Variations of Occipital Artery-Posterior Inferior Cerebellar Artery Bypass: Anatomic Consideration

2017 ◽  
Vol 14 (5) ◽  
pp. 563-571 ◽  
Author(s):  
Ken Matsushima ◽  
Satoshi Matsuo ◽  
Noritaka Komune ◽  
Michihiro Kohno ◽  
J Richard Lister
Keyword(s):  
Artery Bypass ◽  
Posterior Inferior Cerebellar Artery ◽  
Jugular Foramen ◽  
Occipital Artery ◽  
Parent Artery ◽  
Microsurgical Anatomy ◽  
Main Trunk ◽  
Cerebellar Artery ◽  
Cerebellomedullary Fissure ◽  
Pica Aneurysms

Abstract BACKGROUND Advances in diagnosis of posterior inferior cerebellar artery (PICA) aneurysms have revealed the high frequency of distal and/or dissecting PICA aneurysms. Surgical treatment of such aneurysms often requires revascularization of the PICA including but not limited to its caudal loop. OBJECTIVE To examine the microsurgical anatomy involved in occipital artery (OA)-PICA anastomosis at various anatomic segments of the PICA. METHODS Twenty-eight PICAs in 15 cadaveric heads were examined with the operating microscope to take morphometric measurements and explore the specific anatomy of bypass procedures. RESULTS OA bypass to the p2, p3, p4, or p5 segment was feasible with a recipient vessel of sufficient diameter. The loop wandering near the jugular foramen in the p2 segment provided sufficient length without requiring cauterization of any perforating arteries to the brainstem. Wide dissection of the cerebellomedullary fissure provided sufficient exposure for the examination of some p3 segments and all p4 segments hidden by the tonsil. OA-p5 bypass was placed at the main trunk before the bifurcation in 5 hemispheres and at the larger hemispheric trunk in others. CONCLUSION Understanding the possible variations of OA-PICA bypass may enable revascularization of the appropriate portion of the PICA when the parent artery must be occluded. A detailed anatomic understanding of each segment clarifies important technical nuances for the bypass on each segment. Dissection of the cerebellomedullary fissure helps to achieve sufficient exposure for the bypass procedures on most of the segments.

Surgical treatment for vertebral artery–posterior inferior cerebellar artery aneurysms: special reference to the importance of the cerebellomedullary fissure dissection

2013 ◽  
Vol 118 (2) ◽  
pp. 460-464 ◽  
Author(s):  
Masatou Kawashima ◽  
Yukinori Takase ◽  
Toshio Matsushima
Keyword(s):  
Vertebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Neurological Deficits ◽  
Lateral Part ◽  
Microsurgical Anatomy ◽  
Aneurysm Surgery ◽  
Lesion Side ◽  
Cerebellar Artery ◽  
Cerebellomedullary Fissure ◽  
Pica Aneurysms

Object The cerebellomedullary fissure (CMF) is a space between the cerebellum and the medulla oblongata, which often adhere to each other. The purpose of the present study was to demonstrate the importance of the unilateral CMF dissection for clipping vertebral artery (VA)–posterior inferior cerebellar artery (PICA) aneurysms. Methods Five adult cadaveric specimens were studied after colored silicone was infused into the arteries and veins. The microsurgical anatomy of the CMF and the trans-CMF approach for VA-PICA aneurysm surgery were examined in stepwise dissections. In addition, 6 patients underwent surgery for VA-PICA saccular aneurysms (2 ruptured and 4 unruptured aneurysms) via posterolateral approaches, with wide opening of the unilateral CMF to obtain good visualization and a wide working space in the lateral part of the cerebellomedullary cistern. Clinical data including neurological and radiological findings and patient outcomes were analyzed in all 6 cases. Results In all cases, the aneurysm was successfully clipped and no permanent neurological deficits remained. The wide opening of the unilateral CMF on the lesion side made it possible to retract the inferolateral part of the cerebellum easily, provided a wide operative field in the cerebellomedullary cistern, and enabled successful clip placement without difficulty. Conclusions For safe and effective VA-PICA aneurysm surgery, it is very important to dissect the CMF on the lesion side as well as to remove the lateral part of the foramen magnum. Direct clip placement is very safe and useful in cases involving VA-PICA aneurysms.

