- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Japan
Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Japan
DOI:10.4103/2152-7806.114975Copyright: © 2013 Kazumata K This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Kazumata K, Yokoyama Y, Sugiyama T, Asaoka K. Occipital-posterior cerebral artery bypass via the occipital interhemispheric approach. Surg Neurol Int 12-Jul-2013;4:90
How to cite this URL: Kazumata K, Yokoyama Y, Sugiyama T, Asaoka K. Occipital-posterior cerebral artery bypass via the occipital interhemispheric approach. Surg Neurol Int 12-Jul-2013;4:90. Available from: http://sni.wpengine.com/surgicalint_articles/occipital-posterior-cerebral-artery-bypass-via-the-occipital-interhemispheric-approach/
Background:The unavailability of the superficial temporal artery (STA) and the location of lesions pose a more technically demanding challenge when compared with conventional STA-superior cerebellar or posterior cerebral artery (PCA) bypass in vascular reconstruction procedures. To describe a case series of patients with cerebrovascular lesions who were treated using an occipital artery (OA) to PCA bypass via the occipital interhemispheric approach.
Methods:We retrospectively reviewed three consecutive cases of patients with cerebrovascular lesions who were treated using OA-PCA bypass.
Results:OA-PCA bypass was performed via the occipital interhemispheric approach. This procedure included: (1) OA-PCA bypass (n = 1), and combined OA-posterior inferior cerebellar artery and OA-PCA saphenous vein interposition graft bypass (n = 1) in patients with vertebrobasilar ischemia; (2) OA-PCA radial artery interposition graft bypass in one patient with residual PCA aneurysm.
Conclusions:OA-PCA bypass represents a useful alternative to conventional STA-SCA or PCA bypass.
Keywords: Extracranial - intracranial bypass, occipital artery - posterior cerebral artery bypass, occipital interhemispheric approach, superficial temporal artery - superior cerebellar artery bypass, superficial temporal artery - posterior cerebral artery bypass
Superficial temporal artery (STA)-middle cerebral artery (MCA), STA-superior cerebellar artery (SCA), STA-posterior cerebral artery (PCA), and occipital artery (OA)-posterior inferior cerebellar artery (PICA) bypasses represent the mainstays for cerebral revascularization for supra- and infratentorial cerebral ischemia and aneurysms. [
Clinical data, radiographic findings, bypass procedures, and outcomes for the three patients who underwent OA-PCA bypass in 2011 are presented in
The patient was placed in a semiquarter prone position (park bench position). To harvest grsaphenous vein, a leg contralateral side of the craniotomy was disinfected and prepared in the operative field. To harvest radial artery (RA), a forearm ipsilateral to the craniotomy was placed on the armrest. A skin incision was made along the OA with its limb extended along the midline to create a horseshoe shape [
Imaging results for a 70-year-old male (Case 1) with right VA occlusion who underwent OA-PCA anastomosis via the right occipital interhemispheric approach. Illustration showing OA-PCA bypass (a). Preoperative angiography demonstrated occlusion of the right VA (b) and that the left VA terminated at the posterior inferior cerebellar artery. Collateral circulation was demonstrated in the right posterior communicating artery through the diminutive internal carotid artery to upper basilar artery on angiography (c). Postoperative angiography demonstrates patency of the bypass (d; arrow). VA, vertebral artery; OA, occipital artery; PCA, posterior cerebral artery
Imaging results for a 65-year-old male (Case 2) with occlusion of the BA who underwent OA-PICA and OA-SVG-PCA anastomosis in the same operating sequence. Illustration showing OA-PICA and OA-SVG-PCA bypass (a). Preoperative angiography demonstrated occlusion of the midbasilar artery and severe stenosis of the left VA and PICA (b). MCA-to-PCA leptomeningeal collateral circulation was demonstrated in the PCA territory on angiography. The OA-PICA anastomosis was performed using a left transcondylar approach (arrow). We subsequently performed right OA-SVG bypass in the same position through an occipital interhemispheric approach (arrow). Proximal anastomosis was made in a side-to-end fashion using the side branch of the OA (a, c). Postoperative angiography demonstrates antegrade flow of the distal VA to the BA through the OA-PICA bypass (c). OA-SVG-PCA bypass was also patent and may function as a double insurance (c). BA, basilar artery; OA, occipital artery; PCA, posterior cerebral artery. PICA, posterior inferior cerebellar artery; SVG, saphenous vein; VA, vertebral artery; MCA, middle cerebral artery
OA-PCA bypass was employed in three patients. The underlying pathology was unilateral vertebral artery (VA) occlusion with contralateral VA terminating in the PICA in two patients and PCA aneurysm treated previously by endovascular coil embolization in one patient. The reason for use of OA-PCA bypass was the unavailability of STA due to previous bilateral STA-MCA bypass in one patient and the inability to access the recipient artery in one patient. In the remaining case with VA occlusion, other options, such as STA-SCA or STA-PCA bypass were available, but we opted to perform OA-PCA bypass in the hope of minimizing the risk of temporal lobe contusion that is otherwise inherent with a subtemporal approach.
