Abstract
Vertebral artery （VA）Aneurysms involving the origin of the posterior inferior cerebellar artery (PICA) ,occasionally, induce cerebellum and brainstem infarction due to intraluminal thrombus and calcific VA stenosis. At times, vessel occlusion and revascularization is necessary for successful obliteration of these aneurysms.2 The occipital artery (OA) is often the preferred donor graft for lesions of the posterior fossa. Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops , aberrant anatomy or p3 multiple perforators is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead. This video captures the dissection of the OA using an orientational anterograde harvesting technique and the end-to-end anastomosis of the OA to the PICA at the p1 segment. This was performed in a 56-year-old man who presented with posterior circulation ischemia from a fusiform aneurysm with calcific vertebral artery stenosis located at the origin of the right PICA. The patient tolerated the procedure well and suffered no major complications related to the operation. He did experience some mild, posterior neck rigidity at the time of his 6-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. The operation proved the feasibility of end-to-end bypass in OA-p1 PICA.
Keywords: Anastomosis, Aneurysm, Bypass, Ischemia, Occipital artery, Posterior inferior cerebellar artery
Abbreviations
- OA
Occipital artery
- PICA
Posterior inferior cerebellar artery
- VA
Vertebral artery
- SOM
Superior oblique muscle
- INL
Inferior nuchal line
- SNL
Superior nuchal line
Vertebral artery (VA)Aneurysms involving the origin of the posterior inferior cerebellar artery (PICA),occasionally, induce cerebellum and brainstem infarction due to intraluminal thrombus and calcific VA stenosis.1 At times, vessel occlusion and revascularization is necessary for successful obliteration of these aneurysms.2 The occipital artery (OA) is often the preferred donor graft for lesions of the posterior fossa.3,4 Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops, aberrant anatomy or p3 multiple perforators is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead.5 This video captures the dissection of the OA using an orientational anterograde harvesting technique and the end-to-end anastomosis of the OA to the PICA at the p1 segment. This was performed in a 56-year-old man who presented with posterior circulation ischemia from a fusiform aneurysm with calcific vertebral artery stenosis located at the origin of the right PICA. The patient tolerated the procedure well and suffered no major complications related to the operation. He did experience some mild, posterior neck rigidity at the time of his 6-month follow-up, likely due to nerve injury that occurred while harvesting the OA.6 Overall, the patient remains in good neurologic status 1 year after the operation. The operation proved the feasibility of end-to-end bypass in OA-PICA (p1).
CRediT authorship contribution statement
Xiaolong Wang: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Visualization. Lixiong Xue: Supervision, Validation. Li Han: Resources, Software. Xinmin Ding: Conceptualization, Funding acquisition, Supervision, Writing – review & editing.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.wnsx.2024.100288.
Appendix A. Supplementary data
The following is the Supplementary data to this article.
References
- 1.Park W., Ahn J.S., Park J.C., Kwun B.D., Kim C.J. Occipital artery-posterior inferior cerebellar artery bypass for the treatment of aneurysms arising from the vertebral artery and its branches. World Neurosurg. Nov 2014;82(5):714–721. doi: 10.1016/j.wneu.2014.06.053. [DOI] [PubMed] [Google Scholar]
- 2.Sakamoto Y., Maeda K., Takemoto M., et al. A case of Proximal posterior inferior cerebellar artery (PICA) aneurysm treated with PICA-to-PICA bypass and trapping surgery: comparison with occipital artery-PICA bypass. NMC Case Rep J. 2022;9:129–133. doi: 10.2176/jns-nmc.2022-0028. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Wang X., Peng L., Yuan Y., Tuo Y., Han L., Ding X. An orientational harvesting occipital artery technique via far lateral approach: a cadaveric study [published online ahead of print, 2023 Aug 28] World Neurosurg. 2023;S1878–8750(23) doi: 10.1016/j.wneu.2023.08.091. 01203-2. [DOI] [PubMed] [Google Scholar]
- 4.Sundt T.M., Jr., Piepgras D.G. Occipital to posterior inferior cerebellar artery bypass surgery. J Neurosurg. Jun 1978;48(6):916–928. doi: 10.3171/jns.1978.48.6.0916. [DOI] [PubMed] [Google Scholar]
- 5.Nisson P.L., Ding X., Tayebi Meybodi A., Palsma R., Benet A., Lawton M.T. Revascularization of the posterior inferior cerebellar artery using the occipital artery: a cadaveric study comparing the p3 and p1 recipient sites. Oper Neurosurg (Hagerstown). Aug 1 2020;19(2):E122–E129. doi: 10.1093/ons/opaa023. [DOI] [PubMed] [Google Scholar]
- 6.Nisson P.L., James W.S., Berger G.K., Wang X., Ding X. Occipital artery harvesting and anastomosis to P3 segment of posterior inferior cerebellar artery: operative video. World Neurosurg X. Jul 2019;3 doi: 10.1016/j.wnsx.2019.100023. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.