Skip to main content
SpringerLink
Log in

Cerebral revascularization for complex vertebrobasilar artery dissecting aneurysms

  • Research
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

Vertebrobasilar artery dissecting aneurysms (VBDAs) are the most surgically challenging type of aneurysm. Cerebral revascularization is the ultimate treatment for complex VBDAs. We retrospectively analysed the characteristics, surgical outcomes and follow-up data of 21 patients who underwent cerebral revascularization to treat complex VBDAs from 2015 to 2022. According to the location of the aneurysm and the anatomic relationship between the VBDA and the PICA, VBDA patients were classified into four groups: aneurysms located at the VA with PICA involvement (10 patients), aneurysms located at the VA without PICA involvement (1 patient), aneurysms located at the basilar apex segment (1 patient) and aneurysms located at the basilar trunk segment (9 patients). A surgical algorithm for complex VBDAs was determined primarily by the location of the aneurysm, the status of the aneurysm and the ability of retrograde blood flow to reach the proximal vertebrobasilar artery. Surgical modalities for patients with aneurysms in the VA with PICA involvement included low-flow (OA-PICA) bypasses with aneurysm trapping, aneurysm excision or reconstructive clip in 8 patients and STA-PCA bypass combined with PICA preservation and aneurysm trapping in 2 patients. In patients with aneurysms in the VA without PICA involvement, aneurysm excision was performed without cerebral bypass. In patients with aneurysms in the basilar apex segment, high-flow bypass (ECA-RA-P2) with aneurysm trapping was performed. In patients with aneurysms in the basilar trunk segment, surgical modalities included high-flow bypasses (ECA-RA-P2 and LVA-RA-P2) with aneurysm trapping or proximal occlusion in 6 patients, ECA-RA-P2 bypass with partial proximal occlusion in 1 patient, ECA-RA-P2 bypass alone in 1 patient, and STA-PCA bypass with R-VA narrowing in 1 patient. Of the 21 patients, 20 experienced clinical improvement or no change, and 17 of 21 patients achieved favourable functional outcomes (mRS ≤ 2). However, one patient died of infarction and respiratory failure postoperatively. Aneurysms were completely obliterated in 13 patients, shrank in 5 patients and stabilized in 2 patients. The median follow-up period was 32.5 months. During the follow-up period, all bypasses were patent, and further clinical improvement was observed in 11 patients. Cerebral revascularization appears to be safe and effective for the treatment of complex VBDAs, and cerebral revascularization could act as a complementary treatment strategy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

Data availability

No datasets were generated or analysed during the current study.

References

  1. Arauz A, Ruiz A, Pacheco G, Rojas P, Rodríguez-Armida M, Cantú C, Murillo-Bonilla L, Ruiz-Sandoval JL, Barinagarrementeria F (2013) Aspirin versus anticoagulation in intra and extracranial vertebral artery dissection. Eur J Neurol 20(1):167–172. https://doi.org/10.1111/j.1468-1331.2012.03825.x

    Article  CAS  PubMed  Google Scholar 

  2. Mizutani T (2011) Natural course of intracranial arterial dissections. J Neurosurg 114(4):1037–1044. https://doi.org/10.3171/2010.9.JNS10668

    Article  PubMed  Google Scholar 

  3. Takumi I, Mizunari T, Mishina M, Fukuchi T, Nomura R, Umeoka K, Kobayashi S, Teramoto A (2007) Dissecting posterior inferior cerebellar artery aneurysm presenting with subarachnoid hemorrhage right after anticoagulant and antiplatelet therapy against ischemic event. Surg Neurol 68(1):103–107. https://doi.org/10.1016/j.surneu.2006.08.063

    Article  PubMed  Google Scholar 

  4. Debette S, Compter A, Labeyrie MA, Uyttenboogaart M, Metso TM, Majersik JJ, Goeggel-Simonetti B, Engelter ST, Pezzini A, Bijlenga P, Southerland AM, Naggara O, Béjot Y, Cole JW, Ducros A, Giacalone G, Schilling S, Reiner P, Sarikaya H, Welleweerd JC, Bousser MG (2015) Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol 14(6):640–654. https://doi.org/10.1016/S1474-4422(15)00009-5

    Article  PubMed  Google Scholar 

  5. Liu P, Li Z, Hu L, Liu Y, Li P, Zhu W, Tian Y, Mao Y (2022) Clinical characteristics, endovascular choices, and surgical outcomes of intracranial vertebral artery dissecting aneurysms: a consecutive series of 196 patients. J Neurosurg 138(1):215-222 https://doi.org/10.3171/2022.4.JNS22609.

