercise, and socialize (mRS 2).

Figure 27–3 A, Preoperative angiogram (AP view) showing the basilar artery with coil compaction and recurrent aneurysm at the tip. B, DSA showing the Basilar tip aneurysm preoperatively. C, Angiogram right ICA injection lateral view, showing the size of the PCOM preoperatively.

Figure 27–4 A, Immediate postoperative angiogram (right internal carotid angiogram, lateral view) showing the aneurysm completely occluded with the patent bypass and the PCOM. B, Immediate postoperative angiogram vertebral injection AP view. Note the filling of the right PCA. C, Angiograms 18 months postsurgery (RICA lateral view). Showing the patent PCOM and occluded bypass. D, Angiogram 18 months postsurgery (vertebral injection, AP view), showing the aneurysm completely occluded from the circulation. The right PCA is enlarged and filling better compared to immediately after surgery (see Figure 27-2D).

Patient 2

A 62-year-old woman presented with progressive deterioration in her daily abilities and difficulty swallowing over a period of 1 year. She had undergone four coiling procedures over a period of 4 years, for an unruptured basilar tip aneurysm measuring 27 × 22 × 21 mm (Figures 27–5 and 27–6). Her neurological condition had steadily declined. She was unable to swallow liquids, but could swallow solids. On examination, she was awake, was unable to speak, could follow commands intermittently, had right facial paralysis, and had severe right spastic hemiparesis as a result of which she was restricted to a wheelchair. An MRI scan showed a large cyst adjacent to the aneurysm, which was extending into the third and lateral ventricles (see Figure 27–5). The brain cyst had been previously treated using an Ommaya catheter, which had later been fenestrated when clogged. Cerebral angiography demonstrated continued filling of the aneurysm from the BA (see Figure 27–6A). The patient had a very small PCOM artery (<1 mm) on the left side and a large PCOM artery (≥1 mm) on the right (see Figure 27–6B).

Figure 27–5 MRI scans: sagittal (A), coronal (B), and axial (C) showing the cyst in relation to the giant basilar tip aneurysm.

Figure 27–6 Angiogram’s lateral views (vertebral [A] and right ICA injections [B]), showing the giant aneurysm and the recurrence.

After the endoscopic fenestration of the cyst, the treatment of the aneurysm was done in two stages. The first stage was a transtemporal, transpetrosal approach to the posterior fossa with exposure of V2 and V3 segments of the VA and decompression of sigmoid sinus and facial nerve. This approach was the only one implemented due to the time taken for the procedure (about 6 hours). The second stage of the operation was performed 3 days afterward and involved the bypass procedure with a SV graft from the VA (V3 segment) to the right PCA (P2 segment), followed by occlusion of the upper BA (Figure 27–7). During this operation, the aneurysm could not be visualized due to the larger coil mass and the brainstem, which was draped around it. The BA was occluded just inferior to the SCA. A saphenous vein was chosen for the graft, since the radial arteries were not available to be used as a bypass conduit.

Figure 27–7 Illustration showing the SV graft flowing from the vertebral artery to the P2 segment of the PCA, with the clip on the BA in place.

The patient recovered without any postoperative complications. An immediate postoperative angiogram and an MRI scan showed that the aneurysm remnant filling from the right PCOM artery and through the bypass (Figures 27-8 through 27-10). The graft was widely patent, and the BA terminated at the site of the clip. At 18 months follow-up, the patient had improved marginally from her condition at initial presentation. She was able to converse with a few words, remember and speak with family members, and walk a few steps with assistance with her hemiparesis improved. Angiograms at this time showed a patent graft and partially filling stable aneurysm remnant.

Figure 27–8 A, Angiogram lateral view of the basilar tip aneurysm, showing circulant portion of the previously coiled aneurysm, preoperatively. B, 3-D reconstruction angiograms, posterior view of the giant basilar aneurysm.

Figure 27–9 A to C, Day 1 postoperative angiograms and 3-D reconstructions showing the complete exclusion of the aneurysm from the circulation and the vein graft to the PCA from the VA. D, MRI axial postoperative showing filling of the aneurysm.

Figure 27–10 3-D digital subtraction angiograms at 18 months showing the patent vessel graft supplying the PCA and the partially filling aneurysm remnant.

