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Microsurgical anatomy of safe entry zones on the ventrolateral brainstem: a morphometric study. Neurosurg Rev 2021; 45:1363-1370. [PMID: 34546449 DOI: 10.1007/s10143-021-01644-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/14/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
Surgery of the brainstem is challenging due to the complexity of the area with cranial nerve nuclei, reticular formation, and ascending and descending fibers. Safe entry zones are required to reach the intrinsic lesions of the brainstem. The aim of this study was to provide detailed measurements for anatomical landmark zones of the ventrolateral surface of the human brainstem related to previously described safe entry zones. In this study, 53 complete and 34 midsagittal brainstems were measured using a stainless caliper with an accuracy of 0.01 mm. The distance between the pontomesencephalic and bulbopontine sulci was measured as 26.94 mm. Basilar sulcus-lateral side of pons (origin of the fibers of the trigeminal nerve) distance was 17.23 mm, transverse length of the pyramid 5.42 mm, and vertical length of the pyramid 21.36 mm. Lateral mesencephalic sulcus was 12.73 mm, distance of the lateral mesencephalic sulcus to the oculomotor nerve 13.85 mm, and distance of trigeminal nerve to the upper tip of pyramid 17.58 mm. The transverse length for the inferior olive at midpoint and vertical length were measured as 5.21 mm and 14.77 mm, consequently. The thickness of the superior colliculus was 4.36 mm, and the inferior colliculus 5.06 mm; length of the tectum was 14.5 mm and interpeduncular fossa 11.26 mm. Profound anatomical knowledge and careful analysis of preoperative imaging are mandatory before surgery of the brainstem lesions. The results presented in this study will serve neurosurgeons operating in the brainstem region.
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Shindo K, Ogino T, Endo H, Fukuda M, Matsuda M, Yamashita D, Yamaguchi D, Yoshihara R, Morishita M, Tatsuta Y, Sakurai S, Kyono M, Goto D, Asanome T, Osato T, Nakamura H. Target Embolization of Dilated Post-PICA Segment for Ruptured PICA-Involved Type Vertebral Artery Dissecting Aneurysm. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:565-573. [PMID: 37501752 PMCID: PMC10370790 DOI: 10.5797/jnet.oa.2020-0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/27/2020] [Indexed: 07/29/2023]
Abstract
Objective In parent artery occlusion (PAO) for ruptured vertebral artery dissecting aneurysms (RVADA), target embolization using coils in a short segment to occlude only the vasodilated area containing the rupture point is selected as a first-choice procedure at our institute. We focused on RVADA involving the posterior inferior cerebellar artery (PICA) and evaluated the treatment results. Methods This study consisted of eight cases with RVADA involving the PICA which were treated between October 2007 and January 2020. Based on radiological findings such as the bleb, the rupture points were located at the affected vertebral artery (VA) distal to PICA in all cases. Target embolization, by which only coiling at the dilated segment distal to the VA was performed. We aimed to preserve blood flow to the PICA. The incidence and extent of medullary infarctions, and neurological outcome were retrospectively assessed. Results Regarding the diameter of bilateral VA, there were no differences in six cases while the affected VA with RVADA were larger in the remaining two cases. PICA was preserved in all cases but one in which occlusion of complementary PICA was observed. Postoperative medullary infarction was not noted. There was no rebleeding during the follow-up period. However, recanalization of the VA was observed in four cases and additional coil embolization was performed. All patients were discharged with a good outcome (modified Rankin Scale [mRS] 0; seven patients, mRS 2; one patient). Conclusion Target embolization preserving the PICA in PICA-involved type RVADA was considered to be an effective treatment method for cases whose rupture point was located in the VA distal to PICA orifice.
