P2-P3 junction aneurysm of the posterior cerebral artery

Aneurysms in the P2 segment arise between the junction of the posterior communicating artery (PCoA) with the PCA and the posterior part of the midbrain. The pterionalsubtemporal, temporopolar, transpetrous and transcortical transchoroidal fissure are the surgical approaches which have been used to gain access to P2 segment aneurysms.

Endovascular coil occlusion has rapidly evolved as a competing therapeutic alternative to surgical clipping in the treatment of P2 segment aneurysms.

However, surgery is still a well-established option for P 2 segment aneurysms and complete closure of the aneurysm can be achieved by surgical clipping 1).

Treatment

Proximal occlusion of PCA represents a treatment option. However, this procedure carries a high risk of ischemic complication

The STA-P3/PTA bypass through the subtemporal approach is a feasible option to maintain blood flow in cases of PCA fusiform aneurysms requiring trapping of the P2 segment 2).


Progressive deconstruction with flow diversion using a Pipeline embolization device (PED; Medtronic) can be utilized to promote thrombosis of broad-based fusiform aneurysms. Current flow diverters require a 0.027-inch microcatheter for deployment. Vakharia et al., presented a patient with a fusiform P2P3 junction posterior cerebral artery aneurysm in which they demonstrate the importance of haptics in microwire manipulation to recognize large-vessel anatomy versus perforator anatomy that may overlap, especially when access is needed in distal tortuous circulations. In addition, the authors demonstrate the need for appropriate visualization before PED deployment. Postembolization runs demonstrated optimal wall apposition with contrast stasis within the aneurysm dome.The video can be found here: https://youtu.be/8kfsSvN3XqM

 3).

References

1)

Zhitao J, Yibao W, Anhua W, Shaowu O, Yunchao B, Renyi Z, Yunjie W. Microsurgical subtemporal approach to aneurysms on the P(2) segment of the posterior cerebral artery. Neurol India. 2010 Mar-Apr;58(2):242-7. doi: 10.4103/0028-3886.63806. PubMed PMID: 20508343.
2)

Kawashima A, Andrade-Barazarte H, Jahromi BR, Oinas M, Elsharkawy A, Kivelev J, Kubota Y, Kawamata T, Hernesniemi JA. Superficial Temporal Artery: Distal Posterior Cerebral Artery Bypass through the Subtemporal Approach: Technical Note and Pilot Surgical Cases. Oper Neurosurg (Hagerstown). 2017 Jun 1;13(3):309-316. doi: 10.1093/ons/opw033. PubMed PMID: 28521345.
3)

Vakharia K, Munich SA, Waqas M, Setlur Nagesh SV, Levy EI. Deployment of distal posterior cerebral artery flow diverter in tortuous anatomy. Neurosurg Focus. 2019 Jan 1;46(Suppl_1):V9. doi: 10.3171/2019.1.FocusVid.18481. PubMed PMID: 30611181.

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