Trapping and P2-P3 Posterior Inferior Cerebellar Artery Reanastomosis for Treatment of a Ruptured Fusiform Aneurysm: Application of Fourth-Generation Technique: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Tyler T Lazaro ◽  
Visish M Srinivasan ◽  
Patrick C Cotton ◽  
Jacob Cherian ◽  
Jeremiah N Johnson
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Lateral Approach ◽  
Fourth Generation ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Close Proximity ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Distal Artery

Abstract Aneurysms of the posterior inferior cerebellar artery (PICA) represent the second most common posterior circulation aneurysm and commonly have complex morphology. Various bypass options exist for PICA aneurysms,1-6 depending on their location relative to brainstem perforators and the vertebral artery, and the presence of nearby donor arteries. We present a case of a man in his late 40s who presented with 3 d of severe headache. He was found to have a fusiform right P2-segment PICA aneurysm. Preoperative angiogram demonstrated the aneurysm and a redundant P3 caudal loop that came in close proximity to the healthy P2 segment proximal to the aneurysm. The risks and benefits of the procedure were discussed with the patient, and they consented for a right far lateral approach craniotomy with partial condylectomy for trapping of the aneurysm with bypass. The aneurysm was trapped proximally and distally. The P3 was transected just distal to the aneurysm and brought toward the proximal P2 segment, facilitated by a lack of perforators on this redundant distal artery. An end-to-side anastomosis was performed. Postoperative angiogram demonstrated exclusion of the aneurysm and patent bypass. The patient recovered well and remained without any neurological deficit at 6-mo follow-up.  This case demonstrates the use of a “fourth-generation”5,7,8 bypass technique. These techniques represent the next innovation beyond third-generation intracranial-intracranial bypass. In this type 4B reanastomosis bypass, an unconventional orientation of the arteries was used. Whereas reanastomosis is typically performed end-to-end, the natural course of these arteries and the relatively less-mobile proximal P2 segment made end-to-side the preferred option in this case. Fourth-generation bypass techniques open up more configurations for reanastomosis, using the local anatomy to the surgeon's advantage.  The patient consented to the described procedure and consented to the publication of their image.

scholarly journals Far-lateral approach for surgical treatment of fusiform PICA aneurysm

2015 ◽  
Vol 38 (videosuppl1) ◽  
pp. Video10 ◽  
Author(s):  
William T. Couldwell ◽  
Jayson A. Neil
Keyword(s):  
Evoked Potential ◽  
Posterior Inferior Cerebellar Artery ◽  
Motor Evoked Potential ◽  
Lateral Approach ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Vessel Patency ◽  
Far Lateral ◽  
Evoked Potential Monitoring ◽  
Pica Aneurysms

Ruptured fusiform posterior inferior cerebellar artery (PICA) aneurysms can be technically challenging lesions. Surgeons must be ready to employ a variety of strategies in the successful treatment of these aneurysms. Strategies include complex clip techniques including clip-wrapping or trapping and revascularization. The case presented here is of a man with subarachnoid hemorrhage from a fusiform ruptured PICA aneurysm. The technique demonstrated is a far-lateral approach and a clip-wrap technique using muslin gauze. The patient was given aspirin preoperatively in preparation for possible occipital–PICA bypass if direct repair was not feasible. It is the authors' preference to perform direct vessel repair as a primary goal and use bypass techniques when this is not possible. Vessel patency was evaluated after clip-wrapping using intraoperative Doppler. Intraoperative somatosensory and motor evoked potential monitoring is used in such cases. The patient recovered well.The video can be found here: http://youtu.be/iwLqufH47Ds.

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

2009 ◽  
Vol 10 (3) ◽  
pp. 228-233 ◽  
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.

Far-Lateral Approach Without Drilling the Occipital Condyle for Vertebral Artery–Posterior Inferior Cerebellar Artery Aneurysms

Neurosurgery ◽  
2017 ◽  
Vol 81 (2) ◽  
pp. 268-274 ◽  
Author(s):  
Pablo Seoane ◽  
Samuel Kalb ◽  
Justin C. Clark ◽  
Juan C. Rivas ◽  
David S. Xu ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Glasgow Outcome Scale ◽  
Posterior Inferior Cerebellar Artery ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Scale Scores ◽  
Far Lateral ◽  
Pica Aneurysms

