Клипирование аневризмы ствола базилярной артерии из keyhole-ретросигмовидного доступа, дополненного эндоскопической ассистенцией (клинический случай и обзор литературы)

Несмотря на увеличивающееся с каждым годом число эндоваскулярных вмешательств на аневризмах базилярной артерии, сохраняется определенная частота неблагоприятных исходов. С приходом в арсенал нейрохирургов эндоскопической ассистенции возможности открытых вмешательств на церебральных аневризмах расширились, позволяя минимизировать размеры доступов, не изменяя ширину микрохирургических коридоров.

Описано клиническое наблюдение успешного клипирования аневризмы ствола базилярной артерии с использованием ретросигмовидного доступа, дополненного эндоскопической ассистенцией.

Данный клинический случай демонстрирует возможность успешного клипирования аневризмы ствола базилярной артерии, не прибегая к широкому доступу, но с оптимальной визуализацией шейки и купола как до, так и после клипирования, а также с минимальными рисками повреждений важных парастволовых анатомических образований, что в конечном итоге позволяет достичь благоприятного результата. Минимально инвазивные доступы в сочетании с эндоскопической ассистенцией могут быть альтернативой как традиционным доступам, так и эндоваскулярной эмболизации.

1. Inoue Y, Mikami J, Omiya N, Okawara S. Subtemporal transpetrosal approach to ruptured midbasilar trunk aneurysm. Skull Base Surg. 1992;2(2):98–102. https://doi.org/10.1055/s‑2008–1057118

2. Locksley HB. Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section V part 1 Natural history of subarachnoid hemorrhage intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the Cooperative Study. J Neurosurg. 1966;25:219–239. https://doi.org/10.3171/jns.1966.25.2.0219

3. Куканов К. К., Тастанбеков М. М., Олюшин В. Е., Пустовой С. В., Пряников М. В. Менингиомы большого затылочного отверстия: обзор литературы и случай из практики. Российский нейрохирургический журнал им. профессора А. Л. Поленова. 2015;7(1):62–72. EDN: AYGUHH

4. Nakabayashi K, Negoro M, Itou Y, Ichihara K. Endovascular Approach vs Microsurgical Approach for Posterior Circulation Aneurysms. Interv Neuroradiol. 1997;3(suppl 2):171–6. https://doi.org/10.1177/15910199970030S 236

5. Крылов В. В., Дашьян В. Г., Винокуров А. Г. Микрохирургия аневризм сосудов головного мозга. М.: АБВ-пресс; 2022. EDN: IVKOCL

6. Lozier AP, Kim GH, Sciacca RR, Connolly ES Jr, Solomon RA. Microsurgical treatment of basilar apex aneurysms: perioperative and long-term clinical outcome. Neurosurgery. 2004;54(2):286–96; discussion 296–9. https://doi.org/10.1227/01.neu.0000103222.13642.00

7. Qu S, Lv X, Wu Z. Clinical outcomes of basilar artery aneurysms. Neuroradiol J. 2009;22(2):228–38. https://doi.org/10.1177/197140090902200215

8. Winkler EA, Lee A, Yue JK, Raygor KP, Rutledge WC, Rubio RR, Josephson SA, Berger MS, Raper DM S, Abla AA. Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era. Acta neurochirurgica. 2021;163:1527–1540. https://doi.org/10.1007/s00701‑021‑04803‑5

9. Fiorella D, Hsu D, Woo HH, Tarr RW, Nelson PK. Very late thrombosis of a pipeline embolization device construct: case report. Neurosurgery. 2010;67(suppl 3): 313–4; discussion 314. https://doi.org/10.1227/01.NEU.0000383875.08681.23

10. van Rooij WJ, Sluzewski M. P erforator infarction after placement of a pipeline flow-diverting stent for an unruptured A1 aneurysm. AJ NR Am J Neuroradiol. 2010;31(4):43–4. https://doi.org/10.3174/ajnr.A2034

11. Kato Y, Sano H, Behari S, Kumar S, Nagahisa S, Iwata S, Kanno T. Surgical clipping of basilar aneurysms: relationship between the different approaches and the surgical corridors. Minim Invasive Neurosurg. 2002;45(3):142–5. https://doi.org/10.1055/s‑2002–34351

12. Spetzler RF, Kalani Y, Nakaji P. Neurovascular Surgery. 2nd ed. Thieme Medical Publishers; 2015. https://doi.org/10.1055/b‑0035–122313

13. Drake CG. Bleeding aneurysms of the basilar artery. Direct surgical management in four cases. J Neurosurg 1961;18:230–238. https://doi.org/10.3171/jns.1961.18.2.0230

