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Original research
Posterior circulation perforator aneurysms: a proposed management algorithm
  1. Thomas J Buell1,
  2. Dale Ding1,
  3. Daniel M S Raper1,
  4. Ching-Jen Chen1,
  5. Harry R Hixson2,
  6. R Webster Crowley3,
  7. Avery J Evans2,
  8. Mary E Jensen2,
  9. Kenneth C Liu1,2
  1. 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
  2. 2Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
  3. 3Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
  1. Correspondence to Dr Thomas J Buell, Department of Neurosurgery, University of Virginia Health System, Box 800212, Charlottesville, VA 22908, USA; tjb4p{at}


Introduction Subarachnoid hemorrhage (SAH) from posterior circulation perforator aneurysms (PCPAs) is rare and its natural history is unknown. Diagnosis may be difficult, acute management is poorly defined, and long-term recurrent SAH rates and clinical outcome data are lacking.

Methods We searched our institution's records for cases of PCPA rupture and analyzed patient demographics, Hunt and Hess (HH) grades, diagnostic imaging, management, and clinical outcomes. We conducted telephone interviews to calculate modified Rankin Scale (mRS) scores.

Results We identified 9 patients (6 male, 3 female) with a ruptured PCPA who presented to the University of Virginia Health System (Charlottesville, VA, USA) between 2010 and 2016. Median and mean ages were 62 and 63 years, respectively. Median HH grade was 3. Seven of nine (78%) PCPAs were angiographically occult on initial imaging and median time to diagnosis was 5 days. Three conservatively managed patients had a mean mRS score of 0.67 (range 0–1) at mean follow-up of 35.3 months. Antifibrinolytic therapy was administered to all conservatively managed patients without thrombotic complication. Six patients receiving endovascular treatment had a mean mRS score of 2.67 (range 0–6) at mean follow-up of 49.2 months. No cases of recurrent SAH were seen in the study.

Conclusions The rarity of PCPA has precluded long-term clinical follow-up until now. Our experience suggests low recurrent SAH rates. Until further studies are performed, conservative management, possibly combined with antifibrinolytic therapy, may be a viable treatment with acceptable long-term outcome.

  • Subarachnoid
  • Stroke
  • Angiography
  • Aneurysm
  • Hemorrhage

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  • Contributors All authors made substantial contributions to the conception, data acquisition and analysis, interpretation, or drafting of this research article. We approve this final version to be published.

  • Competing interests None declared.

  • Ethics approval University of Virginia institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.