Bypass Surgery for the Treatment of Dolichoectatic Basilar Trunk Aneurysms: A Work in Progress

Document Type

Article

Abstract

BACKGROUND: The treatment of dolichoectatic basilar trunk aneurysms has been ineffectual or morbid due to nonsaccular morphology, deep location, and involvement of brainstem perforators. Treatment with bypass surgery has been advocated to eliminate malignant hemodynamics and to stabilize aneurysm growth. OBJECTIVE: To validate that flow alteration with bypass and parent artery occlusion favorably impacts aneurysm progression. METHODS: Surgical management evolved in 3 phases, each with different hemodynamic alterations. RESULTS: During a 17-year period, 37 patients with dolichoectatic basilar trunk aneurysms were retrospectively identified, of whom 21 patients were observed, 12 treated immediately, and 4 selected for treatment after clinical progression. In phase 1, flow reversal was overly thrombogenic, despite heparin (N = 5, final mortality, 100%). In phase 2, flow reduction with intracranial-to-intracranial bypass was safer than flow reversal, but did not prevent progressive aneurysm enlargement (N = 3, final mortality 67%). In phase 3, distal clip occlusion of the basilar trunk aneurysm preserved anterograde flow in the aneurysm without rupture, but reduced flow threatened perforator patency, despite treatment with clopidogrel (N = 8, final mortality 62%). CONCLUSION: Shifting treatment strategy for dolichoectatic basilar trunk aneurysms improved surgical (80% to 50%) and final mortalities (100% to 62%), with stabilization of aneurysms in the phase 3 survivors. Good outcomes are determined by perforator preservation and mitigating aneurysm thrombosis. Occlusion techniques with increased distal run-off seem to benefit perforators. The treatment of dolichoectatic basilar trunk aneurysms can advance through concentrated management in dedicated centers, concerted efforts to study morphology and hemodynamics with computational methods, and widespread collection of registry data. ABBREVIATIONS: 4D PC-MRI, time-resolved phase-contrast MRIAICA, anterior inferior cerebellar arteryCE-MRA, high-resolution contrast-enhanced MR angiographyEC-IC, extracranial-to-intracranial bypassMCA, middle cerebral arteryMR, magnetic resonancemRS, modified Rankin ScalePCA, posterior cerebral arteryPICA, posterior inferior cerebellar arterySCA, superior cerebellar arterySTA, superficial temporal arteryVA, vertebral artery.

Medical Subject Headings

Adult; Aged; Female; Humans; Intracranial Aneurysm (surgery); Magnetic Resonance Imaging; Male; Microsurgery (adverse effects, methods); Middle Aged; Retrospective Studies; Surgical Instruments; Treatment Outcome; Vascular Surgical Procedures (adverse effects, methods); Vertebral Artery (pathology, surgery)

Publication Date

12-17-2015

Publication Title

Neurosurgery

E-ISSN

1524-4040

Volume

79

Issue

1

First Page

83

Last Page

99

PubMed ID

26671632

Digital Object Identifier (DOI)

10.1227/NEU.0000000000001175

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