Treatment of distal posterior cerebral artery aneurysms: A critical appraisal of the occipital artery-to-posterior cerebral artery bypass

Steve W. Chang, Adib A. Abla, Udaya K. Kakarla, Eric Sauvageau, Shervin R. Dashti, Peter Nakaji, Joseph M. Zabramski, Felipe C. Albuquerque, Cameron McDougall, Robert F. Spetzler

Research output: Contribution to journalArticle

Abstract

OBJECTIVE: This is the largest contemporary series of distal posterior cerebral artery (PCA) aneurysms treated by use of endovascular coiling and stenting as well as surgical clipping, clip wrapping, and bypass techniques. We propose a new treatment paradigm. METHODS: The location, size, type of aneurysm, clinical presentation, treatment, complications, and outcomes associated with 34 distal PCA aneurysms in 33 patients (15 females, 18 males; mean age, 44 years) were reviewed retrospectively. RESULTS: The most common presenting symptom was headache in 19 (58%) followed by contralateral weakness or numbness in 6 (18%) and visual changes in 4 (12%). Eight aneurysms were giant. Of the remaining 26 aneurysms, 17 were fusiform/dissecting, 5 were saccular, and 4 were mycotic. Treatment was primarily endovascular in 22 patients, 12 of whom also had a concomitant surgical bypass procedure. Nine patients underwent microsurgical clipping, and 3 underwent combined treatment of clipping and coiling and/or stenting. There were no significant differences in outcomes between the groups (P = .078). The recurrence rate in patients undergoing coiing was 22% and 0% in patients undergoing clipping. Fourteen aneurysms (41%) involved treatment with an occipital artery-to-PCA bypass or an onlay graft. Compared with their preoperative status, these patients had significantly worse outcomes than those without a bypass (P = .013). CONCLUSION: Bypass techniques for the treatment of distal PCA aneurysms are associated with a higher rate of complications than once thought. In our new treatment paradigm, bypass is a last resort and reserved for patients in whom balloon-test occlusion fails, who refuse parent-vessel sacrifice, and who cannot undergo primary stenting with coiling or clip wrapping.

Original languageEnglish (US)
Pages (from-to)16-25
Number of pages10
JournalNeurosurgery
Volume67
Issue number1
DOIs
StatePublished - Jul 1 2010
Externally publishedYes

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Posterior Cerebral Artery
Intracranial Aneurysm
Arteries
Aneurysm
Surgical Instruments
Therapeutics
Balloon Occlusion
Inlays
Hypesthesia
Headache
Transplants
Recurrence

Keywords

  • Aneurysm
  • Bypass
  • Endovascular
  • Fusiform
  • Microsurgical
  • Occipital artery-to-posterior cerebral artery bypass
  • Posterior cerebral artery

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Treatment of distal posterior cerebral artery aneurysms : A critical appraisal of the occipital artery-to-posterior cerebral artery bypass. / Chang, Steve W.; Abla, Adib A.; Kakarla, Udaya K.; Sauvageau, Eric; Dashti, Shervin R.; Nakaji, Peter; Zabramski, Joseph M.; Albuquerque, Felipe C.; McDougall, Cameron; Spetzler, Robert F.

In: Neurosurgery, Vol. 67, No. 1, 01.07.2010, p. 16-25.

Research output: Contribution to journalArticle

Chang, SW, Abla, AA, Kakarla, UK, Sauvageau, E, Dashti, SR, Nakaji, P, Zabramski, JM, Albuquerque, FC, McDougall, C & Spetzler, RF 2010, 'Treatment of distal posterior cerebral artery aneurysms: A critical appraisal of the occipital artery-to-posterior cerebral artery bypass', Neurosurgery, vol. 67, no. 1, pp. 16-25. https://doi.org/10.1227/01.NEU.0000370008.04869.BF
Chang, Steve W. ; Abla, Adib A. ; Kakarla, Udaya K. ; Sauvageau, Eric ; Dashti, Shervin R. ; Nakaji, Peter ; Zabramski, Joseph M. ; Albuquerque, Felipe C. ; McDougall, Cameron ; Spetzler, Robert F. / Treatment of distal posterior cerebral artery aneurysms : A critical appraisal of the occipital artery-to-posterior cerebral artery bypass. In: Neurosurgery. 2010 ; Vol. 67, No. 1. pp. 16-25.
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abstract = "OBJECTIVE: This is the largest contemporary series of distal posterior cerebral artery (PCA) aneurysms treated by use of endovascular coiling and stenting as well as surgical clipping, clip wrapping, and bypass techniques. We propose a new treatment paradigm. METHODS: The location, size, type of aneurysm, clinical presentation, treatment, complications, and outcomes associated with 34 distal PCA aneurysms in 33 patients (15 females, 18 males; mean age, 44 years) were reviewed retrospectively. RESULTS: The most common presenting symptom was headache in 19 (58{\%}) followed by contralateral weakness or numbness in 6 (18{\%}) and visual changes in 4 (12{\%}). Eight aneurysms were giant. Of the remaining 26 aneurysms, 17 were fusiform/dissecting, 5 were saccular, and 4 were mycotic. Treatment was primarily endovascular in 22 patients, 12 of whom also had a concomitant surgical bypass procedure. Nine patients underwent microsurgical clipping, and 3 underwent combined treatment of clipping and coiling and/or stenting. There were no significant differences in outcomes between the groups (P = .078). The recurrence rate in patients undergoing coiing was 22{\%} and 0{\%} in patients undergoing clipping. Fourteen aneurysms (41{\%}) involved treatment with an occipital artery-to-PCA bypass or an onlay graft. Compared with their preoperative status, these patients had significantly worse outcomes than those without a bypass (P = .013). CONCLUSION: Bypass techniques for the treatment of distal PCA aneurysms are associated with a higher rate of complications than once thought. In our new treatment paradigm, bypass is a last resort and reserved for patients in whom balloon-test occlusion fails, who refuse parent-vessel sacrifice, and who cannot undergo primary stenting with coiling or clip wrapping.",
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AU - Sauvageau, Eric

AU - Dashti, Shervin R.

AU - Nakaji, Peter

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