Graft patency was confirmed on postoperative magnetic resonance angiography (MRA) or cerebral angiography in all cases.
A 70-year-old male with a previous history of bilateral MCA occlusion treated with STA-MCA bypass 20 years ago presented to the emergency room with 3 days of vertigo and nausea. Significant neurological examination findings on admission included horizontal nystagmus and right extremity ataxia. Magnetic resonance imaging (MRI) revealed infarction on the right middle cerebellar peduncle on diffusion-weighted imaging (DWI) as well as poor visualization of the basilar artery. Angiography revealed right VA occlusion and a left VA terminating in a PICA [
A 65-year-old male was admitted to our hospital due to a decreased level of consciousness, nausea, and cerebellar ataxia. Symptoms progressed along with an increase in the size of ischemic lesions in the pons, cerebellum, thalamus, and occipital lobe on DWI, despite intensive medical treatment. Angiography revealed severe stenosis of the left VA, occlusion of the mid-basilar artery, and leptomeningeal anastomosis from the MCA to the PCA [
A 51-year-old male presented with subarachnoid hemorrhage due to rupture of a PCA aneurysm. The lesion was treated by endovascular coil embolization twice because of coil compaction. Follow-up examination by cerebral angiography at 1 month demonstrated recurrence of coil compaction [
Imaging results for a 51-year-old male (Case 3) with right posterior cerebral aneurysm who underwent OA-STA-PCA anastomosis through an occipital interhemispheric approach prior to trapping of the aneurysm using an intravascular procedure. Left vertebral angiography showing coil compaction of the posterior cerebral artery aneurysm (a; black arrow). Postoperative angiography showing complete obliteration of the aneurysm and patency of the OA-RA-PCA bypass (b; white arrow). OA, occipital artery; STA, superficial temporal artery; PCA, posterior cerebral artery; RA, radial artery
The present report describes the use of OA-PCA bypass as an alternative to conventional STA-SCA or in the event that PCA bypasses are unavailable. Few cases of OA-PCA interposition graft bypass via the occipital interhemispheric approach have been reported for VA occlusion and PCA aneurysms. [
The first case presents an example in which the OA was sufficient in size and length to perform OA-PCA bypass in the occipital interhemispheric fissure. The second case could have been treated by STA-SCA bypass alone via the subtemporal approach. However, because of ischemia in the bilateral anterior inferior cerebellar artery (AICA) and distal VA territories, we preferred to perform left OA-PICA bypass in adjunct with reconstruction of upper basilar artery territory. Right OA-PCA bypass via the right occipital interhemispheric approach was considered a better option, and this strategy was performed in the same session as left OA-PICA bypass. The third case represents a typical case in which OA-PCA bypass was performed to reconstruct the distal PCA in multimodality management of complex PCA aneurysms.
