PMC5482208_01
Preoperative picture of the patient showing left-sided tongue atrophy but no deviation
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F1
He developed left-sided tongue atrophy [Figure 1] which progressively worsened during ORL follow-up.
Preoperative images: plain CT (a) showing PICA aneurysm wall calcification (arrow); axial T2-WI (b and c) showing the left VA and PICA (arrow) running very close to the left HN rootlets (arrow); CTA (d) showing left PICA origin fusiform aneurysm (arrow); MRA showing the PICA (arrow) before (e) and after (f) transposition (arrow)
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F2
He was later referred to the neurologists who made a diagnosis of left HN palsy caused by magnetic resonance imaging (MRI) [Figures 2a-c] detected left vertebral artery (VA) compression of the medulla. Three-dimensional computed tomography angiography showed left PICA fusiform aneurysm [Figure 2d]. MR Angiogoraphy showed anterior medullary segment of PICA was successfully transpositioned without stenosis [Figure 2e and f].
Images captured intraoperatively: showing adhesions between the fusiform PICA aneurysm and the HN rootlets (arrow) (a); successful separation of the aneurysm (arrow) from the HN rootlets (b and c); transposition of the PICA with oxidized cellulose (d)
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F3
Intraoperative findings were thickened arachnoid around the lower cranial nerves and fusiform aneurysm of the left PICA at its origin from the left VA which was severely adherent to and compressing the left HN rootlets [Figure 3a]. The HN rootlets were carefully dissected from the aneurysm wall [Figure 3b and c]. The PICA with the aneurysm was transposed caudally and anchored to the dura with three pieces of oxidized cellulose and fibrin glue [Figure 3d].