Patient 3

A 17-year-old boy presented with headaches for 3 days, and stabbing eye pain and vomiting for a day. On CT scan, he was found to have a giant aneurysm with hemorrhage measuring 5 × 4.9 × 4.0 (Figure 27–11A-D) centered around the right hippocampus.

Figure 27–11 Preoperative angiograms (lateral [A] and AP [B]) and vertebral injections (C and D), showing fusiform aneurysm arising from the P2 segment of the PCA.

The angiogram showed a giant aneurysm arising from the P2 segment of the right PCA also associated with an additional fetal PCOM on the same side (see Figure 27–11A-D). A frontotemporal craniotomy with transsylvian approach was used to dissect the aneurysm, although it was found very difficult to identify proximal and distal vessels. Despite the ventriculostomy the brain was found to be rather full and the right temporal gyrus was resected to dissect the aneurysm. Following the puncturing and partial evacuation of blood clots, the aneurysm was clipped and resected completely with a segment of parent vessel (Figure 27–12). Side-to-side anastomosis of the remaining vessel ends was performed, which was later identified as the posterior lateral choroidal branch of the PCA (Figures 27–13 and 27–14).

Figure 27–12 Resected giant aneurysm with thrombosis.

Figure 27–13 A and B, Angiograms showing total removal of aneurysm and the clip in place.

Figure 27–14 Illustrations showing the large aneurysm arising from P2 (A), thrombosed posterior lateral choroidal artery (B), 3rd (1) and 4th (2) cranial nerves.

(Courtesy of Laligam Sekhar.)

Postoperatively, the patient recovered steadily with no complications and vision intact. He had headaches due to hydrocephalus, which were treated with lumbar punctures.

Patient 4

A 42-year-old man presented after an automobile accident, after suddenly passing out. The patient had spells of dizziness and problems with memory for 2 years. CTA showed a giant (27 × 13 mm) diffuse fusifom aneurysm of the BA, arising from below the AICA and ending 1 cm inferior to the origin of SUCA (Figure 27–15). Since the anatomy of the aneurysm was not favorable for endovascular coiling (even with stenting), revascularization was planned. Collateral circulation to the BA, distal to the aneurysm was poor. The patient had a fetal PCOM on the right side and no PCOM on the left side. Via a transpetrosal approach, a left-sided ECA-PCA bypass was performed with an RAG followed by the distal occlusion of the BA (Figures 27–16 and 27–17). The patient recovered well with no complications and was discharged home in 2 weeks. Follow-up angiograms showed a decrease in graft flow and good flow in the left PCA supplied by an enlarged PCOM.

Figure 27–15 Preoperative DSA showing the diffuse fusiform aneurysm.

Figure 27–16 Illustration showing the surgical approach with the graft (1 and 2) in place.

(Courtesy of Laligam Sekhar.)

Figure 27–17 A to C, Follow-up angiograms 30 months postsurgery showing enlarged PCOM and patent but narrower graft.

Patient 5

This 21-year-old man with a known history of collagen vascular disease more prominent on the right side of the body, presented for evaluation of a fusiform aneurysm of the VA (Figures 27–18 and 27–19). Nine years ago, he had a coil embolization of an ICA aneurysm, which resulted in occlusion of the right ICA. The aneurysm measured 1 × 2.2 cm extending from the V3 region to the origin of the PICA, without involving it. He tolerated the balloon occlusion test well, without symptoms. However, the right PICA was not filling with the left vertebral injections, indicating a need for its revascularization. An OC-PICA anastomosis was performed via a far lateral transtubercular approach with the clip occlusion of the right VA (Figure 27–20). Dissection of the occipital artery as well as performing the approach were tedious because the tissues were not elastic and exuberant. The patient recovered well postoperatively with no neurological deficits (Figures 27-21 through 27-23). He developed a CSF leak from the wound (which was re-explored and resutured) and developed hydrocephalus for which a shunt procedure was performed.

Figure 27–18 A, The aneurysm size and location. B, Previously occluded ICA circulation on the right side.

