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Operative Nuances of Side-to-Side In Situ Posterior

Inferior Cerebellar Artery-Posterior Inferior


Cerebellar Artery Bypass Procedure
BACKGROUND: An intracranial posterior circulation revascularization procedure in the
form of a side-to-side in situ posterior inferior cerebellar artery (PICA)-PICA bypass
operation was introduced in 1991. This elegant and apparently low-risk operation is
performed infrequently. Thus, the operative nuances used in this procedure have not
been well reported, limiting the scope of treatment modalities of vertebral artery-PICA
aneurysms and vertebral dissections.
OBJECTIVE: To repair an incidental right-sided PICA aneurysm noted in a 51-year-old
woman in magnetic resonance imaging and subsequent angiography.
METHODS: The patient underwent side-to-side in situ PICA-PICA bypass surgery.
RESULTS: Immediate indocyanine green angiography suggested that the PICA distal to
the aneurysms was filling in a retrograde fashion through the bypass. On the following
day, the patient was taken for coil embolization of the aneurysm. However, angiography
images revealed that the aneurysm was spontaneously thrombosed, the proximal PICA
was patent, and the PICA distal to the aneurysms was filling in a retrograde fashion, as
suspected in intraoperative indocyanine green angiography. No further treatments were
done. The patient recovered fully.
CONCLUSION: We describe in detail the preoperative evaluation, decision process, and
operative techniques for a side-to-side in situ PICA-PICA bypass operation, which is
a relatively safe and elegant posterior circulation bypass procedure.
KEY WORDS: Anastomosis, Aneurysm, Bypass, In situ, PICA-PICA
Neurosurgery 67:[ONS Suppl 2]ons471ons477, 2010 DOI: 10.1227/NEU.0b013e3181f7420e
C
ranial bypass surgeries should be per-
formed without compromising blood
flow to involved vascular territories.
A straightforward nonocclusive bypass procedure
without a considerable risk of intraoperative or
postoperative bypass occlusion would be the
optimal cerebrovascular revascularization opera-
tion. Unlike in the anterior circulation, non-
occlusive bypass options do not exist in the
posterior circulation. Cerebral revascularization
in the posterior circulation must be recognized as
an important adjunct to the treatment strategies
of, for example, complex intracranial aneurysms,
especially when direct treatment of these
aneurysms could lead to a sacrifice of a major
vessel in the posterior circulation.
A side-to-side in situ posterior inferior cere-
bellar artery (PICA)-PICA bypass operation,
1-5
a
rare anastomosis type, may be described as a
relatively straightforward PICA revascularization
procedure. This procedure appears to have a low
risk of occlusion,
1-5
at least in the short term,
and a relatively low risk of procedure-related
complications.
1-5
In this report, we discuss the
operative nuances of the side-to-side in situ
PICA-PICA bypass procedure to reinvigorate its
inclusion in the discussion of treatment of
complex posterior circulation pathologies.
Miikka Korja, MD
Department of Neurosurgery,
Helsinki University Central Hospital,
Helsinki, Finland
Chandranath Sen, MD
Department of Neurosurgery,
Roosevelt Hospital,
New York, New York
David Langer, MD
Department of Neurosurgery,
Roosevelt Hospital,
New York, New York
Reprint requests:
Dr Miikka Korja,
Department of Neurosurgery,
Helsinki University Central Hospital,
PO Box 266,
FI-00029 HUS, Finland.
E-mail: miikka.korja@hus.fi
Received, August 25, 2009.
Accepted, April 5, 2010.
Copyright 2010 by the
Congress of Neurological Surgeons
ABBREVIATIONS: OA, occipital artery; PICA, pos-
terior inferior cerebellar artery; VA, vertebral artery
Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article on
the journals Web site (www.neurosurgery-online.com).
