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      In Situ Intersegmental Anastomosis within a Single Artery for Treatment of an Aneurysm at the Posterior Inferior Cerebellar Artery: Closing Omega Bypass

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          Abstract

          A 74-year-old patient was diagnosed with a subarachnoid hemorrhage suspected from a dissecting aneurysm located at the lateral medullary segment of the posterior inferior cerebellar artery (PICA). Because perforators to the medulla arose both proximal and distal to the dissecting segment, revascularization for distal flow was essential. However, several previously reported methods for anastomosis, such as an occipital artery-PICA bypass or resection with PICA end-to-end anastomosis could not be used. Ultimately, we performed an in situ side-to-side anastomosis of the proximal loop of the PICA with distal caudal loops within a single artery, as a "closing omega," followed by trapping of the dissected segment. The aneurysm was obliterated successfully, with intact patency of the revascularized PICA.

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          Microsurgical anatomy of the posterior inferior cerebellar artery.

          William A Rhoton, David Peace, T Matsushima … (1982)
          Fifty cerebellar hemispheres from 25 adult cadavers were examined. The posterior inferior cerebellar artery (PICA), by definition, arose from the vertebral artery. The vertebral artery was present in 49 and the PICA was present in 42 of the 50 hemispheres. Forty-one of the 42 PICAs arose as a single trunk and 1 arose as a duplicate trunk. The PICA was divided into five segments: the anterior medullary segment lay on the front of the medulla; the lateral medullary segment coursed beside the medulla and extended to the origin of the glossopharyngeal, vagal, and accessory nerves; the tonsillomedullary segment coursed around the caudal half of the cerebellar tonsil; the telovelotonsillar segment coursed in the cleft between the tela choroidea and the inferior medullary velum rostrally and the superior pole of the cerebellar tonsil caudally; and the cortical segment was distributed to the cerebellar surface. Thirty-seven of the 42 PICAs bifurcated into a medial and a lateral trunk. The medial trunk supplied the vermis and the adjacent part of the hemisphere, and the lateral trunk supplied the cortical surface of the tonsil and the hemisphere. The PICA gave off perforating, choroidal, and cortical arteries. The cortical arteries were divided into vermian, tonsillar, and hemispheric groups. Sixteen of the 42 PICAs passed between the rootlets of the accessory nerve, 10 passed between the rootlets of the vagus nerve, 13 passed between the vagus and the accessory nerves, 2 coursed rostral to the glossopharyngeal nerve, and 1 passed between the glossopharyngeal and the vagus nerves.
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            Distal posterior inferior cerebellar artery aneurysms: clinical features and management.

            Brian Day, Pamela Lafrentz, Lindsay B. Lewis … (2002)
            Aneurysms located on the distal portion of the posterior inferior cerebellar artery (PICA) are uncommon, and their underlying pathology, natural history, and clinical management are poorly understood. To clarify these lesions more fully, the authors undertook a retrospective analysis of the clinical features and management results of 22 distal PICA aneurysms in 20 consecutive patients treated at one institution by the same surgeon during the past decade. The series included 10 men and 10 women (mean age at presentation 51 years). Nine patients presented with only subarachnoid and/or intraventricular hemorrhage (median Hunt and Hess Grade II). In seven patients intracerebellar hemorrhage was also found; two patients presented with pressure effects and two hemorrhages were incidentally discovered. Prominent comorbidities included cigarette smoking (50%) and hypertension (50%). The 13 saccular and nine fusiform distal PICA aneurysms were distributed on the following segments of the PICA: lateral medullary (seven lesions), tonsillomedullary (five lesions), telovelotonsillar (five lesions), and cortical (five lesions). Six oases were associated with cerebellar arteriovenous malformations. Skull-base and far-lateral transcondylar surgical approaches were used to secure the aneurysms in 86% of cases, either by direct clipping (13 lesions), vessel sacrifice (four lesions), or vessel sacrifice plus bypass (two lesions). Two aneurysms were treated using endovascular PICA ablation. Overall outcome at hospital discharge was excellent or good in 70% of cases. At long-term follow up (100% of patients, mean 123 days), an excellent or good outcome had been achieved in 85% of cases. Depending on the PICA segment that was affected, variations in clipping strategies and surgical exposures aimed at the PICA branch and main trunk preservation were major contributors to good long-term results.
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              Vertebral artery-posteroinferior cerebellar artery aneurysms: clinical and lower cranial nerve outcomes in 52 patients.

              D Manner, Jonathan White, Samah H Khayat … (2004)
              To identify factors predictive of postoperative lower cranial nerve palsy (LCNP) among patients undergoing surgery for vertebral artery (VA)- posteroinferior cerebellar artery (PICA) aneurysms. The natural history of this LCNP is defined, and its effect on postoperative patient course is analyzed. No similar study has been described in the literature. Fifty-two patients with VA-PICA aneurysms, who were treated surgically between 1996 and 2002, were retrospectively studied to identify factors contributing to postoperative LCNP. The effect of LCNP on intensive care unit stay and development of nosocomial pneumonia also was analyzed. All analyses were performed with Fisher's exact test. Postoperative LCNP occurred in 25 patients (48.1%) with VA-PICA aneurysms. Of the factors investigated, the use of temporary or total occlusion was associated with increased incidence of postoperative LCNP (P <0.001). The average length of stay in the intensive care unit was 13.8 days for patients with LCNP defined as moderate to severe, compared with 7.92 days for patients with LCNP defined as none or mild (P=0.0014). Nosocomial pneumonia occurred only in patients with moderate to severe LCNP (P=0.022). Postoperative LCNP resolved completely within 3 months in 12 patients (48%) and within 6 months in 19 patients (76%) . The results of this study can help to identify the effect and natural history of LCNP after surgical clipping of VA-PICA aneurysms. This information may assist neurosurgeons in expediting treatment, decrease the cost and length of hospital stays, and result in improved outcomes.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Korean Neurosurg Soc
                Journal ID (iso-abbrev): J Korean Neurosurg Soc
                Journal ID (publisher-id): JKNS
                Title: Journal of Korean Neurosurgical Society
                Publisher: The Korean Neurosurgical Society
                ISSN (Print): 2005-3711
                ISSN (Electronic): 1598-7876
                Publication date (Print): November 2015
                Publication date (Electronic): 30 November 2015
                Volume: 58
                Issue: 5
                Pages: 467-470
                Affiliations
                Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea.
                Author notes
                Address for reprints: Seok Keun Choi, M.D. Department of Neurosurgery, College of Medicine, Kyung Hee University, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea. Tel: +82-2-958-8385, Fax: +82-2-958-8380, nscsk@ 123456hanmail.net
                Article
                DOI: 10.3340/jkns.2015.58.5.467
                PMC ID: 4688317
                PubMed ID: 26713148
                SO-VID: 0c2e95a2-582e-4c2c-94d3-cf654458faa1
                Copyright © Copyright © 2015 The Korean Neurosurgical Society
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 27 July 2014
                Date revision received : 21 September 2014
                Date accepted : 23 September 2014
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Surgery
                Keywords: aneurysm,posterior inferior cerebellar artery,cerebral revascularization
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: aneurysm, posterior inferior cerebellar artery, cerebral revascularization

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