The Glossopharyngo-Cochlear Triangle—Part II: Case Series Highlighting the Clinical Application to High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach

2020 ◽  
Author(s):  
Jacob F Baranoski ◽  
Stefan W Koester ◽  
Colin J Przybylowski ◽  
Xiaochun Zhao ◽  
Joshua S Catapano ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Internal Auditory Canal ◽  
Case Series ◽  
Jugular Foramen ◽  
Foramen Magnum ◽  
Aneurysm Neck ◽  
Cerebellar Artery ◽  
Vertebrobasilar Junction ◽  
Surgical Corridor ◽  
Pica Aneurysms

Abstract BACKGROUND Use of the far lateral transcondylar (FL) approach and vagoaccessory triangle is the standard exposure for clipping most posterior inferior cerebellar artery (PICA) aneurysms. However, a distal PICA origin or high-lying vertebrobasilar junction can position the aneurysm beyond the vagoaccessory triangle, making the conventional FL approach inappropriate. OBJECTIVE To demonstrate the utility of the extended retrosigmoid (eRS) approach and a lateral trajectory through the glossopharyngo-cochlear triangle as the surgical corridor for these cases. METHODS High-riding PICA aneurysms treated by microsurgery were retrospectively reviewed, comparing exposure through the eRS and FL approaches. Clinical, surgical, and outcome measures were evaluated. Distances from the aneurysm neck to the internal auditory canal (IAC), jugular foramen, and foramen magnum were measured. RESULTS Six patients with PICA aneurysms underwent clipping using the eRS approach; 5 had high-riding PICA aneurysms based on measurements from preoperative computed tomography angiography (CTA). Mean distances of the aneurysm neck above the foramen magnum, below the IAC, and above the jugular foramen were 27.0 mm, 3.7 mm, and 8.2 mm, respectively. Distances were all significantly lower versus the comparison group of 9 patients with normal or low-riding PICA aneurysms treated using an FL approach (P < .01). All 6 aneurysms treated using eRS were completely occluded without operative complications. CONCLUSION The eRS approach is an important alternative to the FL approach for high-riding PICA aneurysms, identified as having necks more than 23 mm above the foramen magnum on CTA. The glossopharyngo-cochlear triangle is another important anatomic triangle that facilitates microsurgical dissection.

Aneurysms of the posterior inferior cerebellar artery

1983 ◽  
Vol 58 (3) ◽  
pp. 381-387 ◽  
Author(s):  
Rroger J. Hudgins ◽  
Arthur L. Day ◽  
Ronald G. Quisling ◽  
Albert L. Rhoton ◽  
George W. Sypert ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Vascular Anomaly ◽  
Foramen Magnum ◽  
Parent Vessel ◽  
Content Type ◽  
Aneurysm Neck ◽  
Suboccipital Craniectomy ◽  
Cerebellar Artery ◽  
Pica Aneurysms ◽  
Fine Print

✓ The clinical and anatomical features of 21 surgically treated saccular aneurysms of the posterior inferior cerebellar artery (PICA) are analyzed. Seventeen of these lesions originated from the PICA-vertebral junction, and four arose from distal PICA branching sites. Twelve lesions arose from the left PICA, nine were right-sided, and all were small (less than 12.5 mm). Most of these aneurysms occurred in females (16 of 21) and presented as classic subarachnoid hemorrhage. The lack of specific focal deficits prevented an accurate pre-angiographic determination of aneurysm location in most instances. Clinically significant vasospasm and aneurysm multiplicity occurred with approximately equal frequency as at other locations. The angiographic and surgical features of these lesions are determined by the course of the vertebral artery and PICA; that is, they occur at branching sites and at curves in the parent vessel, and point in the direction in which flow would have continued if the curve at the aneurysm's origin had not been present. Aneurysms at the PICA-vertebral junction usually occur at least 1 cm above the foramen magnum level, arise distal to the PICA origin in the angle between the two vessels, and are best approached by a paramedian incision with the patient in the lateral recumbent position. Isolated clipping of the aneurysm neck is essential in this instance, as trapping may compromise vital perforating arteries of the brain stem. More distal (retromedullary) PICA aneurysms are sometimes associated with another vascular anomaly (two cases in this series), and are best handled through a bilateral suboccipital craniectomy. Clipping of the neck is the preferred treatment, but trapping is usually safe, if necessary.

