Riley Moguel Ambar Elizabeth, Serrano-Rubio Alejandro, González Soto José Alfredo, Nuñez-Lupaca Janeth N, Nathal Edgar
Neurosurgery, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, MEX.
Vascular Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX.
Cureus. 2024 Sep 11;16(9):e69186. doi: 10.7759/cureus.69186. eCollection 2024 Sep.
"True" posterior communicating artery (PComA) aneurysms are one of the rarest of all intracranial aneurysms. Diagnosis of this kind of aneurysm and treatment continue to be challenging for neurosurgeons because of the surrounding structures and their importance. Concomitant vascular anomalies, like dissections or hypoplasia, are frequently found with these aneurysms. Multiple aneurysms in the posterior communicating segment are even rarer than true PComA aneurysms alone. To achieve a safe clipping in patients with multiple aneurysms in this location, some coadjuvant maneuvers may be performed, like resection of the anterior part of the uncus. By presenting this case, we aim to show how we managed to treat these rare aneurysms with good outcomes for the patient and microsurgical resolution. We present a representative case of a 50-year-old female with headache, nausea, language disturbances, left hemiparesis, and deterioration of consciousness, referred to our hospital with a diagnosis of subarachnoid hemorrhage (Hunt & Hess grade 3, Fisher grade 4) secondary to a rupture of a true PComA aneurysm. Urgent surgical clipping was performed, and during surgery, a junctional aneurysm and a true PComA aneurysm were found very close to each other, complicating the procedure, so to have more space to work and perform a safe clipping, we resected the anterior part of the uncus, which broadened the retrocarotid space, performing the clipping with complete exclusion of both aneurysms and no complications. The patient was discharged after five days with right partial III nerve palsy. Postsurgical CT angiography (CTA) and perfusion images showed the permeability of branches distal to the clips. Knowledge of microsurgical and vascular anatomy is key to the successful treatment of this type of aneurysm, especially when we have multiple aneurysms so close to each other, like in this case, because of the relation with cranial nerves and perforators. Performing extra procedures or transurgical maneuvers like the anterior resection of uncus to broaden our working space is always helpful to avoid complications or major deficits.
“真性”后交通动脉瘤是所有颅内动脉瘤中最罕见的类型之一。由于其周围结构及其重要性，神经外科医生对这类动脉瘤的诊断和治疗仍然具有挑战性。这些动脉瘤常伴有血管异常，如夹层或发育不全。后交通段的多发性动脉瘤比单纯的真性后交通动脉瘤更为罕见。为了在该部位患有多发性动脉瘤的患者中实现安全夹闭，可能需要采取一些辅助操作，如切除钩回前部。通过展示这个病例，我们旨在说明我们是如何成功治疗这些罕见动脉瘤并取得良好患者预后和显微手术效果的。我们呈现了一个具有代表性的病例，一名50岁女性，有头痛、恶心、语言障碍、左侧偏瘫和意识障碍，因真性后交通动脉瘤破裂导致蛛网膜下腔出血（Hunt & Hess 3级，Fisher 4级）被转诊至我院。进行了紧急手术夹闭，术中发现一个交界性动脉瘤和一个真性后交通动脉瘤彼此非常靠近，使手术过程复杂化，因此为了有更多操作空间并进行安全夹闭，我们切除了钩回前部，这拓宽了颈动脉后间隙，成功夹闭了两个动脉瘤且未出现并发症。患者术后五天出院，遗留右侧部分动眼神经麻痹。术后CT血管造影（CTA）和灌注图像显示夹子远端分支的通畅情况。了解显微手术和血管解剖结构是成功治疗这类动脉瘤的关键，特别是当我们遇到像本病例中这样彼此非常靠近的多发性动脉瘤时，因为它们与颅神经和穿支的关系。进行额外的操作或经手术策略，如钩回前部切除术以拓宽工作空间，总是有助于避免并发症或严重神经功能缺损。
