Ruptured Distal Posterior Inferior Cerebellar Artery (PICA) Aneurysms Associated with Cerebellar Arterial Venous Malformations (AVMs): A Case Series and Review of the Literature Demonstrating the Need for Angiographic Evaluation and Feasibility of Endovascular Treatment

AimTo report our experience with endovascular treatment of posterior inferior cerebellar artery (PICA) aneurysms.MethodsBetween January 2007 and December 2014, 40 patients with 42 PICA aneurysms were treated with endovascular embolization at our institution. Twenty-eight patients had 29 saccular aneurysms and 12 patients had 13 fusiform/dissecting aneurysms. The endovascular modalities were: (1) selective occlusion of the aneurysm with or without stent assistance (n=19); (2) occlusion of the aneurysm and the parent artery (n=22); and (3) occlusion of the aneurysm including the vertebral artery and PICA origin (n=1). Specifically, selective embolization was performed in 93.3% of aneurysms (14/15) proximal to the telovelotonsillary segment.ResultsImmediate angiographic results included 31 complete occlusions (74%), 3 nearly complete occlusions (7%), and 8 incomplete occlusions (19%). Mean follow-up of 20 months in 31 aneurysms showed 27 stable results, 3 further thromoboses, and 1 recurrence. Final results included 27 complete occlusions (87.1%) and 4 incomplete occlusions (12.9%). There were 5 overall procedural-related complications (12.5%), including 1 infarction (2.5%) and 4 intraprocedural ruptures (10.0%). Procedure-related morbidity and morbidity was 5.0% (2/40) and 2.5% (1/40), respectively. Clinical outcome was excellent (Glasgow Outcome Scale 5 in 31 of 33 patients at long-term follow-up).ConclusionsPICA aneurysms may be effectively treated by different endovascular approaches with favorable clinical and radiologic outcomes. Further studies are required to compare the safety and efficacy of endovascular treatment with open surgery.

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Ten years of experience in endovascular treatment of ruptured aneurysms of the posterior inferior cerebellar artery

Interventional Neuroradiology ◽

10.1177/1591019915622164 ◽

2016 ◽

Vol 22 (2) ◽

pp. 129-137 ◽

Cited By ~ 15

Author(s):

Robert Juszkat ◽

Paweł Kram ◽

Katarzyna Stanisławska ◽

Roman Jankowski ◽

Bogumiła Stachowska-Tomczak ◽

...

Keyword(s):

Endovascular Treatment ◽

Clinical Presentation ◽

Posterior Inferior Cerebellar Artery ◽

Years Of Experience ◽

Endovascular Stents ◽

Ruptured Aneurysms ◽

Ruptured Intracranial Aneurysm ◽

Cerebellar Artery ◽

Pica Aneurysms

Background The aim of this study is to present our 10 years of experience in endovascular treatment of ruptured posterior inferior cerebellar artery (PICA) saccular aneurysms and to compare clinical presentation and outcome after endovascular treatment between patients with PICA aneurysms and patients with aneurysms in different locations. Methods and findings Out of 932 patients with a ruptured intracranial aneurysm treated endovascularly in our institution, 38 aneurysms were located at the posterior inferior cerebellar artery. Clinical presentation, mean aneurysm diameter and outcome of the therapy in this group were compared with the same for ruptured aneurysms in other locations. Patients discharged with favourable outcomes were checked angiographically in the follow-up period. Thirty-four patients with ruptured PICA aneurysms were treated by selective endovascular coiling. Two patients with wide-necked aneurysms had endovascular stents implanted. In two cases, the parent vessel was occluded due to failure to catheterise the target aneurysm. The evaluated variables did not differ significantly between two groups, but significantly more ruptured aneurysms in the PICA group were under 6 mm in diameter. 29.4% of controlled aneurysms needed additional reembolisation in the follow-up period. Conclusions Clinical presentation, extension of subarachnoid haemorrhage and outcome after endovascular treatment did not differ significantly between patients with ruptured aneurysms located on the PICA and patients with aneurysms located elsewhere intracranially. Endovascular treatment is an effective method of therapy in patients with ruptured PICA aneurysms. In our experience, even when sacrificing of the PICA is required, the results of treatment are favourable.

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Efficacy and Outcomes of Posterior Inferior Cerebellar Artery (PICA) Bypass for Proximal PICA and Vertebral Artery-PICA Aneurysms: A Case Series

Operative Neurosurgery ◽

10.1093/ons/opx277 ◽

2018 ◽

Vol 15 (4) ◽

pp. 395-403 ◽

Cited By ~ 6

Author(s):

Robert C Rennert ◽

Ben A Strickland ◽

Kristine Ravina ◽

Joshua Bakhsheshian ◽

Vance Fredrickson ◽

...