NEUROSURGERY VOLUME 67 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2010 | ons471
CEREBROVASCULAR Operative Nuances
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PREOPERATIVE EVALUATION
Although the PICA originates from the intracranial portion of the
vertebral artery (VA) in 80% to 95% of cases (on average, 8.6 mm
above the foramen magnum and approximately 1 cm proximal to the
vertebrobasilar junction),
6,7
the PICA origin varies because of the
rather complex, tortuous, and variable course of the PICA.
7
In the
senior authors (C.S., D.L.) institute, the gold standard for visualizing
the PICAs has been a vertebrobasilar angiography, which has to be
performed for both vertebral arteries. Three-dimensional rotational
angiography can also be helpful in determining the anatomic re-
lationship of PICA to PICA. We have no experience in the image
quality of 3-Tmagnetic resonance angiography pictures for visualizing
both PICAs, but most of the time, 1.5-T magnetic resonance
angiography images do not provide the image quality necessary for in
situ PICA-PICA bypass purposes. Computed tomography (CT)
angiography images can be helpful for operative planning. However,
scant filling of the PICA vessels on CT angiography can result in poor
visualization of the relevant PICA anatomy, prohibiting the precise
evaluation of the PICA routes and proximity.
DECISION PROCESS
Indications for bypass surgery in the posterior circulation may
be more ambiguous than those in the anterior circulation, but the
current lack of published data should not hamper the decision
process when revascularization of the PICA territory needs to be
considered. Although collateral networks in posterior fossa are
FIGURE 1. Inferior, posterior, lateral, and midsaggital views of the segments of the posterior inferior cerebellar artery as depicted by Lister et al
7
in 1982. In the
posterior view, the left half of the cerebellum is removed. 4V, fourth ventricle; A.I.C.A., anterior inferior cerebellar artery; Ant. Med. Sed., anterior medullary segment;
B.A., basilar Artery; Ch. PL, choroid plexus; Cort. Seg., cortical segment; F. Luschka, foramen Luschka; F. Magendie, foramen Magendie; Inf. Cer. Ped., inferior
cerebellar peduncle; Inf. Coll., inferior colliculi; Inf. Med. Vel., inferior medullary velum; Int. He. A., intermediate hemispheric artery; Lat. He. A., lateral
hemispheric artery; Lat. Med. Seg., lateral medullary segment; Lat. Tr., lateral trunk of the PICA; Med. He. A., medial hemispheric artery; Med. Ve. A., median
vermian artery; Med. Tr., medial trunk of the PICA; Paramed. Ve. A., paramedian vermian artery; P.C.A., posterior cerebral artery; Mid. Cer. Ped., middle
cerebellar peduncle; S.C.A., superior cerebellar artery; Sup. Cer. Ped., superior cerebellar peduncle; Sup. Med. Vel., superior medullary velum; Tel. Vel. Ton. Seg.,
telovelotonsillar segment; Tel. Vel. Ton. Fiss., telovelotonsillar fissure; Ton. A., tonsillar artery; Ton. Med. Seg., tonsillomedullary segment; Ton. Ped., tonsillar
peduncles; V.A., vertebral artery.
KORJA ET AL
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robust for hemispheric perfusion, the sacrifice of the PICA can
result in significant ischemic injury because of the unique
anatomy of the proximal PICA segment. This proximal PICA
segment maintains the origin of relatively small but extremely
critical perforators feeding the medulla oblongata and cerebel-
lum.
7
To ease the preoperative decision process regarding the
need for PICA revascularization, the imaged PICA should be
divided into 5 segments and 2 loops (Figure 1) as suggested
previously
7,8
: (1) the anterior medullary segment, which extends
posteriorly from the origin of the PICA at the VA to the inferior
olivary prominence and passes near the hypoglossal rootlets; (2)
the lateral medullary segment, which begins at the site where the
PICA passes the most prominent point of the inferior olive and
ends at the origins of the 9th, 10th, and 11th cranial nerves; (3)
the tonsillomedullary segment, which begins at the point where
the PICA passes posterior to the 9th, 10th, and 11th cranial
nerves and then extends medially across the posterior aspect of the
medulla to the level of the tonsillar midportion, before which
the PICA forms a so-called caudal loop at the caudal pole of the
tonsils (the mean diameter of the caudal loop, which is one of the
largest distal cerebellar arteries, is approximately 1.7 mm)
9
; (4)
the telovelotonsillar segment, which begins at the middle section
of the ascent of the PICA along the medial surface of the tonsils
and extends to the suboccipital cortical surface of the cerebellum
and includes the so-called cranial loop; and (5) the cortical
segment, which extends to the cerebellar vermis and hemisphere.
