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Feasibility for Side-to-Side PICA-PICA Bypass and Variations: A Correlative Cadaver and Computed Tomography Angiogram
Bilal Yekeler1, Abdullah Keles1, Ulas Cikla2
1Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.
Operative Neurosurgery (Hagerstown, Md.)
|June 4, 2026
Summary
Posterior inferior cerebellar artery (PICA) bypass feasibility depends on PICA origin and vessel proximity. Preoperative imaging can identify favorable anatomy for PICA-PICA bypass, improving surgical planning.
Area of Science:
- Neurosurgery
- Vascular Anatomy
- Cerebrovascular Surgery
Background:
- The posterior inferior cerebellar artery (PICA) exhibits significant anatomical variability, complicating surgical strategies like PICA-PICA bypass.
- Detailed anatomical criteria for successful PICA-PICA bypass remain undefined, hindering preoperative planning.
Purpose of the Study:
- To define anatomical criteria for side-to-side PICA-PICA bypass.
- To evaluate how PICA variations, particularly origin and bilateral caudal loops (BCL), impact bypass feasibility and surgical planning.
Main Methods:
- Cadaveric dissections (n=25) assessed PICA origins, diameters, and BCL presence, measuring distances to surrounding structures.
- Retrospective analysis of 120 CT angiograms evaluated the prevalence of favorable anatomical configurations for PICA-PICA bypass.
Main Results:
- PICA-PICA bypass was feasible in 52% of cadavers, with ideal cases showing shorter origin-to-dura distances (15.6-16.2 mm).
- Infeasible bypass was linked to absent/hypoplastic PICA, excessive vessel distance, or unfavorable BCLs (48% of cases).
- Lateral medullary PICA origins (61.1%) were most common and associated with BCL presence (95.5%); BCL prevalence was 67% overall.
Conclusions:
- PICA origin, BCL formation, and bilateral vessel proximity are key determinants of PICA-PICA bypass feasibility.
- Distant PICA origins and hypoplastic vessels significantly reduce bypass success rates.
- Preoperative imaging is crucial for identifying favorable anatomy and guiding surgical planning for PICA-PICA bypass.