Abstract BACKGROUND: The far-lateral transcondylar surgical approach is often used to clip vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms. The role of condyle resection during this approach is controversial. OBJECTIVE: To evaluate patient outcomes in patients with VA–PICA aneurysms in whom drilling the occipital condyle was not necessary. METHODS: Between May 2005 and December 2012, a total of 56 consecutive patients with incidental or ruptured VA–PICA aneurysms underwent surgery with a far-lateral approach without condylar resection. Clinical presentation, surgical reports, presurgery and postsurgery radiological examinations, and clinical follow-up reports were assessed. Anatomic aneurysm location was analyzed through angiography or computed tomography angiography. We compared postsurgical Glasgow Outcome Scale scores, modified Rankin Scale scores, and morbidity in 2 groups: those with aneurysms in the anterior medullary segment and those with aneurysms in the lateral medullary segment. RESULTS: The predominant presentation was subarachnoid hemorrhage in 34 patients (60.7%). Most aneurysms (n = 27 [48.2%]) were located in the lateral medullary segment of the PICA, followed by the anterior medullary segment (n = 25 [44.6%]). Total aneurysm occlusion was achieved in 100% of patients, and bypass techniques were necessary in 3 patients (5.4%). Fifty-two patients (92.8%) had Glasgow Outcome Scale scores of 4 or 5 postsurgery. CONCLUSIONS: A far-lateral approach that leaves the occipital condyle intact is adequate for treating most patients with VA–PICA aneurysms.

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

2008 ◽  
Vol 25 (6) ◽  
pp. E9 ◽  
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.

scholarly journals The role of alternative anastomosis sites in occipital artery–posterior inferior cerebellar artery bypass in the absence of the caudal loop using the far-lateral approach

2017 ◽  
Vol 126 (2) ◽  
pp. 634-644 ◽  
Author(s):  
Hitoshi Fukuda ◽  
Alexander I. Evins ◽  
Koichi Iwasaki ◽  
Itaro Hattori ◽  
Kenichi Murao ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Posterior Inferior Cerebellar Artery ◽  
Technical Difficulty ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Difficulty Level ◽  
Occipital Artery ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Far Lateral

OBJECTIVE Occipital artery–posterior inferior cerebellar artery (OA-PICA) bypass is a technically challenging procedure for posterior fossa revascularization. The caudal loop of the PICA is considered the optimal site for OA-PICA anastomosis, however its absence can increase the technical difficulty associated with this procedure. The use of the far-lateral approach for accessing alternative anastomosis sites in OA-PICA bypass in patients with absent or unavailable caudal loops of PICA is evaluated. METHODS A morphometric analysis of OA-PICA bypass with anastomosis on each segment of the PICA was performed on 5 cadaveric specimens through the conventional midline foramen magnum and far-lateral approaches. The difficulty level associated with anastomoses at each segment was qualitatively assessed in each approach for exposure and maneuverability by multiple surgeons. A series of 8 patients who underwent OA-PICA bypass for hemodynamic ischemia or ruptured dissecting posterior fossa aneurysms are additionally reviewed and described, and the clinical significance of the caudal loop of PICA is discussed. RESULTS Anastomosis on the caudal loop could be performed more superficially than on any other segment (p < 0.001). A far-lateral approach up to the medial border of the posterior condylar canal provided a 13.5 ± 2.2–mm wider corridor than the conventional midline foramen magnum approach, facilitating access to alternative anastomosis sites. The far-lateral approach was successfully used for OA-PICA bypass in 3 clinical cases whose caudal loops were absent, whereas the midline foramen magnum approach provided sufficient exposure for caudal loop bypass in the remaining 5 cases. CONCLUSIONS The absence of the caudal loop of the PICA is a major contributing factor to the technical difficulty of OA-PICA bypass. The far-lateral approach is a useful surgical option for OA-PICA bypass when the caudal loop of the PICA is unavailable.

scholarly journals Technical strategies to approach aneurysms of the vertebral and posterior inferior cerebellar arteries

2005 ◽  
Vol 19 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Niklaus Krayenbühl ◽  
Carlos A. Guerrero ◽  
Ali F. Krisht
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Anatomical Location ◽  
Microsurgical Anatomy ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Lower Cranial Nerves

Object Aneurysms of the vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) are rare and challenging lesions, as they are located in front of the brainstem and surrounded by the lower cranial nerves. Many different approaches have been described for their treatment, and have yielded different results. With the use of different examples of lesions, the authors describe their surgical strategy in the management of VA and PICA aneurysms. Methods The far-lateral approach was used, and the potential of its different extensions according to the specific anatomical location and configuration of different types of aneurysms is emphasized. Conclusions With the present knowledge of the microsurgical anatomy in the region of the foramen magnum, the far-lateral approach can be tailored to the specific anatomical and morphological configuration of an aneurysm in this region with good surgical results.

scholarly journals Microneurosurgical Management of Posterior Inferior Cerebellar Artery Aneurysms: Results of a Consecutive Series

