scholarly journals Microneurosurgical Management of Posterior Inferior Cerebellar Artery Aneurysms: Results of a Consecutive Series

2021 ◽  
pp. 33-38
Author(s):  
Mattia Del Maestro ◽  
Sabino Luzzi ◽  
Renato Galzio
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Lateral Approach ◽  
Senior Author ◽  
Preoperative Imaging ◽  
Imaging Evaluation ◽  
Complex Anatomy ◽  
Cerebellar Artery ◽  
Pica Aneurysms

AbstractAneurysms of the posterior inferior cerebellar artery (PICA) are uncommon. The complex anatomy of PICA and its intimate relationships with medulla, lower cranial nerves, and jugular tubercle makes the surgical treatment of these aneurysms fascinating. The reported is study aimed at a critical review of the overall results of a personal series of PICA aneurysms, treated by the senior author, R. Galzio. Demographics, charts, videos, outcome, and follow-up of a cohort of PICA aneurysms managed in the last 10 years were retrospectively analyzed, focusing only upon those treated with microneurosurgery. Twenty-five patients, harboring a single aneurysm, were operated on. Fifteen aneurysms were ruptured. Nineteen were proximal, all of these being been treated through a far-lateral approach. Trans-condylar or trans-tubercular variants were rarely necessary and however reserved to peculiar cases. Twenty-three aneurysms underwent direct treatment consisting of clip ligation. At 6-month follow-up, 60% of patients had a modified Rankin Score (mRS) of 0–2. Given the high anatomical variability of both PICA and patients’ bony anatomy, a case-by-case meticulous preoperative imaging evaluation is mandatory for the choice of the most suitable and tailored surgical corridor which, in turn, is pivotal to achieve the best outcome.

Trapping and P2-P3 Posterior Inferior Cerebellar Artery Reanastomosis for Treatment of a Ruptured Fusiform Aneurysm: Application of Fourth-Generation Technique: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Tyler T Lazaro ◽  
Visish M Srinivasan ◽  
Patrick C Cotton ◽  
Jacob Cherian ◽  
Jeremiah N Johnson
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Lateral Approach ◽  
Fourth Generation ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Close Proximity ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Distal Artery

Abstract Aneurysms of the posterior inferior cerebellar artery (PICA) represent the second most common posterior circulation aneurysm and commonly have complex morphology. Various bypass options exist for PICA aneurysms,1-6 depending on their location relative to brainstem perforators and the vertebral artery, and the presence of nearby donor arteries. We present a case of a man in his late 40s who presented with 3 d of severe headache. He was found to have a fusiform right P2-segment PICA aneurysm. Preoperative angiogram demonstrated the aneurysm and a redundant P3 caudal loop that came in close proximity to the healthy P2 segment proximal to the aneurysm. The risks and benefits of the procedure were discussed with the patient, and they consented for a right far lateral approach craniotomy with partial condylectomy for trapping of the aneurysm with bypass. The aneurysm was trapped proximally and distally. The P3 was transected just distal to the aneurysm and brought toward the proximal P2 segment, facilitated by a lack of perforators on this redundant distal artery. An end-to-side anastomosis was performed. Postoperative angiogram demonstrated exclusion of the aneurysm and patent bypass. The patient recovered well and remained without any neurological deficit at 6-mo follow-up.  This case demonstrates the use of a “fourth-generation”5,7,8 bypass technique. These techniques represent the next innovation beyond third-generation intracranial-intracranial bypass. In this type 4B reanastomosis bypass, an unconventional orientation of the arteries was used. Whereas reanastomosis is typically performed end-to-end, the natural course of these arteries and the relatively less-mobile proximal P2 segment made end-to-side the preferred option in this case. Fourth-generation bypass techniques open up more configurations for reanastomosis, using the local anatomy to the surgeon's advantage.  The patient consented to the described procedure and consented to the publication of their image.

