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Maroufi SF, Turcotte EL, Bendok BR. Letter: Thrombosed Posterior Inferior Cerebellar Artery Aneurysm Mimicking a Medulla Oblongata Cavernous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 27:403-404. [PMID: 39057916 DOI: 10.1227/ons.0000000000001296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/15/2024] [Indexed: 07/28/2024] Open
Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix , Arizona , USA
| | - Evelyn L Turcotte
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix , Arizona , USA
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Phoenix , Arizona , USA
- Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix , Arizona , USA
| | - Bernard R Bendok
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix , Arizona , USA
- Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix , Arizona , USA
- Department of Neurological Surgery, Mayo Clinic, Phoenix , Arizona , USA
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Phoenix , Arizona , USA
- Department of Radiology, Mayo Clinic, Phoenix , Arizona , USA
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Al-Afif S, Lang JM, Abdulbaki A, Palmaers T, Scheinichen D, Abu-Fares O, Hermann EJ, Krauss JK. The safety and utility of the semi-sitting position for clipping of posterior circulation aneurysms. Acta Neurochir (Wien) 2024; 166:341. [PMID: 39160268 PMCID: PMC11333526 DOI: 10.1007/s00701-024-06229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 08/08/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND The semi-sitting position offers advantages for surgeries in the posterior cranial fossa. However, data on its safety and effectiveness for clipping aneurysms in the posterior cerebral circulation are limited. This retrospective cohort study evaluates the safety and effectiveness of using the semi-sitting position for these surgeries. METHODS We conducted a retrospective study of 17 patients with posterior cerebral circulation aneurysms who underwent surgical clipping in the semi-sitting position in the Department of Neurosurgery at Hannover Medical School over a 10-year period. RESULTS The mean age at surgery was 62 years (range, 31 to 75). Fourteen patients were admitted with subarachnoid hemorrhage and 3 patients had incidental aneurysmas. Fifteen patients had PICA aneurysms, and two had aneurysms of the vertebral artery and the superior cerebellar artery, respectively. The median diameter of the aneurysms was 5 mm (range 3-17 mm). Intraoperative venous air embolism (VAE) occurred in 4 patients, without affecting the surgical or clinical course. VAE was associated with a mild decrease of EtCO2 levels in 3 patients and in 2 patients a decrease of blood pressure occurred which was managed effectively. Surgical procedures proceeded as planned in all instances. There were no complications secondary to VAE. Two patients died secondary to respiratory problems (not related to VAE), and one patient was lost to follow-up. Eleven of fourteen patients were partially or completely independent (Barthel index between 60 and 100) at a median follow-up duration of 13.5 months (range, 3-103 months). CONCLUSION The semi-sitting position is a safe and effective technique for the surgical clipping of aneurysms in the posterior cerebral circulation. The incidence of VAE is comparable to that seen in tumor surgery. However, it is crucial for the surgical and anesthesiological team to be familiar with potential complications and to react immediately in case of an occurrence of VAE.
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Affiliation(s)
- Shadi Al-Afif
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
| | - Josef M Lang
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Arif Abdulbaki
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Thomas Palmaers
- Department of Anaesthesiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Dirk Scheinichen
- Department of Anaesthesiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Omar Abu-Fares
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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Baranoski JF, Koester SW, Przybylowski CJ, Zhao X, Catapano JS, Gandhi S, Tayebi Meybodi A, Cole TS, Lee J, Frisoli FA, Lawton MT, Mascitelli JR. The Glossopharyngo-Cochlear Triangle-Part II: Case Series Highlighting the Clinical Application to High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach. Oper Neurosurg (Hagerstown) 2021; 20:252-259. [PMID: 33372992 DOI: 10.1093/ons/opaa362] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 08/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Use of the far lateral transcondylar (FL) approach and vagoaccessory triangle is the standard exposure for clipping most posterior inferior cerebellar artery (PICA) aneurysms. However, a distal PICA origin or high-lying vertebrobasilar junction can position the aneurysm beyond the vagoaccessory triangle, making the conventional FL approach inappropriate. OBJECTIVE To demonstrate the utility of the extended retrosigmoid (eRS) approach and a lateral trajectory through the glossopharyngo-cochlear triangle as the surgical corridor for these cases. METHODS High-riding PICA aneurysms treated by microsurgery were retrospectively reviewed, comparing exposure through the eRS and FL approaches. Clinical, surgical, and outcome measures were evaluated. Distances from the aneurysm neck to the internal auditory canal (IAC), jugular foramen, and foramen magnum were measured. RESULTS Six patients with PICA aneurysms underwent clipping using the eRS approach; 5 had high-riding PICA aneurysms based on measurements from preoperative computed tomography angiography (CTA). Mean distances of the aneurysm neck above the foramen magnum, below the IAC, and above the jugular foramen were 27.0 mm, 3.7 mm, and 8.2 mm, respectively. Distances were all significantly lower versus the comparison group of 9 patients with normal or low-riding PICA aneurysms treated using an FL approach (P < .01). All 6 aneurysms treated using eRS were completely occluded without operative complications. CONCLUSION The eRS approach is an important alternative to the FL approach for high-riding PICA aneurysms, identified as having necks more than 23 mm above the foramen magnum on CTA. The glossopharyngo-cochlear triangle is another important anatomic triangle that facilitates microsurgical dissection.