Because the anterior medullary, lateral medullary, and tonsillo-
medullary segments may give rise to critical perforators, trapping
of VA-PICA aneurysms or PICA occlusion distal to the tonsil-
lomedullary segment usually can be done without revascul-
arization of the PICA.
8
In other words, a PICA revascularization
procedure should be considered if lesions to be treated occur
proximal to the telovelotonsillar segment, when the planned
treatment may potentially occlude patent PICA circulation. The
absence of perforating arteries along the very proximal portion of
the anterior medullary segment does permit direct clip or coil
occlusion of the PICA at its origin. Because we are not aware of
any definite preprocedural assessments, like reliable PICA test
occlusions of the sufficient collateral flow of the PICA territory,
the anatomy-based planning of surgery is the most valuable
evaluation tool in our hands. The most important technical point
in treating VA-PICA lesions is to preserve the critical perforating
branches of the proximal PICA.
After we make the anatomy-based decision of whether to
revascularized the PICA, we evaluate the proximity of the left
and right PICAs. The side-to-side in situ PICA-PICA bypass
requires that both PICAs are in parallel proximity to each an-
other, which is true in most cases because the tonsillomedullary
and telovelotonsillar segments usually course next to each other
distal to the caudal loops and between the cerebellar tonsils in
the cisterna magna. The distance between parallel PICAs should
be less than 4 to 5 mm if possible, which allows PICA mobi-
lization and the side-to-side anastomosis without harsh
manipulation or significant tension placed on the vessels and
their perforators. When the PICA vessels are . 5 mm apart,
increasing tension is applied to the suture line, making the
anastomosis increasingly difficult. Parallel tonsillomedullary and
telovelotonsillar segments may have a rather significant differ-
ence in diameter (the ratio up to 1:2), which does not hinder the
procedure. If there is any concern that the PICA-PICA
anastomosis cannot be performed, we will harvest the occipital
artery (OA). Because of the midline suboccipital approach, side-
to-side in situ PICA-PICA bypass surgery can be performed in
a relatively shallow and wide operative field, which makes the
procedure easier. Additionally, the operation can be performed
in a dual mounted cross-table microscope setup, allowing the
assistant to easily engage in the surgical field.
CLINICAL PRESENTATION
History
A 51-year-old woman was admitted to an outside hospital 6
years earlier with severe idiopathic vertigo. On magnetic reso-
nance imaging years later and in subsequent angiography, an
incidental right-sided fusiform PICA aneurysm was noted
(minute 00:00:0500:00:14 in Video 1, Supplemental Digital
Content 1, http://links.lww.com/NEU/A336). A direct treat-
ment was deferred because of the complexity of the case and the
likelihood of PICA sacrifice. The patient was transferred to the
Roosevelt Hospital for further management.
Surgery
The patient underwent side-to-side in situ PICA-PICA bypass
surgery, the temporary occlusion time of which was 35 minutes.
Immediately after the bypass was made, the aneurysm was ex-
plored. The proximal portion of the aneurysm against the VA was
well visualized. However, because of the proximity of the cranial
nerves and perforators, we felt that a clip could not be placed
across the proximal neck without cranial nerve manipulation and
the risk of perforator occlusion. In flow measurements, the
proximal left PICA maintained the prebypass flow of between
18 and 20 cm
3
/min, whereas the distal left PICA had only
5 cm
3
/min. The contralateral distal right PICA had 15 cm
3
/min,
whereas the proximal right PICA showed no flow. Immediate
indocyanine green angiography suggested that the PICA distal to
the aneurysms was filling in a retrograde fashion through the
bypass (video minute 00:04:3200:04:39).