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Affiliation(s)
- Koichiro Shindo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Tatsuya Ogino
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Hideki Endo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Department of Neurosurgery, Nakamura Memorial South Hospital, Sapporo, Hokkaido, Japan
| | - Mamoru Fukuda
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Megumi Matsuda
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Daisuke Yamashita
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Daishi Yamaguchi
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Ryunosuke Yoshihara
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Masahiro Morishita
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Yasuyuki Tatsuta
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Suguru Sakurai
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Masanori Kyono
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Daigo Goto
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Taku Asanome
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Toshiaki Osato
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
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Saito M, Kawano H, Amano T, Okano H, Iwamoto T, Hirano T. [A case of bilateral medial medullary and left tegmentum of pontine infarction in whom DSA-MR fusion imaging identified infarct-relevant arteries]. Rinsho Shinkeigaku 2020; 60:434-440. [PMID: 32435047 DOI: 10.5692/clinicalneurol.60.cn-001391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
We herein reported a patient with acute ischemic stroke in the bilateral medial medullary and the left tegmentum of the pons who presented with various neurological symptoms. Fusing digital subtraction angiography (DSA) and MRI (DSA-MR fusion imaging) could reveal the infarct-relevant arteries. A 41-year-old male presented with headache, bilateral arm's dysesthesia, quadriplegia, left Horner's syndrome, upbeat nystagmus, internuclear ophthalmoplegia and left peripheral facial paralysis. Diffusion weighted MRI (DWI) revealed the high intensity lesion in the bilateral medial medullary and the left tegmentum of the pons. MRA showed right vertebral artery (VA) occlusion. A high intensity on T1 weighted imaging was shown on the right VA vessel wall. DSA-MR fusion imaging revealed the anterior spinal artery (ASA) occlusion proximal to the infarction. The stenosis was located at the origin of the right VA perforating branch distributing into the infarct lesion. The steno-occlusive lesion of ASA and VA perforating branch due to VA dissection resulted in infarction in the pontomedullary junction and caused various neurological symptoms. DSA-MR fusion imaging would prove the radiological anatomy of infarct-relevant arteries and clarify the etiology of ischemic stroke.
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Affiliation(s)
- Mikito Saito
- Department of Stroke and Cerebrovascular Medicine, Kyorin University Faculty of Medicine
| | - Hiroyuki Kawano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University Faculty of Medicine
| | - Tatsuo Amano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University Faculty of Medicine
| | - Haruko Okano
- Department of Neurology, Kyorin University Faculty of Medicine
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University Faculty of Medicine
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Suzuki T, Kaku S, Nishimura K, Teshigawara A, Sasaki Y, Aoki K, Tanaka T, Karagiozov K, Murayama Y. Multistage "Hybrid" (Open and Endovascular) Surgical Treatment of Vertebral Artery-Thrombosed Giant Aneurysm by Trapping and Thrombectomy. World Neurosurg 2018; 114:144-150. [PMID: 29551721 DOI: 10.1016/j.wneu.2018.03.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Surgical treatment of vertebral artery (VA)-thrombosed giant aneurysms requires achieving both obliteration of the parent artery to prevent bleeding and dome thrombectomy to relieve the brain stem from mass effect. To secure both proximal and distal control of complex VA aneurysms, the contralateral approach to the aneurysm might be a useful alternative, as previously described. We successfully treated a case of VA-thrombosed giant aneurysm in a new, original way by combining craniotomy (ipsilateral and contralateral) and the endovascular technique. CASE DESCRIPTION A 48-year-old man presented with a thrombosed giant aneurysm of the right VA compressing the brain stem. Treatment consisted of endovascular proximal ligation of the VA followed by 2-staged craniotomy for complete trapping of the aneurysm and intra-aneurysmal thrombectomy. The VA distal to the aneurysm was obliterated via contralateral craniotomy as only that provided adequate working space. Finally, intra-aneurysmal partial thrombectomy was performed through an ipsilateral craniotomy, which also made possible the obliteration of the eventually dangerous remaining vasa vasorum and additional proximal ligation of the VA. CONCLUSIONS Based on pathologic and surgical anatomical characteristics, a combination of an endovascular procedure with 2-staged craniotomy for complete trapping, thrombectomy, and vasa vasorum obliteration could be considered a feasible way to treat VA-thrombosed giant aneurysms located ventral to the brain stem and have their distal neck portions/patent vessel beyond the midline toward the contralateral side.
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Affiliation(s)
- Tomoya Suzuki
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan; Department of Neurosurgery, Jikei University Kashiwa Hospital, Chiba, Japan.
| | - Shogo Kaku
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Kengo Nishimura
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Akihiko Teshigawara
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Sasaki
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Ken Aoki
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Toshihide Tanaka
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Chiba, Japan
| | - Kostadin Karagiozov
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
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Kannath S, Rajan Jayadevan E. The Lurking Catastrophic Complication of an Equally Catastrophic Disease: The Lesson Learned. Oper Neurosurg (Hagerstown) 2016; 12:189-192. [PMID: 29506097 DOI: 10.1227/neu.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 09/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Medullary-bridging vein dural arteriovenous fistula (DAVF) is an uncommon type of DAVF with an aggressive clinical course due to direct fistulous shunting into medullary and brainstem veins. Important considerations need to be given to retrograde embolic migration or perforator involvement while treating these fistulas endovascularly with a liquid embolic agent. We report a lateral spinal artery feeding the DAVF, the recognition of which is important to avoid potential catastrophic complications during definitive therapy, and which has not been described before. OBJECTIVE To discuss the anatomy of the lateral spinal artery (LSA) and its communications with pial arteries such as the posterior inferior cerebellar artery (PICA) that may have important implications in the management of neurovascular diseases in and around the foramen magnum. METHODS A retrospective analysis of cerebral angiograms and 3-dimensional rotational angiograms of a patient with medullary-bridging vein DAVF treated by transarterial embolization under balloon protection was performed after the patient developed lateral medullary syndrome in the postoperative period. RESULTS Detailed analysis revealed a dural branch from the LSA feeding the DAVF which anastomosed with rudimentary PICA. CONCLUSION LSA has important anastomoses with perforating arteries of the medulla and cervical cord and, hence, it is important to recognize and identify LSA prospectively in the vascular pathologies of the foramen magnum to avoid fatal neurological complications during endovascular therapy. This is especially important while treating neurovascular pathologies using liquid embolic agents such as Onyx or SQUID, because they can percolate retrogradely through the anastomoses into PICA or other vertebrobasilar perforators.
