Surg Neurol 1990;33:48-5 1
48
Double Giant Fusiform Aneurysms
of the Posterior
Cerebral Artery Patrick
Statham,
Chris Coutinho,
M.B., F.R.C.S.,
Robin Johnston,
M.B., F.R.C.R.,
and Donald
Departments of Neurosurgery Glasgow, Scotland
and Neuroradiology,
Institute
Statham P, Johnscon R, Coutinho C, Hadley D. Double giant fusiform aneurysms of the posterior cerebral artery. Sug Neural 1990;33:48-51. Subarachnoid
hemorrhage
in a patient
with
two
giant
fusiform aneurysms arising from the posterior cerebral artery was treated by clipping the P2 segment of the artery, proximal to the first aneurysm. This combination of aneurysms has not previously been reported. KEY WORDS: Giant fusiform
rhage; Proximal
aneurysm;
Subarachnoid
hemor-
ligation
M.D., F.R.C.S.,
Hadley,
Ph.D.,
of Neurological
F.R.C.R.
Sciences,
Southern
General
Hospital,
encephalic and intraventricular hemorrhage, with two aneurysms arising from the right posterior cerebral circulation (Figure 1 A), confirmed on cerebral angiography (Figure 1 23). They measured 2.5 cm and 3 cm in maximum diameter. Both were fusiform, arising respectively from the P2 and the P4 segments of the posterior cerebral artery, with no filling of the distal P4 segment, the vein of Galen, or the straight sinus. The carotid circulation was normal. At operation 11 days after hemorrhage, clipping of the proximal P2 segment of the right posterior cerebral
Aneurysms of the posterior cerebral artery constitute about 1%~ (0.7$??--2.29%) of all intracranial aneurysms found af angiography El), of which 10% are fusiform {3]. Giant aneurysms account for about 596 (3$X-13%) of all intracranial aneurysms [I]. The combination of multiple giant aneurysms and their fusiform type make this case all the more unusual. Surgical treatment of giant fusiform aneurysms has included proximal occlusion, combined proximal and distal occlusion (trapping), and excision with end-to-end or end-to-side anastomosis [4].
Case
Report
A 45-year-old woman presented in coma after sudden occipital headache. She improved, becoming oriented, with a left homonymous hemianopia. She had no history of hypertension and, on examination, had no bruits or cardiac murmurs. Erythrocyte sedimentation rate was 11 mm/h. Serological tests for syphilis were negative. Computed tomography (CT) scanning showed perimesAddress reprint req,wtJ to: Patrick Statham, M.B., F.R.C.S., Deof Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF, Scotland. Received March 14, 1989; accepted Augusr 11, 1989. partment
0 1990 by Elswier
Science Publishing
Co., Inc.
A oo’)o-301’)/90/$~.50
Surg Neurol 1990;33:48-51
Double Giant Fusiform Aneurysms
B
ure 5 A and B), confirming that the distal aneurysm not arising directly from the vein of Galen.
Figure 1. Continued
artery was performed using a subtemporal approach (Figure 2). Subsequent perioperative digital subtraction angiography showed no filling of either aneurysm (Figure 3). The patient recovered with persisting homonymous hemianopia but no new neurological deficit (Figure 4). Postoperative magnetic resonance (MR) imaging showed a flow void in the vein of Galen and straight sinus separate from both thrombosed aneurysms (Fig-
Figure 2. Ilhtration of the operative findings, showing the giant fusifom aneurym arising from the P2 segment of the posierior cerebral artery.
Occulomotor nerve _>i-/---_ / -~
Suoerior
was
Discussion Posterior cerebral artery aneurysms are uncommon, accounting for 77&15C/p of all posterior circulation aneurysms. Giant aneurysms more often present with focal neurological symptoms or signs from mass effect than from subarachnoid hemorrhage, and are most commonly due to atherosclerosis, but may be mycotic. Giant fusiform aneurysms have been reported in patients with syphilis, Marfan’s syndrome, coarctation of the aorta, pseudoxanthoma elasticum, and giant cell arteritis. This combination of two aneurysms arising from one vessel required a subtemporal approach to the proximal aneurysm and gaining proximal arterial control for the distal aneurysm. The latter would have required an occipital interhemispheric approach for direct clipping, anastomosis, or trapping. The risk of hemisphere swelling or retraction damage from such a combined approach, particularly if draining veins are divided, would become significant. To avoid this, proximal occlusion of the P2 segment of the posterior cerebral artery was performed, with perioperative digital subtraction angiography to ensure that the distal aneurysm was not
50
Surg Neural
Statham
et al
1990;33:48-51
Figure 3. Perioperative angiqram the right po.rterior cerebral artery.
