End-to-end revascularization between the occipital Artery(OA) and the p1 segment of posterior inferior cerebellar Artery(PICA) for a patient with posterior circulation ischemia via a far-lateral approach:2-Dimensional Operative video
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PROVIDER: S-EPMC10914568 | biostudies-literature | 2024 Feb
REPOSITORIES: biostudies-literature
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Project description:Posterior inferior cerebellar artery (PICA) aneurysms often require cerebral vascular reconstruction for surgical treatment because of their characteristic morphology. Despite its potential complications, the occipital artery-to-posterior inferior cerebellar artery (OA-PICA) bypass is a typical treatment because of its versatility. Although a few cases of intracranial-to-intracranial bypass have been reported, this type of vascular reconstruction is only regarded as an alternative to the OA-PICA bypass because of the uncertainty of bypass feasibility and potential risk of ischemic complications. In this article, we report a case of proximal PICA ruptured aneurysm that was treated with a PICA-to-PICA (PICA-PICA) bypass. A 79-year-old man presented with a chief complaint of sudden, severe headache and disturbances in consciousness. Radiological examination revealed a right proximal PICA fusiform aneurysm. The patient had many systemic disorders such as microscopic polyangiitis and steroid-induced diabetes mellitus that could have caused wound dehiscence and cerebrospinal fluid (CSF) leakage. We performed the PICA-PICA bypass and trapping surgery rather than the OA-PICA bypass to avoid skin problems and CSF leakage. The postoperative course was uneventful, and the patient was discharged on day 64 without any neurological disorders. In comparison with the OA-PICA bypass, the PICA-PICA bypass is less likely to cause CSF leakage and skin complications, although it carries the risk of specific ischemic complications and requires advanced surgical techniques. For some patients with systemic disorders, the PICA-PICA bypass could be an optimal treatment option for proximal fusiform PICA aneurysms rather than as an alternative to the OA-PICA bypass.
| S-EPMC9217146 | biostudies-literature
Project description:PurposeTo demonstrate that occipital artery (OA)-p1 posterior inferior cerebellar artery (PICA) bypass can be an alternative for complex posterior circulation aneurysms.MethodsA far-lateral approach to craniotomy was performed on 20 cadaveric specimens, and the OA was obtained 'in-line.' Its length, diameter, and the number of p1/p2 and p3 segmental perforators were determined, and the relationship between the caudal loop and cerebellar tonsil position was also assessed. The distance between the PICA's origin and the cranial nerve XI (CN XI), the buffer length above the CN XI after dissection, the OA length required to complete the OA-p1/p3 PICA bypass, and the p1 and p3 segment diameters were all measured. A bypass training practical scale (TSIO) was used to evaluate the quality of the anastomosis.ResultsAll specimens underwent OA-p1 PICA end-to-end bypass and had favorable results for the TSIO score, 15 sides underwent OA-p3 PICA end-to-side bypass, and the other bypass protocols were less common. The buffer length above the CN XI after dissection, the distance between the PICA's origin and the CN XI, and the first perforator were all of sufficient length. The direct length of the OA needed to complete the OA-p1 PICA end-to-end bypass was significantly less than the available length and the OA-p3 PICA end-to-side bypass, with the OA matching the p1 segment diameter. The number of p1 perforators was less than that of p3, and the OA diameter was equal to that of the p1 segment.ConclusionOA-p1 PICA end-to-end bypass is a feasible alternative in cases in which p3 segment has high caudal loops or anatomic anomalies.
| S-EPMC10317879 | biostudies-literature
Project description:Aneurysms involving the origin of the posterior inferior cerebellar artery (PICA) have a greater incidence of fusiform morphology, intraluminal thrombi, and wall calcifications. At times, a complex treatment strategy with vessel occlusion and revascularization using a bypass graft is necessary for successful obliteration of these aneurysms. The occipital artery (OA) is often the preferred donor graft for lesions of the posterior fossa because of its proximity to the target recipient vessels. However, dissection of an OA can be challenging, given its anatomically tortuous path and the presence of thick surrounding muscles. This video captures the dissection of the OA using an unconventional, "inside-out" harvesting technique and the end-to-side anastomosis of the OA to the PICA at the p3 segment. This was performed in a 58-year-old man who presented with a subarachnoid hemorrhage (Hunt and Hess grade IV) from a ruptured fusiform aneurysm located at the origin of the right PICA. Major steps in Video 1 during this case include 1) dissection and harvesting of the OA using the "inside out" technique, 2) placement of 2 temporary clips occluding the PICA and isolating the P3 segment, 3) end-to-side OA-P3 anastomosis, and 4) removal of the temporary clips and confirmation of the PICA's patency using intraoperative indocyanine green. Due to the potential for infarction of the brainstem, the patient was started on dual antiplatelet therapy postoperatively. The patient tolerated the procedure well and suffered no major complications related to the operation or from being placed on dual antiplatelet therapy. He did experience some mild, posterior neck pain and rigidity at the time of his 3-month follow-up, likely due to nerve injury that occurred while harvesting the OA. Overall, the patient remains in good neurologic status 1 year after the operation. Complex fusiform aneurysms at the origin of PICA can be successfully treated via an OA-PICA bypass.