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Affiliation(s)
- Santhosh Kannath
- Neurointervention Center, Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Interventional Radiology, Trivandrum, Kerala, India
| | - Enakshy Rajan Jayadevan
- Neurointervention Center, Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Interventional Radiology, Trivandrum, Kerala, India
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Sosa P, Dujovny M, Onyekachi I, Sockwell N, Cremaschi F, Savastano LE. Microvascular anatomy of the cerebellar parafloccular perforating space. J Neurosurg 2016; 124:440-9. [DOI: 10.3171/2015.2.jns142693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The cerebellopontine angle is a common site for tumor growth and vascular pathologies requiring surgical manipulations that jeopardize cranial nerve integrity and cerebellar and brainstem perfusion. To date, a detailed study of vessels perforating the cisternal surface of the middle cerebellar peduncle—namely, the paraflocculus or parafloccular perforating space—has yet to be published. In this report, the perforating vessels of the anterior inferior cerebellar artery (AICA) in the parafloccular space, or on the cisternal surface of the middle cerebellar peduncle, are described to elucidate their relevance pertaining to microsurgery and the different pathologies that occur at the cerebellopontine angle.
METHODS
Fourteen cadaveric cerebellopontine cisterns (CPCs) were studied. Anatomical dissections and analysis of the perforating arteries of the AICA and posterior inferior cerebellar artery at the parafloccular space were recorded using direct visualization by surgical microscope, optical histology, and scanning electron microscope. A comprehensive review of the English-language and Spanish-language literature was also performed, and findings related to anatomy, histology, physiology, neurology, neuroradiology, microsurgery, and endovascular surgery pertaining to the cerebellar flocculus or parafloccular spaces are summarized.
RESULTS
A total of 298 perforating arteries were found in the dissected specimens, with a minimum of 15 to a maximum of 26 vessels per parafloccular perforating space. The average outer diameter of the cisternal portion of the perforating arteries was 0.11 ± 0.042 mm (mean ± SD) and the average length was 2.84 ± 1.2 mm. Detailed schematics and the surgical anatomy of the perforating vessels at the CPC and their clinical relevance are reported.
CONCLUSIONS
The parafloccular space is a key entry point for many perforating vessels toward the middle cerebellar peduncle and lateral brainstem, and it must be respected and protected during surgical approaches to the cerebellopontine angle.
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Affiliation(s)
- Pablo Sosa
- 1Department of Neuroscience, Clinical and Surgical Neurology, School of Medicine, National University of Cuyo, Mendoza, Argentina
| | - Manuel Dujovny
- 2Departments of Neurosurgery and Electrical Engineering, Wayne State University, Detroit; and
| | - Ibe Onyekachi
- 2Departments of Neurosurgery and Electrical Engineering, Wayne State University, Detroit; and
| | - Noressia Sockwell
- 2Departments of Neurosurgery and Electrical Engineering, Wayne State University, Detroit; and
| | - Fabián Cremaschi
- 1Department of Neuroscience, Clinical and Surgical Neurology, School of Medicine, National University of Cuyo, Mendoza, Argentina
| | - Luis E. Savastano
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Grigoryan YA, Arustamyan SR, Sitnikov AR, Grigoryan GY. [Giant partially thrombosed aneurysm of the vertebral artery: a case report and literature review]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016. [PMID: 28635695 DOI: 10.17116/neiro2016805106-115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Giant partially thrombosed aneurysms of the vertebral artery are recalcitrant to treatment by microsurgical trapping and thrombectomy. Application of endovascular interventions is limited due to substantial brainstem compression and cranial nerve neuropathy. Combined endovascular exclusion and microsurgical excision provides an approach to treatment of these lesions. CLINICAL CASE A 48-year-old female patient presented with progressive complaints of ataxia, diplopia in left lateral gaze, and dysphagia. Imaging studies (CT, MRI, angiography) revealed a giant partially thrombosed aneurysm of the right vertebral artery and pronounced brainstem