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.

Extended Retrosigmoid Craniotomy and Approach Through the Glossopharyngeal Cochlear Triangle for Clipping of a High-Riding Vertebral-Posterior Inferior Cerebellar Artery Aneurysm: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Geoffrey W Peitz ◽  
Ryan A McDermott ◽  
Jacob F Baranoski ◽  
Michael T Lawton ◽  
Justin R Mascitelli
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Artery Aneurysm ◽  
Cranial Neuropathy ◽  
Aneurysm Neck ◽  
Direct Exposure ◽  
Cerebellar Artery ◽  
Facial Spasm ◽  
History Of

Abstract The far lateral transcondylar (FL) craniotomy is the standard approach for posterior inferior cerebellar artery (PICA) aneurysm exposure through microsurgical dissection in the vagoaccessory triangle (VAT).1,2 However, the extended retrosigmoid (eRS) craniotomy and dissection through the glossopharyngeal-cochlear triangle (GCT) may be more appropriate when the patient has an aneurysm arising from a high-riding vertebral artery (VA)—PICA origin.3-5 We present a case of a 41-yr-old woman with hypertension presenting with left occipital pain and left-side hearing loss and past facial spasm and pain. Computed tomography angiography and digital subtraction angiography demonstrated an unruptured 8.4 × 9.0 × 10.2 mm saccular aneurysm at the left VA-PICA junction. Surgical clipping was chosen over endovascular therapy given the relationship of the PICA origin to the aneurysm neck as well as the history of cranial neuropathy. It was noted that the VA-PICA junction and aneurysm was high-riding at the level of the internal auditory canal. An eRS craniotomy was performed with dissection through the GCT, and the aneurysm was clipped as shown in the accompanying 2-dimensional operative video. Postoperative angiography demonstrated complete occlusion of the aneurysm and patency of the left VA and PICA without stenosis, and the patient had a favorable postoperative course although her left-sided hearing remained diminished. The eRS craniotomy allowed direct exposure via the GCT for clipping of the high-riding VA-PICA junction aneurysm and decompression of the cranial nerves. The traditional FL craniotomy and exposure through the VAT would likely have resulted in a less desirable inferior trajectory. The patient gave informed consent for the operation depicted in the video. Animation at 2:43 in video is used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Efficacy and Outcomes of Posterior Inferior Cerebellar Artery (PICA) Bypass for Proximal PICA and Vertebral Artery-PICA Aneurysms: A Case Series

2018 ◽  
Vol 15 (4) ◽  
pp. 395-403 ◽  
Author(s):  
Robert C Rennert ◽  
Ben A Strickland ◽  
Kristine Ravina ◽  
Joshua Bakhsheshian ◽  
Vance Fredrickson ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Bypass Graft ◽  
Posterior Inferior Cerebellar Artery ◽  
Case Series ◽  
High Morbidity ◽  
Surgical Experience ◽  
Graft Harvest ◽  
Cerebellar Artery ◽  
Pica Aneurysms ◽  
Temporary Clip