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Affiliation(s)
- Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Colin J Przybylowski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jonathan Lee
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Fabio A Frisoli
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Peitz GW, McDermott RA, Baranoski JF, Lawton MT, Mascitelli JR. Extended Retrosigmoid Craniotomy and Approach Through the Glossopharyngeal Cochlear Triangle for Clipping of a High-Riding Vertebral-Posterior Inferior Cerebellar Artery Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E270-E271. [PMID: 33989426 DOI: 10.1093/ons/opab140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/14/2021] [Indexed: 11/12/2022] Open
Abstract
The far lateral transcondylar (FL) craniotomy is the standard approach for posterior inferior cerebellar artery (PICA) aneurysm exposure through microsurgical dissection in the vagoaccessory triangle (VAT).1,2 However, the extended retrosigmoid (eRS) craniotomy and dissection through the glossopharyngeal-cochlear triangle (GCT) may be more appropriate when the patient has an aneurysm arising from a high-riding vertebral artery (VA)-PICA origin.3-5 We present a case of a 41-yr-old woman with hypertension presenting with left occipital pain and left-side hearing loss and past facial spasm and pain. Computed tomography angiography and digital subtraction angiography demonstrated an unruptured 8.4 × 9.0 × 10.2 mm saccular aneurysm at the left VA-PICA junction. Surgical clipping was chosen over endovascular therapy given the relationship of the PICA origin to the aneurysm neck as well as the history of cranial neuropathy. It was noted that the VA-PICA junction and aneurysm was high-riding at the level of the internal auditory canal. An eRS craniotomy was performed with dissection through the GCT, and the aneurysm was clipped as shown in the accompanying 2-dimensional operative video. Postoperative angiography demonstrated complete occlusion of the aneurysm and patency of the left VA and PICA without stenosis, and the patient had a favorable postoperative course although her left-sided hearing remained diminished. The eRS craniotomy allowed direct exposure via the GCT for clipping of the high-riding VA-PICA junction aneurysm and decompression of the cranial nerves. The traditional FL craniotomy and exposure through the VAT would likely have resulted in a less desirable inferior trajectory. The patient gave informed consent for the operation depicted in the video. Animation at 2:43 in video is used with permission from Barrow Neurological Institute, Phoenix, Arizona.
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Affiliation(s)
- Geoffrey W Peitz
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Ryan A McDermott
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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5
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Sai Kiran NA, Sivaraju L, Furtado SV, Vidyasagar K, Raj V, Aryan S, Thakar S, Mohan D, Hegde AS. Far lateral approach without occipital condylar resection for intradural ventral/ventrolateral foramen magnum tumors and aneurysms of V4 segment of vertebral artery: Review of surgical results. Clin Neurol Neurosurg 2020; 197:106163. [PMID: 32916393 DOI: 10.1016/j.clineuro.2020.106163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Controversies exist regarding the need and extent of condylar resection for safe surgical management of intradural ventral/ventrolateral foramen magnum (VFM) tumors and aneurysms of V4 segment of vertebral artery (VA) by far lateral approach. This retrospective study was conducted to evaluate the results of basic far lateral approach(retrocondylar approach) without upfront occipital condylar resection. METHODS AND RESULTS Twenty one patients underwent surgery via far lateral approach for intradural VFM tumors and aneurysms of V4 segment of VA at Sri Sathya Sai Institute of Higher Medical Sciences during 9 years(2008-2016) study period. Eight patients had VA aneurysms and 13 patients had intradural VFM tumors. After basic far lateral approach(retrocondylar approach), dura was opened and checked if the exposure was adequate for safe surgery. Retrocondylar approach provided adequate exposure for all these lesions and resection of occipital condyle/jugular tubercle was not required in any of these cases. Skeletonization or transposition of VA was not done in any of these cases. Gross total resection of the tumor could be done in 9 patients(9/13-69.2 %) and near total excision (>95 %) in 4 patients (4/13-30.8 %). Seven of the 8 VA aneurysms were successfully clipped. Outcome at a final follow up of 3 months or more was good(mRS<2) in 19 patients(19/21-90.5 %) and poor in 2 patients. Complications included lower cranial nerve deficits [transient-2/21(9.5 %), persisting-2/21(9.5 %)], motor deficits(2/21-9.5%), seventh nerve paresis(1/21-4.8%), sixth nerve paresis(2/21-9.5%) and pseudomeningocele(1/21-4.8%). CONCLUSION Basic far lateral (retrocondylar) approach provides excellent exposure for majority of VFM tumors and aneurysms of V4 segment of VA. Condylar resection(transcondylar approach), drilling of jugular tubercle (transtubercular approach), skeletonization/transposition of VA might not be required for safe surgical management of majority of these lesions.