A recipient artery may be found on either the lateral surface of the occipital lobe or in the interhemispheric fissure. The latter entails a deeper and more technically difficult anastomosis, which usually requires an interposition graft. Either a saphenous vein graft (SVG) or the RA can be used as an interposition graft with comparable graft patency. [
An attempt to avoid ischemic complications during the surgery of the complex PCA aneurysm were investigated in a large cohort previously. [
1. Alaraj A, Ashley WW, Charbel FT, Amin-Hanjani S. The superficial temporal artery trunk as a donor vessel in cerebral revascularization: Benefits and pitfalls. Neurosurg Focus. 2008. 24: E7-
2. Ausman JI, Diaz FG, Vacca DF, Sadasivan B. Superficial temporal and occipital artery bypass pedicles to superior, anterior inferior, and posterior inferior cerebellar arteries for vertebrobasilar insufficiency. J Neurosurg. 1990. 72: 554-8
3. Ausman JI, Pearce JE, Vacca DF, Diaz FG, Shrontz CE, Patel S. Tandem bypass: Occipital artery to posterior inferior cerebellar artery side-to-side anastomosis and occipital artery to anterior inferior cerebellar artery end-to-side anastomosis: A case report. Neurosurgery. 1988. 22: 919-22
4. Carlson AP, Yonas H, Chang YF, Nemoto EM. Failure of cerebral hemodynamic selection in general or of specific positron emission tomography methodology.Carotid Occlusion Surgery Study (COSS)?. Stroke. 2011. 42: 3637-9
5. Chang SW, Abla AA, Kakarla UK, Sauvageau E, Dashti SR, Nakaji P. Treatment of distal posterior cerebral artery aneurysms: A critical appraisal of the occipital artery-to-posterior cerebral artery bypass. Neurosurgery. 2010. 67: 16-25
6. Grubb RL, Powers WJ, Clarke WR, Videen TO, Adams HP, Derdeyn CP: Carotid Occlusion Surgery Study Investigators. Surgical results of the Carotid Occlusion Surgery Study. J Neurosurg. 2013. 118: 25-33
7. Hayward PA, Gordon IR, Hare DL, Matalanis G, Horrigan ML, Rosalion A. Comparable patencies of the radial artery and right internal thoracic artery or saphenous vein beyond 5 years: Results from the Radial Artery Patency and Clinical Outcomes trial. J Thorac Cardiovasc Surg. 2010. 139: 60-7
8. Houkin K, Kamiyama H, Kuroda S, Ishikawa T, Takahashi A, Abe H. Long-term patency of radial artery graft bypass for reconstruction of the internal carotid artery.Technical note. J Neurosurg. 1999. 90: 786-90
9. Khodadad G. Occipital artery-posterior inferior cerebellar artery anastomosis. Surg Neurol. 1976. 5: 225-7
10. Korinth MC, Thron A, Bertalanffy H, Gilsbach JM. Coil embolization of an incidental posterior cerebral artery aneurysm after initial OA-PCA bypass surgery. Zentralbl Neurochir. 2000. 61: 158-61
11. Peerless SJ, Ferguson GG, Drake CG. Extracranial-intracranial (EC/IC) bypass in the treatment of giant intracranial aneurysms. Neurosurg Rev. 1982. 5: 77-81
12. Powers WJ, Clarke WR, Grubb RL, Videen TO, Adams HP, Derdeyn CP. COSS Investigators. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: The Carotid Occlusion Surgery Study randomized trial. JAMA. 2011. 306: 1983-92
13. Roski RA, Spetzler RF, Hopkins LN. Occipital artery to posterior inferior cerebellar artery bypass for vertebrobasilar ischemia. Neurosurgery. 1982. 10: 44-9
14. Sakata K, Al-Mefty O, Yamamoto I. Venous consideration in petrosal approach: Microsurgical anatomy of the temporal bridging vein. Neurosurgery. 2000. 47: 153-60
15. Sundt TM. Piepgras DG. Occipital to posterior inferior cerebellar artery bypass surgery. J Neurosurg. 1978. 48: 916-28
16. Touho H, Karasawa J, Ohnishi H, Kobitsu K. Anastomosis of occipital artery to posterior cerebral artery with interposition of superficial temporal artery using occipital interhemispheric transtentorial approach: Case report. Surg Neurol. 1995. 44: 245-50
17. Vishteh AG, Smith KA, McDougall CG, Spetzler RF. Distal posterior cerebral artery revascularization in multimodality management of complex peripheral posterior cerebral artery aneurysms: Technical case report. Neurosurgery. 1998. 43: 166-70
18. Yonekawa Y, Imhof HG, Taub E, Curcic M, Kaku Y, Roth P. Supracerebellar transtentorial approach to posterior temporomedial structures. J Neurosurg. 2001. 94: 339-45