Microsurgical Treatment Strategy of Vertebral Artery Fusiform Aneurysm—From the Standpoint of Hemodynamic Integrity and Perforator Preservation

Abstract

During treatment of vertebral artery (VA) fusiform aneurysms, it is critical to preserve peripheral perforators and anterograde blood flow of the VA and to reduce hemodynamic load to the contralateral VA. Even in the era of endovascular treatment, there are still many benefits to using microsurgical treatments with appropriate clip application and preservation of the perforators around the aneurysm, in conjunction with various bypass techniques. The ideal microsurgical technique involves reconstructive clipping that obliterates the aneurysm but preserves anterograde blood flow of the VA, followed by isolation of the aneurysm and VA reconstruction. If these two methods are unavailable, proximal clipping of the aneurysm combined with flow-augmentation bypass to the distal branch can be considered as an alternative surgical management. We discuss the microsurgical treatment of unruptured VA fusiform aneurysms in our surgical cases on the basis of a review of the current literature.

A vertebrobasilar junction aneurysm successfully treated with a combination of surgical clipping and flow diverter placement based on the results of computational fluid dynamics analysis: illustrative case

“…In the surgical trapping of the VA, direct surgery is more ideal than endovascular internal trapping for placing clips while observing nearby branching arteries and thus reducing postoperative infarction risks despite the risk of cranial nerve palsy. 21 Endovascular internal trapping is effective but carries a high risk of perforator infarction. 22 In this case, occlusion just proximal to the VA union in a short segment was required; therefore, endovascular treatment was considered particularly challenging.…”

Posterior vascular anatomy of the encephalon: a comprehensive review

“…The V3 segment can be delineated into three portions: (a) the vertical portion, located between the transverse processes of the first and second cervical vertebrae; (b) the horizontal portion, which courses within the groove on the upper surface of the posterior arch of the atlas; and (c) the oblique portion, which traverses through the dura mater. Emerging from the third segment of the vertebral artery are the posterior meningeal arteries, posterior spinal arteries, muscular branches, and occasionally the posterior inferior cerebellar arteries [ 31 , 45 ].…”