Case Report: Endovascular Treatment of a Giant Distal PICA Aneurysm in Association With a Cerebellar AVM: A Report on Treatment Considerations and a Literature Review

Background: Distal posterior inferior cerebellar artery (PICA) aneurysms are uncommon intracranial vascular lesions. The coincidence of these aneurysms and Arteriovenous malformation (AVM) is even more rare. Since 1956, a total of 57 cases of distal PICA aneurysms associated with AVM have been reported with clear and adequate description. None of these reports describe a giant prenidal aneurysm at this particular location. The paucity of natural history data as well as lack of consensus about treatment strategies in such cases present a significant challenge that requires an individualized management approach.Case Description: A 68-year-old male presented with recurrent episodes of nausea and vomiting precipitated by physical exertion and change of head position. An MRI of the brain demonstrated a giant partially thrombosed right posterior inferior cerebellar artery (PICA) aneurysm with mass effect on the floor of the fourth ventricle. A conventional cerebral angiogram revealed a giant (3.1 x 3.1 x 2.8cm) distal right PICA pre-nidal aneurysm with two smaller distal PICA aneurysms. An AVM (Spetzler-Martin Grade 1) supplied by the right PICA as well as the right superior cerebellar artery (SCA) was also identified on cerebral angiography (not seen on an MRI). Endovascular coil embolization with parent vessel sacrifice was performed to occlude the giant aneurysm. Due to the asymptomatic nature, low risk of rupture, and the patient's age, AVM treatment was deferred.Conclusion: This paper presents the first case of a giant PICA aneurysm associated with cerebellar AVM. For PICA aneurysm-AVM complexes, meticulous evaluation of the morphology, associated anatomy, and comparative risk analysis for both lesions are key for treatment planning. Distal PICA aneurysms can be treated safely with parent vessel occlusion, particularly in the case of prenidal aneurysms.

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Case Report: Bow Hunter's Syndrome Caused by Compression of Extracranially Originated Posterior Inferior Cerebellar Artery

Frontiers in Neurology ◽

10.3389/fneur.2021.756838 ◽

2021 ◽

Vol 12 ◽

Author(s):

Noriya Enomoto ◽

Kenji Yagi ◽

Shunji Matsubara ◽

Masaaki Uno

Keyword(s):

Case Report ◽

Posterior Inferior Cerebellar Artery ◽

Head Rotation ◽

Radiographic Examination ◽

Posterior Decompression ◽

First Case ◽

Cerebellar Artery ◽

Cervical Approach ◽

The Right ◽

Hunter's Syndrome

Bow hunter's syndrome (BHS) is most commonly caused by compression of the vertebral artery (VA). It has not been known to occur due to an extracranially originated posterior inferior cerebellar artery (PICA), the first case of which we present herein. A 71-year-old man presented with reproducible dizziness on leftward head rotation, indicative of BHS. On radiographic examination, the bilateral VAs merged into the basilar artery, and the left VA was predominant. The right PICA originated extracranially from the right VA at the atlas–axis level and ran vertically into the spinal canal. During the head rotation that induced dizziness, the right PICA was occluded, and a VA stenosis was revealed. Occlusion of the PICA was considered to be the primary cause of the dizziness. The patient underwent surgery to decompress the right PICA and VA via a posterior cervical approach. Following surgery, the patient's dizziness disappeared, and the stenotic change at the right VA and PICA improved. The PICA could be a causative artery for BHS when it originates extracranially at the atlas–axis level, and posterior decompression is an effective way to treat it.

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Use of the Coupler Microanastomotic Device for the Treatment of a Distal Posterior Inferior Cerebellar Artery Aneurysm Via Excision and End-to-End Anastomosis—A Case Report

Neurosurgery Open ◽

10.1093/neuopn/okaa002 ◽

2020 ◽

Vol 1 (2) ◽

Author(s):

Oded Goren ◽

Raghuram Sampath ◽

Akshal S Patel ◽

Christoph J Griessenauer ◽

Clemens M Schirmer ◽

...

