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BACKGROUND: Unlike in aneurysms of the adult-type posterior cerebral artery (PCA), in aneurysms of the fetal-type PCA, parent artery occlusion (PAO) results in vascular insufficiency and major ischemic strokes. Preservation or reconstruction of fetal-type PCAs is necessary to prevent these complications. Furthermore, it is necessary to select an appropriate bypass method and approach for revascularization of the PCA. OBSERVATIONS: The authors report 2 cases of aneurysms of fetal-type PCAs that were successfully treated with PAO with revascularization. A 38-year-old man with a large unruptured right PCA aneurysm at the postcommunicating (P2) segment underwent trapping with superficial temporal artery-PCA bypass via the anterior temporal and subtemporal approaches. In addition, a 45-year-old woman with a left PCA aneurysm at the quadrigeminal (P3)-cortical (P4) segments resulting in subarachnoid hemorrhage underwent proximal clipping of the P3 segment via the occipital interhemispheric approach with an occipital artery-PCA bypass. Although she had perforator infarction, major ischemic stroke was prevented, and aneurysm occlusion was accomplished in both cases. LESSONS: Aneurysms of fetal-type PCAs pose a risk of ischemia due to PAO. The combined use of bypass and revascularization should be considered to prevent major ischemic stroke after occlusion of the fetal-type PCA. However, perforator infarction is a concern.

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OBJECTIVE: To evaluate the incidence of nonconvulsive status epilepticus (NCSE) after surgery for ruptured intracranial aneurysms, to define factors associated with this complication, and to determine its impact on the outcome. PATIENTS AND METHODS: Clinical and neurophysiological data of 66 patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent continuous EEG (cEEG) monitoring after microsurgical clipping (53 cases) or endovascular coiling (13 cases) of the ruptured aneurysm were analyzed retrospectively. The diagnosis of NCSE was based on the American Clinical Neurophysiology Society and Salzburg Consensus criteria. RESULTS: NCSE was revealed in 10 patients (15 %), all of whom underwent craniotomy and aneurysm clipping. In comparison to the subgroup without NCSE, among those who were diagnosed with this complication there was a significantly greater proportion of men (70 % vs. 34 %; P = 0.041), cases with the Glasgow Coma Scale score at admission < 13 (90 % vs. 36 %; P = 0.004), the Hunt and Hess aSAH grades 3-5 (90 % vs. 45 %; P = 0.013), and hydrocephalus (70 % vs. 29 %; P = 0.044). In addition, they required a significantly longer hospital stay (medians, 62.5 vs. 39.5 days; P = 0.015) and showed trend for the lower rate of favorable disability outcomes (20 % vs. 54 %; P = 0.084). CONCLUSIONS: NCSE is encountered rather often after the microsurgical clipping of ruptured intracranial aneurysms, especially in severely disabled patients with high-grade aSAH and/or associated hydrocpephalus, and may significantly affect the clinical course and prolong recovery. cEEG monitoring may be helpful for timely diagnosis and treatment of this complication.

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Intracranial arterial microanastomosis remains an important neurosurgical technique. Intimal dissection of donor or recipient arteries can cause bypass failure. We used a silicone rubber stent while performing arterial microanastomoses, and achieved an excellent postoperative patency rate. In this study, we evaluated the efficacy of the stent in cases of extensive intimal dissection. In 5 cases involving extensive intimal dissection of vessels out of a total of 856 microanastomoses that were performed between November 2000 and August 2014, we placed a silicone rubber stent in the lumen of the recipient artery for donor to recipient suturing. Surgery was performed in 3 cases of cerebrovascular atherosclerotic disease and in 2 cases requiring cerebral revascularization for the treatment of aneurysm recurrence. In one of the 5 cases in which arterial microanastomosis was performed in the spasm period after subarachnoid hemorrhage, a patent anastomosis could not be confirmed. We observed the following advantages of silicone stent use: clear visualization of the orifice created in the vessel, avoidance of suturing or damaging the contralateral side vessel edges, and maintenance of the shape of the anastomosed vessel segment. These advantages made it easier to visualize the intima and to achieve fixation by using tacking sutures.

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