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Original research
Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies
  1. Visish M Srinivasan1,
  2. Michael George Zaki Ghali1,
  3. Oleg E Reznik1,
  4. Jacob Cherian1,
  5. Maxim Mokin2,
  6. Travis M Dumont3,
  7. John R Gaughen4,
  8. Ramesh Grandhi5,
  9. Ajit S Puri6,
  10. Stephen R Chen7,
  11. Jeremiah N Johnson1,
  12. Peter Kan1
  1. 1 Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  2. 2 Departments of Neurology and Neurosurgery, University of South Florida, Tampa, Florida, USA
  3. 3 Division of Neurosurgery, University of Arizona, Tucson, Arizona, USA
  4. 4 Sentara Martha Jefferson Medical and Surgical Associates, Charlottesville, Virginia, USA
  5. 5 Department of Neurosurgery, University of Texas at San Antonio, San Antonio, USA
  6. 6 Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  7. 7 Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
  1. Correspondence to Dr Peter Kan, Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA; peter.kan{at}


Background The pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA.

Methods Institutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study.

Results 10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up.

Conclusions The PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection.

  • posterior inferior cerebellar artery
  • bypass
  • pipeline embolization device
  • flow diversion
  • aneurysm
  • anastomosis
  • vertebral artery

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  • Contributors VMS, OER, TMD, JG, RG, ASP, SRC, JJ, and PK: collection of data. VMS, MGZG, and PK: interpretation of the data. VMS, MGZG, JC, SRC, JJ, and PK: drafting of the manuscript. VMS, MGZG, JC, SRC, JJ, and PK: critical revision of the manuscript. VS, MGZG, OR, JC, MM, TMD, JG, RG, ASP, SRC, JJ, and PK: approval of the final version of the manuscript. VMS and PK: conception and design of the study. MGZG and PK: manuscript correspondence.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval The study was approved by the local institutional review boards at each institution.

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