Grigoryan Yu A, Arustamyan S R, Sitnikov A R, Grigoryan G Yu
Medical Rehabilitation Center, Moscow, Russia.
Burdenko Neurosurgical Institute, Moscow, Russia.
Zh Vopr Neirokhir Im N N Burdenko. 2016;80(5):106-115. doi: 10.17116/neiro2016805106-115.
Giant partially thrombosed aneurysms of the vertebral artery are recalcitrant to treatment by microsurgical trapping and thrombectomy. Application of endovascular interventions is limited due to substantial brainstem compression and cranial nerve neuropathy. Combined endovascular exclusion and microsurgical excision provides an approach to treatment of these lesions.
A 48-year-old female patient presented with progressive complaints of ataxia, diplopia in left lateral gaze, and dysphagia. Imaging studies (CT, MRI, angiography) revealed a giant partially thrombosed aneurysm of the right vertebral artery and pronounced brainstem compression.
The initial phase of treatment involved endovascular occlusion of the vertebral artery and aneurysm trapping that did not lead to changes in the postoperative patient's neurological status. MRI demonstrated complete aneurysm thrombosis and a weak TOF signal in the vertebral artery near the proximal aneurysm neck region. Because of persistent brainstem compression, the patient underwent right suboccipital craniectomy and hemilaminectomy of the CI arch for aneurysm excision one week after endovascular occlusion. After isolating the aneurysmal sac, the vertebral artery was transected, and two small branches extending from the aneurysm neck to the brainstem were also coagulated and transected, followed by aneurysm excision. Numerous vasa vasorum in the wall of the proximal vertebral artery and aneurysm neck were coagulated to stop bleeding. After surgery, the patient developed neurological symptoms (right leg ataxia and dysphagia worsening) due to lateral medullary infarction (confirmed by MRI) that presumably resulted from coagulation of two small perforating branches coming from the aneurysm neck to the brainstem. Recovery of the patient's neurological functions was observed during conservative treatment. The patient was discharged with mild right leg ataxia and preoperative left-sided abducens paresis.
Medulla oblongata compression associated with a giant thrombosed aneurysm of the vertebral artery can be eliminated by endovascular trapping followed by surgical excision of the aneurysm. Preserving the vasa vasorum feeding the brainstem is crucial for prevention of ischemic complications.
巨大的部分血栓形成的椎动脉动脉瘤难以通过显微外科夹闭和血栓切除术进行治疗。由于严重的脑干压迫和颅神经病变，血管内介入治疗的应用受到限制。血管内栓塞联合显微外科切除为治疗这些病变提供了一种方法。
一名48岁女性患者出现进行性共济失调、左侧凝视复视和吞咽困难。影像学检查（CT、MRI、血管造影）显示右侧椎动脉巨大部分血栓形成的动脉瘤及明显的脑干压迫。
治疗的初始阶段包括椎动脉血管内闭塞和动脉瘤夹闭，但术后患者神经状态未发生改变。MRI显示动脉瘤完全血栓形成，近端动脉瘤颈部区域附近椎动脉的TOF信号减弱。由于脑干压迫持续存在，患者在血管内闭塞一周后接受了右枕下开颅术和C1弓半椎板切除术以切除动脉瘤。分离出动脉瘤囊后，切断椎动脉，从动脉瘤颈部延伸至脑干的两个小分支也进行了凝固和切断，随后切除动脉瘤。近端椎动脉壁和动脉瘤颈部的许多滋养血管进行了凝固以止血。术后，患者因延髓外侧梗死（MRI证实）出现神经症状（右腿共济失调和吞咽困难加重），推测是由于来自动脉瘤颈部至脑干的两个小穿支血管凝固所致。在保守治疗期间观察到患者神经功能恢复。患者出院时仍有轻度右腿共济失调和术前左侧展神经麻痹。
通过血管内夹闭随后手术切除动脉瘤可消除与椎动脉巨大血栓形成动脉瘤相关的延髓压迫。保留供应脑干的滋养血管对于预防缺血性并发症至关重要。
