Short-term Results of Surgical Treatment of Patients with Intracranial Saccular Aneurysms of Vertebral Artery

The aim of the investigation is to improve the treatment results of patients with aneurysms of vertebral artery (VA) by improving surgical approach.

Materials and Methods. There were analyzed the operations of 23 patients with saccular aneurysms of the vertebral artery. The age of the patients varied from 30 to 67 years; there were 7 male, and 16 female patients. Aneurysms of the vertebral artery trunk (atVA) were detected in 16 patients, distal aneurysm of posterior inferior cerebellar artery (DaPICA) — in 7. 15 patients were operated in an acute period of hemorrhage, and 8 patients — with the subacute hemorrhage and intact aneurysms. The severity of the patients’ state was evaluated according to Hunt–Hess scale on the day of surgery, the treatment results — according to Glasgow outcomes scale (GOS) on the 30th postoperative day.

Results. An individual approach was used when choosing the treatment modality. Microsurgical treatment was preferred in DaPICA, and endovascular treatment — for patients with atVA. There were performed 11 open and 12 endovascular operations, ventriculoperitoneal shunting in 6 cases. The severity of the patients’ state corresponded to 0 according to Hunt–Hess scale in 5 patients, the I degree — in 3, II — in 1, III — in 7, IV — in 5, V — in 2 cases.

Excellent and good results (GOS I and II) were observed in 20 patients out of 23 (87%). Adverse outcomes (GOS III and IV) — in 2 patients, and lethal outcome — in 1 case (13%). The complications directly related to the surgical treatment were in 4 patients (17%). In 85% of cases no statistically significant differences were found comparing short-term and long-term results of treatment.

Conclusion. Patients with VA aneurysms have a favorable prognosis in case of an individual approach to the surgical treatment strategy. The assessment of short-term treatment results is an important prognostics factor determining long-term functional outcomes of surgical treatment.