Figure 4. Pojtoperatilje iBjerrum’.r Jcreen chart).
after clipping
z’liual field perrmetry
Left Eye
Right Eye 1 Post Omrative
Figure 5. MR images (SE 1600180). CA) Internal cerebral zetn, ?,ein of Galen. and straight situ aneurysm (arrowheads) and clip artefact.
Visual Field Defect 1 demonstrated bJ their ‘;Aou kd.”
(B) TbromboJed
Surg Neurol 1990;33:48-51
Double Giant Fusiform Aneurysms
filling. The aneurysms were considered inappropriate for embolization. Occlusion of the posterior cerebral artery distal to the Pl perforators is relatively safe [2]. Persistent visual defect is unusual due to relatively good collateral blood supply, derived from both middle and anterior cerebral arteries. This patient had a homonymous hemianopia before operation, and no filling of the P4 segment of the vessel could be demonstrated on angiography. Therefore proximal occlusion, distal to the P 1 and P2 perforators, was the safest surgical option.
51
References Locksley HB. Report on the Cooperative Study of intracranial aneurysms and subarachnoid haemorrhage. V Pt. 1 Natural history of subarachnoid haemorrhage and arteriovenous maiformatrons; based on 6368 cases in the Cooperative Study. J Neurosurg 1966;25:215-39. Peerless Wilkins McGraw
SJ. Drake CG. Postertor RH. Rengachary SS, 4s. Hill, 1985: 1422-j’.
ctrculation aneurysms. In: Neurosurgery. New York:
Pia HW, Fontana H. Aneurysms of the posterior cerebral artery; locations and clinical pictures. Acta Neurochir 197’;38:11-35. Sundt TM Jr. Surgtcal technique Neurosurg Rev 1982;5:161-8.
for giant intracranial
aneurysms.
48
Double Giant Fusiform Aneurysms
of the Posterior
Cerebral Artery Patrick
Statham,
Chris Coutinho,
M.B., F.R.C.S.,
Robin Johnston,
M.B., F.R.C.R.,
and Donald
Departments of Neurosurgery Glasgow, Scotland
and Neuroradiology,
Institute
Statham P, Johnscon R, Coutinho C, Hadley D. Double giant fusiform aneurysms of the posterior cerebral artery. Sug Neural 1990;33:48-51. Subarachnoid
hemorrhage
in a patient
with
two
giant
fusiform aneurysms arising from the posterior cerebral artery was treated by clipping the P2 segment of the artery, proximal to the first aneurysm. This combination of aneurysms has not previously been reported. KEY WORDS: Giant fusiform
rhage; Proximal
aneurysm;
Subarachnoid
hemor-
ligation
M.D., F.R.C.S.,
Hadley,
Ph.D.,
of Neurological
F.R.C.R.
Sciences,
Southern
General
Hospital,
encephalic and intraventricular hemorrhage, with two aneurysms arising from the right posterior cerebral circulation (Figure 1 A), confirmed on cerebral angiography (Figure 1 23). They measured 2.5 cm and 3 cm in maximum diameter. Both were fusiform, arising respectively from the P2 and the P4 segments of the posterior cerebral artery, with no filling of the distal P4 segment, the vein of Galen, or the straight sinus. The carotid circulation was normal. At operation 11 days after hemorrhage, clipping of the proximal P2 segment of the right posterior cerebral
Aneurysms of the posterior cerebral artery constitute about 1%~ (0.7$??--2.29%) of all intracranial aneurysms found af angiography El), of which 10% are fusiform {3]. Giant aneurysms account for about 596 (3$X-13%) of all intracranial aneurysms [I]. The combination of multiple giant aneurysms and their fusiform type make this case all the more unusual. Surgical treatment of giant fusiform aneurysms has included proximal occlusion, combined proximal and distal occlusion (trapping), and excision with end-to-end or end-to-side anastomosis [4].