compression. TREATMENT The initial phase of treatment involved endovascular occlusion of the vertebral artery and aneurysm trapping that did not lead to changes in the postoperative patient's neurological status. MRI demonstrated complete aneurysm thrombosis and a weak TOF signal in the vertebral artery near the proximal aneurysm neck region. Because of persistent brainstem compression, the patient underwent right suboccipital craniectomy and hemilaminectomy of the CI arch for aneurysm excision one week after endovascular occlusion. After isolating the aneurysmal sac, the vertebral artery was transected, and two small branches extending from the aneurysm neck to the brainstem were also coagulated and transected, followed by aneurysm excision. Numerous vasa vasorum in the wall of the proximal vertebral artery and aneurysm neck were coagulated to stop bleeding. After surgery, the patient developed neurological symptoms (right leg ataxia and dysphagia worsening) due to lateral medullary infarction (confirmed by MRI) that presumably resulted from coagulation of two small perforating branches coming from the aneurysm neck to the brainstem. Recovery of the patient's neurological functions was observed during conservative treatment. The patient was discharged with mild right leg ataxia and preoperative left-sided abducens paresis. CONCLUSION Medulla oblongata compression associated with a giant thrombosed aneurysm of the vertebral artery can be eliminated by endovascular trapping followed by surgical excision of the aneurysm. Preserving the vasa vasorum feeding the brainstem is crucial for prevention of ischemic complications.
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Fukuda H, Hayashi K, Handa A, Kurosaki Y, Lo B, Yamagata S. Reflux of Anterior Spinal Artery Predicts Recurrent Posterior Circulation Stroke in Bilateral Vertebral Artery Disease. Stroke 2015; 46:3263-5. [PMID: 26419966 DOI: 10.1161/strokeaha.115.011246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 08/31/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUNDS AND PURPOSE Predictive value of reflux of anterior spinal artery for recurrent posterior circulation ischemia in bilateral vertebral arteries steno-occlusive disease was evaluated. METHODS We retrospectively reviewed 55 patients with symptomatic posterior circulation stroke caused by bilateral stenotic (>70%) lesions of the vertebral artery. We investigated any correlation of clinical and angiographic characteristics including collateral flow patterns, with recurrent stroke. Risk factors for poor 3-month functional outcome were also evaluated. RESULTS Recurrent posterior circulation stroke was observed in 15 (27.3%) patients. Multivariable analysis using Cox proportional hazards model showed anterior spinal artery reflux as a significant risk factor for stroke recurrence (adjusted hazard ratio, 19.3 [95% confidence interval, 5.35-69.9]; P<0.001). Anterior spinal artery reflux was also correlated with poor functional outcome (modified Rankin Scale score, 3-6; adjusted odds ratio, 7.41 [95% confidence interval, 1.24-44.4]; P=0.028). CONCLUSIONS In patients with symptomatic bilateral vertebral artery occlusive disease, anterior spinal artery reflux predicted recurrent posterior circulation stroke and poor functional outcome.
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Affiliation(s)
- Hitoshi Fukuda
- From the Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan (H.F., K.H., A.H., Y.K., S.Y.); and Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada (B.L.).
| | - Kosuke Hayashi
- From the Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan (H.F., K.H., A.H., Y.K., S.Y.); and Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada (B.L.)
| | - Akira Handa
- From the Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan (H.F., K.H., A.H., Y.K., S.Y.); and Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada (B.L.)
| | - Yoshitaka Kurosaki
- From the Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan (H.F., K.H., A.H., Y.K., S.Y.); and Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada (B.L.)
| | - Benjamin Lo
- From the Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan (H.F., K.H., A.H., Y.K., S.Y.); and Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada (B.L.)
| | - Sen Yamagata
- From the Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan (H.F., K.H., A.H., Y.K., S.Y.); and Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada (B.L.)
