scholarly journals Management of a Ruptured Posterior Inferior Cerebellar Artery (PICA) Aneurysm With PICA–PICA In Situ Bypass and Trapping: 3-Dimensional Operative Video

2017 ◽  
Vol 13 (3) ◽  
pp. 400-400 ◽  
Author(s):  
Arnau Benet ◽  
Nicola Montemurro ◽  
Michael T. Lawton
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Pica Pica ◽  
3 Dimensional ◽  
Cerebellar Artery ◽  
In Situ Bypass

Cerebral revascularization performed using posterior inferior cerebellar artery—posterior inferior cerebellar artery bypass

2002 ◽  
Vol 97 (1) ◽  
pp. 219-223 ◽  
Author(s):  
G. Michael Lemole ◽  
Jeffrey Henn ◽  
Sam Javedan ◽  
Vivek Deshmukh ◽  
Robert F. Spetzler
Keyword(s):  
Artery Bypass ◽  
Posterior Inferior Cerebellar Artery ◽  
Surgical Techniques ◽  
Cerebral Revascularization ◽  
Pica Pica ◽  
Content Type ◽  
Cerebellar Artery ◽  
In Situ Bypass ◽  
Fine Print

✓ Cerebral revascularization is often required for the surgical treatment of complex intracranial aneurysms. In certain anatomical locations, vascular anatomy and redundancy make in situ bypass possible. The authors present four patients who underwent revascularization performed using the rarely reported posterior inferior cerebellar artery (PICA)—PICA in situ bypass after their aneurysms had been trapped. At Barrow Neurological Institute, between 1991 and the present, four male patients underwent PICA—PICA bypasses to treat aneurysms involving the vertebral artery, the PICA, or both. The mean age of these patients was 34 years (range 5–49 years). Follow-up studies revealed patent bypasses and no evidence of infarction. Patient outcomes were excellent or good. Multiple surgical techniques have been described for revascularization of at-risk cerebral territories. Often, the blood supply must be derived from extracranial sources through a mobilized pedicle or interposited graft. Certain anatomical locations such as the vertebrobasilar junction, the anterior circle of Willis, and the middle cerebral artery bifurcation are amenable to in situ bypass because there is vessel redundancy or proximity to the contralateral analogous vessel. The advantages of an in situ bypass include one suture line, a short bypass distance, and a close match with the caliber of the recipient graft. Although technically challenging, this technique can be successful and should be considered for appropriate candidates.

Far Lateral Craniotomy for Posterior Inferior Cerebellar Artery–Posterior Inferior Cerebellar Artery Bypass and Trapping of Posterior Inferior Cerebellar Artery Aneurysm: 3-Dimensional Operative Video

2018 ◽  
Vol 16 (4) ◽  
pp. E119-E120 ◽  
Author(s):  
Sirin Gandhi ◽  
Justin Mascitelli ◽  
Douglas Hardesty ◽  
Michael T Lawton
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Morphological Characteristics ◽  
Occipital Artery ◽  
Parent Artery ◽  
Pica Pica ◽  
Cerebellar Artery ◽  
Patient Consent ◽  
Far Lateral ◽  
In Situ Bypass

Abstract Posterior inferior cerebellar artery (PICA) aneurysms account for 3% to 4% of all intracranial aneurysms with an unusually high predilection towards a nonsaccular morphology making microsurgical clipping or endovascular reconstruction of the parent artery difficult. The management of these complicated aneurysms may require revascularization procedures for flow preservation with aneurysm trapping. Recently, there is an increasing inclination towards intracranial–intracranial (IC-IC) bypasses over traditional extracranial donors.  This video demonstrates a side-to-side PICA–PICA in situ bypass with trapping of an unruptured incidental right p1-PICA aneurysm. Radiological lesion progression and presence of dysplastic morphological characteristics prompted surgical management. The aneurysm was not amenable to clip reconstruction due to the dysplastic PICA segment and lack of a discernable neck. Institutional Review Board approval and patient consent were sought. With patient in three-quarter-prone position, a right far lateral craniotomy was performed. A left-to-right p3-p3 PICA bypass was completed. The aneurysm was clipped along with proximal PICA at its takeoff from vertebral artery. Indocyanine green videoangiography revealed complete occlusion of aneurysm and proximal PICA and a patent anastomosis with distal right PICA flow. Postoperatively, patient recovered with no new neurological deficits.  Dolichoectatic posterior circulation aneurysms are not readily amenable to clip reconstruction. PICA–PICA in situ bypass is an elegant alternative to existing extracranial–intracranial revascularization constructs (occipital artery to PICA).1 There is lower neurological morbidity associated with IC-IC bypass vs PICA reimplantation due to the deep surgical corridor and its proximity to lower cranial nerves. Additionally, in this patient endovascular occlusion posed a higher risk of thrombotic complications and postprocedural cerebellar edema with brainstem compression.2

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.

