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Case series
Endovascular sacrifice of the proximal posterior inferior cerebellar artery for treatment of ruptured intracranial aneurysms
  1. James G Malcolm1,
  2. Jonathan A Grossberg1,
  3. Nealen G Laxpati1,
  4. Ali Alawieh1,2,
  5. Frank C Tong3,
  6. C Michael Cawley1,3,
  7. Brian M Howard1,3
  1. 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2 Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3 Department of Radiology and Imaging Sciences, Emory University, Altanta, Georgia, USA
  1. Correspondence to Dr Brian M Howard, Neurosurgery, Emory University School of Medicine, Atlanta GA 30322, Georgia, USA; brian.howard{at}


Background Ruptured aneurysms of the intracranial vertebral artery (VA) or posterior inferior cerebellar artery (PICA) are challenging to treat as they are often dissecting aneurysms necessitating direct sacrifice of the diseased segment, which is thought to carry high morbidity due to brainstem and cerebellar stroke. However, relatively few studies evaluating outcomes following VA or proximal PICA sacrifice exist. We sought to determine the efficacy and outcomes of endovascular VA/PICA sacrifice.

Methods A retrospective series of ruptured VA/PICA aneurysms treated by endovascular sacrifice of the VA (including the PICA origin) or proximal PICA is reviewed. Collected data included demographic, radiologic, clinical, and disability information.

Results Twenty-one patients were identified. Median age was 57 years (IQR 11); 15 were female. The Hunt and Hess grade was mostly 3 and 4 (18/21). Seven cases (33%) involved VA-V4 at the PICA take-off, and 14 cases (67%) involved the PICA exclusively. For VA pathology, V4 was sacrificed in all cases, while for PICA pathology, sacrificed segments included anterior medullary (4/14), lateral medullary (7/14), and tonsillomedullary (3/14) segments. Four patients went to hospice (19%). Twelve patients (57%) had evidence of stroke on follow-up imaging: cerebellar (8), medullary (1), and both (3). One patient required suboccipital decompression for brainstem compression. No aneurysm re-rupture occurred. Median discharge modified Rankin Scale score was 2.0 (IQR 2), which decreased to 1.0 (IQR 1) at median follow-up of 6.5 months (IQR 23).

Conclusions Endovascular sacrifice of V4 or PICA aneurysms may carry less morbidity than previously thought, and is a viable alternative for poor surgical candidates or those with good collateral perfusion.

  • aneurysm
  • stroke
  • subarachnoid
  • hemorrhage
  • intervention

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  • JGM and JAG contributed equally.

  • Contributors JGM and JAG contributed equally. Design: JGM, JAG, NGL, BMH. Data collection: All authors. Analysis: JGM, JAG, BMH. Drafting manuscript: All authors. Critical review/revision: All authors. Study supervision: JAG, BMH.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Emory University IRB (approval IRB00069747) with waiver of informed consent due to retrospective collection and analysis of de-identified data.

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