OBJECTIVE Bilateral vertebral artery dissecting aneurysms (VADAs) have a poor prognosis because progressive enlargement of the aneurysms compresses the brainstem or causes subarachnoid hemorrhage. The trapping of 1 vertebral artery (VA) places increased hemodynamic stress on the contralateral VA and may lead to enlargement and rupture. Therefore, management strategies are controversial. This study describes a radical treatment for bilateral VADAs using bypass surgery. METHODS Seven patients with bilateral VADAs were included. Three patients were treated by trapping of 1 VA via coiling or clipping at another hospital; the previously treated VA in 1 patient and the contralateral untreated VA in 2 patients subsequently enlarged. The other 4 patients presented without previous intervention and progressive enlargement of the aneurysms. RESULTS The post-coil embolization patients underwent V-posterior cerebral artery (PCA) bypass and trapping. The other 4 patients underwent VA reconstruction via V-V or V-V bypass, with contralateral trapping on a separate day in 3 patients and observation in 1 patient. Perioperative complications included 1 case of cerebrospinal fluid leakage for which the patient required an additional operation, 1 case of dysphagia and facial palsy due to sigmoid sinus thrombosis, and 1 case of dysphagia. The long-term outcomes of these patients were favorable. CONCLUSIONS Patients with bilateral VADAs require treatment on both sides. If VA trapping is performed first, the treatment options for the other side are limited to V-PCA bypass and trapping. This procedure is effective; however, it is also invasive and technically difficult. In cases of bilateral VADAs in which it is feasible to reconstruct 1 side, the best approach is to begin by reconstructing the VA that appears technically easiest, followed by trapping of the contralateral VADA. This strategy allows enough time to suture vessels because contralateral reverse flow is maintained.

Although craniopharyngioma (CP) and pituitary adenoma (PA) are common tumors of the parasellar lesions, the coexistence of CP and PA is very rare. A 48-year-old male visited our hospital because of consciousness disturbance. The neuroimaging revealed a sellar tumor contact with a massive suprasellar cyst including calcification. Preoperative diagnosis was CP, and the patient underwent craniotomy to resolve the suprasellar mass effect. The histological examination disclosed adamantinomatous CP, and subsequently a transsphenoidal approach was chosen for the residual intrasellar tumor. Against expectations, the histological diagnosis was not CP but PA. The patient underwent gamma knife surgery for the residual tumor, and the postoperative course was good. After a 10-year follow-up, both lesions were still completely controlled. If we had suspected and diagnosed the tumor involved as not only CP but also PA at the first operation, the second operation could have been avoided because we would have chosen gamma knife surgery for the residual tumor. We should draw attention to this rare situation for differential diagnosis of parasellar tumor to avoid unnecessary surgery and to decide the best strategy for treatment. In addition, the biological behavior of collision tumors composed of CP and PA is probably the same as solitary CP or PA based on a long-term follow-up of our case.

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Summary: Giant and complex intracranial aneurysms are associated with poor prognosis because of the high risk of rupture, mass effects on the surrounding brain tissue, and a propensity to lead to the formation of emboli in the downstream vascular territories. The preferred treatment for these aneurysms is direct clipping, but this technique is typically unfeasible. Reconstruction of the main trunk (such as the internal carotid artery, middle cerebral artery, anterior cerebral artery, vertebral artery, or basilar artery) and aneurysm trapping may enable safe treatment for the lesion and simultaneously reduce the risk of ischemic complications. For safe reconstruction of the main trunk, back-up bypass and pressure monitoring during the operation are important. Back-up bypass can serve as a precautionary measure during vessel reconstruction if the reconstructed artery does not function adequately.Monitoring of the pressure in other branches of the back-up bypass is important for the estimation of performance of the reconstructed artery. If the main trunk is occluded as a blind end, delayed thrombosis may be observed. Thus, the preoperative strategy must avoid formation of a blind end. In case the perforating artery is injured, reconstruction using the superficial temporal artery or occipital artery should be attempted.