1/9. Ruptured aneurysm on a double origin of the posterior inferior cerebellar artery: a pathological entity in an anatomical variation. Report of two cases and review of the literature.The posterior inferior cerebellar artery (pica) is known to be very variable, and some of its anatomical variations can explain ischemic complications that occur during endovascular treatment of aneurysms. The authors report two cases of anatomical variation of the pica that they have called its double origin, one of which gave rise to an aneurysm. The first patient was a 36-year-old man who presented with a subarachnoid hemorrhage related to the rupture of a pica aneurysm. The aneurysm was treated by the endovascular route. Selective and superselective studies showed that the pica origin was low on the fourth segment of the vertebral artery (VA). The aneurysm was located on an anastomosis between the pica and a small upper arterial branch originating from the VA. Embolization was performed through the small branch with no problem, but a lateral medullary infarct followed, probably due to occlusion of the perforating vessels. The same anatomical variation was incidentally discovered in the second patient. To the authors' knowledge, neither this anatomical variation of the pica nor the aneurysm's topography have been previously described angiographically. This highlights the role of angiography in pretreatment evaluation of aneurysms especially when perforating vessels or small accessory branches that are poorly visualized on angiographic studies are concerned, as in the territory of the pica. anatomy is sometimes unpredictable, and the surgeon must be very careful when confronted with these variations because they are potentially dangerous for endovascular treatment.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
2/9. vertebral artery-posterior inferior cerebellar artery bypass with a superficial temporal artery graft to treat aneurysms involving the posterior inferior cerebellar artery.OBJECT: In patients with aneurysms that require occlusion of the posterior inferior cerebellar artery (pica), revascularization of this artery should be performed. A novel surgical method for revascularization of the pica is presented. methods: After a segment of the superficial temporal artery (STA) was harvested, the aneurysm was treated by trapping, followed by placement of a vertebral artery (VA)-pica bypass in which the STA segment was used as a graft. When the length of the proximal pica was inadequate, the distal end of the STA was anastomosed to the proximal pica in an end-to-side fashion. When the length of the proximal pica was adequate, the STA was anastomosed to the proximal pica in an end-to-end fashion. In either case, the proximal end of the STA was anastomosed to the VA in an end-to-side fashion. This procedure was used in nine patients whose aneurysms involved the pica. Although partial lateral medullary syndrome developed in one of them, follow-up evaluation revealed graft patency in all patients. There were no instances of recurrent hemorrhage or ischemia. CONCLUSIONS: Although this procedure requires harvesting of an STA graft and two anastomoses, it facilitates anterograde flow to the pica territory. It also involves minimal mobilization of brainstem perforating vessels and the proximal pica.- - - - - - - - - - ranking = 0.5keywords = vessel (Clic here for more details about this article) |
3/9. Treatment of vertebral artery aneurysms with posterior inferior cerebellar artery-posterior inferior cerebellar artery anastomosis combined with parent artery occlusion.BACKGROUND: In patients with aneurysms that involve the origin of the posterior inferior cerebellar artery (pica) and require occlusion of the vertebral artery (VA), revascularization of the pica is commonly performed. We present six patients with dissecting VA aneurysms who underwent pica-pica anastomosis combined with parent artery occlusion. methods: After a lower lateral suboccipital craniectomy and partial resection of the jugular tubercle, anastomoses were performed in a side-to-side fashion at the posterior medullary segment of the pica. The VA was subsequently occluded by clipping proximal and distal to the aneurysm, and the pica was occluded by clipping distal to the aneurysm. RESULTS: Postoperative cerebral angiography demonstrated patency of the anastomosis and regression of the aneurysm in five of six patients. The remaining patient experienced hemorrhage from contralateral VA dissection and subsequently died. One patient experienced myopathy of the lower extremities secondary to intraoperative fixed board compression and developed permanent lower extremity muscular weakness. The remaining four cases experienced no new neurologic deficits. CONCLUSION: pica-pica anastomosis is a useful procedure for reconstruction of the pica when parent vessel occlusion or trapping is necessary to exclude a VA aneurysm involving the origin of the pica.- - - - - - - - - - ranking = 0.5keywords = vessel (Clic here for more details about this article) |
4/9. Are cardiac syndrome X, irritable bowel syndrome and reflex sympathetic dystrophy examples of lateral medullary ischaemic syndromes?Altered pain appreciation and autonomic function are hallmarks of Cardiac syndrome X, irritable bowel syndrome and reflex sympathetic dystrophy. Both pain appreciation and autonomic function are controlled by the lateral medulla. This hypothesis proposes that lateral medullary ischaemia at a microvascular level is responsible for these syndromes and could also be linked to other conditions where autonomic dysfunction is a major feature such as late-onset asthma, type 2 diabetes and essential hypertension. Autonomic function is controlled by the nucleus tractus solitarius, which acts as the main viscero-afferent nucleus in the brain stem regulating vagal tone. It is particularly susceptible to ischaemia since it is highly metabolically active and lies in a medullary arterial watershed zone. The anatomical route of the vertebral artery through cervical vertebra makes it vulnerable to injury from whiplash with or without any genetic predisposition to atheroma formation. This could make microvascular occlusion commonplace and a plausible explanation for the above syndromes. Ischaemia rather than infarction occurs because of the excellent collateral blood supply in the brainstem. In support of this hypothesis, a new Transcranial doppler ultrasonography arterial signal has been described called small vessel knock, the ultrasound signal of small vessel occlusion. Recent evidence has shown that ultrasound targeting of this signal in the vertebral artery improves clinical symptoms in these syndromes which supports this hypothesis. Two such cases are discussed.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
