title: The role of alternative anastomosis sites in occipital artery-posterior inferior cerebellar artery bypass in the absence of the caudal loop using the far-lateral approach.
abstract: OBJECTIVE Occipital artery-posterior inferior cerebellar artery (OA-PICA) bypass is a technically challenging procedure for posterior fossa revascularization. The caudal loop of the PICA is considered the optimal site for OA-PICA anastomosis, however its absence can increase the technical difficulty associated with this procedure. The use of the far-lateral approach for accessing alternative anastomosis sites in OA-PICA bypass in patients with absent or unavailable caudal loops of PICA is evaluated. METHODS A morphometric analysis of OA-PICA bypass with anastomosis on each segment of the PICA was performed on 5 cadaveric specimens through the conventional midline foramen magnum and far-lateral approaches. The difficulty level associated with anastomoses at each segment was qualitatively assessed in each approach for exposure and maneuverability by multiple surgeons. A series of 8 patients who underwent OA-PICA bypass for hemodynamic ischemia or ruptured dissecting posterior fossa aneurysms are additionally reviewed and described, and the clinical significance of the caudal loop of PICA is discussed. RESULTS Anastomosis on the caudal loop could be performed more superficially than on any other segment (p < 0.001). A far-lateral approach up to the medial border of the posterior condylar canal provided a 13.5 ± 2.2-mm wider corridor than the conventional midline foramen magnum approach, facilitating access to alternative anastomosis sites. The far-lateral approach was successfully used for OA-PICA bypass in 3 clinical cases whose caudal loops were absent, whereas the midline foramen magnum approach provided sufficient exposure for caudal loop bypass in the remaining 5 cases. CONCLUSIONS The absence of the caudal loop of the PICA is a major contributing factor to the technical difficulty of OA-PICA bypass. The far-lateral approach is a useful surgical option for OA-PICA bypass when the caudal loop of the PICA is unavailable.
authors.affiliation: Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Fukuda
authors.affiliation: Department of Neurological Surgery, Weill Cornell Medical College, New York, New York.
authors.forename: Alexander I
authors.initials: AI
authors.lastname: Evins
authors.affiliation: Department of Neurosurgery, Himeji Medical Center, Himeji, Hyogo, Japan; and.
authors.forename: Koichi
authors.initials: K
authors.lastname: Iwasaki
authors.affiliation: Department of Neurosurgery, Himeji Medical Center, Himeji, Hyogo, Japan; and.
authors.forename: Itaro
authors.initials: I
authors.lastname: Hattori
authors.affiliation: Department of Neurosurgery, Shiroyama Hospital, Habikino, Osaka, Japan.
authors.forename: Kenichi
authors.initials: K
authors.lastname: Murao
authors.affiliation: Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.
authors.forename: Yoshitaka
authors.initials: Y
authors.lastname: Kurosaki
authors.affiliation: Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.
authors.forename: Masaki
authors.initials: M
authors.lastname: Chin
authors.affiliation: Department of Neurological Surgery, Weill Cornell Medical College, New York, New York.
authors.forename: Philip E
authors.initials: PE
authors.lastname: Stieg
authors.affiliation: Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.
authors.forename: Sen
authors.initials: S
authors.lastname: Yamagata
authors.affiliation: Department of Neurological Surgery, Weill Cornell Medical College, New York, New York.
authors.forename: Antonio
authors.initials: A
authors.lastname: Bernardo
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D002102:Cadaver; D002531:Cerebellum / Q000098:blood supply* / Q000601:surgery; D002548:Cerebral Revascularization / Q000379:methods*; D005260:Female; D005539:Foramen Magnum / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D009778:Occipital Lobe / Q000098:blood supply* / Q000601:surgery
keywords: CN = cranial nerve; OA = occipital artery; PICA = posterior inferior cerebellar artery; VA = vertebral artery; anatomy; aneurysm; bypass; caudal loop; far-lateral approach; foramen magnum; occipital artery; posterior condylar canal; posterior inferior cerebellar artery