Posterior Inferior Cerebellar Artery Aneurysm: Microsurgical Clipping of a Ruptured Posterior Inferior Cerebellar Artery (PICA) Aneurysm Not Well Suited to Endovascular Treatment, Far-Lateral Transcondylar Approach to the Anterior Medullary Segment of the PICA, Complete Exclusion of the Aneurysm with Preservation of the Parent Artery

Abstract Objectives To describe a far lateral approach for microsurgical clipping of a ruptured posterior inferior cerebellar artery (PICA) aneurysm involving the hypoglossal nerve, with emphasis on the microsurgical anatomy, and technique. Design A far lateral craniotomy is performed in the lateral decubitus position and the transverse and sigmoid sinuses were exposed. After opening the dura, sutures are placed to allow gentle mobilization of the sinuses. The ipsilateral cerebellar tonsil is mobilized and the PICA is followed to its junction with the vertebral artery. Hypoglossal nerve rootlets are draped over the dome of the aneurysm. Mobilization of the PICA and the hypoglossal nerve away from the lateral medulla allows microsurgical clipping of the aneurysm neck. Photographs of the region are borrowed from Dr Rhoton's laboratory to illustrate the microsurgical anatomy. Participants The senior authors performed the surgery. The video was edited by Drs. V.N. and J.B. Chart review and literature review were performed by Drs. W.M. and J.B. Outcome Measures Outcome was assessed with successful clip occlusion and postoperative neurological function. Results There was complete clip occlusion of the PICA aneurysm with no postoperative neurological deficits. The patient was discharged home after an uneventful hospital course. Conclusion The far lateral approach provides an adequate corridor to the ventrolateral brainstem for microsurgical treatment of PICA aneurysms. An adequate understanding of the relevant microsurgical anatomy is the key to safe and effective clipping in this region.The link to the video can be found at: https://youtu.be/yhjKRIG5H74.

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012489 ◽

2016 ◽

Vol 9 (1) ◽

pp. 45-51 ◽

Cited By ~ 17

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.

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Combined surgical and endovascular treatment of a giant vertebral artery aneurysm in a child

Journal of Neurosurgery ◽

10.3171/jns.1994.81.2.0304 ◽

1994 ◽

Vol 81 (2) ◽

pp. 304-307 ◽

Cited By ~ 20

Author(s):

Mazen H. Khayata ◽

Robert F. Spetzler ◽

Jan J. A. Mooy ◽

James M. Herman ◽

Harold L. Rekate

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Artery Aneurysm ◽

Mass Effect ◽

Left Vertebral Artery ◽

Parent Artery ◽

Content Type ◽

Cerebellar Artery ◽

Coil Occlusion ◽

Surgical Bypass

✓ The case is presented of a 5-year-old child who suffered a subarachnoid hemorrhage from a giant left vertebral artery-posterior inferior cerebellar artery (PICA) aneurysm. Initial treatment consisted of surgical occlusion of the parent vertebral artery combined with a PICA-to-PICA bypass. Because of persistent filling of the aneurysm, the left PICA was occluded at its takeoff from the aneurysm. Endovascular coil occlusion of the aneurysm and the distal left vertebral artery enabled complete elimination of the aneurysm. Follow-up magnetic resonance imaging and arteriography performed 6 months postoperatively showed persistent occlusion and elimination of the mass effect. Combined surgical bypass and endovascular occlusion of the parent artery may be a useful adjunct in the management of these aneurysms.

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Endovascular Treatment of Ruptured Dissecting Posterior Inferior Cerebellar Artery Aneurysms

Interventional Neuroradiology ◽

10.1177/159101991201800410 ◽

2012 ◽

Vol 18 (4) ◽

pp. 442-448 ◽

Cited By ~ 13

Author(s):

I. Ioannidis ◽

N. Nasis ◽

A. Andreou

Keyword(s):

Endovascular Treatment ◽

Medical Center ◽

Posterior Inferior Cerebellar Artery ◽

Vascular Anatomy ◽

Parent Artery ◽

Parent Vessel ◽

Cerebellar Artery ◽

Clinical Records ◽

Dissecting Aneurysms

Dissecting aneurysms of the posterior inferior cerebellar artery (PICA) distal to its origin from vertebral artery (VA) are very rare. Although rare, they associated with a high risk of rebleeding and they present a therapeutic challenge. This study reviewed the clinical presentations, angiographic characteristics of dissecting aneurysms of the PICA and to assess the clinical and angiographic outcomes of patients who underwent endovascular treatment. Ten patients with ten dissecting aneurysms who underwent endovascular treatment were identified in the clinical records of a single medical center from January 2000 to December 2010. The mean follow-up duration was 2.8 years. All patients presented with subarachnoid hemorrhage (SAH). They all underwent endovascular treatment, which included occlusion of the dissected segment and the parent artery after detailed angiographic evaluation of the vascular anatomy, and test occlusion of the PICA. In all patients the endovascular treatment was successfully completed without procedure related complications. Long-term follow-up studies in seven out of ten patients showed complete occlusion of the aneurysm with no new neurologic deficits. The clinical outcome was good in eight cases, whereas two patients with poor clinical condition at admission died during their initial hospital stay. Endovascular occlusion of the parent vessel and the dissected segment is relatively safe treatment option for dissecting aneurysms of the PICA distal to its origin.