Keyword(s):

Case Report ◽

Intracranial Aneurysms ◽

Clinical Presentation ◽

Posterior Inferior Cerebellar Artery ◽

Artery Aneurysm ◽

Parent Vessel ◽

First Case ◽

Cerebellar Artery ◽

End To End ◽

Coupler Device

ABSTRACT BACKGROUND AND IMPORTANCE The Coupler microanastomotic device (Medical Companies Alliance, Birmingham, Alabama) aims at facilitating safe and efficient end-to-end reconstruction of the native vessel ends following resection of intracranial aneurysms. CLINICAL PRESENTATION We report the first case of the Coupler device used to treat a ruptured posterior inferior cerebellar artery (PICA) aneurysm. Following aneurysmal trapping and excision, the native parent vessel ends were connected in an end-to-end fashion. CONCLUSION The microanastomotic Coupler device is an acceptable option for end-to-end anastomosis and was successfully applied in the management of a ruptured fusiform PICA aneurysm.

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Stent-assisted coil embolization for an unruptured vertebral artery–posterior inferior cerebellar artery aneurysm with retrograde access via type 1 persistent primitive proatlantal artery: A case report

Interventional Neuroradiology ◽

10.1177/1591019920973848 ◽

2020 ◽

pp. 159101992097384

Author(s):

Yasuhiko Nariai ◽

Tomoji Takigawa ◽

Ryotaro Suzuki ◽

Akio Hyodo ◽

Kensuke Suzuki

Keyword(s):

Carotid Artery ◽

Vertebral Artery ◽

Coil Embolization ◽

Posterior Inferior Cerebellar Artery ◽

External Carotid ◽

Proatlantal Artery ◽

Cerebellar Artery ◽

The Right ◽

Pica Aneurysms

Vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysms are rare lesions that are difficult to treat with both endovascular and surgical techniques. Tight angulation of the PICA from VA may make access to the PICA difficult from ipsilateral VA if adjunctive techniques are needed. Recently, the safety and efficacy of retrograde access have been reported. We report a case of endovascular treatment for a VA-PICA aneurysm with a stent-assisted technique using retrograde access via contralateral persistent primitive proatlantal artery (PPA). The patient was a 76-year-old woman with an unruptured VA-PICA aneurysm on the dominant VA side. Coil embolization with a stent-assisted technique using retrograde access seemed appropriate. However, the origin of the left VA was not confirmed. Left common carotid artery angiography demonstrated that the PPA (type 1) branching from external carotid artery joined the VA V4 segment. Retrograde access via the PPA for stenting was performed. A microcatheter for stenting was retrogradely advanced to the right PICA at ease. After deploying the stent, coil insertion was completed from the right VA, and the final angiogram showed adequate occlusion of the aneurysm with preservation of the PICA. Thus, PPA may be an approach route in the treatment of VA-PICA aneurysms with unconfirmed contralateral VA orifice and apparent PPA on angiography, when retrograde access is needed.

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GIANT FUSIFORM ANEURYSM ARISING FROM FENESTRATED POSTERIOR CEREBRAL ARTERY AND BASILAR TIP VARIATION

Neurosurgery ◽

10.1227/01.neu.0000338431.70709.81 ◽

2009 ◽

Vol 64 (3) ◽

pp. E564-E565 ◽

Cited By ~ 6

Author(s):

Marco A. Zanini ◽

Vitor M. Pereira ◽

Mauricio Jory ◽

José G.M.P. Caldas

Keyword(s):

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Superior Cerebellar Artery ◽