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Kochi R, Endo H, Fujimura M, Sato K, Sugiyama SI, Osawa SI, Tominaga T. Outflow Occlusion with Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for Growing Vertebral Artery Fusiform Aneurysm with Ischemic Onset: A Case Report. J Stroke Cerebrovasc Dis 2015; 24:e223-6. [PMID: 25979424 DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 03/21/2015] [Accepted: 04/14/2015] [Indexed: 11/29/2022] Open
Abstract
Surgical treatments should be considered for vertebral artery fusiform aneurysms, which become symptomatic due to cerebral ischemia or mass effect. Ischemic complication is one of the major problems after surgical or endovascular trapping, which is associated with unfavorable outcomes. The authors present a case with growing vertebral artery (VA) fusiform aneurysm with ischemic onset successfully treated with outflow occlusion with occipital artery-posterior inferior cerebellar artery (OA-PICA) bypass. A 50-year-old woman presented with left PICA territory infarction. Left vertebral angiography (VAG) showed occlusion of the left VA at the proximal V4 segment. Right VAG revealed that the distal part of the left V4 segment with fusiform aneurysmal dilatation was reconstituted through vertebrobasilar junction, and the left PICA was the outlet of the blood flow from the fusiform aneurysm. Although the patient was treated conservatively, enlargement of the left VA fusiform aneurysm was observed 8 months after the initial presentation. Considering the potential risks for future stroke or bleeding, we performed clip occlusion of the origin of the left PICA, which could achieve outflow occlusion of the fusiform aneurysm with preservation of the perforators arising around the aneurysm. We created OA-PICA anastomosis for revascularization of the distal PICA. The postoperative course was uneventful, and the postoperative right VAG revealed occlusion of the fusiform aneurysm. Outflow occlusion instead of trapping is an effective surgical option for VA fusiform aneurysm to achieve obliterate the aneurysm with preservation of the perforator at the blind end.
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Affiliation(s)
- Ryuzaburo Kochi
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan; Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan.
| | - Miki Fujimura
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | | | | | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Oh JS, Yoon SM, Shim JJ, Bae HG, Yoon IG. Endovascular treatment for ruptured distal anterior inferior cerebellar artery aneurysm. J Cerebrovasc Endovasc Neurosurg 2014; 16:20-5. [PMID: 24765609 PMCID: PMC3997923 DOI: 10.7461/jcen.2014.16.1.20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 02/07/2014] [Accepted: 02/10/2014] [Indexed: 11/23/2022] Open
Abstract
A 42-year-old woman presented with Hunt and Hess grade (HHG) III subarachnoid hemorrhage (SAH) caused by a ruptured left distal anterior inferior cerebellar artery (AICA) aneurysm. Computed tomography showed a thin SAH on the cerebellopontine angle cistern, and small vermian intracerebral hemorrhage and intraventricular hemorrhage in the fourth ventricle. Digital subtraction angiography revealed the aneurysm on the postmeatal segment of left distal AICA, a branching point of rostrolateral and caudomedial branch of the left distal AICA. Despite thin caliber, tortuous running course and far distal location, the AICA aneurysm was obliterated successfully with endovascular coils without compromising AICA flow. However, the patient developed left side sensorineural hearing loss postoperatively, in spite of definite patency of distal AICA on the final angiogram. She was discharged home without neurologic sequela except hearing loss and tinnitus. Endovascular treatment of distal AICA aneurysm, beyond the meatal loop, is feasible while preserving the AICA flow. However, because the cochlear hair cell is vulnerable to ischemia, unilateral hearing loss can occur, possibly caused by the temporary occlusion of AICA flow by microcatheter during endovascular treatment.
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Affiliation(s)
- Jae-Sang Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Seok-Mann Yoon
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jai-Joon Shim
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hack-Gun Bae
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Il-Gyu Yoon
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Santillan A, Gobin YP, Patsalides A, Riina HA, Rosengart A, Stieg PE. Endovascular management of distal anterior inferior cerebellar artery aneurysms: Report of two cases and review of the literature. Surg Neurol Int 2011; 2:95. [PMID: 21748047 PMCID: PMC3130468 DOI: 10.4103/2152-7806.82577] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 04/20/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Aneurysms of the anterior inferior cerebellar artery (AICA), especially those located in the distal portion of the AICA, are rare. There are few reported cases treated with surgery or endovascular embolization. CASE DESCRIPTION We report two cases of fusiform distal AICA aneurysms presenting with subarachnoid hemorrhage. Parent artery occlusion with coils and n-butyl cyanoacrilate (n-BCA) resulted in complete aneurysm occlusion and prevented rebleeding. Both patients presented postprocedure neurological deficits, but have made a good recovery at 4 and 10 months, respectively. CONCLUSION Occlusion of the parent artery for the treatment of ruptured fusiform distal AICA aneurysms is effective but has significant neurological risks.