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Affiliation(s)
- Narayanam Anantha Sai Kiran
- Department and Institution, Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India
| | - Laxminadh Sivaraju
- Department and Institution, Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India.
| | - Sunil Valentine Furtado
- Department and Institution, Department of Neurosurgery, MS Ramaiah Medical College and Hospital, M S Ramaiah Nagar, Mathikere, Bangalore, 560054, India
| | - Kanneganti Vidyasagar
- Department and Institution, Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India
| | - Vivek Raj
- Department and Institution, Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India
| | - Saritha Aryan
- Department and Institution, Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India
| | - Sumit Thakar
- Department and Institution, Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India
| | - Dilip Mohan
- Department and Institution, Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India
| | - Alangar S Hegde
- Department and Institution, Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India
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Maduri R, Starnoni D, Rocca A, Bervini D, Zumofen DW, Stienen MN, Schatlo B, Fung C, Robert T, Seule MA, Burkhardt JK, Maldaner N, Rothlisberger M, Blackham KA, Marbacher S, D’Alonzo D, Remonda L, Machi P, Gralla J, Bijlenga P, Saliou G, Ballabeni P, Levivier M, Messerer M, Daniel RT. Ruptured posterior circulation aneurysms: epidemiology, patterns of care, and outcomes from the Swiss SOS national registry. Acta Neurochir (Wien) 2019; 161:769-779. [PMID: 30680461 DOI: 10.1007/s00701-019-03812-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/12/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The treatment of ruptured posterior circulation aneurysms remains challenging despite progresses in the endovascular and neurosurgical techniques. OBJECTIVE To provide epidemiological characterization of subjects presenting with ruptured posterior circulation aneurysms in Switzerland and thereby assessing the treatment patterns and neurological outcomes. METHODS This is a retrospective analysis of the Swiss SOS registry for patients with aneurysmal subarachnoid hemorrhage. Patients were divided in 3 groups (upper, lower, and middle third) according to aneurysm location. Clinical, radiological, and treatment-related variables were identified and their impact on the neurological outcome was determined. RESULTS From 2009 to 2014, we included 264 patients with ruptured posterior circulation aneurysms. Endovascular occlusion was the most common treatment in all 3 groups (72% in the upper third, 68% in the middle third, and 58.8% in the lower third). Surgical treatment was performed in 11.3%. Favorable outcome (mRS ≤ 3) was found in 56% at discharge and 65.7% at 1 year. No significant difference in the neurological outcome were found among the three groups, in terms of mRS at discharge (p = 0.20) and at 1 year (p = 0.18). High WFNS grade, high Fisher grade at presentation, and rebleeding before aneurysm occlusion (p = 0.001) were all correlated with the risk of unfavorable neurological outcome (or death) at discharge and at 1 year. CONCLUSIONS In this study, endovascular occlusion was the principal treatment, with a favorable outcome for two-thirds of patients at discharge and at long term. These results are similar to high volume neurovascular centers worldwide, reflecting the importance of centralized care at specialized neurovascular centers.
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Di Somma A, Cancela Caro P, Blanco MO, Somma T, López-González A, Campero A, Emmerich J, Márquez-Rivas J. Modified “Extended” Suboccipital Subtonsillar Clipping of a Ruptured Proximal Pica Aneurysm: Technical Note with Relevant Anatomical Demonstration. World Neurosurg 2018; 117:301-308. [DOI: 10.1016/j.wneu.2018.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/02/2018] [Indexed: 10/14/2022]
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Nakov V, Spiriev T, Stavrev E. How I do it: surgical clipping of vertebrobasilar junction aneurysms through a far-lateral transcondylar approach. Acta Neurochir (Wien) 2018. [PMID: 29541887 DOI: 10.1007/s00701-018-3512-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vertebrobasilar junction aneurysms occur rarely, but have a higher rupture rate than supratentoral aneurysms, and higher morbidity and mortality. Their location ventral to the neuroaxis makes them a challenging surgical lesion. METHODS In this paper, we share our experience with the surgical technique for the management of these complex aneurysms. CONCLUSION An in-depth understanding of the anatomy of these aneurysms, careful preoperative planning, and a meticulous surgical technique, including knowledge of every detail of the procedure-positioning, an advanced skull base technique, and careful aneurysm dissection and clipping-is essential for a successful outcome of the surgery.
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Affiliation(s)
- Vladimir Nakov
- Department of Neurosurgery Acibadem City Clinic Tokuda Hospital, "Nikola Vaptsarov" Blvd. 51b, 1407, Sofia, Bulgaria
| | - Toma Spiriev
- Department of Neurosurgery Acibadem City Clinic Tokuda Hospital, "Nikola Vaptsarov" Blvd. 51b, 1407, Sofia, Bulgaria.
