Thrombotic, dolichoectatic, distal PCA aneurysm treated with excision and P2-P2 reanastomosis

Authors

Christopher S. Graffeo, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.Follow
Lea Scherschinski, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
Jacob F. Baranoski, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.Follow
Visish M. Srinivasan, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
Michael T. Lawton, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona. Electronic address: Neuropub@barrowneuro.org.Follow

Document Type

Article

Abstract

Posterior cerebral artery (PCA) aneurysms are rare and often optimally treated with clip reconstruction. Complex cases may require aneurysm excision with in situ reanatomosis. A woman in her early 40s presented with 2 weeks of severe headache and received a diagnosis of a thrombotic, dolichoectatic, distal right P2 aneurysm. Clip reconstruction was recommended. After providing consent, the patient underwent a right subtemporal approach. The P2 aneurysm was encountered in the ambient cistern. The aneurysm and its inflow and outflow arteries were isolated, and bleeding was controlled with temporary clips. Primary clip reconstruction was aborted due to a neck configuration that precluded preservation of the outflow vessels during primary clip reconstruction. The decision was made to excise the aneurysm and perform a P2-P2 end-to-end reanastomosis. After completion of the initial bypass, indocyanine green (ICG) videoangiography indicated bypass thrombosis, which was thought to be attributable to poor tissue quality from inadequate vessel trimming at the anastomosis site. We elected to excise the bypass, trim both P2 ends back to healthy tissue, and perform a repeat end-to-end P2-P2 reanastomosis, which ultimately resulted in successful revascularization with ICG confirmation. Postoperative angiography confirmed complete obliteration of the aneurysm with stable graft patency, and the patient remained intact at her neurologic baseline through last follow-up at 6 weeks after discharge from the hospital. This video demonstrates microsurgical nuances for deep end-to-end reanastomosis as well as intraoperative troubleshooting in the setting of a complex ruptured posterior circulation aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Publication Date

5-29-2023

Publication Title

World neurosurgery

E-ISSN

1878-8769

PubMed ID

37257648

Digital Object Identifier (DOI)

10.1016/j.wneu.2023.05.089

Recommended Citation

Graffeo, Christopher S.; Scherschinski, Lea; Baranoski, Jacob F.; Srinivasan, Visish M.; and Lawton, Michael T., "Thrombotic, dolichoectatic, distal PCA aneurysm treated with excision and P2-P2 reanastomosis" (2023). Neurosurgery. 1846.
https://scholar.barrowneuro.org/neurosurgery/1846