Postoperative Course
CT control pictures on the first postoperative day revealed no
ischemic lesions. The patient was taken on the following day for coil
embolization of the aneurysm. However, conventional angiography
revealed that the aneurysm was spontaneously thrombosed (video
minute 00:04:4000:04:50). The proximal PICA was patent, and
the PICA distal to the aneurysms was filling in a retrograde fashion
through the bypass (video minute 00:04:4000:04:50). No further
treatment was necessary. Aneurysm thrombosis was probably caused
by temporary occlusion or a bypass-induced competitive flow distal
to the aneurysm. The patient recovered fully after some
IN SITU PICA-PICA BYPASS
NEUROSURGERY VOLUME 67 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2010 | ons473
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postoperative headache problems caused by aseptic meningitis,
which was treated with high-dose steroids.
OPERATIVE TECHNIQUE
Patients are put on aspirin 325 g/d 5 days before operation and
continue it for at least 6 months. Patients can be loaded with
aspirin urgently or at the time of surgery if necessary. No frac-
tionated or unfractionated intravenous heparin is used, except in
local saline flush, during the operation. We routinely assess as-
pirin sensitivity using the Accumetrix system.
CRANIOTOMY
Under general endotracheal anesthesia with propofol, the neu-
rophysiological monitoring of brainstem auditory evoked potentials
and cortical and spinal somatosensory evoked potentials is applied,
and the patient is placed in a prone position in a Sugita head frame.
We perform neurophysiological monitoring in almost all cranioto-
mies, although no clinical evidence exists whether cerebellar or
medullar ischemia resulting from perforator occlusion gives rise to
detectable change in recorded potentials. To date, we have not seen
neurophysiological changes during temporary occlusion of the
PICA. The midline suboccipital and upper cervical regions are
scrubbed and draped. A midline incision caudal to the nuchal line
and cranial to the C1 arch is fashioned with a No. 10 blade. After
hemostasis, a subperiosteal dissection of the C1 arch and the sub-
occipital region is carried out. Self-retaining retractors are placed in
the wound, and a burr hole is fashioned in the midline suboccipital
region. An oval or round midline suboccipital craniotomy of the size
4 to 5 3 3 to 4 cm from foramen magnum to transverse sinuses is
fashioned, and the dura is opened in a V- or Y-shaped fashion and
hinged laterally and superiorly with 4-0 Nurolon sutures. Usually,
good exposure of the tonsillar region of the cerebellum is obtained.
There is no need to visualize the inferior edge of the transverse
sinuses, and the craniotomy can be kept below them.
VESSEL EXPOSURE
Under microscopic vision, the arachnoid and pia mater of the
suboccipital region are incised with microforceps, the right and/or
left cerebellar tonsil is gently retracted, and self-retaining retractors
are placed. This technique allows the tonsils to be elevated away
fromthe area just below the obex while freeing the PICAs fromtheir
surrounding adhesions. Subsequently, the 2 tonsillomedullary and
telovelotonsillar segments of the PICAs are well visualized at the level
of the cerebellomedullary fissure. A number of brainstem perforators
at the tonsillomedullary and telovelotonsillar segments may be seen,
and they should be preserved throughout the operation. After gentle
mobilization of one or both of the vessel segments, they are brought
to close proximity for side-to-side in situ bypass. Often the PICAs
are mobilized with gentle traction after all of the surrounding ad-
hesions and arachnoid veil have been peeled away. Before initiation
of temporary occlusion, the baseline PICA flows are measured with
a flow probe. Small temporary clips (blade length, 6 mm) are placed
cranially and caudally at the anastomosis site and on perforating
vessels originating from the PICA (video minute 00:00:16
00:00:29). Temporary clipping allows a complete flowarrest of the 2
vessel segments at a length of 8 to 16 mm.