| | - Evgeni Stavrev
- Department of Neurosurgery Military Medical Academy, "Georgi Sofiiski str. No 3", 1606, Sofia, Bulgaria
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Tjahjadi M, Rezai Jahromi B, Serrone J, Nurminen V, Choque-Velasquez J, Kivisaari R, Lehto H, Niemelä M, Hernesniemi J. Simple Lateral Suboccipital Approach and Modification for Vertebral Artery Aneurysms: A Study of 52 Cases Over 10 Years. World Neurosurg 2017; 108:336-346. [PMID: 28899830 DOI: 10.1016/j.wneu.2017.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/31/2017] [Accepted: 09/02/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Complex skull base approaches are frequently used to treat intracranial vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) aneurysms. These complex procedures are associated with higher risk of neurovascular injury. Hence, a less-invasive surgical approach is needed to improve the efficacy and safety of treatment. METHODS A retrospective analysis was conducted on clinical and radiologic data from surgeries in which simple lateral suboccipital and "lateral-enough" approaches were used to clip VA aneurysms in the Department of Neurosurgery at Helsinki University Central Hospital from 2000 to 2009. RESULTS Fifty-two VA or PICA aneurysms were treated using the simple lateral suboccipital approach. Sixteen patients (31%) presented with an unruptured aneurysm, 21 patients (40%) with World Federation of Neurosurgical Societies (WFNS) grade 1-3, and 15 patients (29%) with World Federation of Neurosurgical Societies grade 4-5. The aneurysms were saccular in 48 cases (92%), dissecting in 3 cases (6%), and fusiform in 1 case (2%). The most common aneurysm location was the VA-PICA junction (81%). The mean final modified Rankin Scale score was 2, and in unruptured cases, all patients had favorable clinical outcomes. The main causes of unfavorable outcome were poor preoperative clinical grade (P = 0.002), preoperative intraventricular hemorrhage (P = 0.008), postoperative hydrocephalus (P = 0.003), brain infarction (P = 0.005), and postoperative pneumonia (P < 0.001). CONCLUSIONS We describe a 10-year experience using a simple lateral suboccipital approach and its modification by the senior author (J.H.) to treat VA and proximal PICA aneurysms. Unfavorable outcome was related to the poor preoperative clinical grade, preoperative intraventricular hemorrhage, and postoperative pneumonia.
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Affiliation(s)
- Mardjono Tjahjadi
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Joseph Serrone
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Nurminen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Joham Choque-Velasquez
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Lehto
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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The midline suboccipital subtonsillar approach to the cerebellomedullary cistern: how I do it. Acta Neurochir (Wien) 2017; 159:1613-1617. [PMID: 28735380 DOI: 10.1007/s00701-017-3270-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Lesions lateral to the lower brainstem in an area extending from the foraminae of Luschka to the foramen magnum are rare and include different pathologies. There is no consensus on an ideal surgical approach. METHOD To gain access to this area, we use the midline suboccipital subtonsillar approach (STA). This midline approach with unilateral retraction of the cerebellar tonsil enables entry into the cerebellomedullary cistern. CONCLUSIONS The STA offers excellent access with a panoramic view of the cerebellomedullary cistern and its structures and therefore can be useful for a number of different pathologies in the lower petroclival area.
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Seoane P, Kalb S, Clark JC, Rivas JC, Xu DS, Mendes GAC, Preul MC, Zabramski JM, Spetzler RF, Nakaji P. Far-Lateral Approach Without Drilling the Occipital Condyle for Vertebral Artery–Posterior Inferior Cerebellar Artery Aneurysms. Neurosurgery 2017; 81:268-274. [DOI: 10.1093/neuros/nyw136] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 12/15/2016] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: The far-lateral transcondylar surgical approach is often used to clip vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms. The role of condyle resection during this approach is controversial.
OBJECTIVE: To evaluate patient outcomes in patients with VA–PICA aneurysms in whom drilling the occipital condyle was not necessary.
METHODS: Between May 2005 and December 2012, a total of 56 consecutive patients with incidental or ruptured VA–PICA aneurysms underwent surgery with a far-lateral approach without condylar resection. Clinical presentation, surgical reports, presurgery and postsurgery radiological examinations, and clinical follow-up reports were assessed. Anatomic aneurysm location was analyzed through angiography or computed tomography angiography. We compared postsurgical Glasgow Outcome Scale scores, modified Rankin Scale scores, and morbidity in 2 groups: those with aneurysms in the anterior medullary segment and those with aneurysms in the lateral medullary segment.
RESULTS: The predominant presentation was subarachnoid hemorrhage in 34 patients (60.7%). Most aneurysms (n = 27 [48.2%]) were located in the lateral medullary segment of the PICA, followed by the anterior medullary segment (n = 25 [44.6%]). Total aneurysm occlusion was achieved in 100% of patients, and bypass techniques were necessary in 3 patients (5.4%). Fifty-two patients (92.8%) had Glasgow Outcome Scale scores of 4 or 5 postsurgery.
CONCLUSIONS: A far-lateral approach that leaves the occipital condyle intact is adequate for treating most patients with VA–PICA aneurysms.
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Affiliation(s)
- Pablo Seoane
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - Samuel Kalb
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - Justin C. Clark
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - Juan C. Rivas
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - David S. Xu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - George A. C. Mendes
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - Mark C. Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - Joseph M. Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - Robert F. Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hos-pital and Medical Center, Phoenix, Arizona
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Doan V, Lemos-Rodriguez AM, Sreenath SB, Unnithan A, Recinos PF, Zanation AM, Sasaki-Adams DM. Using the Endoscopic Endonasal Transclival Approach to Access Aneurysms Arising from AICA, PICA, and Vertebral Artery: An Anatomical Study. J Neurol Surg B Skull Base 2015; 77:207-11. [PMID: 27175314 DOI: 10.1055/s-0035-1564055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022] Open
Abstract
Objective To explore the use of the endoscopic endonasal transclival approach (EEA) for clipping anterior inferior cerebellar artery (AICA), posterior inferior cerebellar artery (PICA), and vertebral artery (VA) aneurysms. Design Anatomical study. Participants Fifteen adult cadavers. Main Outcome Measures Length of artery exposed and distance from the nasal ala to the arteries. Results The length of the right and left VA exposed were 1.7 ± 0.6 cm and 1.6 ± 0.6 cm, respectively. The distance to the right VA was 11.1 ± 0.9 cm and to the left was 11.1 ± 0.8 cm. Right and left AICA were exposed for an average length of 1.1 ± 0.3 cm and 0.8 ± 0.3 cm, respectively. The distance to the right AICA was 10.3 ± 0.8 cm and to the left was 10.3 ± 0.8 cm. The right PICA was exposed for a length of 0.5 ± 0.2 cm at a distance of 10.9 ± 0.5 cm. The left PICA was exposed for a length of 0.5 ± 0.2 cm at a distance of 11.1 ± 0.9 cm. Conclusion The EEA can provide direct access to AICA, PICA, and VA, making it a potential alternative to the traditional approaches for the clipping of aneurysms arising from those arteries.
