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Clinical presentation and treatment of distal posterior inferior cerebellar artery aneurysms

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Abstract

Aneurysms located at the distal portion of the posterior inferior cerebellar artery (PICA) are rare, and their clinical features are not fully understood. We report the clinical features and management of 30 distal PICA aneurysms in 28 patients treated during the past decade at Kagoshima University Hospital and affiliated hospitals. Our series includes 20 women and eight men. Of their 30 aneurysms, 24 were ruptured, and six were unruptured; there were 27 saccular and two fusiform aneurysms; one was dissecting. Their location was at the anterior-medullary (n = 4), lateral-medullary (n = 9), tonsillomedullary (n = 7), telovelotonsillar (n = 6), and cortical (n = 4) segment of the PICA. In 18 patients, angiographic features suggested hemodynamic stress including an absent contralateral PICA or ipsilateral anterior inferior cerebellar artery, termination of the vertebral artery (VA) at the PICA, and hyperplasia or occlusion of the contralateral VA. As three patients died before surgery, 27 aneurysms in 25 patients were surgically treated. Of these, 6 were unruptured aneurysms; 20 were clipped via midline or lateral suboccipital craniotomy, and 5 were embolized with Guglielmi coils; in one, the PICA flow was reconstructed by OA-PICA anastomosis, and in the other one, the PICA was resected. Of the 25 surgically treated patients, 22 (88%) had good outcomes. The predominant contributor to the development of distal PICA aneurysms is thought to be increased hemodynamic stress attributable to anomalies in the PICA and related posterior circulation. Both direct clipping and coil embolization yielded favorable outcomes in our series. However, considering the difficulties that may be encountered at direct clipping in the acute stage and the availability of advanced techniques and instrumentation, aneurysmal coiling is now the first option to address these aneurysms.

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Acknowledgments

The authors are indebted to Drs. Koichi Uetsuhara and Masayuki Atsuchi, directors of Kagoshima City Hospital and Atsuchi Neurosurgical Hospital, for referring many patients and to Mr. Yusaku Hashinoki for technical assistance.

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Authors and Affiliations

  1. Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan

    Hiroshi Tokimura, Takashi Kamezawa, Tetsuya Nagayama, Sei Sugata, Kosuke Takiguchi, Ayumi Taniguchi, Masaki Niiro, Tatsuki Oyoshi & Kazunori Arita

  2. Division of Neurosurgery, Kagoshima City Hospital, Kagoshima, Japan

    Hitoshi Yamahata & Kazuho Hirahara

  3. Division of Neurosurgery, Sendai Shimin Hospital, Satsumasendai, Japan

    Kenichiro Tajitsu

  4. Division of Neurosurgery, Atsuchi Neurosurgical Hospital, Kagoshima, Japan

    Koji Takasaki

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  1. Hiroshi Tokimura
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  2. Hitoshi Yamahata
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Correspondence to Hiroshi Tokimura.

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Comments

Siamak Asgari, Ingolstadt, Germany

The authors reported about 28 patients with 30 aneurysms located at the distal portion of the PICA. Three patients died without therapy. Twenty-seven aneurysms in 25 patients were treated by microsurgery (n = 22) or coil embolization (n = 5). The authors presented three of these patients in detailed case reports. Additionally, an analysis of the clinical and porphological features was given including appropriate tables. Since this paper described a very large series of these rare aneurysms, it is of high interest for vascular neurosurgeons. Especially a detailed analysis of different coexisting anomalies of the posterior intracranial arterial circulation addressing hemodynamic stress is of great interest for the reader. Though in this series mycotic aneurysms were not detected, the possibility of infectious origin for developing distal PICA aneurysms has to be investigated. Interventional neuroradiologists treat aneurysms of the distal PICA, too. The risk of GDC packing a distal PICA aneurysm is high. Therefore, I recommend microsurgical treatment. The authors have to be congratulated for their revascularization surgery in one of the patients.

William T. Couldwell, Salt Lake City, USA

In “Clinical presentation and treatment of distal posterior inferior cerebellar artery aneurysms,” Tokimura et al. describe their experience with 30 distal posterior inferior cerebellar artery (PICA) aneurysms in 28 patients seen in a recent 10-year period. These are rare lesions, representing less than 1% of the aneurysms seen at their institution over this period. Of these 28 patients, 24 presented with SAH related to the distal PICA aneurysm. The treatment of the lesions is described. Roughly, 50% of the lesions were seen on each side, in contrast to more common proximal vertebral aneurysms in which the left side predominates.

Of the 20 aneurysms treated with surgery, only nine were treated acutely. In addition, two other patients deteriorated from rebleed prior to treatment. This represents a departure from our treatment, which optimally results in early treatment in all patients who are determined within the first 24 h to have suffered a potentially survivable SAH. Of the 27 surgically treated, including six unruptured aneurysms, 20 were clipped; in one, the PICA flow was reconstructed by OA-PICA anastomosis; in one, an aneurysm was resected; and 5 were embolized with Guglielmi coils. These various tailored surgical approaches and endovascular treatments used represent the options to manage these lesions depending upon the vascular anatomy and location of the aneurysm on the distal PICA.

Of the treated aneurysms, the vast majority (88%) of the patients had a good outcome, which attests to the authors' skill in their management. I thank the authors for sharing this experience with the readership.

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Tokimura, H., Yamahata, H., Kamezawa, T. et al. Clinical presentation and treatment of distal posterior inferior cerebellar artery aneurysms. Neurosurg Rev 34, 57–67 (2011). https://doi.org/10.1007/s10143-010-0296-z

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