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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3617_Библиотеки_им_академика_М_И_Перельмана
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PICA-to-PICA Bypass 305
Fig. 14.0c High magnifi cation view of the cerebellar tonsils and the branches of the PICA appropriate for anastomosis.
(Photograph used with permission from Journal of Neurosurgery .)
Fig. 14.0d The tonsils are retracted, demonstrating the two loops of the PICA. (Photograph used with permission from
Journal of Neurosurgery .)
Fig. 14.0e A completed PICA-to-PICA bypass. (Photograph used with permission from Journal of Neurosurgery .)
306 Color Atlas of Cerebral Revascularization
Case 14-1
Diagnosis: Giant left VA aneurysm
Bypass: PICA–to–contralateral PICA
Approach: Left far lateral
a
Fig. 14.1a, b Sagittal ( a ) and axial ( b ) MR images of the brain of a 5-year-old boy with acute SAH show a
large aneurysm compressing the pontomedullary junction toward the left side. The bright T1-weighted
signal suggests the presence of intraluminal thrombus.
b
c
Fig. 14.1c, d Anteroposterior and oblique left VA angiograms show the aneurysm involving the left VA and PICA.
(Used with permission from Journal of Neurosurgery .)
d
PICA-to-PICA Bypass 307
Fig. 14.1e The right VA angiographic injection does not
show the aneurysm but does show a normal right VA, BA,
and vertebrobasilar junction.
Fig. 14.1f The patient is placed in a park bench position
and the hockey stick incision for the left far lateral
approach is outlined on the skin.
Fig. 14.1g The aneurysm is compressing the cervicomedullary junction.
308 Color Atlas of Cerebral Revascularization
Fig. 14.1h High magnifi cation view shows the PICA exiting the aneurysm. The working space near the origin of the
PICA is severely restricted by the mass of the aneurysm.
Fig. 14.1i The lower cranial nerves are splayed over the dome of the aneurysm. A ligature is placed on the left VA
proximal to the aneurysm.
Fig. 14.1j A side-to-side anastomosis of the PICA loops is performed. (Used with permission from Journal of
Neurosurgery .)
PICA-to-PICA Bypass 309
Fig. 14.1k Right VA angiographic injection shows fi lling
of both PICA distributions (arrow) . The dome of the
aneurysm is partially visible because of backfi lling through
the left PICA.
Fig. 14.1l Lateral right VA injection shows that permanent
clipping of the left PICA at the aneurysm isolates the
lesion distally. The distal left VA was coiled to obliterate
residual fi lling from the contralateral VA. (Used with
permission from Journal of Neurosurgery .)
310 Color Atlas of Cerebral Revascularization
m
Fig. 14.1m, n Anteroposterior and lateral right VA angiograms show the coils in the left distal aneurysm, the clip on
the PICA distal to the aneurysm, and no further fi lling of the lumen of the aneurysm. ( Fig. 14.1n used with permission
from Journal of Neurosurgery .)
n
Fig. 14.1o Postoperative sagittal T1-weighted
MR image shows improvement of the mass
eff ect on the brainstem. Clip artifact is also
visible. (Used with permission from Journal of
Neurosurgery) .
PICA-to-PICA Bypass 311
Case 14-2
Diagnosis: Right PICA aneurysm
Bypass: Direct PICA-to-PICA reanastomosis
Approach: Right far lateral
Fig. 14.2a CT scan shows a complex aneurysm in the
region of the right PICA in a patient who presented with
headache and dizziness.
Fig. 14.2b Angiogram shows the complex dissecting PICA
aneurysm.
Fig. 14.2c Three-dimensional angiographic reconstruction
shows the complex nature of the dissecting aneurysm.
Fig. 14.2d The right VA and PICA are identifi ed through a right far lateral approach.
Fig. 14.2e The PICA is followed into the aneurysm.
Fig. 14.2f Distal PICA is identifi ed coursing between CN XII rootlets.
PICA-to-PICA Bypass 313
Fig. 14.2g Diagram illustrates the position of the complex
aneurysm behind CN XII.
Fig. 14.2h A temporary clip is applied on the PICA outfl ow from the aneurysm.
314 Color Atlas of Cerebral Revascularization
Fig. 14.2i After a clip is placed proximal to the aneurysm, the PICA is cut distal to the aneurysm.
Fig. 14.2j The PICA is cut proximal to the aneurysm.
Fig. 14.2k The two cut ends of PICA are approximated.
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