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Affiliation(s)
- Vivian Doan
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Ana M Lemos-Rodriguez
- Department of Ear, Nose, and Throat Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Satyan B Sreenath
- Department of Ear, Nose, and Throat Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Ajay Unnithan
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Pablo F Recinos
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
| | - Adam M Zanation
- Department of Ear, Nose, and Throat Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Deanna M Sasaki-Adams
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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Lau T, Reintjes S, Olivera R, van Loveren HR, Agazzi S. C-shaped Incision for Far-Lateral Suboccipital Approach: Anatomical Study and Clinical Correlation. J Neurol Surg B Skull Base 2015; 76:117-21. [PMID: 25844297 DOI: 10.1055/s-0034-1390396] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 06/13/2014] [Indexed: 10/24/2022] Open
Abstract
Background The standard incision for far-lateral suboccipital approaches has been the classic "reverse hockey stick." Although that incision provides ample exposure, concern has been raised that excessive muscle dissection and skin elevation might lead to accumulation of cerebrospinal fluid (CSF) under the flap with increased risk of CSF leak. We hypothesize that the C-shaped incision can minimize the amount of muscle dissection and provide optimal exposure and surgical outcomes. Objective To describe the anatomical dissection for the C-shaped incision and clinical application of the C-shaped incision for the far-lateral approach. Methods A retrospective analysis of all the patients operated on at our center using this approach for the treatment of aneurysm of the posterior inferior cerebellar artery (PICA) from 2005 to 2011. Results of clinical and operative outcome are evaluated. Surgical techniques are described in detail. Cadaveric dissections using the C-shaped incision were performed to assess the exposure of the far-lateral suboccipital area. Results Eleven consecutive patients who had undergone this procedure were selected. All patients underwent clipping of PICA aneurysms. Nine patients (82%) presented with ruptured aneurysms and subarachnoid hemorrhage. All of them underwent suboccipital craniectomy and C1 laminectomy. The dura mater was closed in a watertight fashion in 10 patients (91%). No CSF leak or pseudomeningocele were reported. In nine SAH patients, two (22%) had postoperative dysphagia and required long-term percutaneous endoscopic gastrostomy tube placement. One patient (11%) had chronic respiratory failure and required a tracheostomy. Three patients (33%) developed hydrocephalus and required a ventriculoperitoneal shunt. Conclusions The C-shaped incision is a valid alternative to the classic reverse hockey-stick incision to gain exposure for far-lateral craniotomies. Knowing the anatomy and dissection techniques can provide an easy and safe route to address anterior lateral cranial-cervical lesions. Our results suggest the C-shaped incision is reliable in preventing CSF leak and the formation of pseudomeningocele.
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Affiliation(s)
- Tsz Lau
- Department of Neurological Surgery, College of Medicine, University of South Florida, Tampa, Florida, United States
| | - Stephen Reintjes
- Department of Neurological Surgery, College of Medicine, University of South Florida, Tampa, Florida, United States
| | - Raul Olivera
- Department of Neurological Surgery, College of Medicine, University of South Florida, Tampa, Florida, United States
| | - Harry R van Loveren
- Department of Neurological Surgery, College of Medicine, University of South Florida, Tampa, Florida, United States
| | - Siviero Agazzi
- Department of Neurological Surgery, College of Medicine, University of South Florida, Tampa, Florida, United States
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Lehto H, Kivisaari R, Niemelä M, Dashti R, Elsharkawy A, Harati A, Satopää J, Koroknay-Pál P, Laakso A, Hernesniemi J. Seventy Aneurysms of the Posterior Inferior Cerebellar Artery: Anatomical Features and Value of Computed Tomography Angiography in Microneurosurgery. World Neurosurg 2014; 82:1106-12. [DOI: 10.1016/j.wneu.2014.03.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 12/03/2013] [Accepted: 03/15/2014] [Indexed: 11/30/2022]
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The midline suboccipital subtonsillar approach to the cerebellomedullary cistern and its structures: Anatomical considerations, surgical technique and clinical application. Clin Neurol Neurosurg 2014; 125:98-105. [DOI: 10.1016/j.clineuro.2014.07.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/07/2014] [Accepted: 07/20/2014] [Indexed: 11/23/2022]
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Kim YD, Mendes GAC, Seoane P, Agrawal A, Maramreddy N, Nakaji P, Spetzler RF, Preul MC. Quantitative Anatomical Study of Tailored Far-Lateral Approach for the VA-PICA Regions. J Neurol Surg B Skull Base 2014; 76:57-65. [PMID: 25685651 DOI: 10.1055/s-0034-1389373] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 06/14/2014] [Indexed: 10/24/2022] Open
Abstract
Objective The extent of the far-lateral approach (FLA) has not yet been quantified for the region of the vertebral and posterior inferior cerebellar arteries (VA-PICA). We quantitatively analyzed six main sequential steps of the FLA. Methods A modified small FLA (msFLA) and a classic large FLA (clFLA) were performed sequentially on both sides of five cadaveric heads. A frameless navigational system was used to quantify the angle of attack for the origin (T1) and lateral medullary segment (T2) of the PICA and the surgical area of exposure above and below the vagus nerve (cranial nerve [CN] X). Results The total area of exposure above CN X increased significantly (p < 0.05) from the msFLA to the clFLA. However, the surgical exposure area below CN X did not change (p > 0.05). C1 hemilaminectomy increased (p < 0.05) the vertical angle of attack, and drilling the posteromedial third of the occipital condyle increased (p < 0.05) the horizontal angle of attack to the origin of the PICA. Conclusions For the VA-PICA region, the msFLA offered a similar practical surgical working area and similar angles of attack when compared with the clFLA. The FLA should be tailored based on the location, size, and pathology of lesions and on the exposure required for effective surgical treatment.
