PICA Aneurysm Research Articles

8536 Unusual Finding of Familial Adenomatous Polyposis in a Patient with X Linked Adrenoleukodystrophy

Abstract Disclosure: A. Deswal: None. A. Dwarakanathan: None. Introduction: X Linked Adrenal Leukodystrophy (X-ALD) is a rare hereditary genetic disorder of impaired peroxisomal metabolism due to a defective transmembrane protein, ADLP. Defective ADLP impairs transport of VLCFA-CoA esters across cytosol into peroxisomes leading to build-up of toxic VLCFA in the cells. X-ALD is caused by mutation in ABCD1 gene, located on X chromosome, which codes for ADLP. It has a broad clinical spectrum including Cerebral ALD, Adrenomyeloneuropathy and Adrenocortical insufficiency. X-ALD has a general prevalence of 1 in 17,000 newborns. Approximately 80% of males with X-ALD develop primary adrenal insufficiency in their lifetime. It can be diagnosed by measuring VLCFA levels in plasma , checking for ABCD1 gene mutation or by doing Brain MRI (depending upon phenotypical presentation ). Case presentation: We report a case of a 23 year old man who had primary adrenocortical insufficiency subtype of X-ALD. His mother was a carrier of ABCD1 gene mutation. He himself tested hemizygous for ABCD1 gene. He came to our office for a follow up visit after an episode of adrenal crisis for which he was hospitalized. He was started on replacement therapy with prednisone and fludrocortisone. Over the next couple of years, he was diagnosed with diabetes mellitus with initial HbA1C of 8.8%. GAD antibody test for type I DM came out negative. His diabetes was managed with metformin and pioglitazone( later discontinued) .By the age of 25,he was found to have polyposis of colon. He tested positive for APC gene mutation . He underwent a J pouch surgery . He also developed PICA aneurysm. Discussion: X-ALD is a hereditary progressive disease with no association between genetic and phenotypic presentations. Adrenal insufficiency type is usually the first to present. Cerebral ALD is typically diagnosed between the ages of 3-18 presenting as psychiatric illness. Myelopathy typically starts by middle age and involves the spinal cord, causing the affected individuals to develop gait disturbances , bladder and bowel dysfunction, with severe mobility dysfunction by 5th-6th decade of life. We present a unique case of a young man with adrenal insufficiency type of X-ALD who also developed gastrointestinal pathology. Per our literature review, X-ALD has not been seen associated with APC gene mutations or colon carcinomas . Pathology behind XLD revolves around ABCD1 gene mutaion causing VLCFA accumulation in plasma, fibroblasts, adrenal glands, oligodendrocytes , astrocytes etc. Whereas FAP involves APC gene mutation which affects the intestinal epithelial cells leading to their apoptosis and polyp formation. X-ALD and FAP are disorders of two different gene mutations with varied clinical presentations. But the question arises regarding finding of APC gene mutation in a patient with ABCD1 gene mutation that if it is a mere co-incidence or common mutation pathway linking these two disorders exists. Presentation: 6/2/2024

The safety and utility of the semi-sitting position for clipping of posterior circulation aneurysms

BackgroundThe semi-sitting position offers advantages for surgeries in the posterior cranial fossa. However, data on its safety and effectiveness for clipping aneurysms in the posterior cerebral circulation are limited. This retrospective cohort study evaluates the safety and effectiveness of using the semi-sitting position for these surgeries.MethodsWe conducted a retrospective study of 17 patients with posterior cerebral circulation aneurysms who underwent surgical clipping in the semi-sitting position in the Department of Neurosurgery at Hannover Medical School over a 10-year period.ResultsThe mean age at surgery was 62 years (range, 31 to 75). Fourteen patients were admitted with subarachnoid hemorrhage and 3 patients had incidental aneurysmas. Fifteen patients had PICA aneurysms, and two had aneurysms of the vertebral artery and the superior cerebellar artery, respectively. The median diameter of the aneurysms was 5 mm (range 3–17 mm). Intraoperative venous air embolism (VAE) occurred in 4 patients, without affecting the surgical or clinical course. VAE was associated with a mild decrease of EtCO2 levels in 3 patients and in 2 patients a decrease of blood pressure occurred which was managed effectively. Surgical procedures proceeded as planned in all instances. There were no complications secondary to VAE. Two patients died secondary to respiratory problems (not related to VAE), and one patient was lost to follow-up. Eleven of fourteen patients were partially or completely independent (Barthel index between 60 and 100) at a median follow-up duration of 13.5 months (range, 3–103 months).ConclusionThe semi-sitting position is a safe and effective technique for the surgical clipping of aneurysms in the posterior cerebral circulation. The incidence of VAE is comparable to that seen in tumor surgery. However, it is crucial for the surgical and anesthesiological team to be familiar with potential complications and to react immediately in case of an occurrence of VAE.