scholarly journals Far-Lateral Craniotomy for Posterior Inferior Cerebellar Artery to Occipital Artery Bypass: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (6) ◽  
pp. E234-E235
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Artery Bypass ◽  
Video Recording ◽  
Posterior Inferior Cerebellar Artery ◽  
Careful Consideration ◽  
Occipital Artery ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Cerebellar Artery ◽  
Far Lateral ◽  
Pica Aneurysms

Abstract Posterior inferior cerebellar artery (PICA) aneurysms are infrequent compared with other intracranial aneurysms and are more commonly distal in origin (35% of PICA aneurysms are distal vs 6.5% of other aneurysms). This makes PICA aneurysms a surgical challenge that requires careful consideration of the patient's angiographic anatomy and perfusion needs before deciding on the appropriate intervention. This patient had a highly calcified left PICA p2 segment aneurysm, which was not favorable for endovascular intervention. An end-to-side anastomosis of the occipital artery to the p3 PICA segment was performed. This anastomosis was achieved with 11-0 suture. A permanent clip was then placed along the vertebral artery occluding both the proximal PICA and the aneurysm. Indocyanine green angiography was performed to demonstrate bypass and PICA patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Intracranial Bypass of Posterior Inferior Cerebellar Artery Aneurysms: Indications, Technical Aspects, and Clinical Outcomes

2017 ◽  
Vol 13 (5) ◽  
pp. 586-595 ◽  
Author(s):  
David J. Bonda ◽  
Mohamad Labib ◽  
Jeffrey M. Katz ◽  
Rafael A. Ortiz ◽  
David Chalif ◽  
...  
Keyword(s):  
Cranial Nerve ◽  
Posterior Inferior Cerebellar Artery ◽  
Surgical Techniques ◽  
Occipital Artery ◽  
Traumatic Aneurysm ◽  
Surgical Clipping ◽  
Bypass Patency ◽  
Cerebellar Artery ◽  
Diseased Segment ◽  
Pica Aneurysms

Abstract BACKGROUND: For some posterior inferior cerebellar artery (PICA) aneurysms, there is no constructive endovascular or direct surgical clipping option. Intracranial bypass is an alternative to a deconstructive technique. OBJECTIVE: To evaluate the clinical features, surgical techniques, and outcome of PICA aneurysms treated with bypass and obliteration of the diseased segment. METHODS: Retrospective review of PICA aneurysms treated via intracranial bypass was performed. Outcome measurements included postoperative stroke, cranial nerve deficits, gastrostomy/tracheostomy requirement, bypass patency, modified Rankin scale (mRS) at discharge, and mRS at 6 mo. RESULTS: Seven patients with PICA aneurysms treated with intracranial bypass were identified. Five had fusiform aneurysms (4 ruptured, 1 unruptured), 1 had a giant partially thrombosed saccular aneurysm (unruptured), and 1 had a dissecting traumatic aneurysm (ruptured). Two aneurysms were at the anteromedullary segment, 4 at the lateral medullary segment, and 1 at the tonsillomedullary segment. Three patients underwent PICA-to-PICA side to side anastomoses, 2 PICA-to-PICA reanastomosis, 1 vertebral artery-to-PICA bypass, and 1 occipital artery-PICA bypass. Six out of 7 aneurysms were obliterated surgically and 1 with additional endovascular occlusion after the bypass. All bypasses were patent intraoperatively; 2 were later demonstrated occluded without radiological signs or symptoms of stroke. No patients had new cranial nerve deficit postoperatively. With the exception of 1 death due to pulmonary emboli 3 mo postoperatively, all others remain at a mRS ≤ 2. CONCLUSION: Constructive bypass and aneurysm obliteration remains a viable alternative for treatment of PICA aneurysms not amenable to direct surgical clipping or to a vessel-preserving endovascular option.