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Affiliation(s)
- Young-Don Kim
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States ; Department of Neurological Surgery, Daegu Catholic University Medical Center, Daegu, Korea
| | - George A C Mendes
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Pablo Seoane
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Abhishek Agrawal
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Naveen Maramreddy
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Robert F Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
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Savardekar A, Tewari MK, Garg R, Gupta V, Ahuja C. Extracranially located PICA aneurysm presenting with supratentorial IVH: A rare event with diagnostic pitfalls. J Neurosci Rural Pract 2013; 4:S99-S101. [PMID: 24174813 PMCID: PMC3808075 DOI: 10.4103/0976-3147.116430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Extracranially located posterior inferior cerebellar artery (PICA) aneurysms are rare with only 21 cases reported till date. They may arise either from the proximal segment of an extracranially originating PICA or from the tip of its caudal loop when it dips below the foramen magnum. A 16-year-old female presenting with sudden onset severe headache and intraventricular hemorrhage (IVH) in the occipital horns of the lateral ventricle and the fourth ventricles, was diagnosed to have an extracranial proximal segment PICA aneurysm on a four vessel digital subtraction angiography (DSA), after initially missing it on the brain magnetic resonance imaging (MRI) with angiogram (MRA) because of its extracranial location. During surgery, the aneurysm was clipped following a far lateral suboccipital craniectomy with C1-C2 hemilaminectomy. The patient showed good recovery. Thus, we emphasize the need for a dedicated four vessel angiography to diagnose such lesions.
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Kayaci S, Caglar YS, Bas O, Ozveren MF. Importance of the perforating arteries in the proximal part of the PICA for surgical approaches to the brain stem and fourth ventricle - an anatomical study. Clin Neurol Neurosurg 2013; 115:2153-8. [DOI: 10.1016/j.clineuro.2013.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 06/29/2013] [Accepted: 08/04/2013] [Indexed: 11/29/2022]
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Chalouhi N, Jabbour P, Starke RM, Tjoumakaris SI, Gonzalez LF, Witte S, Rosenwasser RH, Dumont AS. Endovascular treatment of proximal and distal posterior inferior cerebellar artery aneurysms. J Neurosurg 2013; 118:991-9. [PMID: 23350778 DOI: 10.3171/2012.12.jns121240] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Surgical clipping of posterior inferior cerebellar artery (PICA) aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies. The authors assess the feasibility, safety, and efficacy of endovascular therapy in the largest series of proximal and distal PICA aneurysms to date.
Methods
A total of 76 patients, 54 with proximal and 22 with distal PICA aneurysms, underwent endovascular treatment at Jefferson Hospital for Neuroscience between 2001 and 2011.
Results
Endovascular treatment was successful in 52 patients (96.3%) with proximal aneurysms and 19 patients (86.4%) with distal aneurysms. Treatment consisted of selective aneurysm coiling in 60 patients (84.5%) (including 4 with stent assistance and 4 with balloon assistance) and parent vessel trapping in 11 patients (15.5%). Specifically, a deconstructive procedure was necessary in 9.6% of proximal aneurysms (5 of 52) and 31.6% of distal aneurysms (6 of 19). There were 9 overall procedural complications (12.7%), 6 infarcts (8.5%; 4 occurring after deliberate occlusion of the PICA), and 3 intraprocedural ruptures (4.2%). The rate of procedure-related permanent morbidity was 2.8%. Complete aneurysm occlusion was achieved in 63.4% of patients (45 of 71). One patient (1.4%) treated with selective aneurysm coiling suffered a rehemorrhage on postoperative Day 15. The mean angiographic follow-up time was 17.2 months. Recurrence and re-treatment rates were, respectively, 20% and 17.1% for proximal aneurysms compared with 30.8% and 23.1% for distal aneurysms. Favorable outcomes (moderate, mild, or no disability) at follow-up were seen in 93% of patients with unruptured aneurysms and in 78.7% of those with ruptured aneurysms.
