PICA Aneurysm Research Articles

The Association and Treatment of Distal PICA Aneurysms with Posterior Fossa Arteriovenous Malformation: A Case Series (P3.115)

The Association and Treatment of Distal PICA Aneurysms with Posterior Fossa Arteriovenous Malformation: A Case Series (P3.115)

Complexity of Treatment for Pica Aneurysm: A Case Series and Review of Literature

Complexity of Treatment for Pica Aneurysm: A Case Series and Review of Literature

Re-Growth of a Posterior Inferior Cerebellar Artery Aneurysm after Resection of the Associated Posterior Fossa Arteriovenous Malformation

Arteriovenous malformation (AVM)-related aneurysms have been described in the literature. Their behavior varies based on their location in relation to and the activity of the shunting through the index AVM. The intuitive expectation supported by numerous reports is that these aneurysms should regress if the AVM is excluded from the circulation. We describe a case of 46-year-old man who presented with a posterior fossa AVM with an aneurysm on the posterior inferior cerebellar artery feeding the AVM. The nidus of the AVM was successfully excluded by glue embolization, with initial regression of the PICA aneurysm on serial imaging. Five years after the endovascular treatment, the aneurysm showed significant re-growth necessitating endovascular coiling. This case presents the re-growth of an AVM-related aneurysm and emphasizes the importance of long-term follow-up of such aneurysms even if the AVM is completely excluded.

Endovascular treatment of ruptured proximal PICA aneurysms: a single-center 5-years experience.

Posterior inferior cerebellar artery (PICA) like other intracranial arteries is prone to aneurysm formation. Aneurysms usually arise from the vertebral artery (VA) - PICA junction and the proximal segment of the PICA. The use of endovascular treatment as an alternative treatment to surgery has been increasing. We present our last 5 years' experience in treating the ruptured proximal PICA aneurysms. Retrospective analysis of records of all patients with ruptured VA-PICA junction aneurysms treated at our referral center between July 2008 and July 2013 was performed. Over the last 5 years, we came across 17 patients who had aneurysms of proximal PICA or VA-PICA junction out of which 13 patients underwent endovascular treatment for ruptured saccular VA-PICA junction aneurysms and were the focus of this research. Follow-up studies ranged from 6 months to 3 years. All the patients presented with an acute intracranial hemorrhage on NCCT. All the aneurysms were at VA-PICA junction with partial or complete incorporation of PICA origin in the sac. Endovascular treatment of all the 13 aneurysm was successful in the first attempt. Aneurysms were treated with balloon assisted coiling either by placing the balloon across the VA-PICA junction (n = 3) or in the vertebral artery proper (n = 9). Stent assisted coiling VA-PICA was performed in one aneurysm (n = 1). There was no intra-procedural rupture of the aneurysms. Endovascular therapy of ruptured proximal PICA aneurysms is possible and safe with the use of adjuvant devices and should be considered as first line treatment.

E-063 Endovascular treatment of intracranial aneurysms using a new, low profile intracranial micro-catheter: Initial experience

IntroductionEndovascular treatment of intracranial aneurysms has gained wide acceptance and, in many clinical situations, considered the first line therapy. Despite the technological advancements in the last 2 decades, significant challenges...

Near-infrared indocyanine green videoangiography (ICGVA) and intraoperative computed tomography (iCT): are they complementary or competitive imaging techniques in aneurysm surgery?

