Intracranial arterial reconstructive surgery for unclippable aneurysms. An application of microvascular suturing

Intracranial arterial reconstructive techniques were used in three patients for whom conventional neck clipping was not feasible due to the size, location or symptoms of their aneurysms. In the first case, complicated by subarachnoid hemorrhage, a giant aneurysm in the right middle cerebral artery was excised and the stump of the parent arteries was reconstructed in end-to-end and end-to-side fashion. The second case had a large thrombosed aneurysm in the left vertebral artery compressing the medulla oblongata, with small perforators originating from the proximal posterior inferior cerebellar artery (PICA) feeding the brainstem. The PICA was transposed to cerebellar cortical artery and the aneurysm excised. The third case presented with TIA and small infarctions were observed in the left thalamus. A giant, partially thrombosed, aneurysm in the left posterior cerebral artery (PCA) was trapped with a revascularization of the distal PCA from the superior cerebellar artery in side-to-side fashion. Indications for these intracranial arterial reconstructions in aneurysmal surgery were discussed and pertinent literature was reviewed.