Abstract BACKGROUND Nonsaccular vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms have high morbidity and mortality rates and are difficult to treat using standard microsurgical or endovascular techniques. Definitive revascularization can require clip trapping and/or vessel sacrifice, with PICA bypass. The published surgical experience with these approaches is limited. We herein review our recent surgical experience with PICA revascularization for complex PICA and VA/PICA aneurysms. OBJECTIVE To determine the efficacy and outcomes of PICA bypass for revascularization of nonsaccular PICA and VA/PICA aneurysms. METHODS Retrospective analysis of an institutional review board-approved, prospective database was performed to identify patients with PICA and VA/PICA aneurysms treated with PICA bypass at a single institution. Demographic information, aneurysm characteristics, temporary clip time, and neurological outcomes were recorded. RESULTS Ten cases of PICA revascularization were performed for both ruptured (n = 8) and unruptured (n = 2) nonsaccular proximal PICA or VA/PICA aneurysms. Seven cases were performed without vessel grafts; 3 cases required harvest of the descending branch of the lateral femoral circumflex artery. Mean temporary clip time was 38 min (range 27-50 min). Good outcomes (Glasgow Outcomes Scale score of 5) were achieved in 70% (n = 7) of patients at time of discharge; the remaining patients had a Glasgow Outcomes Scale of 3. Two bypass-related complications occurred in this series; a hematoma at the graft harvest site requiring evacuation, and severe bypass graft spasm requiring multiple endovascular treatments. CONCLUSION PICA bypass can be a safe, effective, and highly customizable tool for the revascularization of patients with nonsaccular proximal PICA and VA/PICA aneurysms.

Extracranial Posterior Inferior Cerebellar Artery Aneurysm Causing Isolated Intraventricular Hemorrhage: A Case Report

Neurosurgery ◽  
1988 ◽  
Vol 23 (6) ◽  
pp. 774-777 ◽  
Author(s):  
Antonio Ruelle ◽  
Paolo Cavazzani ◽  
Giancarlo Andrioli
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Intraventricular Hemorrhage ◽  
Posterior Inferior Cerebellar Artery ◽  
Artery Aneurysm ◽  
Foramen Magnum ◽  
Computed Tomographic ◽  
Left Posterior ◽  
Cerebellar Artery ◽  
Computed Tomographic Scan ◽  
Pica Aneurysms

Abstract The authors report the unusual case of an aneurysm arising on an extracranial loop of the left posterior inferior cerebellar artery (PICA). The computed tomographic scan showed an isolated hemorrhage in the lateral ventricles, and the lesion was recognized 1.5 cm below the foramen magnum at the level of the atlas. The literature concerning peripheral PICA aneurysms is reviewed and the clinical and radiological features of these lesions are discussed. A tendency for subarachnoid bleeding from distal PICA aneurysm ruptures to spread into the ventricular system is suggested. The diagnosis of distal PICA aneurysm should also be considered in cases of isolated intraventricular hemorrhage without obvious parenchymal or subarachnoid hemorrhage. The need for four-vessel angiography when studying patients suffering from a subarachnoid hemorrhage is stressed.

Aneurysms of the Distal Posterior Inferior Cerebellar Artery: Experience with Three Cases and Review of the Literature

Neurosurgery ◽  
1985 ◽  
Vol 16 (6) ◽  
pp. 829-832 ◽  
Author(s):  
Tomoyuki Nishizaki ◽  
Norihiko Tamaki ◽  
Yoshimitsu Nishida ◽  
Katsuzo Fujita ◽  
Satoshi Matsumoto
Keyword(s):  
Computed Tomography ◽  
Mortality Rate ◽  
Turning Point ◽  
Posterior Inferior Cerebellar Artery ◽  
Review Of The Literature ◽  
Aneurysm Neck ◽  
Cerebellar Artery ◽  
Pica Aneurysms

Abstract We report 3 surgically treated aneurysms of the distal posterior inferior cerebellar artery (PICA) and review 36 cases in the literature. More than half of the distal PICA aneurysms arose distal to the choroidal arch. These lesions often arose at a turning point (i.e., a hairpin curve) of an artery instead of at a junction of vessels. Distal PICA aneurysms are likely to be missed and it is necessary to investigate carefully with four-vessel angiography even if computed tomography is done. Eighty-two per cent of the surgically treated 39 patients had good recoveries and 8% had fair results. The mortality rate was 10%. Although clipping of the aneurysm neck is preferable, trapping is useful when neck clipping is impossible in segments distal to the choroidal arch.

