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Techasrisaksakul K, Sriamornrattanakul K, Akharathammachote N, Chonhenchob A, Mongkolratnan A, Ariyaprakai C. Microsurgical partial trapping for the treatment of unclippable vertebral artery aneurysms: Experience from 27 patients and review of literature. World Neurosurg X 2024; 21:100256. [PMID: 38163051 PMCID: PMC10755825 DOI: 10.1016/j.wnsx.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND The efficacy and safety of partial trapping for the treatment of unclippable vertebral artery aneurysms (UVAs) are still questionable. The partial trapping method (proximal or distal occlusion) was used in the treatment of aneurysms to simplify the surgical procedure and avoid postoperative complications. METHODS This study included 27 patients with UVAs who underwent microsurgical partial trapping between January 2015 and August 2022, and their postoperative outcomes and complications were retrospectively reviewed and evaluated. RESULTS Ruptured UVAs were detected in 25 (92.6%) patients, and 13 (48.1%) patients had poor-grade status. Fusiform dissection, dissecting, and fusiform aneurysms were observed in 17 (63%), 7 (25.9%), and 3 (11.1%) patients, respectively. By location, preposterior inferior cerebellar artery (PICA), PICA, post- PICA, and non-PICA types were noted in 7 (25.9%), 9 (33.3%), 6 (22.2%), and 5 (18.5%) patients, respectively. Microsurgical partial trapping was performed in all patients (blind-alley formation in 96.3%). Complete aneurysm obliteration was achieved in 26 (96.3%) patients. Immediate complete obliteration was achieved in 21 (77.8%) patients, delayed thrombosis within 7 days in 5 (18.5%), and nearly complete obliteration in 1 (3.7%). No re-bleeding was detected in all patients. Favorable outcomes 3 months after the operation were achieved by 92.9% of the patients in the good-grade group and 85.2% overall. CONCLUSIONS Microsurgical partial trapping, especially the blind-alley formation technique, was a safe and effective treatment of UVAs with high rates of aneurysm thrombosis. The appropriate sites for clip occlusion were dependent on the angioarchitecture of UVAs.
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Affiliation(s)
- Kittipos Techasrisaksakul
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Kitiporn Sriamornrattanakul
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Nasaeng Akharathammachote
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Areeporn Chonhenchob
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Atithep Mongkolratnan
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Chanon Ariyaprakai
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Saal-Zapata G, Rodriguez-Calienes A, Malaga M, Velasquez-Rimachi V, Moran C, Bustamante-Paytan D, Pacheco-Barrios N, Pacheco-Barrios K, Alva-Diaz C, Walker M. Microsurgical and endovascular treatment of posterior inferior cerebellar artery aneurysms: a systematic review and meta-analysis. J Neurosurg Sci 2023; 67:638-652. [PMID: 35416457 DOI: 10.23736/s0390-5616.22.05710-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Posterior inferior cerebellar artery (PICA) aneurysms are uncommon vascular lesions of the posterior fossa. In addition to aneurysmal morphology, structural anatomic considerations may confer additional procedural risk, and as a result there is currently no consensus as to whether a surgical or endovascular approach offers greater safety and efficacy for patients. EVIDENCE ACQUISITION We systematically examined peer-reviewed literature describing PICA aneurysm treatment planning from January 2000 to May 2021 using the PRISMA methodology. A meta-analysis of proportions was performed. Certainty of the evidence was assessed using the GRADE approach. EVIDENCE SYNTHESIS Fifty-eight studies including 1673 PICA aneurysms were analyzed. Overall treatment occlusion rate was 97% (95% confidence interval [CI]: 93-100%) for surgery and 85% (95% CI: 78-92%) for endovascular therapy. The recurrence rate was 6% in the endovascular group and 1% for surgery. Overall morbidity and mortality were 16% and 7%, respectively. Intraoperative complications occurred in 9% of the surgical patients. CONCLUSIONS Despite a large body of literature, analysis indicates that 62% of studies had moderate or serious risk of bias, suggesting very-low certainty results. Therefore, treatment via either approach should be determined on a case-by-case basis and according to institutional experience.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Section of Endovascular Neurosurgery, Department of Neurosurgery, Guillermo Almenara Irigoyen-EsSalud National Hospital, Lima, Peru -
