Far Lateral Approach and Occipital Artery to Posterior Inferior Cerebellar Artery Bypass With Staged Flow Diversion for Treatment of De Novo Vertebrobasilar Junction Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery(2024)

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摘要
Intracranial aneurysms refractory to endovascular treatment often require complex cerebral revascularization strategies, including combined open-endovascular techniques. 1-3 An adolescent girl presented with headache, and a fusiform right V4 vertebral artery aneurysm was diagnosed. Initial treatment was attempted with coil embolization. Surveillance imaging at 3 years after embolization demonstrated a de novo vertebrobasilar junction (VBJ) aneurysm with involvement of the right anterior inferior cerebellar artery-posterior inferior cerebellar artery (PICA) origin. The VBJ aneurysm was initially observed. Enlargement was noted at 1 year, and secondary treatment was attempted with left V3 segment coil occlusion to induce flow reversal. Follow-up demonstrated progressive VBJ aneurysm enlargement, prompting attempted left occipital artery (OA)-PICA bypass at an outside facility, which was unsuccessful. The patient was referred to our institution. After her parents gave informed consent, she underwent right OA-PICA bypass on the contralateral side through far lateral craniotomy with inside-out harvest of the donor vessel. 4 After trapping and arteriotomy of the recipient PICA, an OA-PICA end-to-side anastomosis was performed using a running continuous technique. 5 Intraoperative indocyanine green videoangiography and postoperative digital subtraction angiography confirmed patency of the bypass. The patient tolerated the procedure well and remained neurologically intact. On postoperative day 3, a staged transcirculation flow diversion device was placed to facilitate progressive thrombosis of the aneurysm. 6,7 Follow-up angiography at 1 year demonstrated complete occlusion of the aneurysm. This video demonstrates successful multimodal management of a complex de novo VBJ aneurysm after a series of refractory endovascular treatments and unsuccessful cerebral revascularization techniques.
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