Case
Report
A 45-year-old woman presented in coma after sudden occipital headache. She improved, becoming oriented, with a left homonymous hemianopia. She had no history of hypertension and, on examination, had no bruits or cardiac murmurs. Erythrocyte sedimentation rate was 11 mm/h. Serological tests for syphilis were negative. Computed tomography (CT) scanning showed perimesAddress reprint req,wtJ to: Patrick Statham, M.B., F.R.C.S., Deof Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF, Scotland. Received March 14, 1989; accepted Augusr 11, 1989. partment
0 1990 by Elswier
Science Publishing
Co., Inc.
A oo’)o-301’)/90/$~.50
Surg Neurol 1990;33:48-51
Double Giant Fusiform Aneurysms
B
ure 5 A and B), confirming that the distal aneurysm not arising directly from the vein of Galen.
Figure 1. Continued
artery was performed using a subtemporal approach (Figure 2). Subsequent perioperative digital subtraction angiography showed no filling of either aneurysm (Figure 3). The patient recovered with persisting homonymous hemianopia but no new neurological deficit (Figure 4). Postoperative magnetic resonance (MR) imaging showed a flow void in the vein of Galen and straight sinus separate from both thrombosed aneurysms (Fig-
Figure 2. Ilhtration of the operative findings, showing the giant fusifom aneurym arising from the P2 segment of the posierior cerebral artery.
Occulomotor nerve _>i-/---_ / -~
Suoerior
was
Discussion Posterior cerebral artery aneurysms are uncommon, accounting for 77&15C/p of all posterior circulation aneurysms. Giant aneurysms more often present with focal neurological symptoms or signs from mass effect than from subarachnoid hemorrhage, and are most commonly due to atherosclerosis, but may be mycotic. Giant fusiform aneurysms have been reported in patients with syphilis, Marfan’s syndrome, coarctation of the aorta, pseudoxanthoma elasticum, and giant cell arteritis. This combination of two aneurysms arising from one vessel required a subtemporal approach to the proximal aneurysm and gaining proximal arterial control for the distal aneurysm. The latter would have required an occipital interhemispheric approach for direct clipping, anastomosis, or trapping. The risk of hemisphere swelling or retraction damage from such a combined approach, particularly if draining veins are divided, would become significant. To avoid this, proximal occlusion of the P2 segment of the posterior cerebral artery was performed, with perioperative digital subtraction angiography to ensure that the distal aneurysm was not
50
Surg Neural
Statham
et al
1990;33:48-51
Figure 3. Perioperative angiqram the right po.rterior cerebral artery.
Figure 4. Pojtoperatilje iBjerrum’.r Jcreen chart).
after clipping
z’liual field perrmetry
Left Eye
Right Eye 1 Post Omrative
Figure 5. MR images (SE 1600180). CA) Internal cerebral zetn, ?,ein of Galen. and straight situ aneurysm (arrowheads) and clip artefact.
Visual Field Defect 1 demonstrated bJ their ‘;Aou kd.”
(B) TbromboJed
Surg Neurol 1990;33:48-51
Double Giant Fusiform Aneurysms
filling. The aneurysms were considered inappropriate for embolization. Occlusion of the posterior cerebral artery distal to the Pl perforators is relatively safe [2]. Persistent visual defect is unusual due to relatively good collateral blood supply, derived from both middle and anterior cerebral arteries. This patient had a homonymous hemianopia before operation, and no filling of the P4 segment of the vessel could be demonstrated on angiography. Therefore proximal occlusion, distal to the P 1 and P2 perforators, was the safest surgical option.
51
References Locksley HB. Report on the Cooperative Study of intracranial aneurysms and subarachnoid haemorrhage. V Pt. 1 Natural history of subarachnoid haemorrhage and arteriovenous maiformatrons; based on 6368 cases in the Cooperative Study. J Neurosurg 1966;25:215-39. Peerless Wilkins McGraw
SJ. Drake CG. Postertor RH. Rengachary SS, 4s. Hill, 1985: 1422-j’.
ctrculation aneurysms. In: Neurosurgery. New York:
Pia HW, Fontana H. Aneurysms of the posterior cerebral artery; locations and clinical pictures. Acta Neurochir 197’;38:11-35. Sundt TM Jr. Surgtcal technique Neurosurg Rev 1982;5:161-8.
for giant intracranial
aneurysms.