PICA flow-related aneurysms and posterior fossa AVM: rare association and challenging management: case presentation and review of literature

BackgroundThe association of an infratentorial arteriovenous malformations (AVMs) with a PICA aneurysm is very rare and the presence of associated aneurysms was an independent predictive factor of poor outcome at follow-up for posterior fossa AVMs (pfAVMs). We report the case of a 57-year-old female patient admitted to our institution with a challenging management of a pfAVM associated with multiple flow-related aneurysms of the PICA.Case presentationA 57-year-old patient with no medical past history was admitted to our emergency department with a sudden onset headache and severe neck stiffness. A cerebral CT Scan showed a cerebellar hematoma. Digital subtraction angiography demonstrates a right paramedian supero-posterior infratentorial AVM located at the posterosuperior part of the right cerebellar hemisphere with a small compact nidus supplied by branches of the right PICA and the right superior cerebellar artery. Venous drainage being toward the torcular. The AVM is associated with 3 flow-related aneurysms. We opted for surgical treatment of the 2 high-flow aneurysms on the distal branch of the right PICA. Patient was then sent for radiosurgery for the AVM. We opted for observation of the left small aneurysm.ConclusionMicrosurgery for PICA aneurysms is particularly well suited because exposure through a far-lateral craniotomy is excellent. Endovascular embolization can be used to occlude the aneurysm as well as treat the AVM at the same time in certain circumstances. Clipping or coiling the aneurysm should be discussed in a multidisciplinary meeting.

Treatment of Proximal Posterior Inferior Cerebellar Artery Aneurysms by Intrasaccular Flow Disruption: A Multicenter Experience.

Treatment of PICA aneurysms can be technically challenging by either surgical or endovascular means. Our aim was to report our preliminary experience with intrasaccular flow disruption using the Woven EndoBridge (WEB) for the treatment of proximal PICA aneurysms. Sixteen PICA aneurysms treated with the WEB at 3 institutions were retrospectively reviewed. Baseline patient and aneurysm characteristics, procedural specifics, clinical outcomes, and angiographic results were evaluated. All aneurysms were located at the proximal, anteromedullary segment of the PICA. Seven aneurysms were ruptured. The median aneurysm size was 3.9 mm (range, 2-12 mm), and all aneurysms were wide-neck. WEB deployment failed in 1 case due to WEB protrusion in a small PICA aneurysm. Additional stent implantation was required for 2 aneurysms to improve intra-aneurysmal WEB positioning. One patient developed a partial posterior cerebral artery territory infarction with transient hemianopsia. Intraoperative rerupture of a ruptured aneurysm could be immediately stopped by WEB deployment due to intrasaccular stasis; however, it might have contributed to a slight disability of the patient. At last angiographic follow-up, 12/15 aneurysms (80%) were completely occluded and 3/15 (20%) had a neck remnant. The preliminary results indicate that WEB treatment of proximal PICA aneurysms is feasible with a reasonable safety and efficacy profile. The advantages of intrasaccular flow disruption include preservation of the PICA, durable aneurysm occlusion, and omission of antiplatelet therapy. The low-profile WEB 17 delivery system might enable navigation to distal PICA aneurysms, which needs to be addressed further.

An Audacious Voyage during COVID-19 Pandemic in Management of Patients with Aneurysmal Subarachnoid Hemorrhage at Annapurna Neurological Institute and Allied Sciences

Introduction: Aneurysmal Subarachnoid Hemorrhage(SAH) is a neurosurgical emergency for which testing for COVID PCR was not an option and was unlikely to change the management of the case. Hence, all surgeries were performed without COVID PCR and Rapid Diagnostic Test (RDT) at our center for the welfare of the patient despite risks involved for the surgeons and supporting staff.
 Methods: Data were collected retrospectively of all cerebral aneurysm patients who received treatment at Annapurna Neurological Institute and Allied Sciences during the covid pandemic between February 2020 to May 2021. Their demographic profile, clinical and imaging characteristics, treatment decision, postoperative complication, postoperative functional status in terms of Modified Rankin Scale were taken into consideration and analyzed.
 Result: 63 patients were enrolled in study with patient age ranging from 9 years to 81 years. Male to female ratio was 1:3. Amongst them, 28% had hypertension. 82% underwent microsurgical clipping while three patients underwent coiling. Basilar Top aneurysm, Para clinoid aneurysm, PICA aneurysm underwent simple coiling. Wrapping, bypass and trapping were performed in 1,1, and 3 cases respectively. At the time of discharge, most of the patients (77%) achieved good functional recovery (mRS ≤ 2) while mortality was reported in 8% of patients. Based on our experience and limited dataset, posterior location of aneurysm, increasing HuntHess Grade and modified fisher grade had poor prognosis, related with degree of cerebral vasospasm, and delayed cerebral ischemia.
 Conclusion: Results from our study showed outcomes in surgical patients with aneurysmal SAH at par with international standards. COVID pandemic although posed initial difficulties, with proper guidelines and protocols in place, we were able to perform the emergency surgeries without compromising our standards.

