Intraoperative Angiography for Hunterian Ligation of a Recurrent Basilar Aneurysm

Abstract

Cerebral aneurysms often recur after selective endovascular treatment with detachable coils and are usually treated by recoiling. Sometimes, however, surgical treatment is required, and application of the clip can be difficult. Evacuation of embolic material risks injuring eloquent structures or perforators, especially in the posterior circulation. In such cases parent vessel occlusion for reversal of flow might be an option. If collateral flow is adequate, an additional bypass is not required. When using this technique, known as Hunterian ligation, intraoperative monitoring such as electrophysiological monitoring and intraoperative angiography can be of great help and are advisable. We describe this procedure and related intraoperative considerations in one case report.

Zusammenfassung

Zerebrale Aneurysmen können nach erfolgtem Coiling rezidivieren und werden meist mit einem erneuten Coiling verschlossen. Manchmal ist jedoch auch eine chirurgische Intervention notwendig und das Platzieren eines Clips kann sich auch schwierig gestalten. Ein Herausschneiden des embolischen Materials birgt das Risiko der Verletzung von eloquenten Strukturen oder Gefäßen, dies trifft insbesondere auf den hinteren Kreislauf zu. In solch einem Fall kann der Verschluss des Hauptgefäßes zur Flussumkehr eine Alternative darstellen. Bei ausreichend vorhandenem kollateralem Fluss ist ein zusätzlicher Bypass nicht notwendig. Bei dieser Ligation nach Hunter ist ein intraoperatives Monitoring sehr hilfreich. Neben den elektrophysiologischen Möglichkeiten ist gerade auch die intraoperative Angiographie hier von großer Bedeutung. Wir beschreiben diese Kombination der Techniken und die Überlegungen in einem illustrierten Fall.

Key words

intracranial aneurysm - parent vessel occlusion - intraoperative angiography

Schlüsselwörter

Intrakranielle Aneurysmen - Hauptgefäß-Verschluss - Intraoperative Angiographie

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Comment

These Hunterian ligations for complex basilar artery aneurysms have become rare since the development of endovascular techniques. Nonetheless, there is a substantial data base in the literature, e.g. Steinberg and Drake's account of the London/Ontario series [2]. Furthermore, I think that the recommendation to use SSEPs as a guide for basilar occlusion is dangerous, although critically discussed. One cannot be sure enough, that no critical perforator is compromised. In case of doubt with regard to to lerance of basilar occlusion, Dr. Drake used to occlude the basilar artery in these situations on the awake patient with the help of a small tourniquet. Local anaesthesia is certainly still the best method to monitor endovascular occlusion of critical arteries, such as carotid or vertebral arteries. The surgical variant of therapeutic occlusion is still an acceptable modality for the basilar artery since there are concerns to use balloon or coil occlusion, i.e. perforator compromise and the danger of dislodgement. Dr. Drake's method was somewhat tricky and is not suitable for occasional use. A balloon occlusion test may also be considered as a method to assess to lerance prior to permanent basilar artery occlusion [1].

References

1. Hartmann A , Conolly ES , Duong DH , Prestigiacomo CJ , Joshi S , Mohr JP , Mast H . Dysarthria during basilar artery balloon occlusion . Neurology 1999 ; Jul 22; 53(2) : 421 - 423

2. Steinberg GK , Drake CG , Peerless SJ . Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients . J Neurosurgery 1993 ; Aug; 79(2) : 161 - 173
   H.-J. Steiger, Düsseldorf

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