Venteicher Andrew S, Goldschmidt Ezequiel, Gardner Paul A
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.
J Neurol Surg B Skull Base. 2021 Feb;82(Suppl 1):S41-S42. doi: 10.1055/s-0040-1701237. Epub 2020 Jul 1.
Aneurysms of the posterior circulation pose a unique challenge due to higher rupture rates, higher recurrence rates following endovascular treatment, and extended open cranial base approaches required to reach the ventrally located brainstem circulation. While endovascular therapy has made tremendous strides in successful treatment for most posterior circulation aneurysms, open microscopic approaches remain essential in specific circumstances. Here, we present a case of a patient who presented with acute, severe headache, and sixth nerve palsies, and who was found to have hydrocephalus and a dissecting aneurysm at the anterolateral medullary segment of the posterior inferior cerebellar artery (PICA). Interestingly, this patient had a history of alpha-1 antitrypsin deficiency that has been linked with spontaneous aortic and cervical arterial dissections. The fusiform geometry of the dissecting aneurysm was deemed suboptimal for endovascular treatment, so an open microsurgical approach for occipital artery to PICA bypass and aneurysm trapping was planned. Because this patient had cerebral edema in the setting of a ruptured aneurysm and hydrocephalus, a far lateral craniotomy combined with drilling of the occipital condyle and jugular tubercle was critical to enhance exposure of the first segment of the PICA and to minimize brain retraction. In this video, we highlight the key steps and nuances for harvest of the occipital artery, achieving control of the extracranial vertebral artery, performing the transcondylar and transtubercular far lateral approach, and bypass with trapping technique for these challenging posterior circulation aneurysms. The link to the video can be found at: https://youtu.be/dqgblwX6t0Q .
后循环动脉瘤因其较高的破裂率、血管内治疗后的较高复发率以及为到达位于腹侧的脑干循环所需的扩大的颅底开放入路而带来独特的挑战。虽然血管内治疗在大多数后循环动脉瘤的成功治疗方面取得了巨大进展，但在特定情况下，开放显微镜下手术入路仍然至关重要。在此，我们报告一例患者，该患者出现急性、严重头痛及第六脑神经麻痹，经检查发现患有脑积水以及小脑后下动脉（PICA）延髓前外侧段的夹层动脉瘤。有趣的是，该患者有α-1抗胰蛋白酶缺乏病史，这与自发性主动脉和颈动脉瘤夹层有关。夹层动脉瘤的梭形形态被认为不适合血管内治疗，因此计划采用枕动脉至PICA搭桥及动脉瘤夹闭的开放显微手术入路。由于该患者在动脉瘤破裂和脑积水的情况下存在脑水肿，远外侧开颅术联合枕髁和颈静脉结节钻孔对于增强PICA第一段的暴露及最小化脑牵拉至关重要。在本视频中，我们重点介绍了获取枕动脉、控制颅外椎动脉、进行经髁和经结节远外侧入路以及针对这些具有挑战性的后循环动脉瘤采用搭桥夹闭技术的关键步骤和细微差别。视频链接可在：https://youtu.be/dqgblwX6t0Q 找到。
