1/14. Direct surgery of basilar trunk and vertebrobasilar junction aneurysms via the combined transpetrosal approach.Surgical access to aneurysms of the basilar trunk and vertebrobasilar junction is hampered by their direct proximity of these lesions to highly vulnerable neural structures like the brain stem and cranial nerves, as well by the bony structure of the petrous bone blocking the direct surgical approach to these aneurysms. Only recently lateral approaches directed through parts of the petrous bone have been reported for surgery of basilar trunk and vertebrobasilar junction aneurysms like the anterior transpetrosal, the retrolabyrinthine transsigmoid, as well as the combined supra-infratentorial posterior transpetrosal approach. As experience in the use of this approach is limited in the neurosurgical literature we present our surgical experiences in 11 patients with basilar trunk and vertebrobasilar junction aneurysms, operated on using the supra-infratentorial posterior transpetrosal approach. In 10 patients, including one patient with a giant partially thrombosed basilar trunk aneurysm, direct clipping of the aneurysm via the transpetrosal route was possible. In one patient with a giant vertebrobasilar junction aneurysm, the completely calcified aneurysm sac was resected after occlusion of the vertebral artery. Of the whole series, one patient died and in three patients postoperative accentuation of preexisting cranial nerve deficits occurred. Except transient cerebrospinal fluid leak in two patients, the postoperative course was uneventful in the remaining patients. Postoperative angiography demonstrated complete aneurysm clipping in ten patients and relief of preoperative brain stem compression in the patient with the giant vertebrobasilar junction aneurysm. It is concluded, that the supra-infratentorial posterior transpetrosal approach allows excellent access to the basilar artery trunk and vertebrobasilar junction and can be considered the approach of choice to selected aneurysms located in this area.- - - - - - - - - - ranking = 1keywords = giant (Clic here for more details about this article) |
2/14. Bypass combined with embolization via a venous graft in a patient with a giant aneurysm in the posterior communicating artery and bilateral idiopathic occlusion of the internal carotid artery in the neck.The authors describe the case of a patient with a symptomatic giant aneurysm of the posterior communicating artery (PCoA) associated with bilateral idiopathic occlusion of the internal carotid artery (ICA). The presence of severe tortuosity of the vertebral arteries (VAs), both at their origin from the subclavian artery and at the level of the third segment, impeded navigation of the catheter for embolization of the aneurysm with Guglielmi detachable coils (GDCs). A direct surgical approach was considered to be a high-risk procedure because of the bilateral occlusion of the ICAs and the size of the aneurysm. The following therapeutic strategy was therefore adopted: 1) balloon occlusion test of the left VA; 2) vertebro-vertebral bypass with saphenous vein graft to provide a pathway for subsequent embolization; 3) ICA-left middle cerebral artery bypass to ensure blood flow in the event that embolization resulted in closure of the PCoA; and 4) GDC embolization of the aneurysm via the posterior circulation graft to ensure complete exclusion of the lesion from the arterial circulation and preservation of the PCoA. At 3-month follow-up review the patient did not present with any neurological deficits; at 1-year control examination, magnetic resonance (MR) imaging and MR angiography both confirmed complete exclusion of the aneurysm and patency of the two bypasses.- - - - - - - - - - ranking = 1.6666666666667keywords = giant (Clic here for more details about this article) |
3/14. Bilateral vertebral artery occlusion resulting from giant cell arteritis: report of 3 cases and review of the literature.giant cell arteritis (GCA) is known to affect the extracranial part of the vertebral arteries. Bilateral vertebral artery occlusion (BVAO) is a rare but serious neurologic condition. We report 3 patients with autopsy-proven (2 patients) or clinically diagnosed (1 patient) GCA causing BVAO. A review of the literature concerning BVAO revealed 5 other cases of BVAO resulting from GCA and 110 cases with underlying arteriosclerotic disease. Our 3 patients (mean age, 66 yr; range, 60-78 yr) with BVAO resulting from GCA all had initial severe headache followed by the onset of stepwise progressive, partly side-alternating neurologic deficits due to bilateral infarctions in the vertebrobasilar circulation territory. This course, more accelerated in BVAO due to GCA than in BVAO of arteriosclerotic origin, seems to be a typical, if not particular, clinical syndrome. BVAO was the first clinical manifestation of GCA in 1 of our patients and in 1 published case. From a clinical view, BVAO resulting from GCA differs from BVAO of arteriosclerotic origin by the much higher mortality rate (75% versus 19%, respectively), the presence of headache (100% versus 22%), fever (50% versus 0%), and elevated erythrocyte sedimentation rate (ESR in all GCA cases >45 mm/h; no data in the arteriosclerotic patient group), but not by the neurologic signs themselves. Therapy of BVAO resulting from GCA is purely empiric. In view of the serious prognosis, we propose treatment with intravenous high-dose glucocorticoids and additional immunosuppression with cyclophosphamide; the use of anticoagulation depends on the individual patient's estimated risk-benefit profile. Although BVAO due to GCA is rare, physicians and especially rheumatologists or neurologists should be aware of this entity because of its high mortality in patients without immediate introduction of a high-dose immunosuppressive therapy. Suspicion of GCA should arise in a patient aged over 50 years with no other vascular risk factors suffering from bilateral symptoms of ischemia in the vertebrobasilar territory, with a quickly progressing stepwise course and with headache, fever, or history of myalgia. ESR and temporal artery biopsy should be performed without delay. early diagnosis of GCA is necessary for immediate initiation of intensive antiinflammatory and immunosuppressive treatment, without which progressive deterioration and systemic involvement are likely to be fatal.- - - - - - - - - - ranking = 1.3333333333333keywords = giant (Clic here for more details about this article) |