Conclusions
Endovascular therapy is a feasible, safe, and effective treatment in patients with proximal and distal PICA aneurysms, providing excellent patient outcomes and adequate protection against rehemorrhage. The long-term incidence of aneurysm recanalization appears to be high, especially in distal aneurysms, and requires careful angiographic follow-up.
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Affiliation(s)
- Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Robert M. Starke
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
- 2Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Stavropoula I. Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - L. Fernando Gonzalez
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Samantha Witte
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Robert H. Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Aaron S. Dumont
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
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Singh RK, Behari S, Kumar V, Jaiswal AK, Jain VK. Posterior inferior cerebellar artery aneurysms: Anatomical variations and surgical strategies. Asian J Neurosurg 2012; 7:2-11. [PMID: 22639684 PMCID: PMC3358952 DOI: 10.4103/1793-5482.95687] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Context: Posterior inferior cerebellar artery (PICA) aneurysms are associated with multiple anatomical variations of the parent vessel. Complexities in their surgical clipping relate to narrow corridors limited by brain-stem, petrous-occipital bones, and multiple neurovascular structures occupying the cerebellomedullary and cerebellopontine cisterns. Aims: The present study focuses on surgical considerations during clipping of saccular PICA aneurysms. Setting and Design: Tertiary care, retrospective study. Materials and Methods: In 20 patients with PICA aneurysms, CT angiogram/digital substraction angiogram was used to correlate the site and anatomical variations of aneurysms located on different segments of PICA with the approach selected, the difficulties encountered and the final outcome. Statistical Analysis: Comparison of means and percentages. Results: Aneurysms were located on PICA at: vertebral artery/basilar artery (VA/BA)-PICA (n=5); anterior medullary (n=4); lateral medullary (n=3); tonsillomedullary (n=4); and, telovelotonsillar (n=4) segments. The Hunt and Hess grade distribution was I in 15; II in 2; and, III in 3 patients (mean ictus-surgery interval: 23.5 days; range: 3-150 days). Eight patients had hydrocephalus. Anatomical variations included giant, thrombosed aneurysms; 2 PICA aneurysms proximal to an arteriovenous malformation; bilobed or multiple aneurysms; low PICA situated at the foramen magnum with a hypoplastic VA; and fenestrated PICA. The approaches included a retromastoid suboccipital craniectomy (n=9); midline suboccipital craniectomy (n=6); and far-lateral approach (n=5). At a follow-up (range 6 months-2.5 years), 13 patients had no deficits (modified Rankin score (mRS) 0); 2 were symptomatic with no significant disability (mRS1); 1 had mild disability (mRS2); 1 had moderately severe disability (mRS4); and 3 died (mRS6). Three mortalities were caused by vasospasm (2) and, rupture of unclipped second VA-BA junctional aneurysm (1). Conclusions: PICA aneurysms may present with only IVth ventricular blood without subarachnoid hemorrhage. PICA may have multiple anomalies and its aneurysms may be missed on CT angiograms. Surgical approach is influenced by VA-BA tortuosity and variations in anatomy, location of the VA-BA junction and the PICA aneurysm relative to the brain-stem, and the pattern of collateral supply. The special category of VA-PICA junctional aneurysms and its management; and, the multiple anatomical variations of PICA aneurysms, merit special surgical considerations and have been highlighted in this study.
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Affiliation(s)
- Rohit K Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Safavi-Abbasi S, de Oliveira JG, Deshmukh P, Reis CV, Brasiliense LBC, Crawford NR, Feiz-Erfan I, Spetzler RF, Preul MC. The craniocaudal extension of posterolateral approaches and their combination: a quantitative anatomic and clinical analysis. Oper Neurosurg (Hagerstown) 2010; 66:54-64. [PMID: 20173573 DOI: 10.1227/01.neu.0000354366.48105.fe] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to describe quantitatively the properties of the posterolateral approaches and their combination. METHODS Six silicone-injected cadaveric heads were dissected bilaterally. Quantitative data were generated with the Optotrak 3020 system (Northern Digital, Waterloo, Canada) and Surgiscope (Elekta Instruments, Inc., Atlanta, GA), including key anatomic points on the skull base and brainstem. All parameters were measured after the basic retrosigmoid craniectomy and then after combination with a basic far-lateral extension. The clinical results of 20 patients who underwent a combined retrosigmoid and far-lateral approach were reviewed. RESULTS The change in accessibility to the lower clivus was greatest after the far-lateral extension (mean change, 43.62 +/- 10.98 mm2; P = .001). Accessibility to the constant landmarks, Meckel's cave, internal auditory meatus, and jugular foramen did not change significantly between the 2 approaches (P > .05). The greatest change in accessibility to soft tissue between the 2 approaches was to the lower brainstem (mean change, 33.88 +/- 5.25 mm2; P = .0001). Total removal was achieved in 75% of the cases. The average postoperative Glasgow Outcome Scale score of patients who underwent the combined retrosigmoid and far-lateral approach improved significantly, compared with the preoperative scores. CONCLUSION The combination of the far-lateral and simple retrosigmoid approaches significantly increases the petroclival working area and access to the cranial nerves. However, risk of injury to neurovascular structures and time needed to extend the craniotomy must be weighed against the increased working area and angles of attack.
