• Journal of Cerebrovascular and Endovascular Neurosurgery
• /
• v.26 no.2
• /
• pp.216-222
• /
• 2024

Dissecting posterior inferior cerebellar artery (PICA) aneurysms are uncommon lesions. Their anatomy and the location of the dissection are variable, however, they usually occurs at the origin of the PICA. Dissecting PICA aneurysms generally have non-vascular morphology involving an entire segment of the artery and cannot be cut. Nevertheless, the detection of these vascular lesions has increased latterly, so it is necessary to recognize it and take the appropriate management modalities for these injuries. In this report, we describe a case of a 73-year-old male patient, who presented a history of severe headache, associated with neck stiffness, nausea, vomiting, dizziness, hypoactivity, mental confusion, and walking difficulty. Radiographic investigation with brain computed tomography (CT) showed mild bleeding in a pre-medullary and pre-pontine cistern, and cerebral angiogram showed a dissecting PICA aneurysm. Despite being a challenging treatment, microsurgery management was the chosen modality. It was performed an end-to-end anastomosis between the p2/p3 segments, showing to be effective with good clinical and radiographic outcomes. We discussed an unusual case, reviewing the current literature on clinical presentations, the angiographic characteristics of the dissecting aneurysms of PICA, and evaluating the clinical and angiographic results of patients undergoing microsurgical treatment.

• Archives of Reconstructive Microsurgery
• /
• v.5 no.1
• /
• pp.24-34
• /
• 1996

There are many kinds of free flaps for management of extensive soft tissue defect of extremities in orthopaedic field. Free vascularized scapular flap is one of the most useful and relatively easy to application. This flap has been utilize clinically from early eighties by many microsurgical pioneers. Authors performed 102 cases of this flap from 1984 to 1995. We have to consider about the surgical anatomy of the flap, technique of the donor harvesting procedures, vascular varieties and anatomical abnormalities and success rate and the weak points of the procedure. This flap nourished by cutaneous branches from circumflex scapular vessels emerges from the lateral aspect of the subscapular artery 2.5-5cm from its lateral origin passing through the triangular space(bounded by subscapularis, teres minor, teres major, long head of triceps). The terminal cutaneous branch runs posteriorly around the lateral border of the scapular and divided into two major branches, those transeverse horizontally and obliquely to the fascial plane of overlying skin of the scapular body. We can utilize these arteries for scapular and parascapular flap. The vascular pedicle ranged from 5 to 10 cm long depends on the dissection, usually two venae comitantes accompanied circumflex scapular artery and its major branches. The diameter of the circumflex scapular artery is more than 1mm in adult, rare vascular variation. Surgical techniques : The scapular flap can be dissected conveniently with prone or lateral decubitus position, prone position is more easier in my experience. There are two kinds of surgical approaches, most of the surgeon prefer elevation of the flap from its outer border towards its base which known easier and quicker, but I prefer elevation of the flap from its outer border because of the lowering the possibilities of damage to vasculature in the flap itself which runs just underneath the subcutaneous tissue of the flap and provide more quicker elevation of the flap with blunt finger dissection after secure pedicle dissection and confirmed the course from the base of the pedicle. There are minimal donor site morbidity with direct skin closure if the flap size is not so larger than 10cm width. This flap has versatility in the design of the flap shape and size, if we need more longer and larger one, we can use parascapular flap or both. Even more, the flap can be used with latissimus dorsi musculocutaneous flap and serratus anterior flap which have common vascular pedicle from subscapular artery, some instance can combined with osteocutaneous flap if we include the lateral border of the scapular bone or parts of the ribs with serratus anterior. The most important shortcoming of the scapular free flap is non sensating, there are no reasonable sensory nerves to the flap to anastomose with recipient site nerve. Results : Among our 102 cases, overall success rate was 89%, most of the causes of the failure was recipient site vascular problems such as damaged recipient arterial conditions, and there were two cases of vascular anomalies in our series. Patients ages from 3 years old to 62 years old. Six cases of combined flap with latissimus dorsi, 4 cases of osteocutaneous flap for bone reconstruction, 62 parascapular flap was performed - we prefer parascapular flap to scapular. Statistical analysis of the size of the flap has less meaningful because of the flap has great versatility in size. In the length of the pedicle depends on the recipient site condition, we can adjust the pedicle length. The longest vascular pedicle was 14 cm in length from the axillary artery to the enter point cutaneous tissue. In conclusion, scapular free flap is one of the most useful modalities to manage the large intractable soft tissue defect. It has almost constant vascular pedicle with rare anatomical variation, easy to dissect great versatility in size and shape, low donor morbidity, thin and hairless skin.

