Kim Yong Bae, Lee Jae Whan, Huh Seung-Kon, Kim Byung Moon, Kim Dong Jun
Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
Clin Neurol Neurosurg. 2013 Oct;115(10):2062-8. doi: 10.1016/j.clineuro.2013.07.004. Epub 2013 Jul 30.
Posterior cerebral artery (PCA) aneurysms are rare and often challenging to manage. Since Drake's historical report regarding PCA aneurysms, there has been limited additional information on recent advancements in either microsurgical or endovascular tools. We report a series of 25 consecutive cases and attempt to extrapolate useful information for managing PCA aneurysms.
A total of 25 cases of PCA aneurysm that were treated either by microsurgical or endovascular methods were selected and retrospectively reviewed. The clinical data, radiographic findings, and outcomes associated with the treatment modality were analysed.
The case series included 13 women and 12 men with a mean age of 52 years, ranging from 11 to 75 years. Fourteen aneurysms were ruptured, 7 aneurysms caused a direct mass effect, and the remaining 4 aneurysms were found incidentally. Most aneurysms were located in the P1 through P2A segment of the PCA (19 aneurysms, 76%). Seven aneurysms (28%) were large-giant in size (>20 mm), 4 of which had a thrombosed sac. Microsurgical treatment was the primary treatment in 15 aneurysms, including 9 successful direct clip ligations, 3 aneurysms that were surgically trapped without a bypass, and 2 wrapped aneurysms. One giant thrombosed aneurysm was incompletely clipped; subsequently, the large remnant was coil-embolised. Endovascular coil embolisation was performed for 6 aneurysms, stent-assisted coil embolisation was performed for 2 aneurysms, and 2 aneurysms were treated by endovascular occlusion of the parent artery. Permanent deficits acquired after treatment included limb weakness, palsy of the third cranial nerve, and hemianopsia in 5 cases (20%). There was no mortality. Overall, 22 patients (88%) showed favourable clinical outcomes according to the modified Rankin Scale Score (≤2) at the mean clinical follow-up period of 43.2 months (range: 2-130 months).
The present case series suggests that treating PCA aneurysms with microsurgical or endovascular options can achieve a comparable outcome when a judicious decision is made. Endovascular treatment had excellent anatomical and clinical outcomes for non-mass compressing, non-giant, saccular aneurysms. Given the propensity for the large-giant, dysplastic nature of PCA aneurysms to develop in younger patients, microsurgical competence should be maintained. Along with careful evaluation of the anatomic collaterals over the PCA territory, therapeutic parent artery sacrifice may be an appropriate option without adding bypass.
大脑后动脉（PCA）动脉瘤较为罕见，其治疗往往具有挑战性。自德雷克关于PCA动脉瘤的历史性报告以来，关于显微外科或血管内治疗工具的最新进展的额外信息有限。我们报告了连续25例病例，并试图推断出管理PCA动脉瘤的有用信息。
总共选择了25例通过显微外科或血管内方法治疗的PCA动脉瘤病例，并进行回顾性分析。分析了与治疗方式相关的临床数据、影像学表现和结果。
该病例系列包括13名女性和12名男性，平均年龄52岁，年龄范围为11至75岁。14例动脉瘤破裂，7例动脉瘤产生直接占位效应，其余4例为偶然发现。大多数动脉瘤位于PCA的P1至P2A段（19例，76%）。7例动脉瘤（28%）为大型-巨大型（>20mm），其中4例有血栓形成的瘤囊。15例动脉瘤以显微外科治疗为主，包括9例成功的直接夹闭，3例未行搭桥手术而被手术包裹的动脉瘤，以及2例包裹的动脉瘤。1例巨大血栓形成的动脉瘤夹闭不完全；随后，对大的残余部分进行了弹簧圈栓塞。6例动脉瘤进行了血管内弹簧圈栓塞，2例动脉瘤进行了支架辅助弹簧圈栓塞，2例动脉瘤通过对载瘤动脉进行血管内闭塞治疗。治疗后出现的永久性缺陷包括肢体无力、动眼神经麻痹和偏盲，共5例（20%）。无死亡病例。总体而言，在平均43.2个月（范围：2至130个月）的临床随访期，根据改良Rankin量表评分（≤2），22例患者（88%）显示出良好的临床结果。
本病例系列表明，当做出明智的决策时，采用显微外科或血管内方法治疗PCA动脉瘤可取得相当的结果。血管内治疗对于无占位压迫、非巨大型、囊状动脉瘤具有良好的解剖学和临床结果。鉴于PCA动脉瘤在年轻患者中具有大型-巨大型、发育异常的倾向，应保持显微外科手术能力。除了仔细评估PCA区域的解剖侧支循环外，在不增加搭桥的情况下，治疗性载瘤动脉牺牲可能是一种合适的选择。