5/9. Unusual dissection of the proximal vertebral artery: description of three cases.We report three cases that reveal an array of etiologic and radiologic findings associated with dissection of the proximal segment of the vertebral arteries. Regardless of etiology, the proximal segment may be the principal site of dissection in these vessels.- - - - - - - - - - ranking = 0.5keywords = vessel (Clic here for more details about this article) |
6/9. Distal posterior inferior cerebellar artery aneurysms: clinical characteristics and surgical management.BACKGROUND: Aneurysms located on the distal posterior inferior cerebellar artery (pica) are rare, and their underlying clinical features and surgical management are poorly understood. We report our series of 16 patients with 18 distal pica aneurysms. METHOD: All patients with distal pica aneurysms were treated between March 1996 and August 2004. We excluded all pica aneurysms that involved the vertebral artery. patients were analysed in the light of their clinical profiles, radiological studies, intraoperative findings and outcomes. All patients underwent non-enhanced and contrast enhanced CT scans followed by 4-vessel cerebral angiography on admission. The hemorrhagic patterns on initial CT scans were assessed using the Fisher Grading Score. The outcomes were documented using the glasgow outcome scale at time of discharge and at three or twelve months follow-up. FINDINGS: The series included 6 men and 10 women. Massive intraventricular haemorrhage was found in 13 patients with proven CT subarachnoid haemorrhage, one patient revealed SAH without intraventricular components, one presented with only intraventricular blood in the occipital horns and 3 aneurysms were found incidentally without presence of blood. Fourteen aneurysms were saccular and four were fusiform. Nine cases were associated with another cerebrovascular lesion. A lateral transcondylar or a median suboccipital approach was used to secure the aneurysms in 15 patients, either by direct clipping (14 lesions) or vessel sacrifice (3 lesions). One aneurysm was treated by an endovascular approach. At long-term follow up, an excellent or good outcome was achieved in 75% of cases. One patient died due to pre-existing cardiopulmonary complications. CONCLUSIONS: Most of our cases of ruptured distal pica aneurysms presented with haematocephalus. These were frequently associated with another vascular abnormality and 22% were fusiform or multilobulated. These specific features require special management strategies entailing an appropriate surgical approach to the aneurysm, clipping method, haematoma removal, ventricular drainage and when suitable choice of endovascular interventions.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
7/9. pain and neuroma formation in Wallenberg's lateral medullary syndrome.We report a patient with a Wallenberg's lateral medullary syndrome in which pain was a prominent feature. This led to substitution of the original and correct diagnosis by that of a thalamic syndrome for which a prefrontal leucotomy was performed. The patient died some years later from a myocardial infarction and autopsy was performed. In the dorsolateral part of the medulla oblongata a cavity was found in which aberrant nerve fibres with neuroma-like formations could be seen. These fibres coursed along blood vessels, and penetrated from the surface of the medulla oblongata. On the base of the clinico-pathological correlations, it is conjectured that destruction of the lateral reticular formation cannot be the sole cause of the severe pain.- - - - - - - - - - ranking = 0.5keywords = vessel (Clic here for more details about this article) |
8/9. Wallenberg's syndrome caused by a craniopharyngioma "en plaque".Wallenberg's syndrome is the clinical manifestation of the obliteration of arterial blood vessels supplying the dorsolateral part of the medulla oblongata, the posterior inferior cerebellar artery being involved in most cases. A patient is described in whom the typical features of Wallenberg's syndrome correlated with cystic necrosis in the perfusion area of the posterior inferior cerebellar artery. A craniopharyngioma spreading along the pons and involving the posterior inferior cerebellar artery, the basilar artery, and its branches was found to be responsible for the infarction of the dorsolateral medulla oblongata.- - - - - - - - - - ranking = 0.5keywords = vessel (Clic here for more details about this article) |
9/9. Dissecting aneurysm in the proximal region of the posterior inferior cerebellar artery presenting as Wallenberg's syndrome--case report.A 29-year-old female presented with an unusual case of Wallenberg's syndrome due to a dissecting aneurysm of the posterior inferior cerebellar artery (pica) manifesting as a sensation of heaviness in the occipital region and vertigo. magnetic resonance imaging revealed infarction of the lateral aspect of the medulla oblongata. Digital subtraction angiography (DSA) revealed a spindle-shaped dilatation of irregular contour in the proximal portion of the left pica. Pooling of contrast medium was noted in the venous phase but not double lumen sign. A suboccipital craniectomy confirmed these findings macroscopically. Blood flow meter monitoring before and after proximal clipping of the diseased vessel ensured the safety of the procedure. Follow-up DSA 3 years after surgery revealed no evidence of aneurysm recurrence.- - - - - - - - - - ranking = 0.5keywords = vessel (Clic here for more details about this article) |