Trapping and V3-radial artery graft-V4 bypass for ruptured dissecting aneurysm of the vertebral artery

The authors show a surgical technique of trapping/resection of ruptured dominant vertebral artery aneurysm in conjunction with reconstruction of vertebral artery by V3–radial artery (RA) graft–V4 bypass through suboccipital craniotomy and far lateral approach. Step by step muscle dissection in posterior fossa enable fine exposure of occipital artery for possible OA-PICA bypass and V3 portion of vertebral artery. Extradural drilling of posterior one-third condyle and condylar fossa facilitate exposure of triangular surgical corridor made by medulla, spinal root of 11th nerve and lower cranial nerves, and thus enabling aneurismal resection and RA–V4 anastomosis.The video can be found here: http://youtu.be/LxsARGdHSVw.

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Unilateral extended suboccipital approach for a C1 dumbbell schwanoma

Romanian Neurosurgery ◽

10.1515/romneu-2015-0004 ◽

2015 ◽

Vol 22 (1) ◽

pp. 38-42

Author(s):

R.M. Gorgan ◽

Angela Neacşu ◽

A. Giovani

Keyword(s):

Vertebral Artery ◽

Fibrous Tissue ◽

Cranial Nerves ◽

Gain Control ◽

Complete Removal ◽

Craniovertebral Junction ◽

Lateral Approach ◽

Far Lateral Approach ◽

Far Lateral ◽

Lower Cranial Nerves

Abstract Craniovertebral junction tumors represent a complex pathology carrying a high risk of injuring the vertebral artery and the lower cranial nerves. Dumbbell C1- C2 schannomas are very rare tumors in this location. We present a case of a 66 years old male accepted for left laterocervical localized pain, headache and vertigo, with a large C1 dumbbell schwannoma extending in lateral over the C1 arch and displacing the C3 segment of the vertebral artery superiorly and anteriorly. Complete removal of the tumor was achieved using a far lateral approach. The approach is discussed with focus on the vertebral artery anatomy as the approach should give enough space to gain control of the artery without creating instability. Safe removal of C1 nerve root schwanomas can be achieved even if they compress and displace the vertebral artery by entering a fibrous tissue plane between the tumor and the vertebral artery.

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Vertebral artery–posterior inferior cerebellar artery bypass using a radial artery graft for hemorrhagic dissecting vertebral artery aneurysms: surgical technique and report of 2 cases

Journal of Neurosurgery ◽

10.3171/2010.5.jns091435 ◽

2011 ◽

Vol 114 (4) ◽

pp. 1074-1079 ◽

Cited By ~ 25

Author(s):

Marcus Czabanka ◽

Muhammad Ali ◽

Peter Schmiedek ◽

Peter Vajkoczy ◽

Michael T. Lawton

Keyword(s):

Vertebral Artery ◽

Radial Artery ◽

Posterior Inferior Cerebellar Artery ◽

Occipital Artery ◽

Radial Artery Graft ◽

Interposition Graft ◽

Endovascular Occlusion ◽

Artery Graft ◽

Cerebellar Artery ◽

Far Lateral Approach

Endovascular occlusion of hemorrhagic dissecting aneurysms of the vertebral artery (VA) is not possible when the posterior inferior cerebellar artery (PICA) originates from the dissecting aneurysm or when the contralateral VA provides inadequate collateral blood flow to the distal basilar circulation. The authors introduce a VA-PICA bypass with radial artery interposition graft and aneurysm trapping as an alternative approach and describe 2 cases in which this bypass was used to treat hemorrhagic dissecting VA aneurysms. The VA-PICA bypass is performed via a standard far lateral approach. An end-to-side anastomosis between the radial artery graft and the PICA at the level of the caudal loop is performed first, and an end-to-side anastomosis is performed between the V3 segment and the proximal end of the radial artery graft. A 56-year-old woman harbored a hemorrhagic dissecting VA aneurysm incorporating the origin of the PICA. Endovascular treatment failed, with aneurysm refilling on follow-up angiography. A 65-year-old man had a hemorrhagic dissecting VA aneurysm and a hypoplastic contralateral VA. Both patients were treated with the VA-PICA bypass and aneurysm trapping, with adequate filling of the PICA territory in the first patient and both the PICA territory and the basilar circulation in the second patient. Vertebral artery–PICA bypass with radial artery interposition graft and subsequent trapping of the dissected VA segment is an alternative to occipital artery–PICA and PICA-PICA bypass for the treatment of hemorrhagic dissecting VA aneurysms that are not suitable for endovascular occlusion.