    Article  PubMed  Google Scholar 

  6. Fang YB, Lin A, Kostynskyy A, Agid R, Tymianski M, Radovanovic I, Krings T, Pereira VM (2018) Endovascular treatment of intracranial vertebrobasilar artery dissecting aneurysms: parent artery occlusion versus flow diverter. Eur J Radiol 99:68–75. https://doi.org/10.1016/j.ejrad.2017.12.009

    Article  PubMed  Google Scholar 

  7. Kikkawa Y, Kayahara T, Teranishi A, Shibata A, Suzuki K, Kamide T, Ikeda T, Kurita H (2019) Predictors of the resolution of cavernous sinus syndrome caused by Large/Giant cavernous carotid aneurysms after parent artery occlusion with High-Flow Bypass. World Neurosurg 132:e637–e644. https://doi.org/10.1016/j.wneu.2019.08.059

    Article  PubMed  Google Scholar 

  8. Kim YS, Kim TS, Yang IC, Joo SP (2019) Staged, combined management of ruptured vertebral artery dissecting aneurysms involving the posterior inferior cerebellar artery: report of 4 cases. 128:444–447. and Review of the Literature. World neurosurgeryhttps://doi.org/10.1016/j.wneu.2019.05.146

  9. Yang Z, Song J, Li P, Zhu W (2021) How I do it? Posterior inferior cerebellar artery-intracranial vertebral artery reimplantation bypass and trapping of dissecting aneurysm involving the proximal posterior inferior cerebellar artery. Acta Neurochir 163(11):2973–2976. https://doi.org/10.1007/s00701-021-04918-9

    Article  PubMed  Google Scholar 

  10. Sia SF, Morgan MK (2013) High flow extracranial-to-intracranial brain bypass surgery. J Clin Neuroscience: Official J Neurosurgical Soc Australasia 20(1):1–5. https://doi.org/10.1016/j.jocn.2012.05.007

    Article  Google Scholar 

  11. Ramanathan D, Starnes B, Hatsukami T, Kim LJ, Di Maio S, Sekhar L (2013) Tibial artery autografts: alternative conduits for high flow cerebral revascularizations. World Neurosurg 80(3–4):322–327. https://doi.org/10.1016/j.wneu.2012.01.035

    Article  PubMed  Google Scholar 

  12. Hendrikse J, van der Zwan A, Ramos LM, Tulleken CA, van der Grond J (2003) Hemodynamic compensation via an excimer laser-assisted, high-flow bypass before and after therapeutic occlusion of the internal carotid artery. Neurosurgery 53(4):858–865. https://doi.org/10.1227/01.neu.0000083552.45265.46

    Article  PubMed  Google Scholar 

  13. Aziz KM, van Loveren HR, Tew JM Jr, Chicoine MR (1999) The Kawase approach to retrosellar and upper clival basilar aneurysms. Neurosurgery 44(6):1225–1236

    CAS  PubMed  Google Scholar 

  14. Goehre F, Kamiyama H, Noda K, Ota N, Tsuboi T, Miyata S, Matsumoto T, Yanagisawa T, Tokuda S, Tanikawa R (2016) Technical description of the medial and lateral anterior temporal Approach for the Treatment of Complex Proximal Posterior Cerebral Artery Aneurysms. World Neurosurg 86:490–496. https://doi.org/10.1016/j.wneu.2015.09.068