Endovascular Surgery for Proximal Posterior Inferior Cerebellar Artery Aneurysms: An Analysis of Glasgow Outcome Score by Hunt-Hess Grades

Neurosurgery ◽  
2006 ◽  
Vol 58 (4) ◽  
pp. 619-625 ◽  
Author(s):  
Robert A. Mericle ◽  
Adam S. Reig ◽  
Matthew V. Burry ◽  
Eric Eskioglu ◽  
Christopher S. Firment ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Endovascular Surgery ◽  
Glasgow Outcome Score ◽  
Clinical Grade ◽  
Outcome Score ◽  
Fisher Grade ◽  
Cerebellar Artery ◽  
Pica Aneurysms ◽  
Angiographic Result

Abstract OBJECTIVE: Proximal posterior inferior cerebellar artery (PICA) aneurysms represent a subset of posterior circulation aneurysms that can be routinely treated with either clipping or coiling. The literature contains limited numbers of patients with proximal PICA aneurysms treated with endovascular surgery. We report our experience with endovascular surgery of proximal PICA aneurysms with emphasis on patients with poor Hunt-Hess grades. METHODS: We reviewed 31 consecutive patients with proximal PICA aneurysms who were treated with endovascular surgery. The following data were analyzed: age, sex, size of aneurysm, Hunt-Hess grade at presentation, Fisher grade at presentation, angiographic result after embolization, complications, number of days hospitalized, duration of follow-up, angiographic follow-up results, and Glasgow Outcome Score at follow-up. RESULTS: Excellent angiographic occlusion was achieved in 30 of 31 (97%) patients. Clinical follow-up with Glasgow Outcome Score was performed on every patient an average of 10 months later. Twenty-one of 31 (68%) patients had good outcomes (Glasgow Outcome Score I or II) at follow-up. Of the patients who presented with a favorable clinical grade (Hunt-Hess 0–III), 13 of 15 (87%) had good outcomes at follow-up. Of the patients who presented with a poor clinical grade (Hunt-Hess Grade IV or higher), 8 of 16 (50%) had good outcomes at follow-up. CONCLUSION: This series demonstrates the safety and efficacy of endovascular surgery for proximal PICA aneurysms. Many patients with poor Hunt-Hess grades from ruptured PICA aneurysms ultimately had a good outcome. This could be secondary to early, aggressive treatment of hydrocephalus and the minimally invasive nature of the endovascular approach.

Endovascular sacrifice of the proximal posterior inferior cerebellar artery for treatment of ruptured intracranial aneurysms

2020 ◽  
Vol 12 (8) ◽  
pp. 777-782
Author(s):  
James G Malcolm ◽  
Jonathan A Grossberg ◽  
Nealen G Laxpati ◽  
Ali Alawieh ◽  
Frank C Tong ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
High Morbidity ◽  
Brainstem Compression ◽  
Cerebellar Artery ◽  
Diseased Segment ◽  
Suboccipital Decompression ◽  
Pica Aneurysms ◽  
Ruptured Intracranial Aneurysms ◽  
Dissecting Aneurysms

BackgroundRuptured aneurysms of the intracranial vertebral artery (VA) or posterior inferior cerebellar artery (PICA) are challenging to treat as they are often dissecting aneurysms necessitating direct sacrifice of the diseased segment, which is thought to carry high morbidity due to brainstem and cerebellar stroke. However, relatively few studies evaluating outcomes following VA or proximal PICA sacrifice exist. We sought to determine the efficacy and outcomes of endovascular VA/PICA sacrifice.MethodsA retrospective series of ruptured VA/PICA aneurysms treated by endovascular sacrifice of the VA (including the PICA origin) or proximal PICA is reviewed. Collected data included demographic, radiologic, clinical, and disability information.ResultsTwenty-one patients were identified. Median age was 57 years (IQR 11); 15 were female. The Hunt and Hess grade was mostly 3 and 4 (18/21). Seven cases (33%) involved VA-V4 at the PICA take-off, and 14 cases (67%) involved the PICA exclusively. For VA pathology, V4 was sacrificed in all cases, while for PICA pathology, sacrificed segments included anterior medullary (4/14), lateral medullary (7/14), and tonsillomedullary (3/14) segments. Four patients went to hospice (19%). Twelve patients (57%) had evidence of stroke on follow-up imaging: cerebellar (8), medullary (1), and both (3). One patient required suboccipital decompression for brainstem compression. No aneurysm re-rupture occurred. Median discharge modified Rankin Scale score was 2.0 (IQR 2), which decreased to 1.0 (IQR 1) at median follow-up of 6.5 months (IQR 23).ConclusionsEndovascular sacrifice of V4 or PICA aneurysms may carry less morbidity than previously thought, and is a viable alternative for poor surgical candidates or those with good collateral perfusion.

