Excision and Primary Reanastomosis of the Anterior Inferior Cerebellar Artery for Treatment of a Ruptured Mycotic Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 19 (1) ◽  
pp. E58-E59 ◽  
Author(s):  
Justin Mascitelli ◽  
Sirin Gandhi ◽  
Claudio Cavallo ◽  
Jacob Baranoski ◽  
Ali Tayebi Meybodi ◽  
...  
Keyword(s):  
Cranial Nerves ◽  
Complete Recovery ◽  
Anterior Inferior Cerebellar Artery ◽  
Occipital Artery ◽  
Indocyanine Green Videoangiography ◽  
Bypass Patency ◽  
Cerebellar Artery ◽  
Alternative Donor ◽  
Immunodeficiency Syndrome ◽  
Lower Cranial Nerves

Abstract Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions with a predisposition for distal location and non-saccular morphology.1,2 These aneurysms are less amenable to clipping and may instead require aneurysm trapping with bypass.3 This video reports a novel bypass for a ruptured, fusiform distal AICA aneurysm. A 51-yr-old woman with newly diagnosed acquired immunodeficiency syndrome presented to the hospital with meningitis and experienced an acute neurological decline while admitted. Neuroimaging revealed a fusiform left a2-AICA aneurysm, thought to be mycotic with diffuse subarachnoid and intraventricular hemorrhage (Hunt-Hess Grade-IV). The occipital artery was harvested as an alternative donor in the myocutaneous flap using a hockey-stick incision. An extended retrosigmoid approach exposed the infectious aneurysm. After aneurysm excision, an a2-AICA-a2-AICA end-to-end reanastomosis was performed in between and deep to the vestibulocochlear nerves superiorly and the glossopharyngeal nerve inferiorly. Indocyanine green videoangiography and postoperative angiogram confirmed bypass patency. Postoperatively, she developed epidural and subdural hematomas due to human immunodeficiency virus-associated coagulopathy and/or increased aspirin sensitivity, requiring reoperation. The patient made a complete recovery at late follow-up. AICA reanastomosis is an elegant intracranial-intracranial bypass for treating distal AICA aneurysms. To our knowledge, this is the first report of AICA reanastomosis in the proximal a2-AICA (lateral pontine) segment. This technique has been reported in the literature for distally located aneurysms (a3-AICA).4 Microanastomosis for more medial AICA aneurysms must be performed deep to the lower cranial nerves. OA to a3-AICA bypass is an alternative in cases where primary reanastomosis is not technically feasible. (Published with permission from Barrow Neurological Institute).

Revascularization of the Posterior Inferior Cerebellar Artery Using the Occipital Artery: A Cadaveric Study Comparing the p3 and p1 Recipient Sites

2020 ◽  
Vol 19 (2) ◽  
pp. E122-E129 ◽  
Author(s):  
Peyton L Nisson ◽  
Xinmin Ding ◽  
Ali Tayebi Meybodi ◽  
Ryan Palsma ◽  
Arnau Benet ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Median Number ◽  
Cerebellar Tonsil ◽  
Occipital Artery ◽  
Recipient Site ◽  
Cerebellar Artery ◽  
Feasible Alternative ◽  
End To End ◽  
Lower Cranial Nerves

Abstract BACKGROUND Revascularization of the posterior inferior cerebellar artery (PICA) is typically performed with the occipital artery (OA) as an extracranial donor. The p3 segment is the most accessible recipient site for OA-PICA bypass at its caudal loop inferior to the cerebellar tonsil, but this site may be absent or hidden due to a high-riding location. OBJECTIVE To test our hypothesis that freeing p1 PICA from its origin, transposing the recipient into a shallower position, and performing OA-p1 PICA bypass with an end-to-end anastomosis would facilitate this bypass. METHODS The OA was harvested, and a far lateral craniotomy was performed in 16 cadaveric specimens. PICA caliber and number of perforators were measured at p1 and p3 segments. OA-p3 PICA end-to-side and OA-p1 PICA end-to-end bypasses were compared. RESULTS OA-p1 PICA bypass with end-to-end anastomosis was performed in 16 specimens; whereas, OA-p3 PICA bypass with end-to-side anastomosis was performed in 11. Mean distance from OA at the occipital groove to the anastomosis site was shorter for p1 than p3 segments (30.2 vs 48.5 mm; P < .001). Median number of perforators on p1 was 1, and on p3, it was 4 (P < .001). CONCLUSION Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops or aberrant anatomy is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead.