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Affiliation(s)
- Alejandro Santillan
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
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Rafael H. Revascularization of the brainstem and cerebellum. Neurosurgery 2010; 67:E521; author reply E521. [PMID: 20644393 DOI: 10.1227/01.neu.0000384042.80164.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Bambakidis NC, Manjila S, Dashti S, Tarr R, Megerian CA. Management of anterior inferior cerebellar artery aneurysms: an illustrative case and review of literature. Neurosurg Focus 2009; 26:E6. [PMID: 19409007 DOI: 10.3171/2009.1.focus0915] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Aneurysms of the anterior inferior cerebellar artery (AICA) are relatively rare among intracranial aneurysms. They can occur in 1 of 3 regions of the AICA: 1) craniocaudal (high or low riding), 2) mediolateral-premeatal (proximal), and 3) meatal-postmeatal (distal). The management strategies for treatment differ according to the location and configuration of the aneurysm. The existing body of neurosurgical literature contains articles published on aneurysms arising from the AICA near the basilar artery (BA), intracanalicular/meatal aneurysms, and distal AICA. Several therapeutic options exist, encompassing microsurgical and endovascular techniques. The authors describe a case of treatment involving a large BA-AICA aneurysm approached via exposure of the presigmoid dura using a retromastoid suboccipital craniectomy and partial petrosectomy. Treatment of these lesions requires detailed knowledge of the anatomy, and an anatomical overview of the AICA with its arterial loops and significant branches is presented, including a discussion of the internal auditory (labyrinthine) artery, recurrent perforating arteries, subarcuate artery, and cerebellosubarcuate artery. The authors discuss the various surgical approaches (retromastoid, far lateral, subtemporal, and transclival) with appropriate illustrations, citing the advantages and disadvantages in accessing these AICA lesions in relation to these approaches. The complications of these different surgical techniques and possible clinical effects of parent artery occlusion during AICA surgery are highlighted.
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Affiliation(s)
- Nicholas C Bambakidis
- Department of Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio 44106, USA.
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14
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Falk S, Rekling JC. Neurons in the preBötzinger complex and VRG are located in proximity to arterioles in newborn mice. Neurosci Lett 2009; 450:229-34. [DOI: 10.1016/j.neulet.2008.11.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 10/30/2008] [Accepted: 11/17/2008] [Indexed: 11/24/2022]
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15
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YAMAKAWA H, YOSHIMURA S, IWAMA T. Anterior Spinal Artery as a Collateral Channel in Patients With Acute Bilateral Vertebral Artery Occlusions -Two Case Reports-. Neurol Med Chir (Tokyo) 2009; 49:354-8. [DOI: 10.2176/nmc.49.354] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Haruki YAMAKAWA
- Department of Neurosurgery, Gifu University Graduate School of Medicine
| | | | - Toru IWAMA
- Department of Neurosurgery, Gifu University Graduate School of Medicine
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Rughani AI, Visioni A, Hamill RW, Tranmer BI. Subclavian artery stenosis causing transient bilateral brachial diplegia: an unusual cause of anterior spinal artery syndrome. J Neurosurg Spine 2008; 9:191-5. [PMID: 18764753 DOI: 10.3171/spi/2008/9/8/191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The author report a case of a 74-year-old man who had presented with transient bilateral brachial diplegia. Investigations led to the diagnosis and treatment of subclavian artery stenosis. There are no known published cases of subclavian artery stenosis associated with transient bilateral arm weakness, and the authors believe that a steal phenomenon leading to vertebrobasilar artery insufficiency and subsequent anterior spinal artery insufficiency may have caused these symptoms, which resolved after correction of the patient's stenosis.
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Affiliation(s)
- Anand I Rughani
- Division of Neurosurgery, Department of Surgery, University of Vermont, College of Medicine, Burlington, Vermont, USA
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17
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Mercier PH, Brassier G, Fournier HD, Picquet J, Papon X, Lasjaunias P. Vascular microanatomy of the pontomedullary junction, posterior inferior cerebellar arteries, and the lateral spinal arteries. Interv Neuroradiol 2008; 14:49-58. [PMID: 20557786 DOI: 10.1177/159101990801400107] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 02/29/2008] [Indexed: 11/16/2022] Open
Abstract
SUMMARY This study of 25 brains at the pontomedullary junction defined the different possible origins of the perforating arteries and lateral spinal arteries in relation to the posterior inferior cerebellar arteries (PICAs). - If the PICA emerges from the common trunk of the AICA-PICA coming from the basilar artery, it never gives perforating arteries or a lateral spinal artery on the lateral surface of the brain stem but supplies blood to a part of the ipsilateral cerebellar hemisphere. - If the PICA arises extradurally at C1, it never gives perforating arteries for the lateral surface of the brain stem, but it gives pial branches for the posterior surface of the medulla oblongata and is always the origin of the lateral spinal artery. - If the PICA emerges in the intradural vertebral artery, it is the source of the perforating arteries for the lateral surface of the brain stem and of the blood supply of the ipsilateral cerebellum.