1. Nagasawa S., Hashimoto N., Yonekawa Y., Handa H. Surgery of vertebral arteryaneurysm at the origin of posterior inferior cerebellar artery with specialreference to operative technics in cases with difficulty in direct operation. No Shinkei Geka 1984 Jul; 12(8): 933–941.
2. Peluso J.P., van Rooij W.J., Sluzewski M., Beute G.N., Majoie C.B. Posterior inferior cerebellar artery aneurysms: incidence, clinical presentation, and outcome of endovascular treatment. AJNR Am J Neuroradiol 2008 Jan; 29(1): 86–90.
3. Yasargil M.G. Vertebrobasilar Aneurysms. In: Microneurosurgery. Vol. II. Stuttgart–New York: Georg Thieme Verlag; 1984; p. 270–338.
4. Kran O.I., Tkachev V.V., Muzlaev G.G., Usachev A.A. Rossiyskiy neyrokhirurgicheskiy zhurnal im. professora A.L. Polenova — Russian Neurosurgical Journal named after A.L. Polenov 2010; 3: 12–19.
5. Harrigan M.R., Deveikis J.P., Ardelt A.A. Handbook of Cerebrovascular Disease and Neurointerventional Technique. Humana Press: Springer; 2009; 741 p.
6. Hurst R.W., Rosenwasser R.H. Interventional neuroradiology. New York–London: Informa Healthcare USA; 2008; 420 p.
7. Raymond J., Guilbert F., Weill A., Georganos S.A., Juravsky L., Lambert A., Lamoureux J., Chagnon M., Roy D. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke 2003 Jun; 34(6): 1398–1403.
8. Rhoton A.L.Jr. The cerebellar arteries. Neurosurgery 2000 Sep; 47(3 Suppl): S29–S68.
9. Kayama T., Sugawara T., Sakurai Y., Ogawa A., Onuma T., Yoshimoto T. Early CT features of ruptured cerebral aneurysms of the posterior cranial fossa. Acta Neurochir (Wien) 1991; 108(1–2): 34–39.
10. Liew D., Ng P.Y., Ng I. Surgical management of ruptured and unruptured symptomatic posterior inferior cerebellar artery aneurysms. Br J Neurosurg 2004 Dec; 18(6): 608–612.
11. Orakcioglu B., Schuknecht B., Otani N., Khan N., Imhof H.G., Yonekawa Y. Distal posterior inferior cerebellar artery aneurysms: cli-nical characteristics and surgical management. Acta Neurochir (Wien) 2005 Nov; 147(11): 1131–1139.
12. Ruelle A., Cavazzani P., Andrioli G. Extracranial posterior inferior cerebellar artery aneurysm causing isolated intraventricular hemorrhage: a case report. Neurosurgery 1988 Dec; 23(6): 774–777.
13. Hudgins R.J., Day A.L., Quisling R.G., Rhoton A.L.Jr., Sypert G.W., Garcia-Bengochea F. Aneurysms of the posterior inferior cerebellar artery. A clinical and anatomical analysis. J Neurosurg 1983 Mar; 58(3): 381–387.
14. Hernesniemi J., Vapalahti M., Niskanen M., Kari A. Management outcome for vertebrobasilar artery aneurysms by early surgery. Neurosurgery 1992 Nov; 31(5): 857–861.
15. Isokangas J.M., Siniluoto T., Tikkakoski T., Kumpulainen T. Endovascular treatment of peripheral aneurysms of the posterior inferior cerebellar artery. AJNR Am J Neuroradiol 2008 Oct; 29(9): 1783–1788.
16. Peerless S.J., Hernesniemi J.A., Gutman F.B., Drake C.G. Early surgery for ruptured vertebrobasilar aneurysms. J Neurosurg 1994 Apr; 80(4): 643–649.
17. Salcman M., Rigamonti D., Numaguchi Y., Sadato N. Aneurysms of the posterior inferior cerebellar artery-vertebral artery complex: variations on a theme. Neurosurgery 1990 Jul; 27(1): 12–20.
18. Karasawa J., Kikuchi H., Furuse S., Sakaki T., Yoshida Y. Surgery of vertebral aneurysms at the origin of PICA. No Shinkei Geka 1976 Dec; 4(12): 1157–1163.
19. Matsushima T., Matsukado K., Natori Y., Inamura T., Hitotsumatsu T., Fukui M. Surgery on a saccular vertebral artery-posterior inferior cerebellar artery aneurysm via the transcondylar fossa (supracondylar transjugular tubercle) approach or the transcondylar approach: surgical results and indications for using two different lateral skull base approaches. J Neurosurg 2001 Aug; 95(2): 268–274.
20. Al-Khayat H., Beshay J., Manner D., White J. Vertebral artery-posteroinferior cerebellar artery aneurysms: clinical and lower cranial nerve outcomes in 52 patients. Neurosurgery 2005; 56(1): 2–10.
21. Mukonoweshuro W., Laitt R.D., Hughes D.G. Endovascular treatment of PICA aneurysms. Neuroradiology 2003 Mar; 45(3): 188–192.
22. Rodriguez-Hernandez A., Lawton M.T. Anatomical triangles defining surgical routes to posterior inferior cerebellar artery aneurysms. J Neurosurg 2011 Apr; 114(4): 1088–1094.
23. Mericle R.A., Reig A.S., Burry M.V., Eskioglu E., Firment C.S., Santra S. Endovascular surgery for proximal posterior inferior cerebellar artery aneurysms: an analysis of Glasgow Outcome Score by Hunt-Hess grades. Neurosurgery 2006 Apr; 58(4): 619–625.
24. Sandalcioglu I.E., Wanke I., Schoch B., Gasser T., Regel J.P., Doerfler A., Forsting M., Stolke D. Endovascularly or surgically treated vertebral artery and posterior inferior cerebellar artery aneurysms: clinical analysis and results. Zentralbl Neurochir 2005 Feb; 66(1): 9–16.
25. Fujimura M., Nishijima M., Midorikawa H., Umezawa K., Hayashi T., Kaimori M. Fatal rupture following intra-aneurysmal embolization for the distal posterior inferior cerebellar artery aneurysm with parent artery preservation. Clin Neurol Neurosurg 2003 Apr; 105(2): 117–120.
26. Benes L., Kappus C., Sure U., Bertalanffy H. Treatment of a partially thrombosed giant aneurysm of the vertebral artery by aneurysm trapping and direct vertebral artery-posterior inferior cerebellar artery end-to-end anastomosis: technical case report. Neurosurgery 2006 Jul; 59(1 Suppl 1): 166–167.
27. Lawton M.T., Quinones-Hinojosa A., Sanai N., Malek J.Y., Dowd C.F. Combined microsurgical and endovascular management of complex intracranial aneurysms. Neurosurgery 2003 Feb; 52(2): 263–274.
28. Lee S.Y., Sekhar L.N. Treatment of aneurysms by excision or trapping with arterial reimplantation or interpositional grafting. Report of three cases. J Neurosurg 1996 Jul; 85(1): 178–185.
29. Quinones-Hinojosa A., Lawton M.T. In situ bypass in the management of complex intracranial aneurysms: technique application in 13 patients. Neurosurgery 2008 Jun; 62(6 Suppl 3): 1442–1449.
30. Park E.K., Ahn J.S., Kwon do H., Kwun B.D. Result of extracranial-intracranial bypass surgery in the treatment of complex intracranial aneurysms: outcomes in 15 cases. J Korean Neurosurg Soc 2008 Oct; 44(4): 228–233.

Tkachev V.V., Usachev A.A., Lepshokov М.K., Muzlaev G.G. Short-term Results of Surgical Treatment of Patients with Intracranial Saccular Aneurysms of Vertebral Artery. Sovremennye tehnologii v medicine 2012; (2): 74