In this pilot study we compared advantages and drawbacks of near-infrared indocyanine green videoangiography (ICGVA) and intraoperative computed tomography (iCT) to investigate if these are complementary or competitive methods to acquire immediate information about blood vessels and potential critical impairment of brain perfusion during vascular neurosurgery. A small subset of patients (n = 10) were prospectively enrolled in this feasibility study and received ICGVA immediately after placement of the aneurysm clips. An intraoperative cranial CT angiography (iCTA) was followed by dynamic perfusion CT scan (iCTP) using a 40-slice, sliding-gantry, CT scanner. The vascular patency of major (aneurysm bearing) arteries, visualisation of arising perforating arteries and brain perfusion after clip application were analysed with both techniques. The ICGVA was able to visualise blood flow and vascular patency of all major vessels and perforating arteries within the visual field of the microscope, but failed to display vessels located within deeper areas of the surgical field. Even small coverage with brain parenchyma impaired detection of vessels. With iCTA high image quality could be obtained in 7/10 cases of clipped aneurysms. Intraoperative CTA was not sufficiently evaluable in one PICA aneurysm and one case of a previously coiled recurrent aneurysm, due to extensive coil artefacts. Small, perforating arteries could not be detected with iCTA. Intraoperative CTP allowed the assessment of global blood flow and brain perfusion in sufficient quality in 5/10 cases, and enabled adequate intraoperative decision making. A combination of ICGVA and iCT is feasible, with very good diagnostic imaging quality associated with short acquisition time and little interference with the surgical workflow. Both techniques are complementary rather than competing analysing tools and help to assess information about local (ICGVA/iCTA) as well as regional (iCTA/iCTP) blood flow and cerebral perfusion immediately after clipping of intracranial aneurysms.

Subarachnoid haemorrhage from PICA aneurysm rupture in a Churg–Strauss patient: A case report and a review of the literature

Churg–Strauss syndrome (CSS) is a systemic small vessel vasulitis, typically presenting as bronchial asthma, eosinophilia nd peripheral neuropathy and occasionally involving the cenral nervous system (CNS). CSS presenting with a subarachnoid emorrhage (SAH) is particularly rare. We report the case of a 64ear-old woman affected by CSS experiencing left Posterior Inferior erebellar Artery (PICA) aneurysm bleeding, requiring two-step ndovascular treatment due to aneurysm recurrence. We reviewed he literature and analyzed the potential correlations between a ecurrent, documented increase of vasculitis markers, aneurysm upture and aneurysm recurrence.

Clinical experiences of ruptured posteroinferior cerebellar artery aneurysms and anatomical analysis in the Cadaver in a single center of China

ObjectivePosteroinferior cerebellar artery (PICA) aneurysms are uncommon and have not been well investigated previously. We report our series of 29 ruptured PICA aneurysms with surgical treatment along with the description of the surgical anatomy of the PICA to the lower cranial nerves in cadaveric specimen. MethodsAll patients with ruptured PICA aneurysms who were surgically treated at the First Affiliated Hospital of Soochow University during the period from January 1995 to December 2008 were reviewed retrospectively. Data relating to clinical, radiological, and intraoperative findings were analyzed. Forty formalin-fixed cerebellar hemispheres provided the material for the study of describing the detailed surgical anatomic relationship of the PICA to the lower cranial nerves. ResultsIn our series, ruptured PICA aneurysms reached an incidence of 2.35% of all ruptured intracranial aneurysms. There were 13 aneurysms (44.8%) located in the proximal segment, and 16 (55.2%) located in the distal segment. Of these, 89.7% were saccular, 6.9% fusiform, and 3.4% dissecting aneurysms. Usually, the surgical outcome was influenced by Poor admission grade, the presence of obstructive hydrocephalus and associated distal AVM. In cadaveric specimen, 17.5% of PICAs passed between the glossopharyngeal and vagus nerves, 7.5% between the vagus and accessory nerves, and 62.5% through the rootlets of the accessory nerve. ConclusionThis report summarizes the presentation and outcome of a large series of 29 patients with ruptured PICA aneurysms, and we conclude that ruptured PICA with surgical treatment usually gets well recovered. The study does, however, also demonstrate that the anatomic relationship of the PICA and lower cranial nerves is somehow variable and irregular. Recognition of the findings in cadaveric dissection is essential in treating lesions of this region.

Delayed Spontaneous Rupture of a Posterior Inferior Cerebellar Artery Aneurysm Following Treatment with Flow Diversion: A Clinicopathologic Study

In this report, we present the fatal spontaneous delayed rupture of a previously unruptured large PICA aneurysm following treatment with the PED. Pathology at postmortem examination has supported the theory that intra-aneurysmal thrombus may acutely destabilize the aneurysm wall. Aneurysms with an anatomic arrangement that promote continued flow into the neck may not be optimal candidates for the flow-diversion treatment strategy.

