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

Sho Tsunoda,Tomohiro Inoue

doi:10.3389/fneur.2021.728176

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.

Highlights

The term “vertebral artery fusiform aneurysm” (VAFA) is generally used for spindle-shaped aneurysms that arise from the main trunk of the vertebral artery (VA)
Once rupture-induced subarachnoid hemorrhage (SAH) occurs, there is a high risk of devastating re-rupture in the acute phase of dissection
We report four cases of unruptured VAFA treated by our custom direct surgical approaches and discuss the treatment of unruptured VAFAs by direct surgery

Summary

Introduction

The term “vertebral artery fusiform aneurysm” (VAFA) is generally used for spindle-shaped aneurysms that arise from the main trunk of the vertebral artery (VA). The clinical and pathological definition is ambiguous and, confusingly, the term is currently used for various types of aneurysms with different clinical and pathological features, including wide-neck saccular, dolichoectatic, and giant serpentine aneurysms. Many of the VAFAs reflect the consequences of dissecting changes at different time phases [1,2,3]. Once rupture-induced subarachnoid hemorrhage (SAH) occurs, there is a high risk of devastating re-rupture in the acute phase of dissection. Immediate treatment of SAH is required to preventing re-rupture [4,5,6]. In patients with no rupture within the acute phase, the medium- to long-term natural history is unknown and there is no consensus regarding the treatment strategy

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Conclusion