2021 ◽  
pp. 33-38
Author(s):  
Mattia Del Maestro ◽  
Sabino Luzzi ◽  
Renato Galzio
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Lateral Approach ◽  
Senior Author ◽  
Preoperative Imaging ◽  
Imaging Evaluation ◽  
Complex Anatomy ◽  
Cerebellar Artery ◽  
Pica Aneurysms

AbstractAneurysms of the posterior inferior cerebellar artery (PICA) are uncommon. The complex anatomy of PICA and its intimate relationships with medulla, lower cranial nerves, and jugular tubercle makes the surgical treatment of these aneurysms fascinating. The reported is study aimed at a critical review of the overall results of a personal series of PICA aneurysms, treated by the senior author, R. Galzio. Demographics, charts, videos, outcome, and follow-up of a cohort of PICA aneurysms managed in the last 10 years were retrospectively analyzed, focusing only upon those treated with microneurosurgery. Twenty-five patients, harboring a single aneurysm, were operated on. Fifteen aneurysms were ruptured. Nineteen were proximal, all of these being been treated through a far-lateral approach. Trans-condylar or trans-tubercular variants were rarely necessary and however reserved to peculiar cases. Twenty-three aneurysms underwent direct treatment consisting of clip ligation. At 6-month follow-up, 60% of patients had a modified Rankin Score (mRS) of 0–2. Given the high anatomical variability of both PICA and patients’ bony anatomy, a case-by-case meticulous preoperative imaging evaluation is mandatory for the choice of the most suitable and tailored surgical corridor which, in turn, is pivotal to achieve the best outcome.

scholarly journals Surgical Management and Outcomes of Aneurysms of Posterior Inferior Cerebellar Artery: Location-Based Approaches with Review of Literature

2020 ◽  
Vol 11 (01) ◽  
pp. 034-043
Author(s):  
Harsh Deora ◽  
Nitish Nayak ◽  
Priyadarshi Dixit ◽  
V. Vikas ◽  
K. V. L. Narasinga Rao ◽  
...  
Keyword(s):  
Surgical Management ◽  
Posterior Inferior Cerebellar Artery ◽  
Lower Cranial Nerve ◽  
Common Location ◽  
Neurosurgical Society ◽  
Cranial Nerve Palsies ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Pica Aneurysms

Abstract Background Posterior inferior cerebellar artery (PICA) is a tortuous, variable, and uncommon site for aneurysms. Surgical management of PICA aneurysms involves careful selection of approach based on the location of the aneurysm and meticulous dissection of the neurovascular structures and perforators. Materials and Methods We did a retrospective review of all the PICA aneurysms operated at our institute in the past 10 years along with the site, presentation, and approach used for the same. Preoperative World Federation of Neurosurgical Society scores and follow-up modified Rankin scores (mRS) were also evaluated. During the same period, data for intervention cases of PICA aneurysm were also collected with follow-ups for a comparative analysis. Results A total of 20 patients with 21 PICA aneurysms were reviewed. All the reviewed cases presented with subarachnoid hemorrhage, and the most common location was the lateral medullary segment and vertebral artery (VA)–PICA junction. Midline approaches were used for distal PICA cases, with far-lateral approach reserved for anterior medullary/VA–PICA junction. No lower cranial nerve palsies were recorded at follow-up. Four cases needed cerebrospinal fluid diversion and two developed cerebellar infarcts. All cases were mRS 0 to 2 at follow-up. Conclusion Our series compares well with some of the larger surgical series of PICA aneurysms. This may be due to early referral patterns and early surgery (<24 hours) policy at our institution. Anatomical knowledge of PICA anatomy and sound perioperative management are keys to good outcomes in these cases.

scholarly journals Far Lateral Approach for Clipping of a Posterior Inferior Cerebellar Artery Aneurysm

2019 ◽  
Vol 80 (S 04) ◽  
pp. S343-S343
Author(s):  
Jaafar Basma ◽  
Vincent N. Nguyen ◽  
William M. Mangham ◽  
Nickalus R. Khan ◽  
Jeffrey Sorenson ◽  
...  
Keyword(s):  
Hypoglossal Nerve ◽  
Posterior Inferior Cerebellar Artery ◽  
Artery Aneurysm ◽  
Lateral Approach ◽  
Microsurgical Anatomy ◽  
Microsurgical Clipping ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Clip Occlusion

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.

Rotational Vertebral Artery Occlusion—Series of 9 Cases

Neurosurgery ◽  
2010 ◽  
Vol 67 (4) ◽  
pp. 1066-1072 ◽  
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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