Successful combined treatment of a giant aneurysm of the posterior inferior cerebellar artery manifesting by brain stem compression

Giant aneurysms of the vertebrobasilar basin manifesting as brain stem compression are a rare pathology with an incidence ranging from 3 to 13,5 %. Surgery of such aneurysms is often associated with unsatisfactory treatment results due to the high traumatic nature of direct surgery on aneurysms of this region, as well as the close proximity of vital brain structures. Surgical intervention is also hampered by the large volume of the aneurysm, possible presence of thrombus in the sac, frequent absence of the neck, location in the anatomically difficult region, and small volume of the posterior cranial fossa (PCF). The above factors make it difficult to clip the aneurysm and increase the risk of perioperative complications. Endovascular intervention is a method of choice in most cases allowing to switch an aneurysm off the blood flow, however in the presence of mass effect aneurysm occlusion does not always achieve a clinical effect due to the preservation of brain stem compression. The aim of this publication was to demonstrate the possibility of successful combined surgical treatment of a giant aneurysm located in the PCF and accompanied by brain stem compression.

1. Сhoi I.S., David C. Giant intracranial aneurysms: development, clinical presentation and treatment. Eur J Radiol 2003; 46:178–94. doi: 10.1016/s0720-048x (03)00090-1.

2. Schubiger O., Valavanis A., Wichmann W. Growth-mechanism of giant intracranial aneurysms; demonstration by CT and MR imaging. Neuroradiology 1987; 29:266–71. doi: 10.1007/BF00451765. 

3. Morley T.P., Barr H.W.K.: Giant intracranial aneurysms: diagnosis, course, and management. Clin Neurosurg 16: 73-94, 1969 doi: 10.1093/neurosurgery/16.cn_suppl_1.73

4. Goroshchenko SA, Petrov AE, Rozhchenko LV, Blagorazumova GP, Vyazgina EM, Ivanov AY. Surgical treatment of large and giant vertebrobasilar aneurysms manifested by brainstem compression symptoms. Zh Vopr Neirokhir Im N N Burdenko. 2018;82(4):32-37. Russian. doi: 10.17116/neiro201882432.

5. Wiebers D.O., Whisnant J.P., Huston J., Meissner I., Brown R.D. Jr, Piepgras D.G., Forbes G.S., Thielen K., Nichols D., O'Fallon W.M., Peacock J., Jaeger L., Kassell N.F., Kongable-Beckman G.L., Torner J.C.; International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003 Jul 12;362(9378):103-10. doi: 10.1016/s0140-6736(03)13860-3

6. Sharma S. Evolution of Giant P2-Posterior Cerebral Artery Aneurysm over 16 Years: Saccular to Serpentine. A Case Report. Neuroradiol J. 2009;22(5):605-611. doi:10.1177/197140090902200514

7. Türe U., Elmaci I., Ekinci G., Pamir M.N. Totally thrombosed giant P2 aneurysm: a case report and review of literature. J Clin Neurosci. 2003 Jan;10(1):115-20. doi: 10.1016/s0967-5868(02)00276-x. 

8. Passero S, Rossi S, Giannini F, Nuti D. Brain-stem compression in vertebrobasilar dolichoectasia. A multimodal electrophysiological study. Clin Neurophysiol. 2001 Aug;112(8):1531-9. doi: 10.1016/s1388-2457(01)00597-1. PMID: 11459694

9. Goroshchenko SA, Sitovskaya DA, Petrov AE, Rozhchenko LV, Khristoforova MI, Samochernykh KA. Unfavorable outcome of giant vertebral artery aneurysm. Clinical case and literature review. Arkh Patol. 2021;83(4):45-51. Russian. doi: 10.17116/patol20218304145. PMID: 34278760.

10. Artmann H, Vonofakos D, Muller H, Grau H: Neuroradiologic and neuropathologic findings with growing giant intracranial aneurysm. Review of the literature. Surg Neurol 21:391–401, 1984. 

11. Hecht ST, Horton JA, Yonas H: Growth of a thrombosed giant vertebral artery aneurysm after parent artery occlusion. AJNR Am J Neuroradiol 12:449–451, 1991.

12. Katayama Y, Tsubokawa T, Miyazaki S, Furuichi M, Hirayama T, Himi K: Growth of totally thrombosed giant aneurysm within the posterior cranial fossa. Diagnostic and therapeutic considerations. Neuroradiology 33:168–170, 1991

13. Nagahiro S, Takada A, Goto S, Kai Y, Ushio Y: Thrombosed growing giant aneurysms of the vertebral artery: Growth mechanism and management. J Neurosurg 82:796–801, 1995 

14. Goroshchenko SA. Diagnosis and treatment of non-saccular vertebrobasilar aneurysms. Zh Vopr Neirokhir Im N N Burdenko. 2022;86(3):109-114. Russian. doi: 10.17116/neiro202286031109.

15. Iihara K, Murao K, Sakai N, Soeda A, Ishibashi-Ueda H, Yutani C, Yamada N, Nagata I: Continued growth of and increased symptoms from a thrombosed giant aneurysm of the vertebral artery after complete endovascular occlusion and trapping: The role of vasa vasorum. Case report. J Neurosurg 98:407–413, 2003

16. Aydin F: Do human intracranial arteries lack vasa vasorum? A comparative immunohistochemical study of intracranial and systemic arteries. Acta Neuropathol 96:22–28, 1998

17. Nakatomi H, Segawa H, Kurata A, Shiokawa Y, Nagata K, Kamiyama H, Ueki K, Kirino T: Clinicopathological study of intracranial fusiform and dolichoectatic aneurysms: Insight on the mechanism of growth. Stroke 31:896–900, 2000

18. Butterfield JT, Chen CC, Grande AW, Jagadeesan B, Tummala R, Venteicher AS. The Rate of Symptomatic Ischemic Events after Passing Balloon Test Occlusion of the Major Intracranial Arteries: Meta-Analysis. World Neurosurg. 2021 Feb;146:e1182-e1190. doi: 10.1016/j.wneu.2020.11.134

19. Shimizu H, Matsumoto Y, Tominaga T. Parent artery occlusion with bypass surgery for the treatment of internal carotid artery aneurysms: clinical and hemodynamic results. Clin Neurol Neurosurg. 2010;112:32-39

20. Snelling BM, Sur S, Shah SS, Wolfson RI, Ambekar S, Yavagal DR, Elhammady MS, Peterson EC. Venous Phase Timing Does Not Predict SPECT Results During Balloon Test Occlusion of the Internal Carotid Artery. World Neurosurg. 2017 Jun;102:229-234. doi: 10.1016/j.wneu.2017.03.023. 

21. Sivakumaran R, Mohamed AZ, AkhunbayFudge CY, Edwards RJ, Renowden SA, Nelson RJ. Internal carotid artery test balloon occlusion using single photon emission computed tomography scan in the management of complex cerebral aneurysms and skull base tumors: a 20-year review. World Neurosurg. 2020;139:e32-e37.

22. Segal DH, Sen C, Bederson JB, Catalano P, Sacher M, Stollman AL, Lorberboym M. Predictive value of balloon test occlusion of the internal carotid artery. Skull Base Surg. 1995;5(2):97-107. doi: 10.1055/s-2008-1058940.

23. Schneweis S, Urbach H, Solymosi L, Ries F. Preoperative risk assessment for carotid occlusion by transcranial Doppler ultrasound. J Neurol Neurosurg Psychiatry. 1997;62:485-489