Keyword(s):

Vertebral Artery ◽

Bypass Graft ◽

Posterior Inferior Cerebellar Artery ◽

Case Series ◽

High Morbidity ◽

Surgical Experience ◽

Graft Harvest ◽

Cerebellar Artery ◽

Pica Aneurysms ◽

Temporary Clip

Abstract BACKGROUND Nonsaccular vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms have high morbidity and mortality rates and are difficult to treat using standard microsurgical or endovascular techniques. Definitive revascularization can require clip trapping and/or vessel sacrifice, with PICA bypass. The published surgical experience with these approaches is limited. We herein review our recent surgical experience with PICA revascularization for complex PICA and VA/PICA aneurysms. OBJECTIVE To determine the efficacy and outcomes of PICA bypass for revascularization of nonsaccular PICA and VA/PICA aneurysms. METHODS Retrospective analysis of an institutional review board-approved, prospective database was performed to identify patients with PICA and VA/PICA aneurysms treated with PICA bypass at a single institution. Demographic information, aneurysm characteristics, temporary clip time, and neurological outcomes were recorded. RESULTS Ten cases of PICA revascularization were performed for both ruptured (n = 8) and unruptured (n = 2) nonsaccular proximal PICA or VA/PICA aneurysms. Seven cases were performed without vessel grafts; 3 cases required harvest of the descending branch of the lateral femoral circumflex artery. Mean temporary clip time was 38 min (range 27-50 min). Good outcomes (Glasgow Outcomes Scale score of 5) were achieved in 70% (n = 7) of patients at time of discharge; the remaining patients had a Glasgow Outcomes Scale of 3. Two bypass-related complications occurred in this series; a hematoma at the graft harvest site requiring evacuation, and severe bypass graft spasm requiring multiple endovascular treatments. CONCLUSION PICA bypass can be a safe, effective, and highly customizable tool for the revascularization of patients with nonsaccular proximal PICA and VA/PICA aneurysms.

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Endovascular treatment of proximal and distal posterior inferior cerebellar artery aneurysms

Journal of Neurosurgery ◽

10.3171/2012.12.jns121240 ◽

2013 ◽

Vol 118 (5) ◽

pp. 991-999 ◽

Cited By ~ 61

Author(s):

Nohra Chalouhi ◽

Pascal Jabbour ◽

Robert M. Starke ◽

Stavropoula I. Tjoumakaris ◽

L. Fernando Gonzalez ◽

...

Keyword(s):

Endovascular Treatment ◽

Endovascular Therapy ◽

Posterior Inferior Cerebellar Artery ◽

Significant Risk ◽

Parent Vessel ◽

Unruptured Aneurysms ◽

Cerebellar Artery ◽

Pica Aneurysms ◽

Aneurysm Coiling

Object Surgical clipping of posterior inferior cerebellar artery (PICA) aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies. The authors assess the feasibility, safety, and efficacy of endovascular therapy in the largest series of proximal and distal PICA aneurysms to date. Methods A total of 76 patients, 54 with proximal and 22 with distal PICA aneurysms, underwent endovascular treatment at Jefferson Hospital for Neuroscience between 2001 and 2011. Results Endovascular treatment was successful in 52 patients (96.3%) with proximal aneurysms and 19 patients (86.4%) with distal aneurysms. Treatment consisted of selective aneurysm coiling in 60 patients (84.5%) (including 4 with stent assistance and 4 with balloon assistance) and parent vessel trapping in 11 patients (15.5%). Specifically, a deconstructive procedure was necessary in 9.6% of proximal aneurysms (5 of 52) and 31.6% of distal aneurysms (6 of 19). There were 9 overall procedural complications (12.7%), 6 infarcts (8.5%; 4 occurring after deliberate occlusion of the PICA), and 3 intraprocedural ruptures (4.2%). The rate of procedure-related permanent morbidity was 2.8%. Complete aneurysm occlusion was achieved in 63.4% of patients (45 of 71). One patient (1.4%) treated with selective aneurysm coiling suffered a rehemorrhage on postoperative Day 15. The mean angiographic follow-up time was 17.2 months. Recurrence and re-treatment rates were, respectively, 20% and 17.1% for proximal aneurysms compared with 30.8% and 23.1% for distal aneurysms. Favorable outcomes (moderate, mild, or no disability) at follow-up were seen in 93% of patients with unruptured aneurysms and in 78.7% of those with ruptured aneurysms. Conclusions Endovascular therapy is a feasible, safe, and effective treatment in patients with proximal and distal PICA aneurysms, providing excellent patient outcomes and adequate protection against rehemorrhage. The long-term incidence of aneurysm recanalization appears to be high, especially in distal aneurysms, and requires careful angiographic follow-up.

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Aneurysms of the Distal Posterior Inferior Cerebellar Artery: Experience with Three Cases and Review of the Literature

Neurosurgery ◽

10.1227/00006123-198506000-00018 ◽

1985 ◽

Vol 16 (6) ◽

pp. 829-832 ◽

Cited By ~ 30

Author(s):

Tomoyuki Nishizaki ◽

Norihiko Tamaki ◽

Yoshimitsu Nishida ◽

Katsuzo Fujita ◽

Satoshi Matsumoto

Keyword(s):

Computed Tomography ◽

Mortality Rate ◽

Turning Point ◽

Posterior Inferior Cerebellar Artery ◽

Review Of The Literature ◽

Aneurysm Neck ◽

Cerebellar Artery ◽

Pica Aneurysms

Abstract We report 3 surgically treated aneurysms of the distal posterior inferior cerebellar artery (PICA) and review 36 cases in the literature. More than half of the distal PICA aneurysms arose distal to the choroidal arch. These lesions often arose at a turning point (i.e., a hairpin curve) of an artery instead of at a junction of vessels. Distal PICA aneurysms are likely to be missed and it is necessary to investigate carefully with four-vessel angiography even if computed tomography is done. Eighty-two per cent of the surgically treated 39 patients had good recoveries and 8% had fair results. The mortality rate was 10%. Although clipping of the aneurysm neck is preferable, trapping is useful when neck clipping is impossible in segments distal to the choroidal arch.