• Archives of Plastic Surgery
• /
• v.34 no.5
• /
• pp.580-586
• /
• 2007

Purpose: High tension electrical injuries result in major tissue(eg. bones, tendons, vessels and nerves) destruction. Therefore, the management of mutilating wrist caused by electrical injuries still represents a challenge. There are various approaches to this problem including local and regional flaps as well as pedicled distant flaps and microsurgical free tissue transfer. Although it has not gained wide acceptance, because of the technically demanding dissection of the pedicle, posterior interosseous flap is now well accepted for the reconstruction of hand and wrist in hand surgery. The principal advantages of this flap are minimal donor site morbidity, minimal vascular compromise, one stage operation. This flap also offers the advantages of ideal color match and composition. In this report, we describe our experience with the reverse posterior interosseous island flap for reconstruction of mutilating wrist with main vessel injuries. Methods: From October, 2004 to June, 2006, we treated 11 patients with soft tissue defects and main vessel injuries on the wrist that were covered with reverse posterior interosseous island flap. Results: These 11 patients were all male. The ages ranged from 27 to 67 years(mean age 41.75) and the follow-up period varied from 4 to 19 months. Complete healing of the reverse posterior interosseous island flaps were observed in 11 patients(12 flaps). The majority of these flaps showed a certain degree of venous congestion, which in a flap was treated with medical leech. 1 flap has partial necrosis owing to sustained venous congestion, requiring secondary skin graft. flap size varied from $3.5{\times}8cm$ to $10{\times}12cm$(mean size $6.4{\times}8.9m$). The donor site defect was closed directly in 5 flaps, and by skin graft in 7 flaps. Conclusion: We found that the reverse posterior interosseous island flap is reliable and very useful for reconstruction of mutilating wrist and we recommend it as first choice in coverage of soft tissue defects in the wrist with electrical arc injuries.

• Archives of Plastic Surgery
• /
• v.36 no.3
• /
• pp.356-360
• /
• 2009

Purpose: Lipofibromatous Hamartoma(LFH) of nerve is a tumor - like lipomatous process principally involving the young persons. This is rare disease characterized by a soft slowly growing mass surrounding and infiltrating major nerves and their branches of the palm and digits. LFH of nerve usually affects the median nerve, with the most common sites of presentation being the distal forearm and hand in the wrist or palm. It may cause symptoms of compression neuropathy and is associated with macrodactyly. Recently, MRI plays a major role in confirming the diagnosis of LFH. Therefore, we present two cases of LFH in the hand with MRI features and surgical management. Methods: One is 6 - years - old female who presented with macrodactyly involving both the soft tissue and bony parts of the second, third and forth digits of her right hand. The other one is 16 - years - old man who presented involving the soft tissue of the second and third digits of his right hand, with pain and numbness, along with motor and sensory deficits in the median nerve distribution. To evaluation about LFH, we enforced preoperative MRI and physical examination. After confirming the diagnosis of LFH, we proposed decompression of all compromised peripheral nerve to help alleviate pain and paresthesia to reduce the likelihood of permanent motor and sensory sequelae. Results: A characteristic feature on MRI is the appearance of serpentiform nerve fascicle surrounded by fibro - fatty tissue within the expended nerve sheet. Distribution of fat between fascicles is asymmetric. Two cases were treated by limited debulking of the redundant tumor tissue and excision of epineurial fatty tissue. These cases were performed with relief of symptom. Conclusion: MRI not only confirms the diagnosis, it also provides a detailed assessment of nerve involvement preoperatively. Especially, on coronal images, the nerve has a spagetti - like appearance that is pathognomonic of LFH. Recommendations for early treatment include decompression of the carpal tunnel, debulking of the fibro - fatty sheath, microsurgical dissection of the neural elements and excision of involve nerve with or without grafting.

• Journal of Korean Neurosurgical Society
• /
• v.67 no.4
• /
• pp.411-417
• /
• 2024

Objective : To confirm the usefulness of the extradural anterior clinoidectomy during the clipping of a low riding posterior communicating artery (PCoA) aneurysm through cadaver dissection. Methods : Anatomic measurements of 12 adult cadaveric heads (24 sides total) were performed to compare the microsurgical exposure of the PCoA and internal carotid artery (ICA) before and after clinoidectomy. A standard pterional craniotomy and transsylvian approach were performed in all cadavers. The distance from the ICA bifurcation to the origin of PCoA (D1), pre-anterior clinoidectomy distance from the ICA bifurcation to tentorium (D2), post-anterior clinoidectomy distance from the ICA bifurcation to tentorium (D3), pre-anterior clinoidectomy distance from the tentorium to the origin of PCoA (D4) and post-anterior clinoidectomy distance from the tentorium to the origin of PCoA (D5) and the distance of the ICA obtained after anterior clinoidectomy (D6) were measured. We measured the precise thickness of the blade for the Yasargil clip with a digital precision ruler to confirm the usefulness of the extradural anterior clinoidectomy. Results : Twenty-four sites were dissected from 12 cadavers. The age of the cadavers was 79.83±6.25 years. The number of males was the same as the females. The space from the proximal origin of the PCoA to the preclinoid-tentorium (D4) was 1.45±1.08 mm (max, 4.01; min, 0.56). After the clinoidectomy, the space from the proximal origin of the PCoA to the postclinoid-tentorium (D5) was 3.612±1.15 mm (max, 6.14; min, 1.83). The length (D6) of the exposed proximal ICA after the extradural clinoididectomy was 2.17±1.04 mm on the lateral side and 2.16±0.89 mm on the medial side. The thickness of the Yasargil clip blade used during the clipping surgery was 1.35 mm measured with a digital precision ruler. Conclusion : The proximal length obtained by performing an external anterior clinoidectomy is about 2 mm, sufficient for proximal control during PCoA aneurysm surgery, considering the thickness of the aneurysm clips. In a subarachnoid hemorrhage, performing an extradural anterior clinoidectomy could prevent a devastating situation during PCoA aneurysm clipping.