Partially Thrombosed Giant Posterior Inferior Cerebellar Artery Aneurysm Mimicking a Fourth Ventricular Tumour

Posterior circulation aneurysms are less common compared to the anterior circulation aneurysms. Dissection distal Posterior Inferior Cerebellar Artery, PICA, aneurysm is very uncommon. In this case report, we describe an adult who had distal PICA aneurysm in the 4^th ventricle which radiologically and symptomatically mimics a fourth ventricular mass lesion. Our aim is to add to the literature about rare but possible differential diagnosis of 4^th ventricular tumour.

Pipeline embolization of distal posterior inferior cerebellar artery aneurysms.

Flow diversion is commonly used to treat intracranial aneurysms in various regions of the cerebral vasculature, but is only approved for use in the internal carotid arteries. Treatment of distal PICA aneurysms with PED is sometimes performed but has not been well studied. Here, we report our experience with flow diversion of distal PICA aneurysms with PED. Clinical and angiographic data of eligible patients was retrospectively obtained and assessed for key demographic characteristics and clinical and angiographic outcomes. Principal outcomes included rates of aneurysm occlusion, ischemic or hemorrhagic complication, technical complication, and in-stent stenosis. Three female and 2 male patients underwent placement of PED in the PICA for treatment of 5 distal PICA aneurysms. Clinical and angiographic follow-up was obtained for all patients. Complete aneurysm occlusion was observed in 100% (5/5) of treated aneurysms at 6 month and longest angiographic follow-up. While there were no ischemic or device-related complications, delayed hemorrhagic complications occurred in 20% (1/5) of patients. Pipeline embolization of distal PICA aneurysms can be performed in select patients. Further study is necessary in larger cohorts to better define clinical scenarios in which flow diversion in the distal PICA should be considered.

Cerebellar Syndrome Revealing a Giant Postero Inferior Cerebellar Artery Aneurysm: A Case Report and a Review of Literature

Context: Cerebellar syndrome caused by disturbances of balance and coordination is not an uncommon neurological disorder. It has varied etiologies usually caused by tumor processes or suppurative collections. Vascular causes remain very rare, especially when it is a giant aneurysm of PICA representing 1% of intracranial aneurysms. Treating giant PICA aneurysms is a very difficult task for neurosurgeons because the surgical dissection can lead to severe damage due to the intimate relationship of PICA with the brainstem or nerve structures. We report a case of giant PICA aneurysm responsible for cerebellar syndrome successfully treated with surgery. The objective of this work is to draw the attention of practitioners to this unusual cause which can lead to diagnosis wandering and a lack of planning at the time of management. Case report: A 65 years old hypertensive patient was seen for a progressive disturbance of balance and walking disorder, but worsened in the last three months with no notion of fever. On admission, the patient was lucid, oriented in time and space and presented with static and kinetic cerebellar syndrome. Brain CT-scan without and with contrast revealed a tissular mass in the posterior fossa suggesting a tumor process, however, CT angiography showed a giant aneurysm of the PICA after reconstruction. A careful microdissection by a sub-occipital approach was decided. Opening the large cistern made it possible to visualize the aneurysm sack surrounded by a yellowish gliosis. The reclining and microdissection revealed the neck of the aneurysm, which was clipped to exclude the giant aneurysm in block. Postoperative follow-up was simple with progressive improvement in the cerebellar syndrome and walking over three months. Conclusion: Giant aneurysm of the PICA is rare. The localization in the posterior cerebral fossa can be confusing. Microsurgery gives a good result.

