It's anterior and ventral to the lower cranial nerves. What is also important clinical anatomy is that the original PICA is very much associated with cranial nerve 12 and it's aneurysm. What it irrigates is very important structures, proximately PICA through its perforators does medulla, cerebellar tonsil, inferior vermis, and the suboccipital face of the cerebellar hemisphere. Although that can be very variable as well. PICA is frequently largest intradural branch, and it rises about 10 millimeter above the foramen magnum and 50 millimeter below the vertebrobasilar junction. And the variation is more specifically in their route. The PICA arms can be very variable and this variation can make the surgery very difficult. And then it really travels superiorly and transverses from lateral to anterior along the cervicomedullary junction. So what is surgically important or relevant for these aneurysms? Vertebral artery enters the subarachnoid space between ring of C1 and foramen magnum, but we obviously know that. And obviously that's because of the close relationship of this vascular structure to foramina of Luschka and Magendie. And obviously you need a four vessel angiogram clearly showing the origin of PICA. Okay, so if you see intervention color hemorrhage, as you can see here, or some blood in the several pontine angle, you should really suspect a PICA aneurysm and make sure that's excluded. Yes, I agree, particularly in Japan as well. And the risk of posterior circulation aneurysms are generally considered to be higher than anterior circulation aneurysms, specifically for aneurysms less than 12 millimeters, Jacques, would you agree with that princ, that basic concept of the rupture, knowing these studies recently? Most of them are left sided as the vertebral is mostly dominant on the left. Very basic concepts, after basilar tip aneurysms, these aneurysms are some of the most common PICA aneurysms. None of us have any disclosures that would interfere with this presentation. We're gonna review a set of slides to review some basic concepts after which we're gonna have about five surgical videos discussing complex technical skills, as well as interoperative ruptures. Jacques Morcos, from University of Miami, has been very kind and gracious to join me for his expert commentary. Hello, ladies and gentlemen, this session will be discussion regarding basic and complex techniques for open clip ligation of posterior inferior cerebellar, or PICA aneurysms.
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