Figure 27–19 A and B, Anatomic origin and location of the aneurysm. Note that the origin of the PICA is not directly from the aneurysm sac. C, MRI showing the filling of the aneurysm. D, Angiogram lateral view, vertebral injection showing the aneurysm.

Figure 27–20 Illustration showing the clipping of vertebral with OC-PICA anastomosis.

(Courtesy of Laligam Sekhar.)

Figure 27–21 A and B, Postoperative angiograms showing complete occlusion of the aneurysm.

Figure 27–22 A and B, Postoperative angiograms showing complete occlusion of the aneurysm.

Figure 27–23 Shows RAG graft from the ECA to M2. The OC-PICA anastomosis was occluded after this procedure and the patient was neurologically intact.

After 40 days, an anterior circulation revascularization was performed with an RAG from the ECA to the M2 segment of the MCA to treat the tenuous nature of blood supply to the right brain, which was dependent on the left ICA (see Figure 27–23). The left VA was chosen, since the right was abnormal, and the right MCA (M2) was found to have a normal caliber and wall thickness during surgery.

Patient 6

A 16-year-old boy had a recurrent giant cell tumor of the lower clivus, C1, occipital condyle, foramen magnum area on the left side, 4 years after initial resection (Figure 27–24). An extreme lateral complete transcondylar approach was performed for a total tumor resection. The tumor was filling the jugular bulb, occluding the sigmoid sinus and encasing the hypoglossal nerve. Gross total resection was pursued meticulously and all extensions of the tumor were removed (Figures 27–24A, 27–25A, and 27-5B). Extracranially, the nondominant left VA was encased by the tumor (Figure 27–26), supplied numerous branches to it, and was damaged during tumor removal. An SV graft was used to replace the affected V3 segment (Figure 27–27). Also, there was an additional area of tumor involvement found at the entrance point of the VA (V3-V4 junction). This segment was resected and the artery primarily resutured (Figure 27–28). He recovered well after surgery and follow-up angiogram confirmed the patency of the VA. Because of the unilateral condylar resection, occiput-C3 fusion was done followed by halo traction. Vocal cord medialization was done later to improve voice quality to compensate for cranial nerve X weakness. The patient remained tumor free 4 years after surgery.

Figure 27–24 MRI (axial [A] and coronal [B]) showing extensions of the tumor.

Figure 27–25 A, Postoperative angiogram, AP view, showing SVG (arrows pointing to SV graft). B, Postoperative angiogram lateral view (arrow pointing to SV graft).

Figure 27–26 Tumor encasing the VA.

(Courtesy of Laligam Sekhar.)

Figure 27–27 SV graft and resection of the stenotic segment and re-anastamosis of V4.

(Courtesy of Laligam Sekhar.)

Figure 27–28 Complete removal of tumor with occlusion of the sigmoid sinus.

(Courtesy of Laligam Sekhar.)

Patient 7

A 10-year-old boy referred for the treatment of a recurrent giant fusiform basilar aneurysm previously coiled two times (Figure 27–29). A right far lateral and transpetrosal approach was used to perform SVG bypass from the V3 segment of the VA to the P2 segment of the PCA along with the proximal occlusion of both VAs for complete obliteration of the aneurysm (Figure 27–30). A postoperative MRI and angiograms showed presence of filling from the contralateral VA (see Figure 27–30). This residual filling was treated with further coil embolizations and the aneurysm was completely obliterated (Figures 27–31 and 27–32). This specific case illustrates the usefulness of endovascular therapy in obliterating minimal remnants, thereby augmenting the success of surgical therapy.

Figure 27–29 A, Fusiform aneurysm with coils inside from previous embolization. B, MRI showing the fusiform aneurysm of the BA.

Figure 27–30 A, Angiogram lateral view vertebral injections showing the patent graft flowing from the VA to the P2 PCA. B, 3-D reconstruction angiogram showing the proximal clip occlusion and residual filling of the aneurysm from the left VA.

Figure 27–31 A, Angiogram AP view showing the coil embolization performed 3 months postoperatively, occluding flow to the aneurysm. B, Angiogram vertebral injection showing the aneurysm completely obliterated by the coiling procedure.

Figure 27–32 One-year follow-up angiograms AP (A) and lateral view (B) showing complete obliteration of the aneurysm and the patent graft.