Abstract
Background
Posterior inferior cerebellar artery (PICA) aneurysms are uncommon, and their management is challenging because of the complex angioarchitecture of the PICA and the frequently nonsaccular aneurysm presentation. Endovascular therapy may not be feasible.
Methods
We describe our technique of clip trapping with occipital artery (OA)-to-PICA bypass to treat a PICA aneurysm. Because the aneurysm affected the ipsilateral, dominant PICA, an OA-PICA bypass was chosen to ensure adequate flow and reduce risk to the contralateral PICA supply.
Conclusion
The OA-PICA anastomosis is a safe and effective method to successfully achieve flow preservation with bypass reconstruction and aneurysm trapping.
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Code availability
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References
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Authors and Affiliations
Contributions
Cameron A. Rawanduzy: methodology, writing—original draft, visualization
Alexander Winkler-Schwartz: methodology, writing—original draft, visualization
Karol P. Budohoski: writing—review and editing
William T. Couldwell: conceptualization, resources, supervision, project administration, writing—review and editing
Corresponding author
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Ethical approval
Approval from the institutional review board is waived for case reports. All procedures performed in studies involving human participants were in accordance with the ethical standards of the (place name of institution and/or national research committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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The patient consented to participate.
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The patient consented to the publication of his case in this paper.
Conflict of interest
The authors declare no competing interests.
Additional information
Key points
1. PICA aneurysms account for 3–5% of all intracranial aneurysms.
2. Because of the vessel tortuosity, the frequently nonsaccular morphology, and the critical cerebellar and brainstem perforators, PICA aneurysms may not be amenable to endovascular treatment.
3. The OA is an ideal bypass donor when the contralateral PICA is of insufficient size to be certain that it will support an ipsilateral dominant PICA, risking bilateral PICA infarcts.
4. The course of the OA is mapped using a Doppler probe along the patient’s scalp, well beyond the planned skin incision.
5. A hockey-stick myocutaneous flap ensures adequate exposure and allows the OA to be dissected along its entirety.
6. Before recipient vessel temporary occlusion, the patient is placed in burst suppression with intravenous anesthetic agents and given heparin.
7. The toe of the beveled and fish-mouthed donor vessel should point in the direction of desired flow.
8. End-to-side bypass allows bypass with minimal movement of recipient vessel and continued filling of all perforating vessels arising from the PICA.
9. Interrupted suture for the anastomosis reduces potential cinching of the anastomotic site and limits the risk of creating “dog-ear” phenomenon with closure.
10.Watertight dural closure is not possible because of the presence of bypass vessel; as such, placement of free fat harvested from the abdomen or thigh prevents pseudomeningocele formation.
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Rawanduzy, C.A., Winkler-Schwartz, A., Budohoski, K.P. et al. Occipital artery-to-PICA bypass: how I do it. Acta Neurochir 165, 3737–3741 (2023). https://doi.org/10.1007/s00701-023-05633-3
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DOI: https://doi.org/10.1007/s00701-023-05633-3