Abstract
Background
Posterior cerebral artery (PCA) P1-2 segment dissecting aneurysms are difficult because regular craniectomy aneurysm clipping or intravascular interventional therapy is not applicable.
Method
We report distal clipping of a PCA P1-2 segment dissection aneurysm with an anterior cerebral artery (ACA) A1-radial artery graft-PCA P2 bypass.
Conclusion
This case demonstrates the value of an ACA-RAG-PCA bypass in the therapy of a PCA dissecting aneurysm.
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References
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Acknowledgements
The authors thank Qiang Xu and Yingtao Liu for imaging processing and Geng Xu for intraoperative electrophysiological monitoring support.
Funding
This study was supported by the Outstanding Academic Leaders Program of Shanghai Municipal Commission of Health and Family Planning (No. 2017BR006 to WZ), Clinical Research Plan of SHDC (No. SHDC2020CR2034B to W. Z., No. SHDC2020CR4033 to K. Q.), Shanghai Municipal Science and Technology Major Project (No. 2018SHZDZX01) and ZJ Lab, and CAMS Innovation Fund for Medical Sciences (CIFMS, 2019-I2 M-5–008).
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Research involving human participants
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Huashan Hospital Institutional Review Board (HIRB), Fudan University, Shanghai, China.
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It represents a video of a surgical case. The patient gave approval for this publication.
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The patient gave approval for publication of this case.
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Key points
1. It is difficult to clip or reconstruct the intracranial dissecting aneurysm.
2. Preoperative high-resolution MRI helps operators assess intramural thrombi and atherosclerosis of the aneurysm wall.
3. AcomA and bilateral well-developed A1 allow bypass using the A1 as the donor. A compression test or balloon occlusion test (BOT) should be performed to evaluate AcomA contralateral compensation.
4. The vessel grafts can be the radial artery or the great saphenous vein.
5. Sufficient sylvian fissure and cistern split are needed for intracranial pressure control and donor vascular exposure.
6. Part of the temporal lobe can be removed when P2 exposure is difficult.
7. When the intracranial pressure in a patient with SAH is difficult to decrease, the lamina terminalis can be opened, or lumbar puncture and intraventricular drainage can be placed before surgery.
8. ICG, Doppler, and SEP/MEP are quick measures to determine the bypass patency and limb dysfunction caused by the blood flow change.
9. Intraoperative DSA can be used to assess the bypass patency and aneurysm distal clipping. The hybrid technique also provides a potential salvage selection, such as coiling, to close the aneurysm after bypass.
10. At least one DSA follow-up is required after discharge.
This article is part of the Topical Collection on Vascular Neurosurgery - Aneurysm
Supplementary Information
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Supplementary file1 (MP4 105750 KB) This video illustrates a left posterior cerebral artery P1-2 segment dissecting aneurysm distal clipping via an A1-RAG-P2 bypass.
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Liu, P., Shi, Y., An, Q. et al. How I do it: left posterior cerebral artery P1-2 segment dissecting aneurysm distal clipping via an A1-RAG-P2 bypass. Acta Neurochir 164, 2447–2451 (2022). https://doi.org/10.1007/s00701-022-05293-9
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DOI: https://doi.org/10.1007/s00701-022-05293-9