An a3-Anterior Inferior Cerebellar Artery to p3-Posterior Inferior Cerebellar Artery Bypass With Thrombectomy and Trapping of an Anterior Inferior Cerebellar Artery Aneurysm: 3-Dimensional Operative Video

2020 ◽  
Vol 19 (3) ◽  
pp. E311-E312
Author(s):  
Justin R Mascitelli ◽  
Sirin Gandhi ◽  
Jacob F Baranoski ◽  
Michael J Lang ◽  
Michael T Lawton
Keyword(s):  
Artery Bypass ◽  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Artery Aneurysm ◽  
Anterior Inferior Cerebellar Artery ◽  
Occipital Artery ◽  
Cerebellar Artery ◽  
Retrograde Filling ◽  
In Situ Bypass

Abstract In situ bypasses to the anterior inferior cerebellar artery (AICA) are unusual because, with only one artery in the cerebellopontine angle (CPA), no natural intracranial donors parallel its course. In rare cases, the posterior inferior cerebellar artery (PICA) may have the tortuosity or redundancy to be mobilized to the AICA to serve as a donor. This video demonstrates this p3 PICA-to-a3 AICA in situ side-to-side bypass. A 75-yr-old woman presented with ataxia and hemiparesis from a large thrombotic right AICA aneurysm compressing the brainstem. Strategy consisted of bypass, trapping, and brainstem decompression. Written informed consent for surgery was obtained from the patient. A hockey-stick incision was made to harvest the occipital artery as a backup donor, but its diminutive caliber precluded its use. The bypass was performed through an extended retrosigmoid craniotomy. The aneurysm was trapped completely and thrombectomized to relieve the pontine mass effect. Indocyanine green videoangiography confirmed patency of the bypass, retrograde filling of the AICA to supply pontine perforators, and no residual aneurysmal filling. This unusual in situ bypass is possible when redundancy of the AICA and PICA allow their approximation in the CPA. The anastomosis is performed lateral to the lower cranial nerves in a relatively open and superficial plane. The extended retrosigmoid approach provides adequate exposure for both the bypass and aneurysm trapping. In situ AICA-PICA bypass enables anterograde and retrograde AICA revascularization with side-to-side anastomosis. The occipital artery-to-AICA bypass and the V3 vertebral artery-to-AICA interpositional bypass are alternatives when intracranial anatomy is unfavorable for this in situ bypass.1–6 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.

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.

scholarly journals Anterior Inferior Cerebellar Aneurysm Treated by Aneurysm Resection and Intracranial Artery Anastomosis in situ: A Case Report and Literature Review

2021 ◽  
Vol 8 ◽  
Author(s):  
Chaojue Huang ◽  
Shixing Qin ◽  
Wei Huang ◽  
Yongjia Yu
Keyword(s):  
Surgical Treatment ◽  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Anterior Inferior Cerebellar Artery ◽  
Intracranial Artery ◽  
Disturbance Of Consciousness ◽  
Cerebellar Artery ◽  
Wide Range ◽  
Aneurysm Resection

Background: Anterior inferior cerebellar artery (AICA) aneurysms are relatively rare in clinical practice, accounting for <1% of all intracranial arteries. After the diagnosis and location are confirmed by angiography, magnetic resonance, and other imaging examinations, interventional, or surgical treatment is often used, but some complex aneurysms require reconstructive surgery.Case Description: An 8-year-old male child was admitted to the hospital due to sudden disturbance of consciousness for 2 weeks. The head CT showed hematocele in the ventricular system with subarachnoid hemorrhage in the basilar cistern and annular cistern. On admission, he was conscious, answered correctly, had a soft neck, limb muscle strength was normal, and had no cranial nerves or nervous system abnormalities. A preoperative examination showed the right side of the anterior distal arteries class under the circular wide neck aneurysm, the distal anterior inferior cerebellar artery supplying a wide range of blood to the cerebellum, the ipsilateral posterior inferior cerebellar artery absent, and the aneurysm close to the VII, VIII nerves. The aneurysm was successfully treated by aneurysm resection and intracranial artery anastomosis in situ of a2 AICA-a2 AICA.Conclusions: AICA aneurysms are relatively rare; in this case, a complex wide-necked aneurysm was successfully treated by aneurysm resection and anastomosis in situ of a2 AICA-a2 AICA. This case can provide a reference for the surgical treatment of complex anterior cerebellar aneurysms.

scholarly journals Anatomical location of AICA loop in CPA as a prognostic factor for ISSNHL

PeerJ ◽  
2019 ◽  
Vol 7 ◽  
pp. e6582 ◽  
Author(s):  
Sang Hyub Kim ◽  
Yeo Rim Ju ◽  
Ji Eun Choi ◽  
Jae Yun Jung ◽  
Sang Yoon Kim ◽  
...  
Keyword(s):  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Anterior Inferior Cerebellar Artery ◽  
Anatomical Location ◽  
Hearing Improvement ◽  
Cerebellar Artery ◽  
Hearing Recovery ◽  
Type Classification ◽  
Pure Tone Threshold

