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Microsurgical anatomy of cerebral revascularization. Part II: posterior circulation.

OBJECT
Revascularization is an important component of treatment for complex aneurysms, skull base tumors, and vertebrobasilar ischemia in the posterior circulation. In this study, the authors examined the microsurgical anatomy related to cerebral revascularization in the posterior circulation and demonstrate various procedures for bypass surgery.


METHODS
The microsurgical anatomy of cerebral and cerebellar vessels as they relate to revascularization procedure and techniques, including extracranial-to-intracranial bypass grafting, arterial interposition grafting, and side-to-side anastomosis, were examined by performing stepwise dissections in 22 adult cadaveric specimens. The arteries and veins in the specimens were perfused with colored silicone. Dominant cerebral and cerebellar revascularization procedures in the posterior circulations include superficial temporal artery (STA)-posterior cerebral artery (PCA), STA-superior cerebellar artery (SCA), occipital artery (OA)-anterior inferior cerebellar artery, OA-posterior inferior cerebellar artery (PICA), and PICA-PICA anastomoses. These procedures are effective in relatively small but critical areas including the brainstem and cerebellum. For revascularization of larger areas a saphenous vein graft is used to create a bypass between the PCA and the external carotid artery. Surgical procedures are generally difficult to perform in deep and narrow operative spaces near critical vital structures.


CONCLUSIONS
Although a clear guideline for cerebral revascularization procedures has not yet been established, it is important to understand various microsurgical techniques and their related anatomical structures. This will help surgeons consider surgical indications for treatment of patients with vertebrobasilar ischemia caused by aneurysms, tumors, or atherosclerotic diseases in the posterior circulation.