Cerebral aneurysm associated with cardiac myxoma: Case Report

Left atrial myxomas are a rare but well known cause of cerebrovascular accidents in young people. Cerebral embolism is the most common cause of cerebral ischemic stroke. The intracranial aneurysm is rarely associated with myxoma. We report the case of a patient who had an operation of PICA aneurysm due to subarachnoid hemorrhage ten months before the discovery of the large left atrial myxoma. Fortunately, the untimely diagnosis of the myxoma did not have other consequences. In order to prevent possible complications of we should keep in mind that these two apparently different entities could be associated.

The utility of angiographic CT in the diagnosis and treatment of neurovascular pathologies in the vicinity of cranial base

This study aims to explore the utility of angiographic computed tomography (CT) in the diagnosis and treatment of neurovascular pathologies in the vicinity of cranial base. Two cases of cranial base dural arteriovenous fistula, one internal carotid pseudoaneurysm and one PICA aneurysm were demonstrated utilizing the angiographic CT for obtaining significant image details on the relative location of the diseases against the neighboring bony structure. An angiography suite outfitted with conventional DSA and rotational volume cone-beam was used, angiographic CT images being concomitantly produced together with the routine angiographic modalities. By virtue of the angiographic CT images integrating the selective angiography and reconstructed cranial base tomography, we succeeded in getting significant information on the relative location of various vascular diseases to the skull base, greatly facilitating the diagnosis and treatment procedures.

The clip-wrap technique in the treatment of intracranial unclippable aneurysms

Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Delayed post-traumatic saccular aneurysm of PICA in an adolescent

Delayed traumatic intracranial aneurysms of the posterior circulation caused by nonpenetrating head injury are rare, especially in pediatric patients. The true incidence and natural history of these aneurysms are poorly understood. We report a case of a 15-year-old boy who initially presented with subarachnoid hemorrhage of the posterior fossa without any evidence of associated aneurysm. On a routine computed tomography of the head, however, he was found to have a saccular aneurysm of the proximal posterior inferior cerebellar artery. The patient was treated successfully by microsurgical clipping and PICA/PICA bypass.

Aneurysms from extracranial, extradurally originating posterior inferior cerebellar arteries: a rare case report

Background Aneurysms arising from the PICA are infrequent and those arising from an extracranially originating PICA in the extracranial intradural region are even rare. We report a case of bilaterally extracranial extradurally originating PICAs, each of which had an aneurysm, both being situated below the foramen magnum. This to the best of our knowledge is the first of its kind to be reported. Case Description A 35-year-old woman presented with giddiness and headache of 2-day duration. CT scan head revealed blood in the 4 th ventricle. 4 vessel angiogram revealed bilateral extracranial, extradural origin of PICAs from the vertebral arteries between C1 and C2 vertebrae. Both PICAs were associated with a saccular aneurysm each, both of which were extracranial. She underwent a midline suboccipital craniectomy, C1 arch excision, and clipping of both aneurysms. Conclusions We report a very rare case of bilateral extracranial PICA aneurysms from an aberrantly originating PICA (ie, extracranial and extradural).

Endovascular Trapping of a Vertebral Artery Segment to Control PICA Origin Tearing

Iatrogenic perforation or rupture during aneurysm coiling can be difficult to manage and may lead to fatal bleeding. We describe a lifesaving technique of isolating the subarachnoid segment of the vertebral artery using two balloons to trap flow to a ruptured PICA aneurysm allowing time to coil the parent artery with the aneurysm. A 58-year-old woman presented with Hunt Hess Grade 3 subarachnoid hemorrhage due to a 3 mm left PICA aneurysm. During placement of the first coil, aneurysm perforation was noted. Despite conventional measures to manage the perforation (anticoagulation reversal, balloon inflation, placement of a second coil, and ventricular drain), contrast extravasation persisted after 45 minutes. A second balloon was positioned via the right vertebral artery at the right vertebrobasilar junction and inflated. The first balloon was pulled back, inflated, allowing trapping of the ruptured site. The aneurysm and adjacent vertebral segment were rapidly coiled to occlude the ruptured site under local flow arrest. The patient awoke with dysarthria, left-sided hemiparesis and dysphagia. Trapping an arterial segment with two balloons may help in the management of PICA origin aneurysm perforation refractory to medical and current endovascular strategies. This technique, while potentially lifesaving, may engender ischemic complications.

PICA Aneurysms: Operative Outcome

Aim: A retrospective study of PICA aneurysms surgically managed from January 1980 to February 2008 was carried out to study the operative outcome.

