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Flow Diversion Radial Artery Bypass Graft Coupled With Terminal Basilar Artery Occlusion for the Treatment of Complex Basilar Apex Aneurysms: Operative Nuances

Mai, Jeffrey C. MD*; Tariq, Farzana MD*; Kim, Louis J. MD*,‡; Sekhar, Laligam N. MD*,‡

doi: 10.1227/NEU.0b013e31827bf2d8
Operative Nuances

BACKGROUND: A subset of basilar apex aneurysms are unsuitable for either primary microsurgical clipping or endovascular coiling. These complex aneurysms can be treated by terminal basilar artery occlusion, but only if collateral circulation is adequate. To circumvent these complications, a high-flow vertebral artery-posterior cerebral artery or middle cerebral artery-posterior cerebral artery bypass may be performed to create an adequate collateral circulation to allow treatment of the aneurysm by basilar artery occlusion and/or clipping.

OBJECTIVE: To discuss the operative nuances of this approach in the case of a 47-year-old man with progressive hemiparesis resulting from brainstem compression from a giant, unruptured basilar apex aneurysm with absent posterior communicating artery collaterals and incorporation of bilateral superior cerebellar arteries and posterior cerebral arteries within the aneurysm neck.

METHODS: The patient underwent a staged bypass from V3 to P2 coupled with terminal basilar artery occlusion.

RESULTS: The patient initially presented as modified Rankin Scale score 2 with right hemiparesis. The aneurysm ruptured after the first stage of the operation, and the patient underwent a V3 to P2 bypass the next day. His postprocedural neurologic decline improved at the 14-month follow-up to modified Rankin Scale score 2, with substantial reduction in aneurysm size observed at 9 months. The outcomes for 3 other bypass cases for basilar apex aneurysms are also summarized.

CONCLUSION: We discuss the indications, preoperative diagnostic workup, operative management, and postoperative outcomes in managing challenging basilar apex aneurysms. In our experience, high-flow bypass procedures with or without hunterian ligation in the treatment of these aneurysms are well tolerated with good long-term results.

ABBREVIATIONS: BA, basilar artery

mRS, modified Rankin Scale

PCA, posterior cerebral artery

PCoA, posterior communicating artery

SCA, superior cerebellar artery

STA, superficial temporal artery

VA, vertebral artery

Departments of *Neurosurgery and

Radiology, University of Washington, Seattle, Washington

Correspondence: Laligam N. Sekhar, MD, FACS, Department of Neurosurgery, University of Washington, Harborview Medical Center, Box 359766, 325 9th Ave, Seattle, WA 9810. E-mail:

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Received June 01, 2012

Accepted October 12, 2012

Copyright © by the Congress of Neurological Surgeons