Fusiform Aneurysm ◽

Parent Vessel ◽

Vessel Occlusion ◽

Cerebellar Artery ◽

Parent Vessel Occlusion ◽

The Right ◽

Double Origin

Abstract OBJECTIVE A giant fusiform aneurysm in the posterior cerebral artery (PCA) is rare, as is fenestration of the PCA and basilar apex variation. We describe the angiographic and surgical findings of a giant fusiform aneurysm in the P1–P2 PCA segment associated with PCA bilateral fenestration and superior cerebellar artery double origin. CLINICAL PRESENTATION A 26-year-old woman presented with a 2-month history of visual blurring. Digital subtraction angiography showed a giant (2.5 cm) fusiform PCA aneurysm in the right P1–P2 segment. The 3-dimensional view showed a caudal fusion pattern from the upper portion of the basilar artery associated with a bilateral long fenestration of the P1 and P2 segments and superior cerebellar artery double origin. INTERVENTION Surgical trapping of the right P1–P2 segment, including the posterior communicating artery, was performed by a pretemporal approach. Angiograms performed 3 and 13 months after surgery showed complete aneurysm exclusion, and the PCA was permeated and filled the PCA territory. Clinical follow-up at 14 months showed the patient with no deficits and a return to normal life. CONCLUSION To our knowledge, this is the first report of a giant fusiform aneurysm of the PCA associated with P1–P2 segment fenestration and other variations of the basilar apex (bilateral superior cerebellar artery duplication and caudal fusion). Comprehension of the embryology and anatomy of the PCA and its related vessels and branches is fundamental to the decision-making process for a PCA aneurysm, especially when parent vessel occlusion is planned.

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Surgical Treatment of Posterior Circulation Aneurysms – Anatomical Study and Surgical Technique

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1639589 ◽

2018 ◽

Vol 37 (01) ◽

pp. 27-37

Author(s):

Vitor Yamaki ◽

Eric Paschoal ◽

Manoel Teixeira ◽

Eberval Figueiredo

Keyword(s):

Surgical Treatment ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Posterior Circulation ◽

Surgical Approaches ◽

Superior Cerebellar Artery ◽

Anterior Circulation ◽

Cerebellar Artery ◽

Risk Of Rupture ◽

Posterior Circulation Aneurysms

AbstractPosterior circulation aneurysms represent 10–15% of intracranial aneurysms. The diagnosis is usually secondary to subarachnoid hemorrhage due to its initial asymptomatic presentation and higher risk of rupture compared with aneurysms in the anterior circulation. The surgical treatment of posterior circulation aneurysms is complex and challenging for neurosurgeons because of the particular anatomy of the posterior circulation with its close relation to the brainstem and cranial nerves and also because of the depth and narrowness of the surgical approach. Aneurysms from different locations have specific anatomical relationships and surgical approaches for better visualization and dissection. Therefore, a detailed anatomy knowledge of the posterior circulation is mandatory for an individualized preoperative planning and good neurological and angiographic outcomes. We selected the main aneurysm sites on the posterior circulation, such as: posterior inferior cerebellar artery, basilar trunk, basilar bifurcation, posterior cerebral artery (PCA) and superior cerebellar artery for a detailed description of the relevant anatomy related to aneurysm, and the main surgical approaches for its surgical treatment. Furthermore, we performed a literature review with the most recent outcomes regarding to the surgical treatment of posterior circulation aneurysms.

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Aneurysms of the posterior inferior cerebellar artery

Journal of Neurosurgery ◽

10.3171/jns.1983.58.3.0381 ◽

1983 ◽

Vol 58 (3) ◽

pp. 381-387 ◽

Cited By ~ 142

Author(s):

Rroger J. Hudgins ◽

Arthur L. Day ◽

Ronald G. Quisling ◽

Albert L. Rhoton ◽

George W. Sypert ◽

...