    Article  PubMed  Google Scholar 

  15. Haque R, Kellner C, Solomon RA (2009) Spontaneous thrombosis of a giant fusiform aneurysm following extracranial intracranial bypass surgery. J Neurosurg 110(3):469–474. https://doi.org/10.3171/2007.12.17653

    Article  PubMed  Google Scholar 

  16. Lee SH, Ahn JS, Kwun BD, Park W, Park JC, Roh SW (2015) Surgical Flow Alteration for the treatment of intracranial aneurysms that are unclippable, untrappable, and Uncoilable. J Korean Neurosurg Soc 58(6):518–527. https://doi.org/10.3340/jkns.2015.58.6.518

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Balik V, Yamada Y, Talari S, Kei Y, Sano H, Suyama D, Kawase T, Takagi K, Takizawa K, Kato Y (2018) State-of-art in surgical treatment of dissecting posterior circulation intracranial aneurysms. Neurosurg Rev 41(1):31–45. https://doi.org/10.1007/s10143-016-0749-0

    Article  PubMed  Google Scholar 

  18. Frisoli FA, Srinivasan VM, Catapano JS, Rudy RF, Nguyen CL, Jonzzon S, Korson C, Karahalios K, Lawton MT (2021) Vertebrobasilar dissecting aneurysms: microsurgical management in 42 patients. J Neurosurg 1–9 Advance online publication. https://doi.org/10.3171/2021.9.JNS21397

  19. Durongwatana N, Sriamornrattanakul K, Wongsuriyanan S, Akharathammachote N (2022) Microsurgical Treatment of vertebral artery dissection: Surgical Strategies and Treatment outcomes. World Neurosurg 159:e375–e388. https://doi.org/10.1016/j.wneu.2021.12.057

    Article  PubMed  Google Scholar 

  20. Cho WC, Lee HJ, Choi JH, Lee KS, Kim BS, Shin YS (2023) Clinical and radiological outcomes of vertebral artery dissecting aneurysms treated with endovascular treatments: a 12-year single-center experience. World Neurosurg 175:e904–e913. https://doi.org/10.1016/j.wneu.2023.04.040

    Article  PubMed  Google Scholar 

  21. Kalani MY, Spetzler RF (2016) Internal carotid artery-to-posterior cerebral artery bypass for revascularization of the brainstem. J Clin Neuroscience: Official J Neurosurgical Soc Australasia 24:151–154. https://doi.org/10.1016/j.jocn.2015.08.007

    Article  Google Scholar 

  22. Ikram A, Zafar A (2023) Basilar artery infarct. StatPearls. StatPearls Publishing

  23. Wang X, Tong X (2023) Vascular reconstruction related to the extracranial vertebral artery: the presentation of the concept and the basis for the establishment of the bypass system. Front Neurol, 14: 1202257 https://doi.org/10.3389/fneur.2023.1202257.

  24. Liu Y, Shi X, Kc KIS, Sun Y, Liu F, Qian H, Zhang J (2018) Microsurgical Treatment for Complex Basilar Artery Aneurysms with Long-Term Follow-Up in a series of 35 cases. World Neurosurg 111:e710–e721. https://doi.org/10.1016/j.wneu.2017.12.158

    Article  PubMed  Google Scholar 

  25. Mai JC, Tariq F, Kim LJ, Sekhar LN (2013) Flow diversion radial artery bypass graft coupled with terminal basilar artery occlusion for the treatment of complex basilar apex aneurysms: operative nuances. Neurosurgery 72(2 Suppl Operative):ons116–ons126. https://doi.org/10.1227/NEU.0b013e31827bf2d8

    Article  PubMed  Google Scholar 

  26. Ravina K, Strickland BA, Buchanan IA, Rennert RC, Kim PE, Fredrickson VL, Russin JJ (2019) Postoperative antiplatelet therapy in the treatment of Complex Basilar Apex aneurysms Implementing Hunterian Ligation and Extracranial-to-intracranial bypass: review of the literature with an illustrative case report. World Neurosurg 123:113–122. https://doi.org/10.1016/j.wneu.2018.11.237