Microvascular decompression for hemifacial spasm

1991 ◽  
Vol 75 (3) ◽  
pp. 388-392 ◽  
Author(s):  
Shinji Nagahiro ◽  
Akira Takada ◽  
Yasuhiko Matsukado ◽  
Yukitaka Ushio
Keyword(s):  
Hemifacial Spasm ◽  
Microvascular Decompression ◽  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Anterior Inferior Cerebellar Artery ◽  
Vascular Compression ◽  
Content Type ◽  
Seventh Cranial Nerve ◽  
Cerebellar Artery

✓ To determine the causative factors of unsuccessful microvascular decompression for hemifacial spasm, the follow-up results in 53 patients were assessed retrospectively. The mean follow-up period was 36 months. There were 32 patients who had compression of the seventh cranial nerve ventrocaudally by an anterior inferior cerebellar artery (AICA) or a posterior inferior cerebellar artery. Of these 32 patients, 30 (94%) had excellent postoperative results. Of 14 patients with more severe compression by the vertebral artery, nine (64%) had excellent results, three (21%) had good results, and two (14%) had poor results; in this group, three patients with excellent results experienced transient spasm recurrence. There were seven patients in whom the meatal branch of the AICA coursed between the seventh and eighth cranial nerves and compressed the dorsal aspect of the seventh nerve; this was usually associated with another artery compressing the ventral aspect of the nerve (“sandwich-type” compression). Of these seven patients, five (71%) had poor results including operative failure in one and recurrence of spasm in four. The authors conclude that the clinical outcome was closely related to the patterns of vascular compression.

Endovascular treatment of posterior inferior cerebellar artery aneurysms: a 7-year single-center experience

2016 ◽  
Vol 9 (1) ◽  
pp. 45-51 ◽  
Author(s):  
Feng Xu ◽  
Yong Hong ◽  
Yongtao Zheng ◽  
Qiang Xu ◽  
Bing Leng
Keyword(s):  
Endovascular Treatment ◽  
Posterior Inferior Cerebellar Artery ◽  
Endovascular Embolization ◽  
Parent Artery ◽  
Selective Embolization ◽  
Single Center Experience ◽  
Cerebellar Artery ◽  
Long Term Follow Up ◽  
Pica Aneurysms

AimTo report our experience with endovascular treatment of posterior inferior cerebellar artery (PICA) aneurysms.MethodsBetween January 2007 and December 2014, 40 patients with 42 PICA aneurysms were treated with endovascular embolization at our institution. Twenty-eight patients had 29 saccular aneurysms and 12 patients had 13 fusiform/dissecting aneurysms. The endovascular modalities were: (1) selective occlusion of the aneurysm with or without stent assistance (n=19); (2) occlusion of the aneurysm and the parent artery (n=22); and (3) occlusion of the aneurysm including the vertebral artery and PICA origin (n=1). Specifically, selective embolization was performed in 93.3% of aneurysms (14/15) proximal to the telovelotonsillary segment.ResultsImmediate angiographic results included 31 complete occlusions (74%), 3 nearly complete occlusions (7%), and 8 incomplete occlusions (19%). Mean follow-up of 20 months in 31 aneurysms showed 27 stable results, 3 further thromoboses, and 1 recurrence. Final results included 27 complete occlusions (87.1%) and 4 incomplete occlusions (12.9%). There were 5 overall procedural-related complications (12.5%), including 1 infarction (2.5%) and 4 intraprocedural ruptures (10.0%). Procedure-related morbidity and morbidity was 5.0% (2/40) and 2.5% (1/40), respectively. Clinical outcome was excellent (Glasgow Outcome Scale 5 in 31 of 33 patients at long-term follow-up).ConclusionsPICA aneurysms may be effectively treated by different endovascular approaches with favorable clinical and radiologic outcomes. Further studies are required to compare the safety and efficacy of endovascular treatment with open surgery.

