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Table of Contents    
COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 2  |  Page : 325-326

Role of Parent Artery Sacrifice in the Treatment of Posterior Cerebral Artery Aneurysms


1 Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
2 Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA

Date of Web Publication15-May-2020

Correspondence Address:
Rimal H Dossani
Department of Neurosurgery, PO BOX 33932, 1501 King's Highway, Shreveport, LA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.284368

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How to cite this article:
Dossani RH, Smolar D, Waqas M. Role of Parent Artery Sacrifice in the Treatment of Posterior Cerebral Artery Aneurysms. Neurol India 2020;68:325-6

How to cite this URL:
Dossani RH, Smolar D, Waqas M. Role of Parent Artery Sacrifice in the Treatment of Posterior Cerebral Artery Aneurysms. Neurol India [serial online] 2020 [cited 2020 May 30];68:325-6. Available from: http://www.neurologyindia.com/text.asp?2020/68/2/325/284368




We read with interest the article by Singh et al. on the treatment of posterior cerebral artery (PCA) aneurysms with parent artery sacrifice.[1] The authors should be congratulated on undertaking a thorough evaluation of their endovascular experience with both ruptured and unruptured PCA aneurysms, which are rare and account for approximately 1% of all intracranial aneurysms. The authors present a series of 11 patients with PCA aneurysms, of which six were treated with parent vessel sacrifice. Of the 5 PCA aneurysms presenting with subarachnoid hemorrhage (SAH), four were treated with parent vessel sacrifice and one with primary coil embolization, thereby avoiding dual antiplatelet therapy in the setting of SAH. Two unruptured PCA aneurysms were treated with stent-assisted coiling (LVIS jr in one case and FRED in another). The aneurysm morphology included five fuso-saccular PCA aneurysms and four giant PCA aneurysms. Of the six patients who underwent parent vessel sacrifice, none of the patients developed significant vision loss and one developed transient hemiparesis. The lack of significant visual symptoms demonstrates the safety of parent vessel sacrifice in select patients with PCA aneurysms.

Treatment options for large PCA aneurysms are generally divided into two groups: deconstructive and reconstructive. Endovascular deconstructive options include parent vessel sacrifice (1) proximal to aneurysm alone or (2) both proximal and distal to aneurysm (also known as aneurysm trapping). Endovascular reconstructive options include primary coiling, balloon-assisted coiling and stent-assisted coiling with preservation of the parent vessel. In a similar case series, Arat et al. reported only one case of occipital infarction in eight cases of parent vessel sacrifice for large and fusiform distal PCA aneurysms.[2] The PCA is amenable to sacrifice due to rich collateral anastomoses: the temporal MCA branches anastomose with temporal PCA branches, the splenial PCA branches join with the pericallosal ACA branches, the short and long circumflex PCA branches receive collaterals from the SCA. However, anastomotic connections between the thalamoperforating branches arising from the P1 are absent in about 20% of cases.[3] While it is critical to preserve the perforators arising from the P1 segment, PCA sacrifice distal to the posterior communicating artery (P2 segment and beyond) is generally safe and reported to cause visual deficits in only about 17% of cases.[4]

Endovascular treatment options have been shown to be superior to open neurosurgical options for distal PCA aneurysms. A critical evaluation of the occipital artery to posterior cerebral artery bypass showed that bypass techniques for the treatment of distal PCA aneurysms are associated with a higher rate of complications and should be reserved in patients who fail balloon-test occlusion or those who refuse parent vessel sacrifice.[5] As much as possible, endovascular methods should aim to preserve the parent vessel. However, in extenuating circumstances when parent vessel preservation is either not feasible or requires the use of stents and consequent dual antiplatelet therapy, which may be problematic in the setting of SAH, PCA sacrifices distal to the P2 segment is a safe and acceptable alternative.

It is advantageous to perform balloon-test occlusion with the patient awake to allow real-time evaluation for neurological deficits prior to parent vessel sacrifice. Also, mean arterial pressure may be reduced to 70% of baseline during balloon-test occlusion to evaluate the strength of collateral supply to the territory at risk. If the patient tolerates balloon test occlusion with MAP reduction, the parent vessel is safe to sacrifice, as its territory is likely well collateralized. In patients who do not tolerate balloon-test occlusion, strong consideration should be given to endovascular techniques allowing parent artery preservation or to neurosurgical techniques such as clip reconstruction or bypass.



 
  References Top

1.
Singh V, Phadke RV, Agarwal V, Behari S, Neyaz Z, Chauhan G. Posterior cerebral Artery Aneurysms: Parent Vessel Occlusion Being a Viable Option in Era of Flowdivertors. Neurol India 2020;68: 307-13.  Back to cited text no. 1
    
2.
Arat A, Islak C, Saatci I, Kocer N, Cekirge S. Endovascular parent vessel occlusion in large-giant or fusiform distal posterior cerebral artery aneurysms. Neuroradiology 2002;44:700-5.  Back to cited text no. 2
    
3.
Marinkovic SV, Milisavlievic MM, Kovacevic MS. Anatomoses among the thalamoperforating branches of the posterior cerebral artery. Arch Neurol 1986;43:811-4.  Back to cited text no. 3
    
4.
Sishteh AH, Smith KA, McDougall CG, Spetzler RF. Distal posterior cerebral artery revascularization in multimodality management of complex peripheral posterior cerebral artery aneurysms. Neurosurgery 1998;43:166-70.  Back to cited text no. 4
    
5.
Chang SW, Abla AA, Kakarla UK, Sauvageau E, Dashti SR, Nakaji P, Zabramski JM, et al. Treatment of distal posterior cerebral artery aneurysms: A critical appraisal of the occipital artery-to-posterior cerebral artery bypass. Neurosurgery 2010;67:16-26.  Back to cited text no. 5
    




 

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