Cavallo Claudio, Labib Mohamed, Gandhi Sirin, Moreira Leandro Borba, Mascitelli Justin, Lawton Michael T
Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona.
Oper Neurosurg (Hagerstown). 2020 Apr 1;18(4):E114. doi: 10.1093/ons/opz155.
Posterior inferior cerebellar artery (PICA) aneurysms have an increased tendency towards a fusiform morphology precluding primary clip reconstruction. The management of these complex aneurysms might require cerebral revascularization to preserve flow in a distal PICA territory. This video illustrates a case of a ruptured p2-PICA aneurysm excision followed by a PICA reanastomosis. A 54-yr-old male presented with a sudden-onset severe headache, diplopia, and complete left cranial nerve six (CN VI) palsy. Neuroimaging demonstrated diffuse subarachnoid hemorrhage in basal cisterns. A catheter angiogram shows a ruptured small fusiform aneurysm in the p2-PICA segment. After obtaining consent for surgery, the patient was placed in a three-quarter prone position. After a hockey stick skin incision and C1 laminectomy, a lateral suboccipital craniotomy was performed. The aneurysm was identified within the vagoaccessory triangle. Cerebral protection consisted of propofol-induced electroencephalography burst suppression during the clamp time for the bypass, without hypothermia or hypertension. After trapping the aneurysm and excising the diseased arterial segment, the distal end of the p2-PICA was reanastomosed to the proximal parent vessel in an end-to-end fashion. Indocyanine green angiography confirmed patency of the anastomosis. Postoperatively, the patient was neurologically at his baseline. The CN VI palsy had completely resolved at a follow-up visit. Reanastomosis is an effective modality for reconstructing PICA following the excision of the fusiform aneurysm. The redundancy of the tonsillomedullary segment of PICA allows for easier distal segment reapproximation in the inferior hypoglossal triangle. An intracranial-intracranial revascularization technique eliminates the need for harvesting the occipital artery. Additionally, it prevents iatrogenic ischemic injury to contralateral PICA, if used for a PICA-PICA bypass.1 © Barrow Neurological Institute, used with permission.
小脑后下动脉（PICA）动脉瘤呈梭形形态的倾向增加，这使得无法进行初次夹闭重建。这些复杂动脉瘤的治疗可能需要进行脑血运重建，以维持PICA远端区域的血流。本视频展示了一例破裂的p2-PICA动脉瘤切除并进行PICA重新吻合的病例。一名54岁男性突发剧烈头痛、复视及左侧完全性展神经（CN VI）麻痹。神经影像学检查显示基底池弥漫性蛛网膜下腔出血。导管血管造影显示p2-PICA段有一个破裂的小型梭形动脉瘤。在获得手术同意后，患者取3/4俯卧位。经曲棍球棒状皮肤切口及C1椎板切除术，行枕下外侧开颅术。在迷走副神经三角内识别出动脉瘤。脑保护措施包括在旁路夹闭期间通过丙泊酚诱导脑电图爆发抑制，未进行低温或高血压处理。在阻断动脉瘤并切除病变动脉段后，将p2-PICA的远端与近端母血管进行端端重新吻合。吲哚菁绿血管造影证实吻合通畅。术后，患者神经功能恢复至基线水平。随访时展神经麻痹已完全消失。重新吻合是梭形动脉瘤切除后重建PICA的有效方式。PICA扁桃体延髓段的冗余使得在下舌下神经三角更容易将近端段重新靠近。颅内-颅内血运重建技术无需采集枕动脉。此外，如果用于PICA-PICA旁路，可防止对侧PICA发生医源性缺血性损伤。1 ©巴罗神经学研究所，经许可使用。