Clinical presentation and treatment of distal posterior inferior cerebellar artery aneurysms: report on 5 cases

Background Aneurysms of the PICA are uncommon. Most of them arise at the PICA origin from the VA, whereas distal PICA aneurysms are exceptional. A retrospective analysis of 457 patients with SAH treated in our hospital found 5 patients with 6 distal PICA aneurysms (approximately 1% of SAHs). Case Description All patients were female, with a mean age of 54 years. A 4-vessel cerebral angiogram performed immediately after admission showed an aneurysm located on the distal PICA. One patient was treated by an endovascular approach, and 3 patients were treated by surgical approach. The last patient had 2 distal high-flow aneurysms located on the distal PICA, which was the main arterial feeder of an AVM. The patient refused surgery or endovascular therapy. All 4 treated patients had good outcome at 3-month clinical follow-up. Conclusions Distal PICA aneurysms are exceptionally rare and may be treated successfully with surgical or endovascular techniques. The therapeutic strategy, either surgical or endovascular, should be selected according to the condition of the patient, the arterial and aneurysmal morphology, and the preference of the medical team.

Distal posterior cerebellar artery aneurysm: Case report

Vertebrobazilar aneurysms make about 15% of all intracranial aneurysms, from which one fifth belongs to aneurysms a posterior inferior cerebelli (PICA). Majority of PICA aneurysms is located in the place of separation from a.vertebralis. Aneurysms of distal part of PICA are very rare, according to literature they make 0.5 to 3% of all aneurysms. 70 years old man came to neurologist because sudden headache, pain in the neck and a feeling of stiffness followed by throwing up in stream. On the occasion of medical check up attack of spontaneous subarachnoid hemorhage was suspected. Clinical gradus according to H&H III, initial CT of endocranium showed existence of smaller intracerebellar hematoma next to lateral wall of IV ventricle and trace of blood in the very ventricle without signs of acute hydrocephalus. The seventh day after the hemorrhage angio CT was done and it showed existence of aneurysm on distal part of PICA, more specially in the televelotonzilar segment on the right. After the diagnostics supplemented with standard digital substractional angiography which confirmed nature and localization of the lesion. In the postponed procedure, and in conformity with strategy of surgical timing of aneurysms in the back circulation, patient was operated three weeks after the attack of hemorrhage. Disregarding low incidence of existence of aneurysms of distal circulation (under 1% of all in the back circulation) high level of suspicion should be present and angio CT should be done as screening method, if CT shows hemorrhage which according to localization responses to possible aneurysm.

Posterior inferior cerebellar artery with extracranial origin harboring an extracranial aneurysm

Background We report on a rare case of a saccular aneurysm on the TM segment of the right PICA. The aneurysm was located at the nonbifurcation region of the PICA. Case description The patient underwent a brain CT scan that revealed a diffuse SAH and an IVH in the fourth ventricle with obstructive hydrocephalus. After external ventricular drainage to relieve the hydrocephalus, the aneurysm was demonstrated by cerebral digital subtraction angiography. Conclusions The origin of the PICA aneurysm was extracranial and intradural, illustrating a rare location of such type of aneurysm.

Hiccup and neurosurgeons: a report of 4 rare dorsal medullary compressive pathologies and review of the literature

Objective The aim of this study was to present 4 rare cases of medullary compressive lesions presenting with IH, to discuss the indications for neurosurgical decompression in such cases, and to review the possible etiologies of IH briefly. Methods The reported cases include (1) a 19-year-old adolescent boy and a 21-year-old man with Chiari I malformation and cervical syrinx compressing or tightening the cervico-medullary junction; (2) a 35-year-old man with ependymoma extending from the lower half of the fourth ventricle to C1/C2 junction and compressing this part of the medulla; and (3) a 16-year-old adolescent boy who was referred to the emergency department in severe distress because of IH, occurring as a result of a distal PICA aneurysm located on the floor of the lower triangle of the fourth ventricle. Results Surgical decompression in all the cases was successful in withholding the hiccups. Conclusion The dorsal medullary area is not an unusual location for genesis of hiccup. When encountering a case of IH, appropriate CNS imaging studies should be included in the evaluation protocol.