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Craniocervical Junction Vertebral Artery Dural Arteriovenous Fistula With Cranial and Spinal Venous Reflux: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz213 ◽

2019 ◽

Vol 18 (5) ◽

pp. E162-E163 ◽

Cited By ~ 1

Author(s):

Krunal Patel ◽

Leonardo Desessards Olijnyk ◽

Anderson Chun On Tsang ◽

Vitor Mendes Pereira ◽

Ivan Radovanovic

Keyword(s):

Vertebral Artery ◽

Arteriovenous Fistula ◽

Dural Arteriovenous Fistula ◽

Craniocervical Junction ◽

Lateral Approach ◽

Venous Reflux ◽

Suboccipital Craniotomy ◽

Far Lateral Approach ◽

Key Steps ◽

Midline Approach

Abstract Dural arteriovenous fistulae at the craniocervical junction are rare. When present together with spinal and cranial venous reflux they can have an aggressive natural history with hemorrhage or progressive myelopathy from venous congestion. In this operative video we demonstrate key steps in the surgical ligation of a dural arteriovenous fistula supplied by meningeal branches of the V4 segment of the vertebral artery. Informed consent was obtained. The patient was positioned prone with chin tucked. Utilizing a midline suboccipital craniotomy and removal of the arch of C1, the vertebral artery was identified at its V4 segment at it transitions from extra to intradural. The video illustrates how a midline approach can be used to access this lesion and a far lateral approach is not required to access the vertebral artery and its dural branches at the craniocervical junction. Division of the denticulate ligaments and mobilization of the spinal accessory nerve allows visualization of the proximal portion of the draining vein. Important anatomy in this region is demonstrated. The critical use of indocyanine green (ICG) dye is demonstrated as the first 2 clip applications were not proximal enough to obliterate the proximal draining vein and persistent early venous reflux was still seen on ICG. The importance of access to and obliteration of the proximal draining vein is shown. An intraoperative ICG and postoperative angiogram demonstrates complete occlusion of the dural arteriovenous fistula. In this case the patient had minor sensory deficits postoperatively which were resolved by 6 wk postoperatively.

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Foramen Magnum Meningioma: Far Lateral Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1695701 ◽

2019 ◽

Vol 80 (S 04) ◽

pp. S363-S364

Author(s):

Ciro Vasquez ◽

Alexander Yang ◽

A. Samy Youssef

Keyword(s):

Vertebral Artery ◽

Cranial Nerves ◽

Mass Effect ◽

Craniocervical Junction ◽

Foramen Magnum ◽

Lateral Approach ◽

Neurological Deficits ◽

Occipital Condyle ◽

Far Lateral Approach ◽

Far Lateral

We present a case of a foramen magnum meningioma in a 42-year-old female who presented with headaches for 2 years, associated with decreased sensation and overall feeling of “heaviness” of the right arm. The tumor posed significant mass effect on the brainstem, and given the location of the tumor in the anterolateral region of the foramen magnum, a right far lateral approach was chosen. The approach incorporates the interfascial dissection technique to safely expose and preserve the vertebral artery in the suboccipital triangle. After drilling the posteromedial portion of the occipital condyle and opening the dura, the tumor can be entirely exposed with minimal retraction on the cerebellum. The working space offered by the far lateral approach allows careful dissection at the lateral craniocervical junction, and preservation of the V4 segment of the vertebral artery and the lower cranial nerves. Simpson's grade-2 resection was achieved with coagulation of the dural base around the vertebral artery. The postoperative course was unremarkable for any neurological deficits. At the 2-year follow-up, imaging identified no recurrence of tumor and the patient remains asymptomatic.The link to the video can be found at: https://youtu.be/IMN1O7vO5B0.