14. Drake CG. The surgical treatment of aneurysms of the basilar artery. J Neurosurg 1968;29:436–446. https://doi.org/10.3171/jns.1968.29.4.0436

15. Sugita K, Kobayashi S, Takemae T, Tada T, Tanaka Y. Aneurysms of the basilar artery trunk. J Neurosurg. 1987;66(4):500–5. https://doi.org/10.3171/jns.1987.66.4.0500

16. Mizoi K, Yoshimoto T, Takahashi A, Ogawa A. Direct clipping of basilar trunk aneurysms using temporary balloon occlusion. J Neurosurg. 1994;80(2):230–6. https://doi.org/10.3171/jns.1994.80.2.0230

17. Taki W, Nakahara I, Sakai N, Irie K, Murao K, Ohkata N, Tanaka M, Kikuchi H. L arge and giant middle to lower basilar trunk aneurysms treated by surgical and interventional neuroradiological methods. Neurol Med Chir (Tokyo). 1998;38(12):826–34; discussion 834–5. https://doi.org/10.2176/nmc.38.826

18. Terasaka S, Itamoto K, Houkin K. Basilar trunk aneurysm surgically treated with anterior petrosectomy and external carotid artery-toposterior cerebral artery bypass: technical note. Neurosurgery. 2002;51(4):1083–7; discussion 1087–8. https://doi.org/10.1097/00006123‑200210000‑00044

19. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P. International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366(9488):809–17. https://doi.org/10.1016/S 0140–6736 (05) 67214‑5

20. Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, Nakaji P, Wallace RC. The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg. 2013;119(1):146–57. https://doi.org/10.3171/2013.3.JNS 12683

21. Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RDJr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O’Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner J C. International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362(9378):103–10. https://doi.org/10.1016/s0140–6736 (03) 13860‑3

22. Sanai N, Tarapore P, Lee AC, Lawton MT. The current role of microsurgery for posterior circulation aneurysms: a selective approach in the endovascular era. Neurosurgery. 2008;62(6):1236–49; discussion 1249–53. https://doi.org/10.1227/01.neu.0000333295.59738.de

23. Sekhar LN, Tariq F, Morton RP, Ghodke B, Hallam DK, Barber J, Kim LJ. Basilar tip aneurysms: a microsurgical and endovascular contemporary series of 100 patients. Neurosurgery. 2013;72(2):284–98; discussion 298–9. https://doi.org/10.1227/NEU.0b013e3182797952

24. Naggara ON, White PM, Guilbert F, Roy D, Weill A, Raymond J. Endovascular Treatment of Intracranial Unruptured Aneurysms: Systematic Review and Meta-Analysis of the Literature on Safety and Efficacy. Radiology. 2010;256:887–97. https://doi.org/10.1148/radiol.10091982

25. Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A , Lamoureux J, Chagnon M, Roy D. Long-Term Angiographic Recurrences After Selective Endovascular Treatment of Aneurysms With Detachable Coils. Stroke. 2003;34:1398–403. https://doi.org/10.1161/01.STR.0000073841.88563.E 9

26. Lecler A, Raymond J, Rodriguez-Régent C, Shareef FA, Trystram D, Godon-Hardy S, Hassen WB, Meder JF, Oppenheim C, Naggara ON. Intracranial Aneurysms: Recurrences More than 10 Years after Endovascular Treatment-A Prospective Cohort Study, Systematic Review, and Meta-Analysis. Radiology 2015;277:173–80. https://doi.org/10.1148/radiol.2015142496

27. Soize S, Gawlitza M, Raoult H, Pierot L. Imaging Follow-Up of Intracranial Aneurysms Treated by Endovascular Means: Why, When, and How? Stroke. 2016;47(5):1407–12. https://doi.org/10.1161/STROKEAHA.115.011414

28. Lanzino G, Murad MH, d’Urso PI, Rabinstein AA. Coil embolization versus clipping for ruptured intracranial aneurysms: a meta-analysis of prospective controlled published studies. AJ NR Am J Neuroradiol. 2013;34(9):1764–8. https://doi.org/10.3174/ajnr.A3515

29. Li H, Pan R, Wang H, Rong X, Yin Z, Milgrom DP, Shi X, Tang Y, Peng Y. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke. 2013;44(1):29–37. https://doi.org/10.1161/STROKEAHA.112.663559

30. Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Nakaji P, Karis JP , Wallace RC. Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg. 2019;132(3):771–776. https://doi.org/10.3171/2018.8.JNS181846

