Far Lateral Approach and Occipital Artery to Posterior Inferior Cerebellar Artery Bypass With Staged Flow Diversion for Treatment of De Novo Vertebrobasilar Junction Aneurysm: 2-Dimensional Operative Video

Intracranial aneurysms refractory to endovascular treatment often require complex cerebral revascularization strategies, includingcombined open-endovascular techniques.1-3An adolescent girl presented with headache, and a fusiform right V4 vertebral arteryaneurysm was diagnosed. Initial treatment was attempted with coil embolization. Surveillance imaging at 3 years after embolizationdemonstrated a de novo vertebrobasilar junction (VBJ) aneurysm with involvement of the right anterior inferior cerebellar artery-posterior inferior cerebellar artery (PICA) origin. The VBJ aneurysm was initially observed. Enlargement was noted at 1 year, andsecondary treatment was attempted withleft V3 segment coil occlusion to induceflow reversal. Follow-up demonstrated pro-gressive VBJ aneurysm enlargement, prompting attempted left occipital artery (OA)-PICA bypass at an outside facility, which wasunsuccessful. The patient was referred to our institution. Afterher parents gave informed consent, she underwent right OA-PICAbypass on the contralateral side through far lateral craniotomy with inside-out harvest of the donor vessel.4After trapping andarteriotomy of the recipient PICA, an OA-PICA end-to-side anastomosis was performed using a running continuous technique.5Intraoperative indocyanine green videoangiography and postoperative digital subtraction angiography confirmed patency of thebypass. The patient tolerated the procedure well and remained neurologically intact. On postoperative day 3, a staged trans-circulationflow diversion device was placed to facilitate progressivethrombosis of the aneurysm.6,7Follow-up angiography at 1 yeardemonstrated complete occlusion of the aneurysm. This video demonstrates successful multimodal management of a complex denovo VBJ aneurysm after a series of refractory endovascular treatments and unsuccessful cerebral revascularization techniques.