The cerebellopontine angle (CPA) is a triangular-shaped space that lies at the junction of the pons and cerebellum. It contains cranial nerves and the anterior inferior cerebellar artery (AICA). The anatomical shape and location of the AICA is variable within the CPA and internal auditory canal (IAC). A possible etiology of idiopathic sudden sensorineural hearing loss (ISSNHL) is ischemia of the labyrinthine artery, which is a branch of the AICA. As such, the position of the AICA within the CPA and IAC may be related to the clinical development of ISSNHL. We adopted two methods to classify the anatomic position of the AICA, then analyzed whether these classifications affected the clinical features and prognosis of ISSNHL. We retrospectively reviewed patient data from January 2015 to March 2018. Two established classification methods designed by Cahvada and Gorrie et al. were used. Pure tone threshold at four different frequencies (0.5, 1, 4, and 8 kHz), at two different time points (at initial presentation and three months after treatment), were analyzed. We compared the affected and unaffected ears, and investigated whether there were any differences in hearing recovery and symptoms between the two classification types. There was no difference in AICA types between ears with and without ISSNHL. Patients who had combined symptoms such as tinnitus and vertigo did not show a different AICA distribution compared with patients who did not. There were differences in quantitative hearing improvement between AICA types, although without statistic significance (p = 0.09–0.13). At two frequencies, 1 and 4 kHz, there were differences in Chavda types between hearing improvement and no improvement (p < 0.05). Anatomical variances of the AICA loop position did not affect the incidence of ISSNHL or co-morbid symptoms including tinnitus and vertigo. In contrast, comparisons of hearing improvement based on Chavda type classification showed a statistical difference, with a higher proportion of Chavda type 1 showing improvements in hearing (AICA outside IAC).

Anastomosis of occipital artery to anterior inferior cerebellar artery with interposition of superficial temporal artery. Case report

1993 ◽  
Vol 40 (2) ◽  
pp. 164-170 ◽  
Author(s):  
Hajime Touho ◽  
Jun Karasawa ◽  
Hideyuki Ohnishi ◽  
Hiroyuki Nakase ◽  
Yasuharu Watabe ◽  
...  
Keyword(s):  
Case Report ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Occipital Artery ◽  
Cerebellar Artery

Microsurgical Reconstruction of the Posterior Circulation

1984 ◽  
Vol 92 (1) ◽  
pp. 102-108 ◽  
Author(s):  
James I. Ausman ◽  
Fernando G. Diaz
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Superior Cerebellar Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Occipital Artery ◽  
Vertebrobasilar Insufficiency ◽  
Surgical Morbidity ◽  
Microsurgical Reconstruction ◽  
Cerebellar Artery ◽  
Vertebrobasilar Junction

Thirty-four patients with vertebrobasilar Insufficiency (VBI) were evaluated between 1974 and 1982. Twenty-two presented with transient VBI and 12 with residual strokes. The frequency of preoperative symptoms varied from once or twice a month to multiple daily events. Four patients with high-grade vertebral stenosis were treated by local vertebral endarterectomy at the C1 level. Seven patients underwent an anastomosis of the occipital artery to the posterior inferior cerebellar artery for distal vertebral basilar junction stenosis or occlusion. Three patients underwent anastomosis of the occipital artery to the anterior inferior cerebellar artery for vertebral basilar junction occlusion. Twenty patients underwent anastomosis of the superficial temporal to the superior cerebellar artery for distal vertebrobasilar junction stenosis or occlusion or midbasilar occlusive lesions. In 26 of 27 patients (95%), the anastomoses were patent. Two patients died, one from congestive heart failure and one from a brain stem infarct. Immediate complications included meningitis, CSF leaks, temporal lobe swelling, and seizures. Although the early surgical morbidity is high, it is only transient. Twenty-six patients have had complete resolution of their symptoms, and three have minor residual dizziness. Long-term morbidity has been limited to a patient with residual Wallenberg's syndrome secondary to the surgical occlusion of the vertebral artery, a patient who remained in a locked-in syndrome as before surgery, and a patient who developed Brown-Séquard syndrome. No further VBI symptoms occurred in one patient who died 4 years after surgery of a myocardial infarction. We believe the surgical approach to the vertebrobasilar area is feasible and can lead to the ultimate recovery of most patients.

scholarly journals Endoscopic endonasal approach for clipping of a PICA aneurysm

2020 ◽  
Vol 2 (2) ◽  
pp. V14
Author(s):  
Ezequiel Goldschmidt ◽  
Philippe Lavigne ◽  
Carl Snyderman ◽  
Paul A. Gardner
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Neurological Deficits ◽  
Csf Leak ◽  
Open Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Posthemorrhagic Hydrocephalus ◽  
Cerebellar Artery ◽  
Lower Cranial Nerves

This video depicts the case of a 59-year-old woman that presented to the emergency department with the worst headache of her life. CT showed subarachnoid hemorrhage and digital subtraction angiogram demonstrated a right-side posterior inferior cerebellar artery (PICA) aneurysm. Given the medial and ventral position of the aneurysm, deep to the lower cranial nerves, which obviated distal control from an open approach, and the absence of an endovascular option able to reliably preserve the PICA, an endonasal approach was offered. A far medial approach was performed, and the aneurysm was successfully clipped. The patient developed a postoperative CSF leak with persistent posthemorrhagic hydrocephalus treated with reexploration and an eventual ventriculoperitoneal shunt. The patient was discharged without neurological deficits.The video can be found here: https://youtu.be/_9hsM2CaMow.

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