Abstract
Although rare, thrombosed vertebral artery aneurysms can lead to severe symptoms and are challenging to treat due to their proximity to vital structures. The location of a thrombosed aneurysm on the anterior aspect of the brainstem poses a significant challenge to conventional microscopic approaches. We herein report a 78-year-old man with a thrombosed right vertebral artery aneurysm who developed progressive quadriparesis, dysphagia, and respiratory failure despite prior interventions, including flow diverter stent placement, parent artery occlusion, and microscopic thrombectomy. Given worsening medullary compression and poor clinical status, intra-aneurysmal thrombectomy was performed using an exo-endoscopic 2-step approach. The procedure involved reopening the previous suboccipital craniotomy, partial condylectomy, and C1 hemilaminectomy. Exoscopic thrombus de-bulking was followed by endoscopic evacuation of the residual thrombus compressing the ventral brainstem. Postoperatively, no complication was observed, and the patient demonstrated gradual neurological improvement, including recovery of spontaneous respiration and the ability to wean from mechanical ventilation within 3 weeks. Follow-up imaging confirmed resolution of medullary compression without thrombus recurrence. The exo-endoscopic 2-step approach is a viable option for surgical decompression of thrombosed vertebral artery aneurysms that cause brainstem compression. This enhances surgical access and visualization, particularly in the ventral brainstem, while potentially minimizing brainstem manipulation. Further investigation is warranted to better define the indications, efficacy, and safety of the management of complex thrombosed aneurysms.