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Contralateral far-lateral approach for clipping of a ruptured vertebral artery–posterior inferior cerebellar artery aneurysm

Neurosurgical FOCUS ◽

10.3171/foc.2008.25.12.e9 ◽

2008 ◽

Vol 25 (6) ◽

pp. E9 ◽

Cited By ~ 11

Author(s):

Taryn McFadden Bragg ◽

Edward A. M. Duckworth

Keyword(s):

Computed Tomography ◽

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Artery Aneurysm ◽

Lateral Approach ◽

Cerebellar Artery ◽

Far Lateral Approach ◽

Far Lateral ◽

The Right ◽

Pica Aneurysms

Numerous nuanced approaches have been used to access posterior inferior cerebellar artery (PICA) aneurysms for microsurgical clipping. The authors report the case of a patient with a right vertebral artery (VA)–PICA aneurysm that was reached via a contralateral far-lateral approach. The wide-necked saccular/fusiform aneurysm arose from the lateral aspect of the right V4 segment just proximal to the PICA origin, anterior to the jugular tubercle at the level of the hypoglossal canal. Computed tomography angiograms demonstrated the size and configuration of the aneurysm, and 3D reconstructions revealed the tortuosity of the right VA, defining its location just left of the midline adjacent to the lower clivus. A contralateral far-lateral approach to VA–PICA aneurysms should be considered when aneurysms cross the midline. Computed tomography angiography with volume rendering and interactive software capabilities can help identify the relationship of such an aneurysm to an individual's particular skull base osseous anatomy and is paramount in selecting the optimal microsurgical approach.

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Far Lateral Approach (Transcondylar, Transtubercular) for Bypass and Trapping of a Ruptured, Dissecting PICA Aneurysm

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1701237 ◽

2020 ◽

Author(s):

Andrew S. Venteicher ◽

Ezequiel Goldschmidt ◽

Paul A. Gardner

Keyword(s):

Endovascular Treatment ◽

Posterior Inferior Cerebellar Artery ◽

Lateral Approach ◽

Dissecting Aneurysm ◽

Posterior Circulation ◽

Occipital Artery ◽

Unique Challenge ◽

Far Lateral Approach ◽

Posterior Circulation Aneurysms ◽

Far Lateral

AbstractAneurysms of the posterior circulation pose a unique challenge due to higher rupture rates, higher recurrence rates following endovascular treatment, and extended open cranial base approaches required to reach the ventrally located brainstem circulation. While endovascular therapy has made tremendous strides in successful treatment for most posterior circulation aneurysms, open microscopic approaches remain essential in specific circumstances. Here, we present a case of a patient who presented with acute, severe headache, and sixth nerve palsies, and who was found to have hydrocephalus and a dissecting aneurysm at the anterolateral medullary segment of the posterior inferior cerebellar artery (PICA). Interestingly, this patient had a history of alpha-1 antitrypsin deficiency that has been linked with spontaneous aortic and cervical arterial dissections. The fusiform geometry of the dissecting aneurysm was deemed suboptimal for endovascular treatment, so an open microsurgical approach for occipital artery to PICA bypass and aneurysm trapping was planned. Because this patient had cerebral edema in the setting of a ruptured aneurysm and hydrocephalus, a far lateral craniotomy combined with drilling of the occipital condyle and jugular tubercle was critical to enhance exposure of the first segment of the PICA and to minimize brain retraction. In this video, we highlight the key steps and nuances for harvest of the occipital artery, achieving control of the extracranial vertebral artery, performing the transcondylar and transtubercular far lateral approach, and bypass with trapping technique for these challenging posterior circulation aneurysms.The link to the video can be found at: https://youtu.be/dqgblwX6t0Q.

