case_images: PMC11787819_01
case_images: Preoperative head computed tomography and three-dimensional computed tomography angiography.. (A) Computed tomography of the head showed Fisher 2 subarachnoid hemorrhage (arrow). (B) Three-dimensional computed tomography angiography demonstrating right vertebral artery-PICA aneurysm. Note the PICA originated from the neck of the aneurysm (arrow).. PICA: posterior inferior cerebellar artery
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case_images: FIG1
case_images: Coma Scale. Computed tomography (CT) of the head demonstrated Fisher 2 subarachnoid hemorrhage (Figure 1A). Three-dimensional computed tomography angiography (CTA) revealed a right VA-PICA aneurysm (Figure 1B).
case_images: Overcoming clipping challenges and ensuring recovery with a PICA-to-PICA bypass.. (A) Proximal vertebral artery (arrow) and PICA (arrowhead) are shown. The distal vertebral artery is not visible. (B) PICA-to-PICA anastomosis.. PICA: posterior inferior cerebellar artery
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case_images: FIG2
case_images: We secured and followed the right VA and identified the PICA origin; however, the distal VA could not be observed (Figure 2A). A running suture was performed on the back wall, and intermittent sutures were performed on the front wall with a 10-0 nylon (Figure 2B).
case_images: Intraoperative indocyanine green test.. The test demonstrates good patency of the PICA-to-PICA bypass (arrow).. PICA: posterior inferior cerebellar artery
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case_images: FIG3
case_images: After declamping, an indocyanine green test demonstrated good PICA-to-PICA bypass patency (Figure 3).
case_images: Occlusion of the PICA distal to the aneurysm. The PICA distal to the aneurysm was occluded using a titanium clip (arrow).. PICA: posterior inferior cerebellar artery
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case_images: PMC11787819_01_cureus-0017-00000076863-i04.jpg
case_images: FIG4
case_images: The PICA distal to the aneurysm was occluded using a titanium clip to avoid bypass thrombosis owing to antegrade blood flow from the right PICA (Figure 4).
case_images: Postoperative left vertebral angiography and diffusion-weighted head magnetic resonance imaging.. (A) Postoperative left vertebral angiography. Sacrifice of the vertebral artery-PICA aneurysm together with the right vertebral artery was performed (arrow). Right PICA was seen through the PICA-to-PICA anastomosis (arrowhead). (B) Diffusion-weighted head magnetic resonance imaging revealed a small infarction in the right medulla (arrow).. PICA: posterior inferior cerebellar artery
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case_images: FIG5
case_images: Therefore, we decided to embolize the right VA including the aneurysm (Figure 5A). Diffusion-weighted head magnetic resonance imaging revealed a small infarction in the right medulla that seemed to be responsible for these symptoms (Figure 5B).