- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Neurosurgery, National Cerebral and Cardiovascular Research Center Hospital, Osaka, Japan
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyusyu University, Fukuoka, Japan
Correspondence Address:
Yukihiro Yamao
Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
DOI:10.4103/2152-7806.145657
Copyright: © 2014 Yamao Y. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Yamao Y, Takahashi JC, Satow T, Iihara K, Miyamoto S. Successful flow reduction surgery for a ruptured true posterior communicating artery aneurysm caused by the common carotid artery ligation for epistaxis. Surg Neurol Int 28-Nov-2014;5:
How to cite this URL: Yamao Y, Takahashi JC, Satow T, Iihara K, Miyamoto S. Successful flow reduction surgery for a ruptured true posterior communicating artery aneurysm caused by the common carotid artery ligation for epistaxis. Surg Neurol Int 28-Nov-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/successful-flow-reduction-surgery-ruptured-true-posterior-communicating-artery-aneurysm-caused-common-carotid-artery-ligation-epistaxis/
Abstract
Background:Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging.
Case Description:The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery.
Conclusions:M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators.
Keywords: Common carotid artery ligation, extra-intracranial bypass, flow reduction, true posterior communicating artery aneurysm
INTRODUCTION
A true posterior communicating artery (PCoA) aneurysm is defined as an aneurysm originating with and involving the PCoA itself.[
CASE REPORT
History and findings
A 62-year-old female presented with sudden headache and vomiting was referred to our institute. Her consciousness level was evaluated as 14 points on the Glasgow Coma Scale (E3V5M6), and no weakness was observed in her extremities. Computed tomography (CT) demonstrated subarachnoid hemorrhage [SAH;
Figure 1
Schema of the timing of imaging and surgery. (a) CT image obtained at onset showing subarachnoid hemorrhage. (b) Three-dimensional digital subtraction angiography (3D-DSA) showing an irregular-shaped aneurysm on the right posterior communicating artery (white arrow). (c) Follow-up 3D-DSA showing enlargement of the aneurysm (white arrowhead). (d) Postoperative 3D-DSA showing reduction of the aneurysm (double white arrowheads). (e) Follow-up three-dimensional CT angiography (3D-CTA) after 4 years showing further reduction of aneurysm
Emergent digital subtraction angiography (DSA) revealed that the right CCA was occluded at its origin [
Figure 2
DSA before (a-d) and after surgery (e-f). (a) The right CCA occluded at its origin (arrow). (b, c) The blood flow to the right MCA territory originated mainly from the right PCA through the enlarged PCoA. The left ICA aneurysm had been completely clipped. (d) The blood flow from VA to OA (through the dilated muscle branches) had reversed toward ECA and the carotid bifurcation (white arrowhead). (e, f) The bypass was patent (arrow head). (g, h) The flow through the PCoA finally directed to the cortical artery of the distal M1, preserving the flow of M1 and its perforators (double arrows)
Diagnosis of the ruptured true PCoA aneurysm was made from the radiological data. The lesion did not appear amenable to simple neck clipping or coil embolization. Trapping of the PCoA with bypass to the anterior circulation was considered, but insufficient flow of the ECA precluded a standard bypass strategy such as STA-MCA bypass or ECA-RA-MCA bypass. In addition, trapping of the PCoA could cause thrombosis of the perforators arising from the PCoA, which could lead to thalamic infarction. A surgical treatment strategy in the acute stage, therefore, was abandoned, and the patient was kept under sedation for 14 days. When the sedative was discontinued, she was found to have right oculomotor nerve palsy (anisocoria) and mild left hemiparesis. Repeated DSA did not demonstrate vasospasm, but demonstrated enlargement of the aneurysm [
Surgical treatment
Surgery to reduce the PCoA flow was designed to prevent rebleeding and further growth of the aneurysm. The strategy consisted of (i) OA-RA free graft-MCA bypass and (ii) subsequent obliteration of the distal M1 portion of the right MCA with a clip [
Figure 3
The diagram of surgical flow reduction. The radial artery graft was anastomosed to the M2, and the M1 segment was obliterated with two Sugita Elgiloy clips just distal to bifurcation of the cortical branch. The opposite side of the radial artery graft was anastomosed to the dilated muscle branch of the occipital artery. AchoA: Anterior choroidal artery; LSA: Lenticulostriate artery
The patient was positioned supine with her head turned 80° to the left. A retromastoid linear incision was made to expose the OA and its dilated muscle branch. The RA was harvested from her left forearm. After the right frontotemporal craniotomy, the RA graft was implanted from the retromastoid field to the frontotemporal field through the subcutaneous tunnel. The Sylvian fissure was opened and the superior and inferior trunk (M2) of the MCA was exposed. The RA graft was anastomosed to the superior trunk in end-to-side fashion with interrupted 10-0 nylon sutures. Subsequently, the opposite side of the RA was anastomosed to the dilated muscle branch of the OA with interrupted 9-0 nylon sutures. After the bypass was opened, the M1 segment of the MCA was observed carefully. A cortical branch with 2 mm in caliber was found to originate from the M1 approximately 1.5 cm proximal to the MCA bifurcation. The M1 was then obliterated with two Sugita Elgiloy clips just distal to this point, leaving the cortical branch proximally to function as a flow-outlet of the collateral flow through the PCoA [
Postoperative course and follow-up
Postoperative DSA revealed sufficient bypass flow perfusing the MCA territory and extremely reduced collateral flow through the PCoA [Figure
After the placement of the ventricular-peritoneum shunt system for the hydrocephalus, the patient was discharged without major sequelae. Three-dimensional CT angiography performed 4 years after surgery demonstrated further reduction of the aneurysm [
DISCUSSION
Long-standing hemodynamic stress following CCA occlusion can cause an ipsilateral true PCoA aneurysm.[
In the present case, a flow reduction strategy was adopted instead of conventional trapping of the PCoA. True PCoA aneurysms are usually not amenable to neck clipping, and the only surgical strategy reported has been the trapping of the aneurysm and the PCoA.[
Obliteration of the distal M1 had reduced the collateral flow through the PCoA. The cortical branch remaining just proximal to the obliteration site functioned as a sufficient flow outlet, and the flow of the M1 and its perforators were well preserved. Although the aneurysm did not disappear, it did shrink, and the patient has been doing well for 5 years. Few reports exist regarding this kind of flow reduction surgery in MCA and basilar artery aneurysms.[
OA-RA-MCA bypass was used to secure the MCA territory from the hemodynamic ischemia caused by the M1 clipping. Because the ipsilateral CCA had been previously occluded and the ECA was small in caliber, the authors judged that STA-MCA bypass or ECA-RA-MCA bypass was insufficient to supply the entire MCA territory. Bypass grafting from the contralateral STA, known as a “Bonnet” bypass, has been reported.[
Surgical treatment of a secondarily formed, flow-related unclippable true PCoA aneurysm is quite challenging. Judging from the clinical course of the present case, M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option. Obliteration designed to leave a sufficient flow outlet is mandatory to avoid unexpected occlusion of the M1 and its perforators.
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