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Affiliation(s)
- P H Mercier
- Laboratoire d'Anatomie, Faculté de Médecine, Angers cédex, France -
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Sricharoenvej S, Niyomchan A, Lanlua P, Piyawinijwong S, Roongruangchai J. Microvasculature of the medulla oblongata in the Lyle's flying fox (Pteropus lylei). Anat Histol Embryol 2008; 37:401-7. [PMID: 18460051 DOI: 10.1111/j.1439-0264.2008.00856.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The microvasculature of the medulla oblongata in 15 adult Lyle's flying foxes (Pteropus lylei) was elucidated by using the vascular corrosion cast technique combined with scanning electron microscopy. The study showed that the medulla received the main arterial supply from branches of the vertebrobasilar system. The supplied areas were divided into three groups: ventral, lateral and dorsal groups. All vessel groups gave off circumferential and perforating branches; moreover, these branches anastomosed with one another in two fashions: end-to-end and side-by-side arrangements. In addition, the ramifications of the branches were L and Y types. The L type was more frequently found than the Y one. The density of capillaries in the nuclei was greater than that in the area of nerve fibres. Numerous arterial sphincters and smooth muscle cells were observed. Furthermore, capillaries in the medulla were of the continuous type, whereas those in the area postrema were fenestrated. The venous drainage system of the medulla was classified into caudal, middle and rostral parts. All of them emptied into both the sigmoid sinus and internal jugular vein. It was concluded that these vascular patterns provide sufficient blood supply to the medulla oblongata of P. lylei when abrupt changes in the position of this bat occurs.
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Affiliation(s)
- S Sricharoenvej
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok 10700, Thailand.
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Peltier J, Fichten A, Page C, Havet E, Foulon P, Mertl P, Le Gars D, Laude M. [Endoscopic anatomy of the terminal portion of the basilar artery and its distal perforating branches]. Morphologie 2008; 92:31-36. [PMID: 18424150 DOI: 10.1016/j.morpho.2008.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The aim of this study was to describe and highlight the endoscopic anatomy of the tip of the basilar artery and its perforating branches. Knowledges of the anatomy are crucial for neurosurgeons to avoid pitfalls during endoscopic third ventriculostomy.
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Affiliation(s)
- J Peltier
- Laboratoire d'Anatomie et d'Organogenèse, Faculté de Médecine, Université de Picardie-Jules-Verne, Amiens, France.
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Abstract
BACKGROUND Detailed knowledge of the pattern of origin of the anterior spinal artery is critical as surgical and endovascular procedures involving the area of the ventral medulla and the vertebrobasilar junction are commonplace. We conducted a detailed microanatomical study to elucidate the site and pattern of origin of this critically important artery. METHOD Nine adult cadaveric heads (18 sides) were examined after injection of colored silicon. In every specimen, the site of origin of the rami of the anterior spinal artery, their course, branching pattern and anastomoses, external diameters, and the distance from neighbor critical vessels were recorded. The dissections were performed with the aid of both the surgical microscope and a 0 degree endoscope. FINDINGS The pattern and site of origin of the anterior spinal artery show great variability. Also the distance of the origin of the two rami (right and left) forming the anterior spinal artery from the vertex of the vertebrobasilar junction and from the origin of the posterior inferior cerebellar artery is highly variable. CONCLUSIONS Knowledge of the different pattern of origin and course of the proximal portion of the anterior spinal artery is critically important when planning and executing endovascular and surgical procedures involving the distal vertebral artery, the vertebrobasilar junction and the ventral medulla. On the basis of our and other authors' findings, we propose an overall classification of the pattern of origin and distribution of the proximal anterior spinal artery, which has clinical repercussions.
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Affiliation(s)
- U Er
- Departments of Neurosurgery and Radiology, Microneurosurgery Laboratory, Illinois Neurological Institute, University of Illinois College of Medicine at Peoria, Peoria, IL, USA.
