PMC4828954_01
Initial digital subtraction angiography (DSA) (2004) shows a left fusiform vertebral artery (VA) aneurysm (a). DSA performed after the first embolization on the left fusiform VA aneurysm demonstrates aneurysm exclusion (b)
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F1
An incidental left fusiform vertebral artery (VA) aneurysm was coiled in a 60-year-old man [Figure 1].
DSA performed 6 years after the first embolization on left fusiform VA aneurysm (2011) shows aneurysm recanalization and enlargement (a). DSA performed after the second embolization on left fusiform VA aneurysm shows a new contralateral fusiform VA aneurysm (2013) (b)
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F2
Although the patient was asymptomatic, follow-up with magnetic resonance imaging (MRI) and digital subtraction angiography after 3 and 10 months, showed enlargement of both aneurysms [Figures 2 and 3].
Preoperative cerebral computed tomography angiography (CTA) showing a revascularization of the left VA fusiform coiled aneurysm and a new contralateral VA fusiform aneurysm. Anterior-posterior view, right (a) and left (b) VA contrast injection (2014)
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F3
Although the patient was asymptomatic, follow-up with magnetic resonance imaging (MRI) and digital subtraction angiography after 3 and 10 months, showed enlargement of both aneurysms [Figures 2 and 3].
Operative right park bench position and an L-shape postauricular skin incision. M: Mastoid tip, A: Asterion
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F4
An L-shape postauricular skin incision was made [Figure 4].
Intraoperative images. Fusiform left VA aneurysm located ventral to the IX, X (a) and XI (b) cranial nerves. Coils within the open aneurysm (c)
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F5
The giant coiled aneurysm was ventral to the caudal cranial nerves (CNs) [Figures 5a, b and 6a]. After temporary trapping, the aneurysm coil mass was incised by monopolar coagulator [Figure 5c].
Illustration depicting giant fusiform coiled aneurysm located ventral to the XI, X, IX and VII, VIII cranial nerves (a). Surgical proximal VA trapping. Giant coiled aneurysm was removed. Low flow bypass: Occipital artery-small branch arising proximal from the aneurysm, end-to-side anastomosis. High flow bypass: Radial artery graft-intracranial V4 end-to-end and radial artery graft-V3-extracranial end-to-side fashion (b)
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F6
The giant coiled aneurysm was ventral to the caudal cranial nerves (CNs) [Figures 5a, b and 6a]. A small arterial branch arising from the proximal portion of the aneurysm was reconstructed by OA with end-to-side anastomosis [Figures 6b and 7a]. Subsequently both ends of RAG were anastomosed with VA in a fish mouth trimming: RAG to intracranial V4 end-to-end and RAG to V3 end-to-side fashion [Figures 6b and 7b].
Intraoperative images. Low flow bypass: Occipital artery-small branch arising proximal from the aneurysm, end-to-side anastomosis (a). High flow bypass: Radial artery graft-intracranial V4 end-to-end and radial artery graft-V3-extracranial end-to-side fashion (b)
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F7
A small arterial branch arising from the proximal portion of the aneurysm was reconstructed by OA with end-to-side anastomosis [Figures 6b and 7a]. Subsequently both ends of RAG were anastomosed with VA in a fish mouth trimming: RAG to intracranial V4 end-to-end and RAG to V3 end-to-side fashion [Figures 6b and 7b].
Postoperative CTA revealed good patency of the bypasses. Anterior-posterior (a) and lateral (b) view
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F8
Proximal aneurysm clipped reinforced was applied [Figure 8].
Magnetic resonance imaging (MRI) shows enlargement of the left fusiform VA aneurysm and a new contralateral right fusiform VA aneurysm (2013) (a). MRIs immediately after surgery (b), 6 months (c) and 18 months (d) later show small left infarction of medulla oblongata and no changes in the right fusiform VA aneurysm
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F9
The patient could walk without assistance after 7 days, although left thermal hypoalgesia, due to Wallenberg's syndrome appeared because of small infarction of medulla oblongata [Figure 9].
DSA performed 1 year (a) and 18 months (b) after the surgery show bypass patency and no changes on the right fusiform VA aneurysm
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F10