scholarly journals Extracranially located PICA aneurysm presenting with supratentorial IVH: A rare event with diagnostic pitfalls

2013 ◽  
Vol 04 (S 01) ◽  
pp. S99-S101
Author(s):  
Amey Savardekar ◽  
Manoj Kumar Tewari ◽  
Rajeev Garg ◽  
Vivek Gupta ◽  
Chirag Ahuja
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Rare Event ◽  
Brain Magnetic Resonance Imaging ◽  
Foramen Magnum ◽  
Sudden Onset ◽  
Proximal Segment ◽  
Suboccipital Craniectomy ◽  
Cerebellar Artery ◽  
Magnetic Resonance Imaging Mri ◽  
Pica Aneurysms

ABSTRACTExtracranially located posterior inferior cerebellar artery (PICA) aneurysms are rare with only 21 cases reported till date. They may arise either from the proximal segment of an extracranially originating PICA or from the tip of its caudal loop when it dips below the foramen magnum. A 16-year-old female presenting with sudden onset severe headache and intraventricular hemorrhage (IVH) in the occipital horns of the lateral ventricle and the fourth ventricles, was diagnosed to have an extracranial proximal segment PICA aneurysm on a four vessel digital subtraction angiography (DSA), after initially missing it on the brain magnetic resonance imaging (MRI) with angiogram (MRA) because of its extracranial location. During surgery, the aneurysm was clipped following a far lateral suboccipital craniectomy with C1‑C2 hemilaminectomy. The patient showed good recovery. Thus, we emphasize the need for a dedicated four vessel angiography to diagnose such lesions.

The Glossopharyngo-Cochlear Triangle—Part I: Quantitative Anatomic Analysis of High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach

2020 ◽  
Author(s):  
Xiaochun Zhao ◽  
Ali Tayebi Meybodi ◽  
Komal Naeem ◽  
Evgenii Belykh ◽  
Mohamed A Labib ◽  
...  
Keyword(s):  
Patient Selection ◽  
Posterior Inferior Cerebellar Artery ◽  
Spatial Relationship ◽  
Abducens Nerve ◽  
Foramen Magnum ◽  
Retrosigmoid Approach ◽  
Vertebrobasilar System ◽  
Cerebellar Artery ◽  
The Mean ◽  
Pica Aneurysms

Abstract BACKGROUND An extended retrosigmoid approach can offer sufficient space for clip reconstruction of some high-riding posterior inferior cerebellar artery (PICA) aneurysms. OBJECTIVE To quantitatively investigate the glossopharyngo-cochlear triangle (GCT) and anatomic structures within it. METHODS Extended retrosigmoid craniotomies were performed on 10 sides of cadaveric heads, and the GCT was identified in each specimen. The length of the base and the area of the GCT were measured. The depth of the vertebrobasilar system and the abducens nerve to the GCT were measured. The proximal and distal exposable and controllable points on the vertebrobasilar system were identified. Two imaging-based patient selection algorithms are provided using the lengths from those points to the vertebral artery dural entry point and the superoinferior distances from those points to the inferior edge of the foramen magnum. Other factors related to accessibility via the GCT were investigated. RESULTS The mean (standard deviation [SD]) area of the GCT was 45.7 (12.55) mm2. The mean (SD) depth of the abducens nerve was 14.3 (1.42) mm. The mean (SD) superoinferior distances from the foramen magnum to those points were 23.1 (7.39), 24.7 (8.25), 30.0 (9.56), and 32.6 (7.79) mm, respectively. The lower segment of the vertebrobasilar system was more superficial in the setting of a high-lying vertebrobasilar junction (VBJ) than a low-lying VBJ. CONCLUSION We describe the GCT in an extended retrosigmoid approach for high-riding PICA aneurysms and evaluate the spatial relationship of the neurovascular structures within it. Two potential algorithms are offered for preoperative patient selection.

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.

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