| | - Aaron Rodriguez-Calienes
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
| | - Marco Malaga
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
| | - Victor Velasquez-Rimachi
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
| | - Cristian Moran
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
- Scientific University of the South, Lima, Peru
| | | | - Niels Pacheco-Barrios
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
- Faculty of Human Medicine, San Martin de Porres University, Lima, Peru
| | - Kevin Pacheco-Barrios
- Alberto Hurtado Faculty of Medicine, Cayetano Heredia Peruvian University, Lima, Peru
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, MA, USA
| | - Carlos Alva-Diaz
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
| | - Melanie Walker
- Research Unit for the Generation and Synthesis of Health Evidence, San Ignacio de Loyola University, Lima, Perú
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Sriamornrattanakul K, Akharathammachote N, Chonhenchob A, Mongkolratnan A, Niljianskul N, Phoominaonin IS, Ariyaprakai C. Far-lateral approach without C1 laminectomy for microsurgical treatment of vertebral artery and proximal posterior inferior cerebellar artery aneurysms: Experience from 48 patients. World Neurosurg X 2023; 19:100216. [PMID: 37251244 PMCID: PMC10209739 DOI: 10.1016/j.wnsx.2023.100216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/10/2023] [Indexed: 05/31/2023] Open
Abstract
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.
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Ali AMS, Hannan CJ, Islim AI, Mascitelli JR, Javadpour M. Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysms: Systematic Review and Meta-Analysis. World Neurosurg 2022; 162:e168-e177. [PMID: 35257955 DOI: 10.1016/j.wneu.2022.02.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The optimal treatment modality for saccular aneurysms of the posterior inferior cerebellar artery (PICA) remains unclear. A previous meta-analysis on the topic included a heterogenous study population, limiting the conclusions that can be drawn from its results. The aim of this study was to perform a systematic review and meta-analysis to compare outcomes of microsurgical and endovascular treatment (EVT) of these aneurysms. METHODS A search of 4 online databases was performed for studies describing the management of saccular PICA aneurysms. The primary outcome was complete aneurysm occlusion. Data were also collected on neurologic outcomes, cranial nerve palsies, and requirement for re-treatment. A random effects model was used for calculation of pooled proportions. Our protocol was registered with PROSPERO (CRD42021232784). RESULTS A total of 17 studies were included in the final analysis, reporting the treatment outcomes of 455 aneurysms, with a mean follow-up of 20 months. The pooled occlusion rates were 94.8% (95% confidence interval [CI] 90.6%-97.8%) for surgical treatment and 69.1% (95% CI 55.0%-81.7%) for EVT. Pooled rates of good neurologic outcome (modified Rankin scale score ≤2, Glasgow Outcome Scale score ≥4) at last follow-up were 78.1% (95% CI 67.4%-87.1%) for surgery and 77.6% (95% CI 67.9%-86.0%) for EVT. CONCLUSIONS This meta-analysis demonstrates that in the treatment of saccular PICA aneurysms, microsurgical clipping results in superior angiographic outcomes, similar functional outcomes, but higher rates of lower cranial nerve palsy compared with EVT. Further studies are required to assess the duration and severity of cranial nerve palsies following surgical treatment, and long-term aneurysm occlusion and the requirement for re-intervention following EVT.