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Abstract
An 81-year-old right handed man presented with bilateral leg weakness. The patient had been previously independent and was medicated with warfarin for atrial flutter. He had longstanding type 2 diabetes, controlled by oral hypoglycemic medication. At presentation, he reported sudden onset left sided weakness with accompanying neck pain at 22h00 the previous evening. Pertinent findings on neurological examination included a left pronator drift and profound left leg weakness with unsustained antigravity strength. Deep tendon reflexes were brisk throughout but absent at the ankles and there was a left extensor plantar response. Cranial nerve and sensory examinations were normal.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurosciences, University of Western Ontario, London Health Sciences Centre, London, ON, Canada
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Santos-Franco JA, de Oliveira E, Mercado R, Ortiz-Velazquez RI, Revuelta-Gutierrez R, Gomez-Llata S. Microsurgical considerations of the anterior spinal and the anterior-ventral spinal arteries. Acta Neurochir (Wien) 2006; 148:329-38; discussion 338. [PMID: 16328774 DOI: 10.1007/s00701-005-0663-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Accepted: 09/22/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are few data describing the microanatomy of the anterior-ventral spinal (AVSA) and anterior spinal arteries (ASA) and discussing their clinical and surgical implications. We describe the anatomical features of this arterial complex, and highlight their use when planning and performing surgical approaches to lesions involving the ventral aspect of the medulla and the foramen magnum. METHOD The microsurgical anatomy and branching pattern of the AVSA and the ASA from fifty human cadaver brain stems is described using a surgical microscope. RESULTS We found one anterior-ventral spinal artery at each side in 30 of the brain stems (60%). The ASA was a direct branch emerging from the left vertebral artery (VA) in 15 (30%), from the right VA in 4 (8%), and from the basilar artery (BA) in one brain stem (2%). The previously described as "typical pattern" of the junction of the AVS arteries from both sides, was observed only in 9 brain stems (18%). The anterior communicating spinal artery (ACoSA) was observed in 15 brain stems (30%). Also multiple ACoS arteries were described in one brain stem. Both, the AVSA and the ASA were observed to send long circumferential branches that supplied irrigation to the olive in 42 (84%) brain stems. CONCLUSIONS This anatomical study gives important information for a better understanding of the clinical picture of ischemic lesions of the brain stem, such as the medial medullary syndrome, and highlights the remarkable role of the AVSA and ASA as anatomical landmarks during the surgical approaches to lesions involving the ventral aspect of the medulla and the foramen magnum.
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Affiliation(s)
- J A Santos-Franco
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico.
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Verstegen MJT, Hulsmans FJH, Majoie CBLM, Bouma GJ. The use of CT-angiography for monitoring thrombus formation after balloon occlusion of a dissecting vertebral artery pseudoaneurysm. Clin Neurol Neurosurg 2002; 104:371-6. [PMID: 12140108 DOI: 10.1016/s0303-8467(02)00015-x] [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: 11/27/2022]
Abstract
We present a 49-year-old man with a subarachnoid haemorrhage from a dissecting vertebral artery (VA) pseudoaneurysm treated with a proximal balloon occlusion. The clinical course was complicated by the sudden appearance of a lateral medullary syndrome (Wallenberg), which completely resolved after anticoagulant therapy. During this course, CT-angiography (CTA) enabled monitoring of both the progression and partial resolution of the thrombus in the occluded VA. An anatomical variant of a perforating artery originating from the VA proximal to the posterior inferior cerebral artery (PICA) was subsequently demonstrated, explaining the ischemic event. The value of CTA in clinical management is discussed. The prophylactic use of anticoagulant therapy especially in the case of a perforating artery to the lateral medulla originating proximally to the PICA, is suggested.
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Affiliation(s)
- Marco J T Verstegen
- Department of Neurosurgery H2-225, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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25
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Mercier PH, Brassier G, Brillu C, Cronier P, Fournier HD, Papon X, Villapadierna F. Is the foramen caecum the uppermost part of the spinal medulla? Interv Neuroradiol 2001; 5:307-12. [PMID: 20670528 DOI: 10.1177/159101999900500407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/1999] [Accepted: 10/25/1999] [Indexed: 11/15/2022] Open
Affiliation(s)
- P H Mercier
- Laboratoire d'Anatomie, Faculté de Médecine; Angers, France
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Suzuki K, Meguro K, Wada M, Fujita K, Nose T. Embolization of a ruptured aneurysm of the distal anterior inferior cerebellar artery: case report and review of the literature. SURGICAL NEUROLOGY 1999; 51:509-12. [PMID: 10321881 DOI: 10.1016/s0090-3019(97)00462-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Aneurysms of the distal anterior inferior cerebellar artery (AICA) are rare and almost all of them have been treated surgically, by wrapping or trapping, in the previous literature. Most cases of aneurysms associated with the auditory artery resulted in a hearing disturbance from the surgical procedure, although aneurysms far from the auditory artery had no deficit from trapping. METHODS An 81-year-old woman presented with a ruptured aneurysm of the distal AICA. We planned a delayed treatment with intravascular embolization because of her advanced age and poor clinical status. Embolization of the distal anterior inferior cerebellar artery using detachable coils remote from the auditory artery was successful. RESULTS Magnetic resonance imaging after embolization demonstrated no remaining lesion. The patient has been through rehabilitation and has gradually improved. CONCLUSION Intravascular treatment of distal AICA aneurysms remote from the auditory artery may be safer and simpler than surgical treatment.
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Affiliation(s)
- K Suzuki
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Japan
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