Left Far Lateral Craniotomy for Clipping of a Posterior Inferior Cerebellar Artery Aneurysm

Authors

Xiaochun Zhao, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States.
Robert T. Wicks, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States.
Celene B. Mulholland, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States.
Andrew F. Ducruet, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States.Follow
Peter Nakaji, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States.

Document Type

Article

Abstract

The complex anatomical relationships of neurovascular structures at the craniovertebral junction make the clipping of a posterior inferior cerebellar artery (PICA) aneurysm surgically challenging. We demonstrate the clipping of a PICA aneurysm in the video.  A 65-year-old woman presented with a nonsymptomatic unruptured left PICA aneurysm; follow-up angiography showed an increase in its size. Preoperative angiography demonstrated a PICA aneurysm with the neck close to the origin of the PICA. A daughter sac of the aneurysm was also noted. A left far lateral approach was performed. The vagoaccessory triangle was exposed after opening the arachnoid membrane. The origin of the PICA and the aneurysm were revealed after exploration. The aneurysm neck was identified both proximally and distally. Two fenestrated clips were applied; subsequent indocyanine green (ICG) videoangiography demonstrated that the PICA was obstructed. One clip was adjusted, and repeated ICG videoangiography showed the PICA was patent. An endoscope was used before and after the clip application to better understand the anatomy of the aneurysm and inspect clip positions ( Fig. 1 ).  The patient was neurologically intact postoperatively and was discharged on postoperative day 4.  PICA aneurysms require careful treatment. Impingement of adjacent structures can cause severe complications. Lower cranial nerve damage can cause dysphagia, and compromised vertebral/PICA circulation can cause brainstem symptoms, such as Wallenberg's syndrome. Intraoperative ICG videoangiography should be used to evaluate vessel patency, and the endoscope should be used to fully inspect the aneurysm and evaluate the clip application. The link to the video can be found at: https://youtu.be/dKxFQTRA89g .

Keywords

aneurysm, craniovertebral junction, far lateral approach, posterior inferior cerebellar artery

Publication Date

12-1-2019

Publication Title

Journal of neurological surgery. Part B, Skull base

ISSN

2193-6331

Volume

80

Issue

Suppl 4

First Page

S341

Last Page

S342

PubMed ID

31750053

Digital Object Identifier (DOI)

10.1055/s-0039-1698825

Recommended Citation

Zhao, Xiaochun; Wicks, Robert T.; Mulholland, Celene B.; Ducruet, Andrew F.; and Nakaji, Peter, "Left Far Lateral Craniotomy for Clipping of a Posterior Inferior Cerebellar Artery Aneurysm" (2019). Translational Neuroscience. 2121.
https://scholar.barrowneuro.org/neurobiology/2121