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Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients.
J Neurosurg 2016; 124(5):1275-86JN

Abstract

OBJECT Intracranial-to-intracranial (IC-IC) bypasses are alternatives to traditional extracranial-to-intracranial (EC-IC) bypasses to reanastomose parent arteries, reimplant efferent branches, revascularize branches with in situ donor arteries, and reconstruct bifurcations with interposition grafts that are entirely intracranial. These bypasses represent an evolution in bypass surgery from using scalp arteries and remote donor sites toward a more local and reconstructive approach. IC-IC bypass can be utilized preferentially when revascularization is needed in the management of complex aneurysms. Experiences using IC-IC bypass, as applied to posterior inferior cerebellar artery (PICA) aneurysms in 35 patients, were reviewed.

METHODS

Patients with PICA aneurysms and vertebral artery (VA) aneurysms involving the PICA's origin were identified from a prospectively maintained database of the Vascular Neurosurgery Service, and patients who underwent bypass procedures for PICA revascularization were included.

RESULTS

During a 17-year period in which 129 PICA aneurysms in 125 patients were treated microsurgically, 35 IC-IC bypasses were performed as part of PICA aneurysm management, including in situ p3-p3 PICA-PICA bypass in 11 patients (31%), PICA reimplantation in 9 patients (26%), reanastomosis in 14 patients (40%), and 1 V3 VA-to-PICA bypass with an interposition graft (3%). All aneurysms were completely or nearly completely obliterated, 94% of bypasses were patent, 77% of patients were improved or unchanged after treatment, and good outcomes (modified Rankin Scale ≤ 2) were observed in 76% of patients. Two patients died expectantly. Ischemic complications were limited to 2 patients in whom the bypasses occluded, and permanent lower cranial nerve morbidity was limited to 3 patients and did not compromise independent function in any of the patients.

CONCLUSIONS

PICA aneurysms receive the application of IC-IC bypass better than any other aneurysm, with nearly one-quarter of all PICA aneurysms treated microsurgically at our center requiring bypass without a single EC-IC bypass. The selection of PICA bypass is almost algorithmic: trapped aneurysms at the PICA origin or p1 segment are revascularized with a PICA-PICA bypass, with PICA reimplantation as an alternative; trapped p2 segment aneurysms are reanastomosed, bypassed in situ, or reimplanted; distal p3 segment aneurysms are reanastomosed or revascularized with a PICA-PICA bypass; and aneurysms of the p4 segment that are too distal for PICA-PICA bypass are reanastomosed. Interposition grafts are reserved for when these 3 primary options are unsuitable. A constructive approach that preserves the PICA with direct clipping or replaces flow with a bypass when sacrificed should remain an alternative to deconstructive PICA occlusion and endovascular coiling when complete aneurysm occlusion is unlikely.

Authors+Show Affiliations

Department of Neurological Surgery, University of California, San Francisco, California.Department of Neurological Surgery, University of California, San Francisco, California.Department of Neurological Surgery, University of California, San Francisco, California.Department of Neurological Surgery, University of California, San Francisco, California.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