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Far Lateral Transcondylar Transtubercular Approach for Microsurgical Resection of Foramen Magnum Meningioma: Operative Video and Technical Nuances

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1716533 ◽

2020 ◽

Author(s):

James K. Liu ◽

Vincent N. Dodson ◽

Ali T. Meybodi

Keyword(s):

Vertebral Artery ◽

Cranial Nerve ◽

Cranial Nerves ◽

Foramen Magnum ◽

Lateral Approach ◽

Neurological Deficits ◽

Endoscopic Endonasal ◽

Surgical Access ◽

Far Lateral Approach ◽

Far Lateral

AbstractSurgical access to the ventral foramen magnum remains a technical challenge. With large lesions in this region compressing the brainstem and distorting the regional neurovascular relationships, formulating a surgical plan and its appropriate execution have crucial importance in achieving favorable outcomes. While the endoscopic endonasal approaches have gained increasing attention to access the clivus and the ventral brainstem, foramen magnum meningiomas are still preferred to be removed via an approach that obviates a trajectory through the nasopharyngeal mucosa. Therefore, the far lateral approach remains one of the most practical approaches for these challenging lesions. This operative video demonstrates the use of the far lateral transcondylar transtubercular approach to remove a large meningioma in the ventral foramen magnum in a 63-year-old male with progressive cervical myelopathy, presenting as spastic quadriparesis without any cranial nerve abnormality. Using a right-sided far lateral transcondylar transtubercular approach, the meningioma was exposed within the cerebellomedullary gutter engulfing the vertebral artery and distorting the course of the adjacent cranial nerves. Using the different corridors identified between the vertebral artery, spinal accessory, vagus, and hypoglossal nerves, multiple angles of attacks to the tumor were established and utilized to resect the lesion. A gross total resection was achieved and the patient was neurologically intact without any neurological deficits. This video demonstrates the importance of understanding the intricacies of neurovascular anatomy of the cervicomedullary region (i.e., the various triangles formed between these structures), and the effective use of these corridors to safely and efficiently remove a challenging ventral foramen magnum meningioma with neurovascular involvement, while preserving cranial nerve function. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/s1dFhuaRSt8.

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Rotational Vertebral Artery Occlusion—Series of 9 Cases

Neurosurgery ◽

10.1227/neu.0b013e3181ee36db ◽

2010 ◽

Vol 67 (4) ◽

pp. 1066-1072 ◽

Cited By ~ 33

Author(s):

Daniel C Lu ◽

Zsolt Zador ◽

Praveen V Mummaneni ◽

Michael T Lawton

Keyword(s):

Blood Loss ◽

Minimally Invasive ◽

Vertebral Artery ◽

Anterior Approach ◽

Lateral Approach ◽

Preoperative Imaging ◽

Cervical Instability ◽

Far Lateral Approach ◽

Far Lateral

Abstract BACKGROUND: Rotational vertebral artery syndrome (RVAS) is a rare entity about which previously published studies are mostly limited to individual case reports. OBJECTIVE: To report our decade-long experience with this syndrome in 9 patients with compression ranging from the occiput to C6. METHODS: We utilized a posterior approach for lesions rostral to C4 and an anterior approach for lesions at or caudal to C4. Furthermore, we demonstrated the feasibility and efficacy of a minimally invasive posterior cervical approach. Patient profile, operative indications, surgical approach, operative findings, complications, and long-term follow-up were reviewed and discussed. RESULTS: Average follow-up was 47 months. All procedures provided excellent outcomes by Glasgow Outcome Scale scores. The anterior approach had significantly less blood loss (187.5 mL vs 450 mL, P = .00016) and shorter hospitalization length (2 days vs 4.5 days; P = .0001) compared with the far-lateral approach. There was one complication of cervical instability in the far-lateral approach cohort. As an alternative to the far-lateral surgery, a minimally invasive approach resulted in shorter hospitalization (2 days) and less blood loss (10 mL) while avoiding the complication of cervical instability. CONCLUSION: We demonstrated the safety, efficacy, and durability of 3 surgical approaches for RVAS. Proper examination, preoperative imaging, and surgical planning were necessary for a satisfactory outcome.

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