4/14. Spontaneous partial thrombosis of a basilar artery giant aneurysm in a child.We report the complete, spontaneous obliteration of a partially thrombosed dissecting giant aneurysm in the basilar artery by occlusion of both the lumen of the aneurysm and the parent artery in a 15-year-old girl.- - - - - - - - - - ranking = 1.6666666666667keywords = giant (Clic here for more details about this article) |
5/14. Progressive growth of a giant dolichoectatic vertebrobasilar artery aneurysm after complete Hunterian occlusion of the posterior circulation: case report.OBJECTIVE AND IMPORTANCE: Dolichoectatic vertebrobasilar artery aneurysms are often extremely difficult, if not impossible, to treat with microneurosurgical clip reconstruction. As such, a Hunterian strategy via vertebral or basilar artery sacrifice is often used. We have encountered a patient in whom deliberate bilateral vertebral artery sacrifice was insufficient to avoid progressive expansion of a giant dolichoectatic vertebrobasilar artery aneurysm. On the basis of a review of the literature, we are unaware of another reported case. CLINICAL PRESENTATION: A 60-year-old man presented with signs and symptoms of brainstem compression from a large fusiform aneurysm involving the distal dominant vertebral and proximal basilar arteries. Results of angiographic evaluation were highly characteristic of underlying dolichoectasia. INTERVENTION: The patient was treated initially with staged bilateral vertebral artery occlusion and adjunctive posterior circulation revascularization. After this therapy failed, he underwent a trapping procedure and aneurysm deflation. CONCLUSION: Unclippable aneurysms of the vertebrobasilar system are formidable lesions. They are not uniformly treatable by direct surgical reconstruction, and their growth is not consistently stabilized by the implementation of a complete Hunterian strategy. Future developments related to the use of endovascular stent technology may offer a more successful treatment approach for patients with these complex cerebrovascular lesions.- - - - - - - - - - ranking = 1.6666666666667keywords = giant (Clic here for more details about this article) |
6/14. Transcerebellar thrombectomy for the successful clipping of thrombosed giant vertebral artery-posterior inferior cerebellar artery aneurysm: case report.The operative technique used for a thrombosed vertebral artery-posterior inferior cerebellar artery aneurysm that was treated by combined transcerebellar (petrosal surface) thrombectomy and neck clipping is presented. Transcerebellar thrombectomy permitted the successful clipping of this thrombosed vertebral artery-posterior inferior cerebellar artery aneurysm via the cerebello-medullary cistern.- - - - - - - - - - ranking = 1.3333333333333keywords = giant (Clic here for more details about this article) |
7/14. Bilateral obstruction of internal carotid artery from giant-cell arteritis and massive infarction limited to the vertebrobasilar area.We have studied a patient with tight narrowing of both internal carotid arteries (ICAs) due to giant-cell arteritis. Although the brain supply through the internal and external carotid arteries pathways was totally inefficient, the patient suffered a progressive extensive infarction limited to the vertebrobasilar/posterior cerebral arteries area, except small lesions in the internal capsules. Both vertebral arteries were patent, although a fresh clot partially filled one of them. Without evidence for distal embolization, intracranial involvement by the arteritis, or generalized hypotension, we suggest that our patient suffered an intracranial steal phenomenon from the vertebrobasilar system towards the carotid circulation.- - - - - - - - - - ranking = 1.6666666666667keywords = giant (Clic here for more details about this article) |
8/14. Giant fusiform aneurysm of the vertebro-basilar artery presenting with stroke.The authors describe a case of giant fusiform aneurysm of the basilar artery presenting with ischemic symptoms. angiography and CT revealed vertebro-basilar fusiform aneurysmal dilatation. Fusiform vertebro-basilar aneurysm is associated with various complications particularly brain stem infarction. Similar lesions in the literature are reviewed and the relationship between this clinical entity and cerebral ischemia, particularly brain-stem infarction are discussed.- - - - - - - - - - ranking = 0.33333333333333keywords = giant (Clic here for more details about this article) |
9/14. cardiopulmonary bypass, hypothermic circulatory arrest and barbiturate cerebral protection for the treatment of giant vertebrobasilar aneurysms in children.Intracranial aneurysms in the pediatric population are rare lesions with a significant proportion occurring as giant aneurysms involving the vertebrobasilar system. The complex anatomy of these lesions frequently creates an extremely difficult management dilemma. We present two patients, a 9-year-old and a 13-year-old, with giant fusiform vertebrobasilar aneurysms, to illustrate the utility of cardiopulmonary bypass, hypothermic circulatory arrest and barbiturate cerebral protection for successful surgical treatment of these complex intracranial vascular lesions in children.- - - - - - - - - - ranking = 2keywords = giant (Clic here for more details about this article) |
10/14. Giant basilar artery aneurysm associated with moya-moya disease. Case report and review of the literature.The case of a 32-year-old man with a giant, partially thrombosed, basilar artery aneurysm associated with moya-moya disease is described. The patient exhibited symptoms due to compression of the aneurysm on the right cerebral peduncle. He was discharged after conservative treatment for 10 days. Pathogenesis and management of this rare case are discussed in the light of data reported from the literature.- - - - - - - - - - ranking = 0.33333333333333keywords = giant (Clic here for more details about this article) |
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