| S-EPMC6584454 | biostudies-literature
Project description:Background In the endovascular era, most of vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms were mainly treated with endovascular procedures. This study aimed to demonstrate the microsurgical treatment via the far-lateral approach without C1 laminectomy and its clinical outcomes. Methods Forty-eight patients with VA and proximal PICA aneurysms treated by microsurgery through the far-lateral approach without C1 laminectomy, between January 2016 and June 2021, were retrospectively evaluated. Results Most patients (87.5%) presented with subarachnoid hemorrhage. Grading at presentation was poor in 41.7%. The rates of VA dissecting aneurysms, saccular aneurysms of the VA–PICA junction, and true PICA saccular aneurysms were 54.2, 18.7, and 14.6%, respectively. All aneurysms were located above the lower margin of the foramen magnum. The far-lateral approach without C1 laminectomy was successfully used in all patients without residual aneurysms. Various surgical strategies were applied depending on the characteristics of the aneurysm. Good outcomes 3 months postoperatively were achieved in 77.1% and 89.3% for the overall and good-grade groups, respectively. Conclusions Microsurgery is a safe and effective treatment of VA and proximal PICA aneurysms. Moreover, the far-lateral approach without C1 laminectomy was adequate and effective for aneurysms located above the lower border of the foramen magnum.
| S-EPMC10209739 | biostudies-literature
Project description:BackgroundGiant thrombosed vertebral artery aneurysms (GTVAs) are difficult disease to treat. Here, we are reporting a case of GTVA successfully treated with excluding the pathological segment and restoring the anterograde blood flow of the parent artery, highlighting the reliable surgical procedure.Case descriptionA 55-year-old man with a left GTVA complained of right hemiparesis (manual muscle testing 4/5) represented by hand clumsiness and gait disturbance, in addition to severe left-sided dysesthesia, was referred to our hospital. The posterior inferior cerebellar artery (PICA) was incorporated into the GTVA segment, and the contralateral vertebral artery showed atherosclerotic change. Thus, we decided to treat the aneurysm with aneurysm trapping and thrombectomy, in conjunction with V3-radial artery graft (RAG)-V4 bypass and occipital artery (OA)-PICA bypass through a suboccipital transcondylar approach. The distal end of the dilated segment was meandering and deflecting outwardly to the vicinity of the internal auditory canal and was stretched in an axial direction. Thus, the V4 stump can be transposed to the triangle space made by the medulla, lower cranial nerves, and sigmoid sinus, and we could perform a safe and reliable anastomosis through the corridor. After the surgery, the compression of the brain stem was released, and right hemiparesis was improved completely after rehabilitation. The patient was discharged with a modified Rankin Scale score of 1.ConclusionTrapping of the aneurysm and thrombectomy are the most radical treatment for GTVA, and if possible, reconstruction of anterograde blood flow with V3-RAG-V4 bypass and OA-PICA bypass is desirable.
| S-EPMC6884950 | biostudies-literature
Project description:BackgroundAneurysms of the lower basilar artery (BA) are rare, accounting for <1% of all intracranial aneurysms. This location has been described as "No man's land" since it poses a potential challenge for microsurgery. Recently, endovascular treatment has become an alternative option; however, there are some disadvantages regarding the obliteration rate, patency of the parent, and perforating arteries.Case descriptionWe present the case of a 69-year-old female with an incidentally found lower BA aneurysm. The imaging examinations revealed a wide-neck aneurysm size of 8.5 mm arising just distal to the vertebrobasilar junction, with involvement of the left anterior inferior cerebellar artery (AICA). After a discussion with the patient, she opted to undergo the surgical treatment. We described the detailed steps of our surgical techniques in performing a combined transpetrosal-transtentorial approach. First, the occipital artery (OA) was harvested. Then, the posterior transpetrosal (retrolabyrinthine) and a far-lateral suboccipital approach were conducted with tentorial sectioning to expose the aneurysm. After AICA was confirmed to arise from the aneurysm sac, the OAAICA bypass was established to ensure AICA patency, followed by complete aneurysm clipping. The approach provided both the presigmoid and retrosigmoid corridors for bypass and clipping procedures, respectively. The patient tolerated the procedure well. Postoperative imaging examinations showed complete aneurysm obliteration and bypass patency without complications. She was discharged without neurological deficits (modified Rankin Scale 0).ConclusionThe combined transpetrosal approach is safe and effective for revascularization and clipping procedure for a lower BA aneurysm.
