Combined Open Surgical and Endovascular Management of a Giant Posterior Cerebral Artery Aneurysm: 2-Dimensional Operative Video

A 17-year-old female patient presented with worsening intractable headaches which were initially diagnosed as migraine headaches. The patient's headaches were refractory to medical management and continued to worsen in both severity and frequency. Computed tomography angiography and digital subtraction angiography demonstrated a giant posterior cerebral artery aneurysm with contributions from the internal carotid artery through the posterior communicating artery. During the surgical planning period, the patient continued to have worsening headaches, intractable nausea, vomiting, left upper extremity weakness, and associated visual obfuscations. Repeated angiography revealed spontaneous thrombosis of the posterior communicating artery contribution with additional sudden onset hemianopsia on balloon test occlusion of the posterior cerebral artery, prompting urgent surgical intervention. A right subtemporal approach was used for a superficial temporal artery to posterior cerebral artery bypass, followed by coil occlusion of the aneurysm inlet at the posterior cerebral artery on postoperative day 1. The patient consented to the procedure. Postoperative angiography demonstrated successful superficial temporal artery to posterior cerebral artery anastomosis with occluded posterior cerebral artery after coiling. At 1-year follow-up, the patient remained neurologically intact with a patent bypass and regression of the trapped aneurysm. We present this case to demonstrate the successful management of a complex posterior cerebral artery aneurysm with both surgical bypass and endovascular parent artery coil occlusion. 1-6