Occipital Artery -Posterior Inferior Cerebellar Artery Bypass Combined with Aneurysm Trapping for a Recurrent Ruptured Vertebral Artery-Posterior Inferior Cerebellar Artery Aneurysm: Two-Dimensional Operative Video.

Vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysm is challenging owing to its variable anatomy and interference of lower cranial nerves. A recurrent ruptured VA-PICA aneurysm was successfully treated by occipital (OA)-PICA bypass with aneurysm trapping (Video 1). Informed consent was obtained from the patient. A ruptured right VA aneurysm was found in a 47-year-old man and treated by endovascular treatment. Follow-up angiography at 1 month revealed aneurysm recurrence with migration of endovascular materials. The patient was placed in a park-bench position for the far-lateral approach. A J-shaped incision was used for craniotomy. A 1-piece myocutaneous flap was raised, and the OA was skeletonized in a distal-to-proximal fashion. After craniotomy, the VA-PICA aneurysm with endovascular material inside was located under the vagoaccessory triangle. The tonsillomedullary segment or P3 of the PICA was robust and long enough as the recipient candidate for anastomosis. A linear arteriotomy was performed on the recipient artery, and an end-to-side OA-PICA bypass was achieved. Occlusion of the aneurysm was achieved by placing permanent clips on the VA proximal and distal to the aneurysm and the PICA next to the aneurysm sac without occluding the perforator. The postoperative course was uneventful with bypass patency. We believe this case demonstrates the surgical tenet of OA-PICA bypass for VA-PICA aneurysm.