ARTERIOTOMY AND SUTURING
Using a back-cutting microknife (APEX Inc), we make arteriot-
omies approximately 4 to 6 mm (at least double the diameter of the
wider PICA) long (video minute 00:00:2800:00:43). To eliminate
small blind arterial pouches, so-called dog ears, both arteriotomies
need to be exactly the same length. Methylene blue is applied ex-
travascularly and occasionally intravascularly to allow better visuali-
zation of the arteriotomy site (video minute 00:00:4600:00:56).
The lumens of the 2 vessels are aggressively irrigated with heparinized
saline. A running anastomosis is made with a 9-0 nylon. The most
important step of the bypass procedure is to make tight first sutures
on the back wall of the anastomosis. After approximating the 2
arteries, the first (stay) suture is placed at the apex of the arteriotomy
by passing the needle from outside the vessel lumen to inside the
same vessel lumen and then from inside the other vessel lumen to
outside the same vessel lumen (Figures 2A and 3A; video minute
00:00:5700:02:29). This is done to have the knot outside the vessel
lumens. The tail of the first suture is left long enough that it can be
used when tightening the final suture. After the stay suture is made,
the needle is taken underneath the knot (Figures 2B and 3B; video
minute 00:02:3000:02:51). Then, a running suture is started by
passing the needle very close to the stay suture (periapical) from
outside to inside the (left or right) vessel lumen (video minute
00:02:5200:03:15) and then either from inside the vessel to inside
the adjacent vessel lumen (Figure 2C; video minute 00:03:16
00:03:31) or from inside to outside the same vessel lumen (Figure
2C). After these most crucial steps of the anastomosis (Figures 2A
through 2C and 3A through 3C), the back wall of the bypass can be
sutured in a running fashion from the intravascular side (Figures 2D
and 3D). When the other apex of the anastomosis is reached, the
needle is passed frominside to outside the apex and then fromoutside
to inside of the adjacent apex (Figures 2D and 3D; video minute
00:03:3200:04:12). Then, the anterior wall is sutured from outside
the lumen with a continuous suture (Figures 2E and 3E). Once the
sutures attaching the entire anterior wall are loosely placed, the bypass
lumen is inspected with a small nerve hook (video minute 00:04:13
00:04:21) and flushed with heparinized saline. If the anastomosis is
widely patent, the continuous suture can be tightened with the long
end of the very first suture (Figures 2F and 3F). Interrupted sutures
may also be used for the final suture or two. Temporary occlusion
time typically varies between 20 and 60 minutes.
RECIRCULATION
Temporary clips are first removed distal to the bypass, then
proximal to the bypass, and finally from the perforators. When
continuous sutures are used, anastomosis leakage should be minimal.
On recirculation, bilateral flow volumes and directions are measured
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proximal and distal to the bypass with a flow probe. Flows in the
range of 8 to 12 cm
3
/min are usually measured in both PICA limbs
proximal and distal to the site of the anastomosis. Flow measure-
ments are repeated a few times before and after an intraoperative
indocyanine green angiogram, which confirm the patency of the
bypass (video minute 00:04:3200:04:39). Flow measurements
distal to the bypass can be done after a test occlusion of the proximal
PICA, and a flow decrease of , 25% in the occluded limb is
strongly suggestive of the functional bypass if the PICA origin has to
be sacrificed. If the PICA origin has to be occluded, the newly made
anastomosis allows the contralateral PICA to supply the ipsilateral
anteromedullary segment of the PICA in a retrograde fashion. In
other words, the main idea of the bypass is to provide sufficient
blood flow into the anteromedullary segment of the PICA. Theo-
retically, if an immediate bypass failure in the formof occlusion takes
place, the sutures should be opened, the lumens flushed with
heparinized saline, and the anastomosis resutured.