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Affiliation(s)
- Ahmad M S Ali
- The Walton Centre for Neurology and Neurosurgery, Liverpool, England
| | | | | | | | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; School of Medicine, Trinity College Dublin, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
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Bypass Surgery Management of Complex Proximal and Distal Posterior Inferior Cerebellar Artery Aneurysms. J Craniofac Surg 2022; 33:2049-2054. [PMID: 35119411 DOI: 10.1097/scs.0000000000008507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/13/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND For the complex posterior inferior cerebellar artery (PICA) aneurysms, standard microsurgical or endovascular technical options were not feasible. To determine the efficacy and outcomes of bypass surgery for complex PICA aneurysms, the authors herein review our recent surgical experience for complex PICA aneurysms. METHODS The authors retrospectively reviewed our experience of extracranial-intracranial bypass and intracranial-intracranial bypass surgery in treatment of proximal and distal complex PICA aneurysms at our institution from 2016 to 2020. RESULTS Twelve patients harboring 12 complex PICA aneurysms received bypass surgery at our institution. Seven (58.3%) patients with proximal PICA aneurysms underwent extracranial-intracranial bypass. Five (41.7%) patients with distal PICA aneurysms accepted intracranial-intracranial bypass. The postoperative symptom improvement: Of the 6 patients with preoperative hypoperfusion or ischemic of the cerebellar hemisphere, the symptom resolved in 5 patients, improved in 1 patient, of 5 patients with preoperative mass effect, the symptom resolved in 5 patients. During the follow-up period, ten patients had a modified Rankin scale (mRS) score of 0 to 1, and 1 patient had an mRS score of 2. One patient had an mRS score of 3. The long-term graft patency rate was 91.7%. All patients had no recurrence of intracranial aneurysm. CONCLUSIONS Base on the complexity of anatomy structure and the vascular architecture, an individualized strategy was proposed for each patient. The use of different types of bypass procedures (occipital artery-PICA end-to-end bypass, PICA-PICA end-to-end anastomosis, and/or occipital artery graft) can safely and effectively manage these complex PICA aneurysms.
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Durongwatana N, Sriamornrattanakul K, Wongsuriyanan S, Akharathammachote N. Microsurgical treatment of vertebral artery dissection: Surgical strategies and treatment outcomes. World Neurosurg 2021; 159:e375-e388. [PMID: 34954059 DOI: 10.1016/j.wneu.2021.12.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Nithipat Durongwatana
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Kitiporn Sriamornrattanakul
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
| | - Somkiat Wongsuriyanan
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Nasaeng Akharathammachote
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Miao HL, Zhang DY, Wang T, Jiao XT, Jiao LQ. Clinical Importance of the Posterior Inferior Cerebellar Artery: A Review of the Literature. Int J Med Sci 2020; 17:3005-3019. [PMID: 33173421 PMCID: PMC7646108 DOI: 10.7150/ijms.49137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022] Open
Abstract
The posterior inferior cerebellar artery (PICA), with its unique anatomical complexity, is of great clinical importance and involved in many diseases including aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM), and brain tumor. However, a comprehensive systematic review of the importance of the PICA is currently lacking. In this study, we perform a literature review of PICA by searching all the associated papers in the PUBMED database hoping to provide a better understanding of the artery. The PICA has tortuous and variable course and territory, divided into 5 segments. Various aneurysms involving PICA were not uncommon, of which the treatment is challenging. The PICA infarct typically manifests lateral medullary syndrome (LMS) and is more likely to cause mass effects. The PICA frequently compresses the medulla and the cranial nerves resulting in various neurovascular compression syndromes (NVCS). Arteriovenous malformation (AVM) fed by PICA are associated with aneurysm and dissection which have high risk of rupture and worse outcome. PICA injured by head trauma can cause fatal SAH. VA terminating in PICA probably cause Bow hunter's syndrome (BHS). The PICA supplies many brain tumors and can be used in intracerebellar chemotherapy. The PICA can be exposed and injured during surgeries especially in telovelar approach, and it also plays an important role in bypass surgeries, hinting the surgical importance of PICA. In conclusion, PICA is very important in clinical practice.
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Affiliation(s)
- Hui-Lei Miao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Deng-Yan Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China.,School of General Practice and Continuing Education, Capital Medical University, Beijing 100069,China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
| | - Xiao-Tian Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
| | - Li-Qun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
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