Operative Nuances of Side-to-Side In Situ Posterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery Bypass Procedure

2010 ◽  
Vol 67 (suppl_2) ◽  
pp. ons471-ons477 ◽  
Author(s):  
Miikka Korja ◽  
Chandranath Sen ◽  
David Langer
Keyword(s):  
Indocyanine Green ◽  
Indocyanine Green Angiography ◽  
Posterior Inferior Cerebellar Artery ◽  
Posterior Circulation ◽  
Treatment Modalities ◽  
Bypass Operation ◽  
Pica Pica ◽  
Bypass Procedure ◽  
Cerebellar Artery

ABSTRACT BACKGROUND: An intracranial posterior circulation revascularization procedure in the form of a side-to-side in situ posterior inferior cerebellar artery (PICA)-PICA bypass operation was introduced in 1991. This elegant and apparently low-risk operation is performed infrequently. Thus, the operative nuances used in this procedure have not been well reported, limiting the scope of treatment modalities of vertebral artery-PICA aneurysms and vertebral dissections. OBJECTIVE: To repair an incidental right-sided PICA aneurysm noted in a 51-year-old woman in magnetic resonance imaging and subsequent angiography. METHODS: The patient underwent side-to-side in situ PICA-PICA bypass surgery. RESULTS: Immediate indocyanine green angiography suggested that the PICA distal to the aneurysms was filling in a retrograde fashion through the bypass. On the following day, the patient was taken for coil embolization of the aneurysm. However, angiography images revealed that the aneurysm was spontaneously thrombosed, the proximal PICA was patent, and the PICA distal to the aneurysms was filling in a retrograde fashion, as suspected in intraoperative indocyanine green angiography. No further treatments were done. The patient recovered fully. CONCLUSION: We describe in detail the preoperative evaluation, decision process, and operative techniques for a side-to-side in situ PICA-PICA bypass operation, which is a relatively safe and elegant posterior circulation bypass procedure.

scholarly journals Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients

2016 ◽  
Vol 124 (5) ◽  
pp. 1275-1286 ◽  
Author(s):  
Adib A. Abla ◽  
Cameron M. McDougall ◽  
Jonathan D. Breshears ◽  
Michael T. Lawton
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Endovascular Coiling ◽  
Pica Pica ◽  
Lower Cranial Nerve ◽  
Complex Aneurysms ◽  
Cerebellar Artery ◽  
Ischemic Complications ◽  
Pica Aneurysms ◽  
Vascular Neurosurgery

OBJECT Intracranial-to-intracranial (IC-IC) bypasses are alternatives to traditional extracranial-to-intracranial (EC-IC) bypasses to reanastomose parent arteries, reimplant efferent branches, revascularize branches with in situ donor arteries, and reconstruct bifurcations with interposition grafts that are entirely intracranial. These bypasses represent an evolution in bypass surgery from using scalp arteries and remote donor sites toward a more local and reconstructive approach. IC-IC bypass can be utilized preferentially when revascularization is needed in the management of complex aneurysms. Experiences using IC-IC bypass, as applied to posterior inferior cerebellar artery (PICA) aneurysms in 35 patients, were reviewed. METHODS Patients with PICA aneurysms and vertebral artery (VA) aneurysms involving the PICA’s origin were identified from a prospectively maintained database of the Vascular Neurosurgery Service, and patients who underwent bypass procedures for PICA revascularization were included. RESULTS During a 17-year period in which 129 PICA aneurysms in 125 patients were treated microsurgically, 35 IC-IC bypasses were performed as part of PICA aneurysm management, including in situ p3-p3 PICA-PICA bypass in 11 patients (31%), PICA reimplantation in 9 patients (26%), reanastomosis in 14 patients (40%), and 1 V3 VA-to-PICA bypass with an interposition graft (3%). All aneurysms were completely or nearly completely obliterated, 94% of bypasses were patent, 77% of patients were improved or unchanged after treatment, and good outcomes (modified Rankin Scale ≤ 2) were observed in 76% of patients. Two patients died expectantly. Ischemic complications were limited to 2 patients in whom the bypasses occluded, and permanent lower cranial nerve morbidity was limited to 3 patients and did not compromise independent function in any of the patients. CONCLUSIONS PICA aneurysms receive the application of IC-IC bypass better than any other aneurysm, with nearly one-quarter of all PICA aneurysms treated microsurgically at our center requiring bypass without a single EC-IC bypass. The selection of PICA bypass is almost algorithmic: trapped aneurysms at the PICA origin or p1 segment are revascularized with a PICA-PICA bypass, with PICA reimplantation as an alternative; trapped p2 segment aneurysms are reanastomosed, bypassed in situ, or reimplanted; distal p3 segment aneurysms are reanastomosed or revascularized with a PICA-PICA bypass; and aneurysms of the p4 segment that are too distal for PICA-PICA bypass are reanastomosed. Interposition grafts are reserved for when these 3 primary options are unsuitable. A constructive approach that preserves the PICA with direct clipping or replaces flow with a bypass when sacrificed should remain an alternative to deconstructive PICA occlusion and endovascular coiling when complete aneurysm occlusion is unlikely.