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Distal Aneurysms of Cerebellar Arteries—Case Series

Brain Sciences ◽

10.3390/brainsci10080538 ◽

2020 ◽

Vol 10 (8) ◽

pp. 538

Author(s):

David Krahulik ◽

Miroslav Vaverka ◽

Lumir Hrabálek ◽

Štefan Trnka ◽

Martin Kocher ◽

...

Keyword(s):

Endovascular Treatment ◽

Posterior Inferior Cerebellar Artery ◽

Case Series ◽

Superior Cerebellar Artery ◽

Endovascular Coiling ◽

Anterior Inferior Cerebellar Artery ◽

Cerebellar Artery ◽

Intraventricular Bleeding ◽

Treatment Table

(1) Background: Distal aneurysms of cerebellar arteries are very rare. The authors report their case series of distal aneurysms of the cerebellar arteries solved successfully by microsurgery or by endovascular treatment (Table 1) (2) Materials and Methods: Between January 2010 and March 2020, 346 aneurysms were treated in our institution. Eleven aneurysms in seven patients were located on distal cerebellar arteries and, in three patients, the aneurysms were combined with arteriovenous malformations. There were four women and three men, ranging from 50 to 72 years of age. Five patients presented with different grades of subarachnoid hemorrhage or intraventricular bleeding, and two patients were diagnosed because of headache. Aneurysm location was the posterior inferior cerebellar artery in six cases, the superior cerebellar artery in three cases, and the anterior inferior cerebellar artery in 2 cases. One patient had three aneurysms, and two patients had two aneurysms. (3) Results: Nine aneurysms were treated by microsurgery trapping or clipping and, in two patients, the associated arteriovenous malformation (AVM) was resected. Two aneurysms were treated by endovascular coiling, and one associated AVM was successfully embolized. Clinical follow-up was a mean of 11.5 months (range, 3–45 months). (4) Conclusion: The authors present their experience with the treatment of 11 peripheral aneurysms on distal branches of the cerebellar circulation in seven patients which were excluded from circulation by microsurgery or endovascular treatment. In three patients, the associated AVM was treated (two with microsurgery, one with embolization).

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The Glossopharyngo-Cochlear Triangle—Part II: Case Series Highlighting the Clinical Application to High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach

Operative Neurosurgery ◽

10.1093/ons/opaa362 ◽

2020 ◽

Author(s):

Jacob F Baranoski ◽

Stefan W Koester ◽

Colin J Przybylowski ◽

Xiaochun Zhao ◽

Joshua S Catapano ◽

...

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Internal Auditory Canal ◽

Case Series ◽

Jugular Foramen ◽

Foramen Magnum ◽

Aneurysm Neck ◽

Cerebellar Artery ◽

Vertebrobasilar Junction ◽

Surgical Corridor ◽

Pica Aneurysms

Abstract BACKGROUND Use of the far lateral transcondylar (FL) approach and vagoaccessory triangle is the standard exposure for clipping most posterior inferior cerebellar artery (PICA) aneurysms. However, a distal PICA origin or high-lying vertebrobasilar junction can position the aneurysm beyond the vagoaccessory triangle, making the conventional FL approach inappropriate. OBJECTIVE To demonstrate the utility of the extended retrosigmoid (eRS) approach and a lateral trajectory through the glossopharyngo-cochlear triangle as the surgical corridor for these cases. METHODS High-riding PICA aneurysms treated by microsurgery were retrospectively reviewed, comparing exposure through the eRS and FL approaches. Clinical, surgical, and outcome measures were evaluated. Distances from the aneurysm neck to the internal auditory canal (IAC), jugular foramen, and foramen magnum were measured. RESULTS Six patients with PICA aneurysms underwent clipping using the eRS approach; 5 had high-riding PICA aneurysms based on measurements from preoperative computed tomography angiography (CTA). Mean distances of the aneurysm neck above the foramen magnum, below the IAC, and above the jugular foramen were 27.0 mm, 3.7 mm, and 8.2 mm, respectively. Distances were all significantly lower versus the comparison group of 9 patients with normal or low-riding PICA aneurysms treated using an FL approach (P < .01). All 6 aneurysms treated using eRS were completely occluded without operative complications. CONCLUSION The eRS approach is an important alternative to the FL approach for high-riding PICA aneurysms, identified as having necks more than 23 mm above the foramen magnum on CTA. The glossopharyngo-cochlear triangle is another important anatomic triangle that facilitates microsurgical dissection.

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