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Vascular Anomaly ◽

Foramen Magnum ◽

Parent Vessel ◽

Content Type ◽

Aneurysm Neck ◽

Suboccipital Craniectomy ◽

Cerebellar Artery ◽

Pica Aneurysms ◽

Fine Print

✓ The clinical and anatomical features of 21 surgically treated saccular aneurysms of the posterior inferior cerebellar artery (PICA) are analyzed. Seventeen of these lesions originated from the PICA-vertebral junction, and four arose from distal PICA branching sites. Twelve lesions arose from the left PICA, nine were right-sided, and all were small (less than 12.5 mm). Most of these aneurysms occurred in females (16 of 21) and presented as classic subarachnoid hemorrhage. The lack of specific focal deficits prevented an accurate pre-angiographic determination of aneurysm location in most instances. Clinically significant vasospasm and aneurysm multiplicity occurred with approximately equal frequency as at other locations. The angiographic and surgical features of these lesions are determined by the course of the vertebral artery and PICA; that is, they occur at branching sites and at curves in the parent vessel, and point in the direction in which flow would have continued if the curve at the aneurysm's origin had not been present. Aneurysms at the PICA-vertebral junction usually occur at least 1 cm above the foramen magnum level, arise distal to the PICA origin in the angle between the two vessels, and are best approached by a paramedian incision with the patient in the lateral recumbent position. Isolated clipping of the aneurysm neck is essential in this instance, as trapping may compromise vital perforating arteries of the brain stem. More distal (retromedullary) PICA aneurysms are sometimes associated with another vascular anomaly (two cases in this series), and are best handled through a bilateral suboccipital craniectomy. Clipping of the neck is the preferred treatment, but trapping is usually safe, if necessary.

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Fusiform superior cerebellar artery aneurysm treated with flow diversion: A case report

Surgical Neurology International ◽

10.25259/sni_556_2020 ◽

2020 ◽

Vol 11 ◽

pp. 330

Author(s):

Yafell Serulle ◽

Deepak Khatri ◽

Jada Fletcher ◽

Anna Pappas ◽

Audrey Heidbreder ◽

...

Keyword(s):

Artery Aneurysm ◽

Flow Diversion ◽

Superior Cerebellar Artery ◽

Parent Artery ◽

Fusiform Aneurysm ◽

Parent Vessel ◽

Pipeline Embolization Device ◽

Head Ct ◽

Cerebellar Artery ◽

The Right

Background: Fusiform aneurysms of the distal superior cerebellar artery are rare and challenging to treat. Due to the rarity of these lesions, there is little consensus regarding their management. Treatment options have traditionally included parent artery sacrifice with either an endovascular approach or microsurgical clipping. Given the small diameter of the superior cerebellar artery, flow diversion has not been typically considered as a viable treatment option for these aneurysms. Case Description: A 67-year-old female presented complaining of severe sudden onset headache. Noncontrast head CT demonstrated no intracranial hemorrhage. Head CT angiogram demonstrated a 4.2 mm fusiform aneurysm in the distal right superior cerebellar artery. The patient underwent treatment with the Pipeline embolization device which was deployed in the right superior cerebellar artery covering the aneurysm. Six-month posttreatment follow-up angiogram demonstrated resolution of the aneurysm with patency of the parent vessel. Conclusion: To the best of our knowledge, this is the first report of a distal superior cerebellar artery aneurysm treated with the Pipeline embolization device. The use of a Pipeline stent to create flow diversion should be considered in a case of a fusiform aneurysm of the right superior cerebellar artery. Treatment with flow diversion may allow for the treatment of the aneurysm while preserving patency of the parent vessel.

