J Cerebrovasc Endovasc Neurosurg.  2022 Mar;24(1):73-78. 10.7461/jcen.2022.E2021.05.002.

Endoport-assisted microsurgical treatment for a ruptured posterior cerebral artery aneurysm: A technical note

• Gómez-Amador JL
• Sangrador-Deitos MV
• Uribe-Pacheco R
• Guinto-Nishimura GY
• Mondragón-Soto MG

• KMID: 2527598
• DOI: http://doi.org/10.7461/jcen.2022.E2021.05.002

Abstract

Posterior Cerebral Artery aneurysms are scarce, yet its territory is frequently associated to large and giant aneurysms. Treatment is mostly a binary option between microsurgical clipping and endovascular coiling. Hybrid approaches are an option too, whereas innovation with less frequent techniques such as endoscope-controlled and endoscope-assisted procedure may provide a safer surgical approach with same successful results. Hereby we report a case of a 53 years old male examined at the ER after presenting generalized seizures and altered state of consciousness. Upon arrival, neurological evaluation revealed homonymous right hemianopia. Computed tomography (CT) scan revealed a subarachnoid hemorrhage and left parieto-occipital intraparenchymal hemorrhage with intraventricular extension; computed tomography angiogram (CTA) revealed an aneurysm at the left posterior cerebral artery (PCA) in its P4 segment. We performed a vascular exploration with drainage of the occipital and intraventricular hematoma through a single endoscopic port through transulcal approach guided by neuronavigation, in addition to clipping and aneurysmectomy. The combination of microsurgical clipping with previous Endoport-guided endoscopic procedure may be a surgical-operative option that not only may facilitate the approach to the desired lesion, but also provides a safer surgical scenario.

Keyword

Aneurysm; Endoscopic neurosurgery; Aneurysm clipping; Endoport; Vascular neurosurgery; Technical note

Figure

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  Fig. 1. (A) Preoperative axial CT scan showing subarachnoid hemorrhage with left parieto-occipital parenchymal hemorrhage with ventricular extension. No hydrocephalus nor midline deviation is observed. (B and C) Preoperative CTA: (B) Axial scan in which an irregular, hyperdense projection arising from the posterior circulation is observed (red circle), (C) 3D reconstruction shows a saccular aneurysm from the P4 segment of the left PCA. CT, computed tomography; CTA, computed tomography angiogram; PCA, posterior cerebral artery

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  Fig. 2. Surgical approach and findings. (A) 21 mm / 15 mm / 7 cm TC model Vycor Viewsite Brain Access System (VBAS) (Vycor MedicalTM, FL, USA). (B) After performing a tailored incision and craniotomy, the endoport was introduced through the interparietal sulcus. (C) Upper left inset: endoscopic view after arachnoid dissection, in which the aneurysm dome and neck can be observed (red circle), signaled by the neuronavigation probe (arrow). Upper right inset: axial, lower left inset: sagittal, and lower right inset: coronal reconstructions in the neuronavigation system in which the navigation probe (green line), hematoma (green continuous line), and aneurysm (pink circle) can be observed. (D) Arachnoid dissection of the perianeurysmatic architecture in order to achieve an adequate visualization of the aneurysm’s neck (arrowhead), at the tip of the suction probe (arrow). (E) Endoscopic view after aneurysm exclusion. A straight 7 mm clip was placed between the aneurysm’s dome (arrowhead) and the P4 segment of the posterior cerebral artery (arrow)

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  Fig. 3. Postoperative CT scan (A and B): axial reconstructions with no residual hemorrhage. (A) Aneurysm was trapped by clipping. (B) Left occipito-temporal hypodensity corresponding to an ipsilateral PCA remaining infarction. CT, computed tomography; PCA, posterior cerebral artery

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