scholarly journals Treating a Ruptured Fusiform Aneurysm of the Posterior Inferior Cerebellar Artery (PICA) using PICA-PICA Anastomosis combined with Trapping: A Case Report

2010 ◽  
Vol 19 (5) ◽  
pp. 420-424
Author(s):  
Kenta Aso ◽  
Yoshitaka Kubo ◽  
Shunsuke Kakino ◽  
Hiroshi Kashimura ◽  
Atsushi Sugawara ◽  
...  
Keyword(s):  
Case Report ◽  
Posterior Inferior Cerebellar Artery ◽  
Fusiform Aneurysm ◽  
Pica Pica ◽  
Cerebellar Artery

Treatment of an Anterior Inferior Cerebellar Artery Aneurysm With Microsurgical Trapping and In Situ Posterior Inferior Cerebellar Artery to Anterior Inferior Cerebellar Artery Bypass: Case Report

2017 ◽  
Vol 15 (4) ◽  
pp. 418-424 ◽  
Author(s):  
Bryan S Lee ◽  
Alex M Witek ◽  
Nina Z Moore ◽  
Mark D Bain
Keyword(s):  
Artery Bypass ◽  
Posterior Inferior Cerebellar Artery ◽  
Significant Risk ◽  
Artery Aneurysm ◽  
Lateral Approach ◽  
Anterior Inferior Cerebellar Artery ◽  
Parent Vessel ◽  
Cerebellar Artery ◽  
Far Lateral Approach

Abstract BACKGROUND Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment can involve microsurgical and/or endovascular techniques. Such treatment can be challenging and may carry a significant risk of neurological morbidity. OBJECTIVE To demonstrate a case involving a complex AICA aneurysm that was treated with a unique microsurgical approach involving trapping the aneurysm and performing in Situ bypass from the posterior inferior cerebellar artery (PICA) to the distal AICA. The nuances of AICA aneurysms and revascularization strategies are discussed. METHODS The aneurysm and the distal segments of AICA and PICA were exposed with a retrosigmoid and far lateral approach. A side-to-side anastomosis was performed between the adjacent caudal loops of PICA and AICA. The AICA aneurysm was then treated by trapping the aneurysm-bearing segment of the parent vessel between 2 clips. RESULTS A postoperative angiogram demonstrated a patent PICA-AICA bypass and complete occlusion of the AICA aneurysm. There were no complications, and the patient made an excellent recovery. CONCLUSION The combination of parent vessel sacrifice and bypass remains an excellent option for certain difficult-to-treat aneurysms. This case involving PICA-AICA bypass to treat an AICA aneurysm serves as an example of the neurosurgeon's ability to develop unique solutions that take advantage of individual anatomy.

Treatment of vertebral artery aneurysms with transposition of the posterior inferior cerebellar artery to the vertebral artery combined with parent artery occlusion

2006 ◽  
Vol 105 (5) ◽  
pp. 781-784 ◽  
Author(s):  
Kuniaki Ogasawara ◽  
Yoshitaka Kubo ◽  
Nobuhiko Tomitsuka ◽  
Masayuki Sasoh ◽  
Yasunari Otawara ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Artery Occlusion ◽  
The Other ◽  
Parent Artery ◽  
Pica Pica ◽  
Suboccipital Craniectomy ◽  
Parent Artery Occlusion ◽  
Cerebellar Artery ◽  
Good Patency

✓ The authors describe transposition of the posterior inferior cerebellar artery (PICA) to the vertebral artery (VA) combined with parent artery occlusion for the treatment of VA aneurysms in cases in which a clip could not be applied because of the origin of the ipsilateral PICA. The aneurysm is trapped through a lower lateral suboccipital craniectomy. The PICA is then cut just distal to the aneurysm, and the PICA and VA proximal to the aneurysm are anastomosed in an end-to-end or end-to-side fashion. The surgical procedure was successfully performed in two patients, each of whom had hypoplastic occipital arteries (OAs). The PICA contralateral to the lesion was hypoplastic in one patient and distant to the ipsilateral PICA in the other patient. Mild transient dysphagia developed postoperatively in one patient due to glossopharyngeal and vagus nerve palsy, and the other patient had an uneventful postoperative course. In both patients, postoperative cerebral angiography demonstrated good patency of the transposed PICA. These results show that transposition of the PICA to the VA is a useful procedure for the reconstruction of the PICA when parent artery occlusion is necessary to exclude a VA aneurysm involving the origin of the PICA and when OA–PICA anastomosis or PICA–PICA anastomosis cannot be performed.

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