Posterior inferior cerebellar artery (
PICA)
aneurysms have an increased tendency towards a fusiform morphology precluding primary
clip reconstruction. The management of these complex
aneurysms might require
cerebral revascularization to preserve flow in a distal
PICA territory. This video illustrates a case of a ruptured p2-PICA
aneurysm excision followed by a
PICA reanastomosis. A 54-yr-old male presented with a sudden-onset severe
headache,
diplopia, and complete left cranial nerve six (CN VI)
palsy. Neuroimaging demonstrated diffuse
subarachnoid hemorrhage in basal cisterns. A
catheter angiogram shows a ruptured small
fusiform aneurysm in the p2-PICA segment. After obtaining consent for surgery, the patient was placed in a three-quarter prone position. After a hockey stick skin incision and C1
laminectomy, a lateral suboccipital
craniotomy was performed. The
aneurysm was identified within the vagoaccessory triangle. Cerebral protection consisted of
propofol-induced electroencephalography burst suppression during the clamp time for the bypass, without
hypothermia or
hypertension. After trapping the
aneurysm and excising the diseased arterial segment, the distal end of the p2-PICA was reanastomosed to the proximal parent vessel in an end-to-end fashion.
Indocyanine green angiography confirmed patency of the anastomosis. Postoperatively, the patient was neurologically at his baseline. The CN VI
palsy had completely resolved at a follow-up visit. Reanastomosis is an effective modality for reconstructing
PICA following the excision of the
fusiform aneurysm. The redundancy of the tonsillomedullary segment of
PICA allows for easier distal segment reapproximation in the inferior hypoglossal triangle. An intracranial-intracranial revascularization technique eliminates the need for harvesting the occipital artery. Additionally, it prevents iatrogenic ischemic injury to contralateral
PICA, if used for a
PICA-
PICA bypass.1 © Barrow Neurological Institute, used with permission.