Operative nuances of an occipital artery to posterior inferior cerebellar artery bypass

2009 ◽  
Vol 26 (5) ◽  
pp. E19 ◽  
Author(s):  
R. Webster Crowley ◽  
Ricky Medel ◽  
Aaron S. Dumont
Keyword(s):  
Artery Bypass ◽  
Posterior Inferior Cerebellar Artery ◽  
Occipital Artery ◽  
Complex Aneurysms ◽  
Cerebellar Artery ◽  
Proximal Occlusion ◽  
Attention To Detail

Occipital artery to posterior inferior cerebellar artery bypasses remain an important tool for cerebrovascular neurosurgeons, particularly in the management of complex aneurysms of the posterior inferior cerebellar artery requiring proximal occlusion or trapping. The procedure requires meticulous technique and attention to detail. The authors outline their technique for accomplishing this bypass emphasizing nuances for complication avoidance.

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.

Occipital Artery to Posterior Inferior Cerebellar Artery Bypass for Vertebrobasilar Ischemia

Neurosurgery ◽  
1982 ◽  
Vol 10 (1) ◽  
pp. 44-49 ◽  
Author(s):  
Richard A. Roski ◽  
Robert F. Spetzler ◽  
Leo N. Hopkins
Keyword(s):  
Artery Bypass ◽  
Posterior Inferior Cerebellar Artery ◽  
Graft Patency ◽  
Occipital Artery ◽  
Operative Morbidity ◽  
Intraoperative Hypotension ◽  
Vertebrobasilar Ischemia ◽  
Cerebellar Artery ◽  
Noticeable Improvement

Abstract Fourteen patients who underwent occipital to posterior inferior cerebellar arterial bypass are reviewed. All of the patients were treated for severe vertebrobasilar ischemia secondary to lesions of the distal vertebral artery. There was no operative death or permanent postoperative morbidity. On follow-up evaluation (averaging 13 months after operation), there has been 100% graft patency and a noticeable improvement in the neurological function in all patients. Operating with the patient in the prone position and avoiding intraoperative hypotension help to minimize the operative morbidity from this procedure.

Decision Making in Surgery for Nonsaccular Posterior Inferior Cerebellar Artery Aneurysms With Special Reference to Intraoperative Assessment of Collateral Blood Flow and Neurophysiological Function

2017 ◽  
Vol 14 (4) ◽  
pp. 422-431 ◽  
Author(s):  
Alessandro Narducci ◽  
Ran Xu ◽  
Peter Vajkoczy
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Neurophysiological Monitoring ◽  
Occipital Artery ◽  
Pica Pica ◽  
Endovascular Techniques ◽  
Vessel Occlusion ◽  
Cerebellar Artery ◽  
Pica Aneurysms ◽  
Intraoperative Test ◽  
Time Assessment

Abstract BACKGROUND Posterior inferior cerebellar artery (PICA) aneurysms represent a challenging pathology. PICA sacrifice is often necessary, due to the high proportion of nonsaccular aneurysms that can be found in this location. Several treatments are available, but the infrequency of these aneurysms and the increasing number of endovascular techniques have limited the development of a standardized algorithm for cases in which open surgery is indicated. OBJECTIVE We present our series of nonsaccular PICA aneurysms, in the attempt to define an algorithm for their surgical management. METHODS We retrospectively reviewed the operation database, identifying patients harboring nonsaccular PICA aneurysms who were surgically treated at our institution from 2007 to 2016. RESULTS During a 9-yr period, 17 patients harboring 18 nonsaccular PICA aneurysms were surgically treated at our institution. Fourteen (7.7%) aneurysms were located within the proximal PICA (including those located at the vertebral artery–PICA junction), and 4 were located distally. We performed PICA revascularization in 8 (57.1%) cases of proximal aneurysms (n = 4, PICA–PICA bypass; n = 4, occipital artery–PICA bypass). We based our decision whether to perform bypass on intraoperative test occlusion with indocyanine green (ICG) videoangiography and neurophysiological monitoring. In no cases, bypass was necessary for distal aneurysms. CONCLUSION For nonsaccular PICA aneurysms, in which vessel occlusion is often necessary, it is possible to adopt a selective use of revascularization techniques. Intraoperative occlusion test with ICG videoangiography and neurophysiological monitoring provides reliable indications, allowing real-time assessment of collateral circulation.

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