CLOSURE
After the final inspection of the bypass, a watertight dural
closure is of great importance. A dural patch can be used
together with tissue glue. If any doubt of the water tightness of
the dura exists, we recommend using a postoperative lumbar
drain for a minimum of 2 to 3 days to prevent postoperative
cerebrospinal fluid leakage. The bone flap is replaced and
secured with titanium microplates, or a titanium mesh is used
to cover the craniectomy defect. The wound itself is then
closed with 0-0 absorbable Vicryl sutures for the deep muscle
and muscle fascia, 2-0 absorbable Vicryl sutures for the sub-
cutaneous tissue, and interrupted or continuous 3-0 Ethilon
sutures for the skin closure.
POSTOPERATIVE COURSE
Patients undergo CT examination and interventional angi-
ography on the first postoperative day. At this time, the inter-
ventionalist can use intravenous heparinization without
a significant risk of postoperative bleeding complications.
However, if intraoperative bleeding is of any concern, it is rea-
sonable to postpone any endovascular procedures for a few days.
If no clinical symptoms of ischemic complications occur, addi-
tional control imaging studies are not necessarily needed.
FIGURE 2. A detailed illustration showing the manner of suturing the side-to-side in situ posterior inferior cerebellar artery-
posterior inferior cerebellar artery anastomosis. All steps are described in detail in the Arteriotomy and Suturing section.
IN SITU PICA-PICA BYPASS
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DISCUSSION
The ability to revascularize an intracranial artery creates
treatment options beyond direct clipping or coiling when treating
cerebrovascular lesions. Since Ausman and colleagues
10
per-
formed the first PICA revascularization procedure in the form of
an OA-PICA bypass, the OA-PICA bypass has been the most
common revascularization procedure in the posterior circulation.
Even though the OA is a relatively suboptimal donor because of
its early branching, rapid loss of diameter, laborious and tedious
harvesting, and potentially higher susceptibility to occlusions,
3
the side-to-side in situ PICA-PICA anastomosis has remained
unfamiliar to neurosurgeons. In situ bypasses, in general, are
appealing and elegant bypass choices because they are entirely
intracranial, are less vulnerable to injury, probably have better
patency rate than graft-using bypasses, do not require extracranial
vessel harvesting, have arteries with similar diameters, and require
just 1 site of anastomosis. An in situ bypass procedure can be used
for revascularization of the most critical portion of the PICA, ie
anterior medullary segment, after occlusion of its proximal origin.
The proximity and parallel courses of the bilateral tonsillome-
dullary and telovelotonsillar segments of the PICAs usually allow
their mobilization for side-to-side in situ bypass.
One criticism of the PICA-PICA bypass is that vessel occlusion
or bypass failure could compromise circulation of both PICA
territories with a subsequent risk of bilateral or wide-ranging
ischemic events. Although this concern is valid, PICA-PICA
bypass thrombosis would lead to occlusion of the PICAs distal to
the telovelomedullary segment; therefore, any resulting cerebellar
hemispheric infarction will probably be mild as a result of the rich
anastomoses through various cerebellar arteries. Occlusion of
critical brainstem perforators resulting from bypass thrombosis is
unlikely. Because of the midline suboccipital approach in the
prone position, the bypass procedure is performed quite easily.
Lesions that necessitate a bypass are usually complex, and their
treatment carries significant risks related to perforator and cranial
nerve injury. A multidisciplinary approach combining the side-to-
side in situ PICA-PICA bypass and endovascular aneurysmal de-
construction in the treatment of complex VA-PICA lesions may be
advantageous compared with a sole microsurgical approach.
FIGURE 3. An optional manner for suturing the side-to-side in situ posterior inferior cerebellar artery-posterior inferior
cerebellar artery anastomosis. Steps C and D differ from the technique illustrated in Figure 2.
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CONCLUSION
The side-to-side PICA-PICA bypass technique is a technically
straightforward, low-risk technique that can be used in the
management of complex VA-PICA aneurysms and VA dis-
sections. This technique is useful to microvascular neurosurgeons
treating complex VA-PICA vascular pathologies and can be used
in combination with endovascular therapies, lessening the risks of
both open and endovascular treatments.