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Endovascular Management of Complete Vertebral Artery Dissection Presenting with Subarachnoid Haemorrhage

Interventional Neuroradiology ◽

10.1177/159101999900500209 ◽

1999 ◽

Vol 5 (2) ◽

pp. 161-166 ◽

Cited By ~ 4

Author(s):

R.K. Lenthall ◽

B.D. White ◽

N.S. McConachie

Keyword(s):

Subarachnoid Haemorrhage ◽

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Vertebral Artery Dissection ◽

Artery Dissection ◽

Endovascular Techniques ◽

First Case ◽

Surgical Clip ◽

Cerebellar Artery ◽

The Right

Spontaneous vertebral artery (VA) dissection may involve the intradural segment of the VA and result in subarachnoid haemorrhage (SAH). These lesions are frequently associated with recurrent SAH, and have a high mortality. Prior to the development of endovascular techniques the majority of these lesions were treated surgically. In cases where the dissection involved the posterior inferior cerebellar artery (PICA) origin surgery was associated with significant complications including recurrent SAH from retrograde VA flow into the dissected segment above the surgical clip. We describe two cases of complete VA dissection in which the entire intradural VA was sacrificed to prevent recurrent SAH. The first case tolerated planned left PICA occlusion without developing a significant neurological deficit. The second case had infarcted the right PICA territory at presentation.

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Tentorial edge traumatic aneurysm of the superior cerebellar artery

Journal of Neurosurgery ◽

10.3171/jns.1997.87.6.0950 ◽

1997 ◽

Vol 87 (6) ◽

pp. 950-954 ◽

Cited By ~ 15

Author(s):

François Proust ◽

Françoise Callonec ◽

Francis Bellow ◽

Annie Laquerriere ◽

Didier Hannequin ◽

...

Keyword(s):

Free Edge ◽

Pathological Examination ◽

Superior Cerebellar Artery ◽

Traumatic Aneurysm ◽

Parent Vessel ◽

Content Type ◽

Cerebellar Artery ◽

Patient’S Outcome ◽

Closed Head Trauma ◽

The Right

✓ The authors report an unusual case of a traumatic aneurysm of the right superior cerebellar artery (SCA). A 22-year-old woman presented with continuous headaches that appeared 15 days after she experienced closed head trauma as a result of a cycling accident. Computerized tomography scanning performed 3 months later showed a nodular lesion on the free edge of the tentorium, which mimicked a meningioma. The aneurysm was identified on magnetic resonance angiography, which showed the SCA as the parent vessel. The parent vessel was trapped, and the aneurysm sac was excised via right temporal craniotomy. Pathological examination of the sac revealed a false aneurysm. The patient's outcome was excellent. The pathophysiology of traumatic aneurysm at such a location suggests that surgery may be the treatment of choice.

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Contralateral far-lateral approach for clipping of a ruptured vertebral artery–posterior inferior cerebellar artery aneurysm

Neurosurgical FOCUS ◽

10.3171/foc.2008.25.12.e9 ◽

2008 ◽

Vol 25 (6) ◽

pp. E9 ◽

Cited By ~ 11

Author(s):

Taryn McFadden Bragg ◽

Edward A. M. Duckworth

Keyword(s):

Computed Tomography ◽

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Artery Aneurysm ◽

Lateral Approach ◽

Cerebellar Artery ◽

Far Lateral Approach ◽

Far Lateral ◽

The Right ◽

Pica Aneurysms

Numerous nuanced approaches have been used to access posterior inferior cerebellar artery (PICA) aneurysms for microsurgical clipping. The authors report the case of a patient with a right vertebral artery (VA)–PICA aneurysm that was reached via a contralateral far-lateral approach. The wide-necked saccular/fusiform aneurysm arose from the lateral aspect of the right V4 segment just proximal to the PICA origin, anterior to the jugular tubercle at the level of the hypoglossal canal. Computed tomography angiograms demonstrated the size and configuration of the aneurysm, and 3D reconstructions revealed the tortuosity of the right VA, defining its location just left of the midline adjacent to the lower clivus. A contralateral far-lateral approach to VA–PICA aneurysms should be considered when aneurysms cross the midline. Computed tomography angiography with volume rendering and interactive software capabilities can help identify the relationship of such an aneurysm to an individual's particular skull base osseous anatomy and is paramount in selecting the optimal microsurgical approach.

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