PMC4278098_01
(a) Preoperative axial MRI diffusion-weighted imaging depicting multiple, scattered, and punctate areas of restricted diffusion within the right cerebellar hemisphere. A large territory brainstem or cerebellar stroke was not evident. (b) Anteroposterior (AP) and (c) lateral preoperative DSA displaying severe, near-total occlusive focal plaque at the V4 segment. The ipsilateral PICA does not opacify. (d) 3D-reconstructed images from the postoperative CT-angiogram revealing patency and slight dilation at the endarterectomy site. A single clip at the transected posterior meningeal branch is also seen. (e) Postoperative AP and (f) lateral DSA 10 months postsurgery reveal patency without significant change at the endarterectomy site
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F1
Computed tomography (CT) angiography obtained on admission at our institution showed absent left vertebral flow below posterior inferior cerebellar artery (PICA) and right VA origin stenosis [Figure 1]. Ten-month follow-up angiography revealed satisfactory posterior circulation perfusion, wide patency at the treated VA segment, and mild (non flow-limiting) in-stent restenosis at the right VA origin [Figure 1].
Intraoperative photographs displaying (a) completion of the endarterectomy using micro-forceps and 6-Penfield microdissector and (b) completion of the nonautologous patch angioplasty. Used with permission from Barrow Neurological Institute
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F2
Endarterectomy was performed without complication in the standard fashion with a Penfield 6 microdissector and microforceps [Figure 2]. Flagstaff, AZ) patch was trimmed and sutured in place with 9-0 prolene, accommodating a slight dilation at the site of the arteriotomy. Frequent and repeated back-bleeding from both the proximal and distal ends of the VA and brisk irrigation with heparinized saline at the anastomosis line was performed at 2-minute intervals during closure to prevent thrombosis [Figure 2].