scholarly journals Technical strategies to approach aneurysms of the vertebral and posterior inferior cerebellar arteries

2005 ◽  
Vol 19 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Niklaus Krayenbühl ◽  
Carlos A. Guerrero ◽  
Ali F. Krisht
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Anatomical Location ◽  
Microsurgical Anatomy ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Lower Cranial Nerves

Object Aneurysms of the vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) are rare and challenging lesions, as they are located in front of the brainstem and surrounded by the lower cranial nerves. Many different approaches have been described for their treatment, and have yielded different results. With the use of different examples of lesions, the authors describe their surgical strategy in the management of VA and PICA aneurysms. Methods The far-lateral approach was used, and the potential of its different extensions according to the specific anatomical location and configuration of different types of aneurysms is emphasized. Conclusions With the present knowledge of the microsurgical anatomy in the region of the foramen magnum, the far-lateral approach can be tailored to the specific anatomical and morphological configuration of an aneurysm in this region with good surgical results.

scholarly journals Far-lateral approach for surgical treatment of fusiform PICA aneurysm

2015 ◽  
Vol 38 (videosuppl1) ◽  
pp. Video10 ◽  
Author(s):  
William T. Couldwell ◽  
Jayson A. Neil
Keyword(s):  
Evoked Potential ◽  
Posterior Inferior Cerebellar Artery ◽  
Motor Evoked Potential ◽  
Lateral Approach ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Vessel Patency ◽  
Far Lateral ◽  
Evoked Potential Monitoring ◽  
Pica Aneurysms

Ruptured fusiform posterior inferior cerebellar artery (PICA) aneurysms can be technically challenging lesions. Surgeons must be ready to employ a variety of strategies in the successful treatment of these aneurysms. Strategies include complex clip techniques including clip-wrapping or trapping and revascularization. The case presented here is of a man with subarachnoid hemorrhage from a fusiform ruptured PICA aneurysm. The technique demonstrated is a far-lateral approach and a clip-wrap technique using muslin gauze. The patient was given aspirin preoperatively in preparation for possible occipital–PICA bypass if direct repair was not feasible. It is the authors' preference to perform direct vessel repair as a primary goal and use bypass techniques when this is not possible. Vessel patency was evaluated after clip-wrapping using intraoperative Doppler. Intraoperative somatosensory and motor evoked potential monitoring is used in such cases. The patient recovered well.The video can be found here: http://youtu.be/iwLqufH47Ds.

scholarly journals Ten years of experience in endovascular treatment of ruptured aneurysms of the posterior inferior cerebellar artery

2016 ◽  
Vol 22 (2) ◽  
pp. 129-137 ◽  
Author(s):  
Robert Juszkat ◽  
Paweł Kram ◽  
Katarzyna Stanisławska ◽  
Roman Jankowski ◽  
Bogumiła Stachowska-Tomczak ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Clinical Presentation ◽  
Posterior Inferior Cerebellar Artery ◽  
Years Of Experience ◽  
Endovascular Stents ◽  
Ruptured Aneurysms ◽  
Ruptured Intracranial Aneurysm ◽  
Cerebellar Artery ◽  
Pica Aneurysms

