Sakamoto Yusuke, Suzuki Osamu, Fukuoka Toshiki, Awaya Takayuki, Saito Ryuta
Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, JPN.
Neurosurgery, Nagoya Ekisaikai Hospital, Nagoya, JPN.
Cureus. 2025 Jan 3;17(1):e76863. doi: 10.7759/cureus.76863. eCollection 2025 Jan.
Treating vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms poses challenges because of their complex anatomy. Although endovascular treatment is commonly preferred, direct surgery offers better recovery prospects than endovascular surgery aided by bypass techniques. We present a VA-PICA aneurysm case treated with VA internal trapping, using a PICA-to-PICA bypass without direct clipping. A 64-year-old man presented with complaints of severe headache and was diagnosed with a right VA-PICA wide neck aneurysm. The PICA originated from the neck of the aneurysm. We consulted an endovascular surgeon and opted for direct clipping via the transcondylar fossa approach. During surgery, we secured and followed the right VA, identified the PICA origin, and observed the proximal neck of the aneurysm. However, securing the distal VA was challenging because the dissector was inaccessible. Instead of direct clipping, a PICA-to-PICA bypass was selected following internal trapping. After anastomosis, the proximal PICA was occluded, whereas the small perforating artery was preserved. The next day, internal trapping of the right VA was performed. The patient's postoperative course was uneventful, except for mild dysphagia. Head magnetic resonance imaging revealed a small infarction on the right medulla. Three-dimensional computed tomography angiography revealed perfect PICA-to-PICA bypass patency. The patient was subsequently transferred to a rehabilitation hospital. The patient had no neurological symptoms at the six-month follow-up (Modified Rankin Score = 0). The preoperative feasibility of direct clipping of complex PICA aneurysms while preserving PICA is unpredictable. Various bypass methods, including the PICA-to-PICA bypass, are potential treatment options for complicated VA-PICA aneurysms.
由于椎动脉-小脑后下动脉（VA-PICA）动脉瘤解剖结构复杂，其治疗颇具挑战性。尽管血管内治疗通常是首选，但与借助搭桥技术的血管内手术相比，直接手术能带来更好的恢复前景。我们报告一例采用VA血管内套扎术治疗的VA-PICA动脉瘤病例，术中使用PICA-to-PICA搭桥术，未进行直接夹闭。一名64岁男性因严重头痛就诊，被诊断为右侧VA-PICA宽颈动脉瘤。PICA起源于动脉瘤颈部。我们咨询了血管内外科医生，选择经髁窝入路进行直接夹闭。手术过程中，我们固定并追踪右侧椎动脉，确定PICA起源，观察动脉瘤近端颈部。然而，由于无法触及剥离器，固定椎动脉远端颇具挑战性。因此，未进行直接夹闭，而是在血管内套扎后选择了PICA-to-PICA搭桥术。吻合后，近端PICA被闭塞，但小穿支动脉得以保留。次日，对右侧椎动脉进行了血管内套扎。患者术后恢复顺利，仅出现轻度吞咽困难。头部磁共振成像显示右侧延髓有小梗死灶。三维计算机断层血管造影显示PICA-to-PICA搭桥术通畅良好。患者随后被转至康复医院。在六个月的随访中，患者无神经症状（改良Rankin评分=0）。在保留PICA的同时直接夹闭复杂PICA动脉瘤的术前可行性难以预测。包括PICA-to-PICA搭桥术在内的各种搭桥方法，都是复杂VA-PICA动脉瘤的潜在治疗选择。