| S-EPMC11618824 | biostudies-literature
Project description:This is the third reported case of a posterior inferior cerebellar artery (PICA) aneurysm presenting as intractable hiccups (IH). A previously healthy 29-year-old woman was admitted with a 2-week history of hiccups occurring >100 times per minute. Symptoms persisted despite numerous noninvasive therapies. Magnetic resonance imaging and magnetic resonance angiogram of the brain showed a left PICA aneurysm that was confirmed by catheter angiography. Symptoms resolved following suboccipital craniotomy and resection. Although rare, PICA aneurysm is a potentially curable cause of IH.
| S-EPMC4521002 | biostudies-other
Project description:Background and purposeResults of endovascular treatment of PICA aneurysms are not well established. The purpose of this study was to report incidence, clinical presentation, and outcome of endovascular treatment in 46 patients with 47 posterior inferior cerebellar artery (PICA) aneurysms.Materials and methodsOf 2169 aneurysms treated between January 1995 and March 2007, 60 were located on the PICA (incidence, 2.8%). Forty-seven proximal PICA aneurysms in 46 patients were treated with endovascular techniques, 37 ruptured (79%) and 10 unruptured (21%). Four patients presented with lower cranial nerve palsies. Mean aneurysm size was 6.8 mm (median, 6 mm; range, 2-32 mm). Forty-three aneurysms were occluded with coils (6 including the PICA origin), and 4 were treated with proximal vertebral artery (VA) occlusion.ResultsFour aneurysms treated with proximal VA occlusion were not occluded. Procedural rupture occurred in 9 aneurysms leading to death in 2 patients and to permanent disability in 1 patient. One patient developed lateral medullary and cerebellar infarctions after PICA occlusion. Combined mortality and morbidity was 8.6% (4 of 46). Outcome at 6 months in 38 surviving patients was good in 35 and moderate in 3. No hemorrhage occurred during 109 patient-years of follow-up. Symptoms of mass effect resolved in all 4 patients.ConclusionIn our experience, PICA aneurysms were challenging lesions, prone to procedural rupture. In some instances, endovascular treatment required occlusion of the parent PICA; usually this was well tolerated. In other instances, treatment required occlusion of the VA. Although this was effective in alleviation of symptoms of mass effect, it was not effective in causing thrombosis of the aneurysm.
| S-EPMC8119094 | biostudies-literature
Project description:Ruptured fusiform aneurysms of the vertebral artery involving posterior inferior cerebellar artery (PICA) origin are difficult to manage without sacrificing PICA. In this report, two very unusual cases are described which highlight different revascularization strategies that may be required. The first case initially appeared to be a small saccular PICA origin aneurysm, but detailed angiography showed a serpentine recanalization of a fusiform aneurysm. This was treated with PICA-PICA anastomosis and trapping of the aneurysm. The second case is a dissecting vertebral aneurysm with both PICA and the anterior spinal artery originating from the dome. PICA was found to be a bihemispheric variant, so no in situ bypass was available, and an occipital artery to PICA bypass was performed. The vertebral artery was occluded proximally only and follow-up angiography showed remodeling of the distal vertebral artery with the anterior spinal artery filling by retrograde flow from the distal vertebral artery. These cases illustrate both the anatomic variability of this region as well as the need to be familiar with multiple treatment strategies including revascularization techniques to be able to successfully treat these aneurysms.
| S-EPMC4648730 | biostudies-other
Project description:PurposeTo describe a patient with acute central retinal artery occlusion (CRAO) during vitrectomy surgery and the possible role of vitrectomy in acute CRAO management.ObservationsAn 84-year-old man presented with broad vitreomacular traction and epiretinal membrane in the right eye. Preoperative assessment clearly showed normal retinal vasculature. On starting vitrectomy, complete CRAO with marked segmentation of all retinal vessels was noted. Vitrectomy was performed in the usual manner and once the posterior hyaloid detached from the disc, immediate complete revascularization of the retinal vessels was noted. The patient had a complete visual recovery.Conclusions and importanceImmediate vitrectomy with induction of posterior vitreous detachment may have a role in selected cases of acute CRAO, particularly if performed within a short window.
| S-EPMC5786868 | biostudies-literature