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Affiliation(s)
- Sam Safavi-Abbasi
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Diagnosis and surgical management of extracranial PICA aneurysms presenting through subarachnoid haemorrhage: Case report and review of the literature. Clin Neurol Neurosurg 2009; 111:758-61. [PMID: 19651470 DOI: 10.1016/j.clineuro.2009.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 03/21/2009] [Accepted: 05/26/2009] [Indexed: 11/21/2022]
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Jeon SG, Kwon DH, Ahn JS, Kwun BD, Choi CG, Jin SC. Detachable coil embolization for saccular posterior inferior cerebellar artery aneurysms. J Korean Neurosurg Soc 2009; 46:221-5. [PMID: 19844622 DOI: 10.3340/jkns.2009.46.3.221] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 07/22/2009] [Accepted: 09/03/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Surgical treatment of posterior inferior cerebellar artery (PICA) aneurysms is challenging due to limited surgical accessibility. Endovascular approach has a benefit of avoiding direct injury to the brainstem or lower cranial nerves. Therefore, it has recently been considered an alternative or primary modality for PICA aneurysms. We retrospectively assessed outcomes following detachable coil embolization of saccular PICA aneurysms. METHODS From February 1997 to December 2007, we performed endovascular procedures to treat 15 patients with 15 PICA aneurysms. Fourteen patients with 14 PICA aneurysms morphology of which was saccular were reviewed retrospectively. Twelve patients had ruptured aneurysms. The aneurysms arose from the PICA origin site (n = 12), the PICA lateral medullary segment (n = 1), or the PICA tonsilomedullary segment (n = 1). RESULTS Complete aneurysm occlusion was achieved in 10 patients, residual neck in 3, and residual sac in one. Radiological follow-up was performed in 7 patients with mean duration of 34.7 months (range, 1-97 months) and showed stable or complete occlusion in 6 patients. There were no rebleeding or retreatment after endovascular treatment. Thromboembolism was the only procedure-related complication (n = 4 ; 28.6%). Asymptomatic PICA infarction occurred in two patients and symptomatic PICA infarction in two elderly patients with poor clinical grade. Of these procedural PICA infarction cases, 1 symptomatic PICA infarction patient developed ventriculitis and septic shock leading to death. The clinical outcome was good in 10 patients (71.4%). CONCLUSIONS In the present study, detachable coil embolization has shown as an efficient modality for PICA saccular aneurysms challenging indications of microsurgery. However, thromboembolic complications should be considered, especially in poor clinical elderly patients with ruptured aneurysms.
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Affiliation(s)
- Su-Gi Jeon
- Department of Neurological Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Sanai N, Tarapore P, Lee AC, Lawton MT. THE CURRENT ROLE OF MICROSURGERY FOR POSTERIOR CIRCULATION ANEURYSMS. Neurosurgery 2008; 62:1236-49; discussion 1249-53. [PMID: 18824990 DOI: 10.1227/01.neu.0000333295.59738.de] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Nader Sanai
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Sanai N, Tarapore P, Lee AC, Lawton MT. THE CURRENT ROLE OF MICROSURGERY FOR POSTERIOR CIRCULATION ANEURYSMS. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000316415.51936.ab] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Peluso JP, van Rooij WJ, Sluzewski M, Beute GN, Majoie CB. Posterior inferior cerebellar artery aneurysms: incidence, clinical presentation, and outcome of endovascular treatment. AJNR Am J Neuroradiol 2007; 29:86-90. [PMID: 17928380 DOI: 10.3174/ajnr.a0758] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Results of endovascular treatment of PICA aneurysms are not well established. The purpose of this study was to report incidence, clinical presentation, and outcome of endovascular treatment in 46 patients with 47 posterior inferior cerebellar artery (PICA) aneurysms. MATERIALS AND METHODS Of 2169 aneurysms treated between January 1995 and March 2007, 60 were located on the PICA (incidence, 2.8%). Forty-seven proximal PICA aneurysms in 46 patients were treated with endovascular techniques, 37 ruptured (79%) and 10 unruptured (21%). Four patients presented with lower cranial nerve palsies. Mean aneurysm size was 6.8 mm (median, 6 mm; range, 2-32 mm). Forty-three aneurysms were occluded with coils (6 including the PICA origin), and 4 were treated with proximal vertebral artery (VA) occlusion. RESULTS Four aneurysms treated with proximal VA occlusion were not occluded. Procedural rupture occurred in 9 aneurysms leading to death in 2 patients and to permanent disability in 1 patient. One patient developed lateral medullary and cerebellar infarctions after PICA occlusion. Combined mortality and morbidity was 8.6% (4 of 46). Outcome at 6 months in 38 surviving patients was good in 35 and moderate in 3. No hemorrhage occurred during 109 patient-years of follow-up. Symptoms of mass effect resolved in all 4 patients. CONCLUSION In our experience, PICA aneurysms were challenging lesions, prone to procedural rupture. In some instances, endovascular treatment required occlusion of the parent PICA; usually this was well tolerated. In other instances, treatment required occlusion of the VA. Although this was effective in alleviation of symptoms of mass effect, it was not effective in causing thrombosis of the aneurysm.
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Affiliation(s)
- J P Peluso
- Department of Radiology, St. Elisabeth Ziekenhuis, Tilburg, the Netherlands
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