31. Johnston SC, Dowd CF, Higashida RT, Lawton MT, Duckwiler GR, Gress DR. CARAT Investigators. Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the Cerebral Aneurysm Rerupture After Treatment (CARA T) study. Stroke. 2008;39(1):120–5. https://doi.org/10.1161/STROKEAHA.107.495747

32. Munich SA, Cress MC, Rangel-Castilla L, Sonig A, Ogilvy CS, Lanzino G, Petr O, Mocco J, Morone PJ, Snyder KV, Hopkins LN, Siddiqui AH, Levy EI. Neck Remnants and the Risk of Aneurysm Rupture After Endovascular Treatment With Coiling or Stent-Assisted Coiling: Much Ado About Nothing? Neurosurgery. 2019;84(2):421–427. https://doi.org/10.1093/neuros/nyy056

33. Darflinger R, Thompson LA, Zhang Z, Chao K. R ecurrence, retreatment, and rebleed rates of coiled aneurysms with respect to the Raymond-Roy scale: a meta-analysis. J Neurointerv Surg. 2016;8(5):507–11. https://doi.org/10.1136/neurintsurg‑2015–011668

34. Giannotta SL, Maceri DR. Retrolabyrinthine transsigmoid approach to basilar trunk and vertebrobasilar artery junction aneurysms. Technical note. J Neurosurg. 1988;69(3):461–6. https://doi.org/10.3171/jns.1988.69.3.0461

35. Kawase T, Toya S, Shiobara R, Mine T. Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg. 1985;63(6):857–61. https://doi.org/10.3171/jns.1985.63.6.0857

36. Motoyama Y, Ohnishi H, Koshimae N, Kanemoto Y, Kim YJ, Yamada T, Kobitsu K. D irect clipping of a large basilar trunk aneurysm via the posterior petrosal (extended retrolabyrinthine presigmoid) approach — case report. Neurol Med Chir (Tokyo). 2000;40(12):632–6. https://doi.org/10.2176/nmc.40.632

37. Seifert V. Direct surgery of basilar trunk and vertebrobasilar junction aneurysms via the combined transpetrosal approach. Neurol Med Chir (Tokyo). 1998;38(suppl):86–92. https://doi.org/10.2176/nmc.38.suppl_86

38. Fischer J, Mustafa H. Endoscopic-guided clipping of cerebral aneurysms. Br J Neurosurg. 1994;8(5):559–65. https://doi.org/10.3109/02688699409002948

39. Perneczky A, Boecher-Schwarz HG. Endoscope-assisted microsurgery for cerebral aneurysms. Neurol Med Chir (Tokyo). 1998;38(suppl):33–4. https://doi.org/10.2176/nmc.38.suppl_33

40. Kato Y, Sano H, Nagahisa S, Iwata S, Yoshida K, Yamamoto K, Kanno T. Endoscope-assisted microsurgery for cerebral aneurysms. Minim Invasive Neurosurg. 2000;43(2):91–7. https://doi.org/10.1055/s‑2000–12260

41. Kalavakonda C, Sekhar LN, Ramachandran P, Hechl P. Endoscopeassisted microsurgery for intracranial aneurysms. Neurosurgery. 2002;51(5):1119–26; discussion 1126–7. https://doi.org/10.1097/00006123‑200211000‑00004

42. Galzio RJ, Di Cola F, Raysi Dehcordi S, Ricci A, De Paulis D. Endoscope-assisted microneurosurgery for intracranial aneurysms. Front Neurol. 2013;4:201. https://doi.org/10.3389/fneur.2013.00201

43. Peris-Celda M, Da Roz L, Monroy-Sosa A, Morishita T, Rhoton AL Jr. Surgical anatomy of endoscope-assisted approaches to common aneurysm sites. Neurosurgery. 2014;10(suppl1):121–44; discussion 144. https://doi.org/10.1227/NEU.0000000000000205

44. Джинджихадзе Р. С., Древаль О. Н., Лазарев В. А., Камбиев Р. Л., Богданович И. О. Трансциллиарный миниорбитозигоматический keyhole доступ к аневризмам верхних отделов основной артерии. Клинический пример и обзор литературы. Российский нейрохирургический журнал им. профессора А. Л. Поленова. 2017; 9(1):69–74. EDN: LGIPTF

45. Джинджихадзе Р. С., Древаль О. Н., Лазарев В. А., Поляков А. В., Камбиев Р. Л., Давудов А. М. Эндоскопическая ассистенция при keyhole-доступах в хирургии церебральных аневризм. Журнал «Вопросы нейрохирургии» имени Н. Н. Бурденко. 2018;82(4):38–44. https://doi.org/10.17116/neiro201882438.