Occipital to posterior inferior cerebellar artery bypass surgery

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✓ The results, complications, and technical aspects of occipital to posterior inferior cerebellar artery (PICA) bypass surgery are reviewed. Patients were divided into two groups: those considered to be a high risk for posterior circulation infarct but not disabled by the symptoms or deficits (eight patients), and those moderately or severely disabled at the time of admission (eight patients). Postoperative angiography revealed that 15 of the 16 grafts were patent. In 10 of the 15 patent grafts, the bypass graft served as a sole or major blood supply of the vertebral basilar system; in five patients, flow was limited to the distribution of the PICA. Eight patients achieved full employment or normal activity, six were improved but did not return to full employment, and two patients were unchanged. Ataxia was the major residual deficit in these patients.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., CV Research, Room 4–437, Alfred Building, St. Mary's Hospital, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 6. Angiogram 6 months after bypass surgery. The bypass graft is the primary source of blood flow to the proximal vertebrobasilar system.

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    Case 5. Angiogram 5 days after bypass surgery. The graft appears to be the primary source of blood flow to the proximal vertebrobasilar system.

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    Case 9. Angiogram 1 week after bypass surgery demonstrates severe spasm of the occipital artery caused by an epidural hematoma.

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    Case 9. Angiogram 2 months after bypass surgery demonstrates excellent flow through the graft, with the graft now serving as the major source of blood to the posterior circulation.

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    Case 9. Angiogram 9 months after surgery.

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    Sketch of surgical procedure. A: A hockey-stick skin incision is made extending above the level of superior nuchal line. B: Deep neck muscles are cut from their insertion, leaving a cuff of tissue for closure. C: The occipital artery is identified in the mastoid groove posterior and superior to the mastoid process. D: The occipital artery is dissected free from adjacent tissue. The vessel lies deep to splenius capitis and longissimus capitis. The dissection is simplified by maintaining this tissue plane. E: The occipital artery, lying free in the muscle bed from which it was dissected. F: A small unilateral suboccipital craniectomy is made, with a unilateral resection of arch of C-1. G: The dura is opened with a straight incision. H: The dura is sutured to the margins of the craniectomy, and the medullary loop of the PICA identified. I: The PICA is elevated by means of a temporary rubber dam. J: The PICA is opened with a linear incision, and the occipital artery fish-mouthed. K and L: Anastomosis is performed with interrupted 9-0 monofilament nylon sutures. M: The completed anastomosis. N: The transplanted course of occipital artery.

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    Case 5. Operative photographs before anastomosis (upper left), during anastomosis (upper right), and after anastomosis (lower left and right) of the right occipital artery to the right PICA. Occipital artery has been brought through a separate dural incision.

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