Article
Decision making in surgery for non-saccular PICA aneurysms
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Authors
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Alessandro Narducci
- Charitè - Universitätsmedizin Berlin, Department of Neurosurgery, Berlin, Deutschland
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Ran Xu
- Charité – Universitätsmedizin Berlin , Neurochirurgische Klinik, Berlin, Deutschland
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Peter Vajkoczy
- Charité - Universitätsmedizin Berlin, Campus Mitte, Neurochirurgische Klinik, Berlin, Deutschland
| Published: | June 9, 2017 |
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Outline
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Objective: Posterior inferior cerebellar artery (PICA) aneurysms represent a challenging pathology. PICA sacrifice is often necessary, due to high proportion of non-saccular aneurysms that can be found in this location. Several surgical treatments are available to face this complex vascular lesions, with or without revascularization, but the infrequency of these aneurysms and increasing number of endovascular techniques have limited the development of a standardized algorithm for treatment. The aim of this study was to present our series of non-saccular PICA aneurysms in the attempt to define an algorithm for their surgical management.
Methods: We retrospectively reviewed the our operation database, identifying patients harbouring non-saccular PICA aneurysms who were surgically treated at the Department of Neurosurgery, Charité University Hospital, Berlin from 2007 – 2016.
Results: During a 9-year period, 17 patients harbouring 18 non-saccular PICA aneurysms were surgically treated at our institution. Fourteen (77.7%) aneurysms were located within the proximal PICA (including those located at Vertebral Artery (VA)-PICA junction), and four (22,2%) were located distally. We performed PICA revascularization in eight (57.1%) cases of proximal aneurysms (n= 4: PICA-PICA bypass; n= 4: Occipital Artery (OA) to PICA bypass). We based our decision whether to perform bypass on intraoperative test occlusion with Indocyanine Green (ICG) videoangiography and neurophysiological monitoring. In no cases bypass was necessary for distal aneurysms. We did not experience major post-operative complications. One patient died a few weeks after surgical procedure, due to very poor clinical grading on admission (H-H V).
Conclusion: For non-saccular PICA aneurysms, microsurgery has the advantage of direct inspection of anatomy, live assessment of collateral vascularization and the possibility to perform revascularization in case of PICA occlusion. PICA-PICA and OA-PICA bypass are, in our opinion, the best choices for revascularization, providing good results in terms of bypass function, and a lower complication rate compared to other techniques. Intraoperative occlusion test with ICG videoangiography and neurophysiological monitoring plays a critical role in decision making whether to proceed with revascularization, providing live assessment of collateral circulation within the PICA territory.
