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Pica artery surgery9/27/2023 Therefore, we decided on a conservative management with antiplatelet therapy and planned for a follow- up TFCA 2 weeks later. Since 10 days had passed after dissection, a procedure-related risk from stent insertion or stent-assisted coil embolization was thought to be larger than a rupture risk. ![]() ![]() The follow-up TFCA 1 week later showed no change of stenosis of the right proximal PICA, but an additional finding of a pre-stenotic fusiform dilatation (3 x 4 mm) of the right proximal PICA was newly observed ( Fig. The origin of PICA was extracranial and dissection occurred at the lateral medullary segment of PICA, which was intradural. The transfemoral cerebral angiography (TFCA), performed 4 days after the onset of symptoms showed an abrupt segmental stenosis of the right proximal PICA, which is suggestive of dissection ( Fig. The magnetic resonance angiography (MRA) showed an abrupt luminal stenosis and subtle dilatation of the proximal segment of the right PICA, suggestive of possible dissection ( Fig. The brain magnetic resonance imaging (MRI) was performed 2 days after the onset of symptoms and showed an acute infarction in the right lateral medulla ( Fig. The existence of an embryologic correlation between the course of the PICA and its level of origin may be useful in the evaluation of its angiographic anatomy.Routine blood tests were unremarkable. The different origins and courses of the PICA derive from the selection of different branches of the primitive vertebrobasilar plexus during the development of the cerebellum. The TM and the TVT segments show caudal and cranial loops. In the lateral medullary segment, it follows a rectilinear course (54%) and passes the plane formed by the IX, X, and XI cranial nerves at an intermediate level with respect to the other two patterns. 1) Many cases of PICA aneurysms are nonsaccular or fusiform aneurysms in which a simple clipping technique cannot be applied, and trapping surgery with vascular reconstruction is often required. (3) When the PICA arises from the premedullary segment of the VA, it passes above, below, or through the rootlets of the hypoglossal nerve. Posterior inferior cerebellar artery (PICA) aneurysms are rare and account for only 3-4 of all brain aneurysms. The TM and the TVT segments do not have loops. The lateral medullary segment forms a loop with lateral convexity (78%) and passes above or through the glossopharyngeal nerve, frequently showing a recurrent course among the roots of the IX, X, or XI cranial nerve. (2) When the PICA arises from the BA, it passes above the hypoglossal nerve. ![]() The tonsillomedullary (TM) segment shows a caudal loop and the telovelotonsillary (TVT) has a cranial loop. It passes at the level of the accessory nerve. (1) When it arises from the lateral medullary segment of the VA, it passes below the hypoglossal nerve, and the lateral medullary segment may form a loop with an anterosuperior convexity towards the pontomedullary sulcus (41%), or it may follow a rectilinear course (41%). With reference to the level of origin, three patterns of course for the lateral medullary segment of the PICA can be outlined. In 42.5% of instances, the PICA originated from the lateral medullary segment of the vertebral artery (VA), in 32.5% from its premedullary segment, in 22.5% from the basilar artery (BA), and in 2.5% it was absent. The course of the posterior inferior cerebellar artery (PICA) was analyzed with reference to its origin and relationships with the medullary and cerebellar surfaces and the adjacent cranial nerves in 40 brains after the injection with acrylic resins of the vertebrobasilar system.
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