Background The aim of this study is to present our 10 years of experience in endovascular treatment of ruptured posterior inferior cerebellar artery (PICA) saccular aneurysms and to compare clinical presentation and outcome after endovascular treatment between patients with PICA aneurysms and patients with aneurysms in different locations. Methods and findings Out of 932 patients with a ruptured intracranial aneurysm treated endovascularly in our institution, 38 aneurysms were located at the posterior inferior cerebellar artery. Clinical presentation, mean aneurysm diameter and outcome of the therapy in this group were compared with the same for ruptured aneurysms in other locations. Patients discharged with favourable outcomes were checked angiographically in the follow-up period. Thirty-four patients with ruptured PICA aneurysms were treated by selective endovascular coiling. Two patients with wide-necked aneurysms had endovascular stents implanted. In two cases, the parent vessel was occluded due to failure to catheterise the target aneurysm. The evaluated variables did not differ significantly between two groups, but significantly more ruptured aneurysms in the PICA group were under 6 mm in diameter. 29.4% of controlled aneurysms needed additional reembolisation in the follow-up period. Conclusions Clinical presentation, extension of subarachnoid haemorrhage and outcome after endovascular treatment did not differ significantly between patients with ruptured aneurysms located on the PICA and patients with aneurysms located elsewhere intracranially. Endovascular treatment is an effective method of therapy in patients with ruptured PICA aneurysms. In our experience, even when sacrificing of the PICA is required, the results of treatment are favourable.

Far-Lateral Approach Without Drilling the Occipital Condyle for Vertebral Artery–Posterior Inferior Cerebellar Artery Aneurysms

Neurosurgery ◽  
2017 ◽  
Vol 81 (2) ◽  
pp. 268-274 ◽  
Author(s):  
Pablo Seoane ◽  
Samuel Kalb ◽  
Justin C. Clark ◽  
Juan C. Rivas ◽  
David S. Xu ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Glasgow Outcome Scale ◽  
Posterior Inferior Cerebellar Artery ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Scale Scores ◽  
Far Lateral ◽  
Pica Aneurysms

Abstract BACKGROUND: The far-lateral transcondylar surgical approach is often used to clip vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms. The role of condyle resection during this approach is controversial. OBJECTIVE: To evaluate patient outcomes in patients with VA–PICA aneurysms in whom drilling the occipital condyle was not necessary. METHODS: Between May 2005 and December 2012, a total of 56 consecutive patients with incidental or ruptured VA–PICA aneurysms underwent surgery with a far-lateral approach without condylar resection. Clinical presentation, surgical reports, presurgery and postsurgery radiological examinations, and clinical follow-up reports were assessed. Anatomic aneurysm location was analyzed through angiography or computed tomography angiography. We compared postsurgical Glasgow Outcome Scale scores, modified Rankin Scale scores, and morbidity in 2 groups: those with aneurysms in the anterior medullary segment and those with aneurysms in the lateral medullary segment. RESULTS: The predominant presentation was subarachnoid hemorrhage in 34 patients (60.7%). Most aneurysms (n = 27 [48.2%]) were located in the lateral medullary segment of the PICA, followed by the anterior medullary segment (n = 25 [44.6%]). Total aneurysm occlusion was achieved in 100% of patients, and bypass techniques were necessary in 3 patients (5.4%). Fifty-two patients (92.8%) had Glasgow Outcome Scale scores of 4 or 5 postsurgery. CONCLUSIONS: A far-lateral approach that leaves the occipital condyle intact is adequate for treating most patients with VA–PICA aneurysms.

Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies

2017 ◽  
Vol 10 (7) ◽  
pp. 663-668 ◽  
Author(s):  
Visish M Srinivasan ◽  
Michael George Zaki Ghali ◽  
Oleg E Reznik ◽  
Jacob Cherian ◽  
Maxim Mokin ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Flow Diversion ◽  
Partial Reduction ◽  
Anterior Circulation ◽  
Cerebellar Artery ◽  
Institutional Experience ◽  
Pica Aneurysms ◽  
Anterior Circulation Aneurysms ◽  
Direct Placement

BackgroundThe pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA.MethodsInstitutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study.Results10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up.ConclusionsThe PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection.

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