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Treatment of Unruptured Vertebral Artery Aneurysm Involving Posterior Inferior Cerebellar Artery With Pipeline Embolization Device

Frontiers in Neurology ◽

10.3389/fneur.2021.622457 ◽

2021 ◽

Vol 12 ◽

Author(s):

Weiqi Fu ◽

Huijian Ge ◽

Gang Luo ◽

Xiangyu Meng ◽

Jiejun Wang ◽

...

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Artery Aneurysm ◽

Artery Occlusion ◽

Parent Artery ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Parent Artery Occlusion ◽

Cerebellar Artery

Background: Treatment of unruptured vertebral artery aneurysm involving posterior inferior cerebellar artery (PICA) is challenging. The experience of pipeline embolization device (PED) therapy for these lesions is still limited.Objective: To evaluate the safety and efficacy of the PED for unruptured vertebral artery aneurysm involving PICA.Methods: Thirty-two patients with unruptured vertebral artery aneurysm involving PICA underwent treatment with PED were retrospectively identified. Procedure-related complications, PICA patency, clinical, and angiographic outcomes were analyzed.Results: Thirty-two aneurysms were successfully treated without any procedure-related complications. Images were available in 30 patients (93.8%) during a period of 3–26 months follow-up (average 8.4 months), which confirmed complete occlusion in 17 patients (56.5%), near-complete occlusion in 9 patients (30%), and incomplete occlusion in one patient (3.3%). Parent artery occlusion (PAO) was occurred in 3 patients (10%). Twenty-eight of 30 PICA remained patent. The two occlusions of PICA were secondary to PAO. At a mean of 20.7 months (range 7–50 months) clinical follow-up, all the patients achieved a favorable outcome without any new neurological deficit.Conclusion: PED seems to be a safe and effective alternative endovascular option for patients with unruptured vertebral artery aneurysm involving PICA.

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Microsurgical anatomy of the posterior spinal artery via a far-lateral transcondylar approach

Journal of Neurosurgery Spine ◽

10.3171/2008.12.spine08289 ◽

2009 ◽

Vol 10 (3) ◽

pp. 228-233 ◽

Cited By ~ 11

Author(s):

Hakan Seçkin ◽

Özkan Ateş ◽

Andrew M. Bauer ◽

Mustafa K. Başkaya

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Lateral Approach ◽

Microsurgical Anatomy ◽

Posterior Spinal Artery ◽

Transcondylar Approach ◽

Cerebellar Artery ◽

Far Lateral Approach ◽

Close Proximity ◽

Far Lateral ◽

Clinically Significant

Object The posterior spinal artery (PSA) is a clinically significant vessel that may frequently be encountered during the far-lateral transcondylar approach. There have been a limited number of reports on the specific origin of the PSA in the literature. The aim of this study was to demonstrate the origin of the PSA. Methods Thirteen cadaveric heads (26 sides) were injected with colored silicon. A bilateral far-lateral transcondylar approach was performed on each side. In every specimen the site of the origin of the PSAs, as well as their course, branching pattern and anastomoses, external diameters, and neighboring vascular and nervous structures were recorded. Microanatomical dissections were performed using the surgical microscope. In addition, 8 surgical cases in which the far-lateral approach was used were collected prospectively to record the course and origin of the PSA. Altogether, a total of 34 sides were analyzed for their PSA origin and course. Results In the cadaveric specimens, the PSA was found to originate from the vertebral artery (VA) in 25 sides (96%). In 13 specimens (50%) the PSA originated from the V4 segment of the VA intradurally. In 12 specimens (46%) the PSA originated from the V3 segment of the VA extradurally. In 1 specimen (4%), in whom the posterior inferior cerebellar artery (PICA) had an early origin from the VA extradurally at the C-1 level, the PSA originated from the PICA. Of the 8 surgical cases, 2 patients had extradural origin of the PSA from the V3 segment of the VA, whereas 6 patients had intradural origin of the PSA from the V4 segment. Conclusions Although the usual origin of the PSA is from the VA either intra- or extradurally, its origin is closely related to the origin of the PICA. The PSA originates from the PICA in cases in which the PICA originates extradurally from the VA. In the far-lateral transcondylar approach, the dura is opened in close proximity to the VA. Knowledge of the origin and course of the PSA is critically important when executing the far-lateral approach to avoid its injury.

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