title: Flow diversion radial artery bypass graft coupled with terminal basilar artery occlusion for the treatment of complex basilar apex aneurysms: operative nuances.
abstract: BACKGROUND
  A subset of basilar apex aneurysms are unsuitable for either primary microsurgical clipping or endovascular coiling. These complex aneurysms can be treated by terminal basilar artery occlusion, but only if collateral circulation is adequate. To circumvent these complications, a high-flow vertebral artery-posterior cerebral artery or middle cerebral artery-posterior cerebral artery bypass may be performed to create an adequate collateral circulation to allow treatment of the aneurysm by basilar artery occlusion and/or clipping.
  
  
  OBJECTIVE
  To discuss the operative nuances of this approach in the case of a 47-year-old man with progressive hemiparesis resulting from brainstem compression from a giant, unruptured basilar apex aneurysm with absent posterior communicating artery collaterals and incorporation of bilateral superior cerebellar arteries and posterior cerebral arteries within the aneurysm neck.
  
  
  METHODS
  The patient underwent a staged bypass from V3 to P2 coupled with terminal basilar artery occlusion.
  
  
  RESULTS
  The patient initially presented as modified Rankin Scale score 2 with right hemiparesis. The aneurysm ruptured after the first stage of the operation, and the patient underwent a V3 to P2 bypass the next day. His postprocedural neurologic decline improved at the 14-month follow-up to modified Rankin Scale score 2, with substantial reduction in aneurysm size observed at 9 months. The outcomes for 3 other bypass cases for basilar apex aneurysms are also summarized.
  
  
  CONCLUSIONS
  : We discuss the indications, preoperative diagnostic workup, operative management, and postoperative outcomes in managing challenging basilar apex aneurysms. In our experience, high-flow bypass procedures with or without hunterian ligation in the treatment of these aneurysms are well tolerated with good long-term results.
authors: Department of Neurosurgery, University of Washington, Seattle, WA, USA.
authors: Jeffrey C
authors: JC
authors: Mai
authors: Farzana
authors: F
authors: Tariq
authors: Louis J
authors: LJ
authors: Kim
authors: Laligam N
authors: LN
authors: Sekhar
mesh_terms: D001488:Basilar Artery / Q000601:surgery*; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D013525:Surgical Instruments; D060205:Therapeutic Occlusion / Q000295:instrumentation / Q000379:methods*; D013997:Time Factors; D014656:Vascular Surgical Procedures / Q000295:instrumentation / Q000379:methods*