J Cerebrovasc Endovasc Neurosurg.  2020 Sep;22(3):141-155. 10.7461/jcen.2020.22.3.141.

Role of microsurgery for treatment of posterior circulation aneurysms in the endovascular era

• Kim DJ
• Heo Y
• Byun J
• Park JC
• Ahn JS
• Lee DH
• Kwun BD
• Park W

• KMID: 2506761
• DOI: http://doi.org/10.7461/jcen.2020.22.3.141

Abstract

Objective
Several studies have reported that the outcomes of endovascular treatment were superior to those of microsurgical treatment for posterior circulation aneurysms. Thus, this study compared outcomes of endovascular and microsurgical treatment for posterior circulation aneurysms and assess the usefulness of microsurgery in these patients.
Methods
Outcomes were retrospectively evaluated after endovascular and microsurgical treatment of 621 posterior circulation aneurysms. The 621 aneurysms included 187 treated by surgical clipping and 434 treated by endovascular coiling.
Results
In patients with unruptured aneurysms the rates of residual lesions and retreatment were significantly lower in those who underwent microsurgical than endovascular treatment. However immediate postoperative and 6 month follow-up Glasgow outcome scale (GOS) scores did not differ significantly in the two groups. In patients with ruptured aneurysms, the rates of residual lesions and retreatment were significantly lower in the microsurgery than in the endovascular treatment group. Even so immediate postoperative and 6 month follow-up GOS scores did not differ significantly in the two groups.
Conclusions
Endovascular treatment has increasingly become an alternative modality for microsurgery in posterior circulation aneurysm, whereas the indication for microsurgery is greatly reduced. However, the absolute number of microsurgery is maintained showing that it is a still valuable technique, as advances in endovascular or stent-assisted coiling have not solved many of the challenges inherent in the management of complex aneurysms. Hence, the advantages and limitations of both modalities must be carefully concerned in posterior circulation aneurysm to obtain favorable outcome.

Keyword

Endovascular procedures; Intracranial aneurysms; Microsurgery; Outcome; Posterior circulation

Figure

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  Fig. 1 (A) Three dimensional reconstruction of conventional cerebral angiography showing a fusiform aneurysm at the PCA. (B) A Coronal image with a T2 sequence at the level of the PCA dissecting aneurysm obtained through high-resolution magnetic resonance imaging. Black arrow indicates aneurysmal dilatation. (C) A Coronal image with a gadolinium-enhanced T1-weighted sequence at the level of the PCA dissecting aneurysm obtained through high-resolution magnetic resonance imaging. White arrow indicates intimal flap and double lumens. (D) Conventional cerebral angiography showing trapping of right proximal P2 segment of PCA. (E) Conventional cerebral angiography showing patent anastomosis of STA to the right distal P2 segment. PCA, posterior cerebral artery; STA, superficial temporal artery.

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  Fig. 2 (A) Three dimensional reconstruction of conventional cerebral angiography showing a superior cerebellar artery aneurysm. (B) Simple skull x-ray showing stent material (black arrow). (C) Conventional cerebral angiography following coil embolization showing complete obliteration of the aneurysm with coil mass (black arrow).

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  Fig. 3 (A) Three dimensional reconstruction of conventional cerebral angiography showing a vertebral artery aneurysm. (B) Conventional cerebral angiography after embolization showing complete obliteration of the aneurysm. (C) Follow-up angiography showing recurrence due to coil compaction. (D) Conventional cerebral angiography after additional coiling, showing complete obliteration of the aneurysm.

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  Fig. 4 (A) Number of microsurgery and endovascular treatment groups by year in total aneurysms. (B) Number of microsurgery and endovascular treatment groups by year in unruptured aneurysms. (C) Number of microsurgery and endovascular treatment groups by year in ruptured aneurysms.

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