    Article  PubMed  Google Scholar 

  27. Zhang J, Feng Y, Zhao W, Liu K, Chen J (2021) Safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms: a single-centre long-term retrospective study. BMC Neurol 21(1):307. https://doi.org/10.1186/s12883-021-02339-w

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Wang X, Tong X, Liu J, Shi M, Shang Y, Wang H (2023) Petrous Carotid to Upper posterior circulation bypass for the Treatment of Basilar Trunk Aneurysm: a Novel High-Flow Intracranial-Intracranial Skull Base bypass for posterior circulation. 24(3):301–309 Operative neurosurgery (Hagerstown, Md.). https://doi.org/10.1227/ons.0000000000000510

  29. Orita E, Murai Y, Sekine T, Takagi R, Amano Y, Ando T, Iwata K, Obara M, Kumita S (2019) Four-dimensional Flow MRI Analysis of Cerebral Blood Flow before and after High-Flow Extracranial-Intracranial bypass surgery with Internal Carotid Artery Ligation. Neurosurgery 85(1):58–64. https://doi.org/10.1093/neuros/nyy192

    Article  PubMed  Google Scholar 

  30. Lu X, Huang Y, Zhou P, Zhu W, Wang Z, Chen G (2021) Cerebral revascularization for the management of complex middle cerebral artery aneurysm: a case series. Experimental Therapeutic Med 22(2):883. https://doi.org/10.3892/etm.2021.10315

    Article  CAS  Google Scholar 

  31. Kurşun B, Uğur L, Keskin G (2018) Hemodynamic effect of bypass geometry on intracranial aneurysm: a numerical investigation. Computer methods and programs in biomedicine. 158:31–40. https://doi.org/10.1016/j.cmpb.2018.02.008

  32. van den Berg R, Doorschodt TC, Sprengers ME, Vandertop WP (2015) Treatment of dissecting aneurysms of the PICA: anatomical considerations and clinical outcome. J Neuroradiol = J de Neuroradiologie 42(5):291–297. https://doi.org/10.1016/j.neurad.2014.10.001

    Article  Google Scholar 

  33. Shi L, Xu K, Sun X, Yu J (2016) Therapeutic progress in treating vertebral dissecting aneurysms involving the posterior inferior cerebellar artery. Int J Med Sci 13(7):540 https://doi.org/10.7150/ijms.15233.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Inoue T, Tamura A, Saito I (2015) Trapping and V3-radial artery graft-V4 bypass for ruptured dissecting aneurysm of the vertebral artery. NeuroSurg Focus 38(VideoSuppl1). https://doi.org/10.3171/2015.V1.FOCUS14465. Video1

  35. Wongsuriyanan S, Sriamornrattanakul K (2020) Blind-Alley Formation and Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for the Treatment of Unclippable Vertebral Artery Aneurysms with Posterior Inferior Cerebellar Artery Involvement. World neurosurgery, 138, e539–e550 https://doi.org/10.1016/j.wneu.2020.02.174.

Download references

Funding

Not applicable

Author information

Authors and Affiliations

  1. Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China

    Li-tian Huang & Xiaoguang Tong

  2. The school of medicine, Nankai University, 94 Weijin Road, Tianjin, 300071, China

    Meng Zhang

Authors
  1. Li-tian Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Meng Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xiaoguang Tong
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Li-tian Huang: write manuscript and make drafting the figures; Xiaoguang Tong: conception and design of the study; Meng Zhang: material preparation and data collection.

Corresponding author

Correspondence to Xiaoguang Tong.

Ethics declarations

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This is a retrospective review study. Collection of retrospective data was approved by Institutional Ethics Committee of Tianjin Huanhu Hospital. For this type of study, no ethical approval is required

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary Material 2

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Huang, Lt., Zhang, M. & Tong, X. Cerebral revascularization for complex vertebrobasilar artery dissecting aneurysms. Neurosurg Rev 47, 138 (2024). https://doi.org/10.1007/s10143-024-02365-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10143-024-02365-5

Keywords

Search

Navigation