Disclosure
The authors have no personal financial or institutional interest in any of the
drugs, materials, or devices described in this article
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Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of this
article on the journals Web site (www.neurosurgery-online.com).
COMMENTS
T
he posterior inferior cerebellar artery (PICA)-PICA bypass is an
elegant example of intracranial-to-intracranial bypass, which is
gradually replacing some conventional extracranial-to-intracranial by-
passes because it is equally safe, more anatomical, and avoids the tedious
harvest of a donor artery.
1
I strongly prefer the PICA-PICA bypass over
the occipital artery-to-PICA bypass, and have used the former almost
exclusively in my practice. This article provides an outstanding review of
the microsurgical technique and a virtuoso video by Dr Langer. The
authors use a single running suture for both suture lines. I prefer a knot at
each end of the suture line instead because it allows the deep suture line to be
tightened and tied before proceeding to the superficial suture line. I con-
gratulate the authors for a contribution here that will surely reinvigorate the
use of PICA-PICA bypasses in treating complex PICA aneurysms
Michael T. Lawton
San Francisco, California
1. Sanai N, Zador Z, Lawton MT. Bypass surgery for complex brain aneurysms: an
assessment of intracranial-intracranial bypass. Neurosurgery. 2009;65(4):670-683.
T
he report by Korja et al is a well written and well illustrated technical
description of the technique of PICA to PICA bypass by a group of
authors with a great deal of experience in bypass techniques , an includes
a clear video, illustrating the technique. The authors point out some of the
nuances and pitfalls in performing the technique including checking for
adequately sized arteries on the pre op angio. Although the technique has
been described before in detail and other reports include descriptions in
multiple cases, this is a clear description for someone wishing to review the
technical essentials of the procedure. The authors make the correct point that
with proximal PICA lesions, it is difficult to assess the collateral network
before an intervention that has a high likelihood of sacrificing the parent
vessel. Most of the collateral circulation can come fromthe network between
the vermial branches of the superior cerebellar artery and the vermian
branches of PICA. These collaterals may not provide adequate collateral
support to sacrificing PICA in all cases, and this is difficult to predict. A
bypass can be warranted in this situation. The authors describe some of the
pitfalls of the alternative procedure of occipital artery to PICA bypass which
are valid. One advantage of the occipital artery to PICA bypass is however
that there will only be one side of the cerebellum at risk if the bypass fails. In
the case described, the authors had planned to perform an interventional
sacrifice of the proximal PICA after the bypass to occlude the aneurysm,
however it occluded spontaneously obviating the need for this. One danger
in this approach is that aneurysms can rupture during the waiting period
after distal bypass. Another alternative is to clip the PICA origin after the
bypass is in place to avoid this risk.
David W. Newell
Seattle, Washington
T
he authors describe an elegant manner of performing revascularization of
the PICA distribution in cases where proximal vessel sacrifice is required.
The PICA-PICA bypass is relatively straightforward and avoids utilizing the
occipital artery, isolation of which is often tedious and time consuming. Note
should be made that one potential downside of such bypass techniques is that
it does put an otherwise normal cortical vessel at risk should the bypass fail. In
my experience the technical difficulty is performing this type of anastomosis is
lies in the initial suture line along the back wall, and the importance of
practicing this bypass routinely and gaining adequate proficiency cannot be
overemphasized. Additionally, the authors describe a midline approach. Care
must be made in cases where laterally placed pathology must be simulta-
neously addressed (a fusiform PICA aneurysm arising at the VB-PICA
junction, for example) that the exposure is adequate.
Nicholas C. Bambakidis
Cleveland, Ohio
Acknowledgments
We would like to thank Professors Juha Hernesniemi and
Mika Niemela very warmly for their constructive comments on
this article. We would also like to thank Jill Gregory for creating
the definite illustration.
IN SITU PICA-PICA BYPASS
NEUROSURGERY VOLUME 67 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2010 | ons477
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