26566199

Citation

Abla, Adib A., et al. "Intracranial-to-intracranial Bypass for Posterior Inferior Cerebellar Artery Aneurysms: Options, Technical Challenges, and Results in 35 Patients." Journal of Neurosurgery, vol. 124, no. 5, 2016, pp. 1275-86.
Abla AA, McDougall CM, Breshears JD, et al. Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients. J Neurosurg. 2016;124(5):1275-86.
Abla, A. A., McDougall, C. M., Breshears, J. D., & Lawton, M. T. (2016). Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients. Journal of Neurosurgery, 124(5), pp. 1275-86. doi:10.3171/2015.5.JNS15368.
Abla AA, et al. Intracranial-to-intracranial Bypass for Posterior Inferior Cerebellar Artery Aneurysms: Options, Technical Challenges, and Results in 35 Patients. J Neurosurg. 2016;124(5):1275-86. PubMed PMID: 26566199.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients. AU - Abla,Adib A, AU - McDougall,Cameron M, AU - Breshears,Jonathan D, AU - Lawton,Michael T, Y1 - 2015/11/13/ PY - 2015/11/14/entrez PY - 2015/11/14/pubmed PY - 2016/12/16/medline KW - DSA = digital subtraction angiography KW - EC-IC = extracranial-to-intracranial KW - IC-IC = intracranial-to-intracranial KW - PICA = posterior inferior cerebellar artery KW - RAG = radial artery interposition graft KW - VA = vertebral artery KW - aneurysm KW - bypass KW - intracranial KW - mRS = modified Rankin Scale KW - posterior inferior cerebellar artery KW - vascular disorders SP - 1275 EP - 86 JF - Journal of neurosurgery JO - J. Neurosurg. VL - 124 IS - 5 N2 - OBJECT Intracranial-to-intracranial (IC-IC) bypasses are alternatives to traditional extracranial-to-intracranial (EC-IC) bypasses to reanastomose parent arteries, reimplant efferent branches, revascularize branches with in situ donor arteries, and reconstruct bifurcations with interposition grafts that are entirely intracranial. These bypasses represent an evolution in bypass surgery from using scalp arteries and remote donor sites toward a more local and reconstructive approach. IC-IC bypass can be utilized preferentially when revascularization is needed in the management of complex aneurysms. Experiences using IC-IC bypass, as applied to posterior inferior cerebellar artery (PICA) aneurysms in 35 patients, were reviewed. METHODS Patients with PICA aneurysms and vertebral artery (VA) aneurysms involving the PICA's origin were identified from a prospectively maintained database of the Vascular Neurosurgery Service, and patients who underwent bypass procedures for PICA revascularization were included. RESULTS During a 17-year period in which 129 PICA aneurysms in 125 patients were treated microsurgically, 35 IC-IC bypasses were performed as part of PICA aneurysm management, including in situ p3-p3 PICA-PICA bypass in 11 patients (31%), PICA reimplantation in 9 patients (26%), reanastomosis in 14 patients (40%), and 1 V3 VA-to-PICA bypass with an interposition graft (3%). All aneurysms were completely or nearly completely obliterated, 94% of bypasses were patent, 77% of patients were improved or unchanged after treatment, and good outcomes (modified Rankin Scale ≤ 2) were observed in 76% of patients. Two patients died expectantly. Ischemic complications were limited to 2 patients in whom the bypasses occluded, and permanent lower cranial nerve morbidity was limited to 3 patients and did not compromise independent function in any of the patients. CONCLUSIONS PICA aneurysms receive the application of IC-IC bypass better than any other aneurysm, with nearly one-quarter of all PICA aneurysms treated microsurgically at our center requiring bypass without a single EC-IC bypass. The selection of PICA bypass is almost algorithmic: trapped aneurysms at the PICA origin or p1 segment are revascularized with a PICA-PICA bypass, with PICA reimplantation as an alternative; trapped p2 segment aneurysms are reanastomosed, bypassed in situ, or reimplanted; distal p3 segment aneurysms are reanastomosed or revascularized with a PICA-PICA bypass; and aneurysms of the p4 segment that are too distal for PICA-PICA bypass are reanastomosed. Interposition grafts are reserved for when these 3 primary options are unsuitable. A constructive approach that preserves the PICA with direct clipping or replaces flow with a bypass when sacrificed should remain an alternative to deconstructive PICA occlusion and endovascular coiling when complete aneurysm occlusion is unlikely. SN - 1933-0693 UR - https://www.unboundmedicine.com/medline/citation/26566199/Intracranial_to_intracranial_bypass_for_posterior_inferior_cerebellar_artery_aneurysms:_options_technical_challenges_and_results_in_35_patients_ L2 - https://thejns.org/doi/10.3171/2015.5.JNS15368 DB - PRIME DP - Unbound Medicine ER -