Microsurgical Management of PICA Aneurysms

Microsurgical Management of PICA Aneurysms

Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment

ObjectiveDespite contemporary diagnostic and therapeutic techniques intracranial emergencies in the obstetric setting pose still a major challenge for the clinicians. There are limited guidelines and differing ethical views. Multidisciplinary teams are needed to support the pregnant woman in a way that she can deliver a viable and healthy child. The aim of the present study was to scrutinize the management of intracranial emergencies during pregnancy which needed urgent neurosurgical treatment. Patients and methodsData of all pregnant women who presented with newly diagnosed intracranial pathologies and neurological symptoms caused by these pathologies in an emergency setting were collected over a 10-year period (2008–2018). Patient characteristics including maternal age, gestational age, and preoperative work-up of both mother and fetus were recorded. Furthermore, the surgical treatment, mode of delivery, and neonatal and maternal outcomes were analysed. ResultsThe mean maternal age was 32.7 years and most patients were in their third trimester. There was one twin pregnancy (total of 12 fetuses). Five out of eleven pregnant women suffered from intracerebral haemorrhage (epidural haematoma (1), arteriovenous malformation (1), subarachnoid haemorrhage (2) and intracerebral haemorrhage (1)) and the other six patients had intracranial neoplasms (primary meningeal sarcoma (1), trigeminal schwannoma (1), anaplastic astrocytoma (2), glioblastoma (1) and sphenoid wing meningioma (1)).Neurosurgical procedures were performed via craniotomies in eight patients. A stereotactic biopsy via a frontal burr hole was achieved one patient. The two other patients with subarachnoid haemorrhage due to rupture of PICA aneurysms were treated with coil embolization. Depending on the gestational age and the clinical condition of the pregnant women it was decided to perform an emergency Caesarean section prior to further therapeutic measures in seven patients. Two out of 12 fetuses were unviable. Six women survived, while five women succumbed to the intracranial pathology. ConclusionThe individualized treatment approach in this peculiar obstetric scenario needs to consider various issues such as the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. The primary concern in this context must be the mother`s health and safety. Caesarean section is the primary mode of delivery in most cases. While contemporary care can insure survival for the majority of infants, maternal mortality still poses an extraordinary challenge. Interdisciplinary consulting of the patient and/or her family is necessary to develop a treatment strategy for both the expectant woman and her offspring.

Distal Aneurysms of Posterior Inferior Cerebellar Artery: Report of Two Cases

Arterial aneurysms of the PICA are rare. They account for either 1% or less [1,2] or up to 3% of all the intracranial aneurysms in different casuistic [3-5]. As rule they are located at the origin of the artery from the vertebral artery. Approximately 15% of these PICA aneurysms occur distally to the origin of the artery itself [5], a fact which indicates distal PICA aneurysms to be exceedingly rare: 268 of 9709 in Lehto et al. series [5], 60 of 2169 in Peluso et al. series [4], 27 patients from 1989 to 1997 in the Bertalanffy et al. review article [3]

Technical considerations and challenges in treatment of a ruptured PICA aneurysm in a morbidly obese patient

Morbid obesity presents unique challenges in the treatment of many neurosurgical conditions. In ruptured posterior circulation aneurysms, endovascular treatment has emerged as the safest and most efficacious treatment modality in the majority of cases. We present a technical report of a patient with extensive subarachnoid hemorrhage from a ruptured distal PICA aneurysm. The patient was taken to the hybrid OR with biplane fluoroscopy, utilizing a unique operative set-up to enable safe endovascular treatment. The PICA aneurysm was treated via a transradial approach with distal PICA occlusion using Onyx liquid embolysate. The patient remained neurologically intact and was discharged home after 14 days. This case illustrates a number of technical adjustments that may be made in the safe treatment of patients in whom obesity otherwise limits treatment options.

Abstract WP33: Early Lessons Learned From the WEB Device: Feasibility, Technique and Complications—A Real Life Experience

Introduction: Wide-neck bifurcation cerebral aneurysms have always posed a treatment challenge and have historically required either clip ligation, or stent vs. balloon-assisted coil embolization. This predicament led to the development of the newly FDA-approved Woven EndoBridge (WEB) aneurysm embolization system (Sequent Medical Inc, Aliso Viejo, CA) Which is a self-expanding mesh that achieves intrasaccular flow disruption and does not require antithrombotic medications. In this study, we report our experience with the first 64 consecutive aneurysms treated via WEB embolization at two high-volume institutions. Methods: We reviewed our first 61 consecutive patients with 64 cerebral aneurysms who underwent WEB embolization from February-August 2019. We collected data on patient demographics and clinical presentation, aneurysm characteristics, device and procedural details, and functional outcomes. Results: A total of 64 aneurysms were included in our study. Fifteen patients (24.1%) presented with acutely ruptured aneurysm while the rest were unruptured. The majority of patients (82.8%) required only one attempt for successful device deployment, while a stent was necessary as an adjunct treatment in 4 patients (6.3%) due to WEB herniation. Two patients had residual aneurysm that had to undergo additional treatment; one of them underwent second WEB embolization and one underwent clip ligation. One patient with a PICA aneurysm had device dislodgment with injury to the parent vessel—Onyx and coils were used to deconstruct the vertebral artery. Conclusions: The advent of the WEB device has significantly impacted the surgical decision-making for the treatment of bifurcation, wide-neck aneurysms. We discuss in detail the lessons learned from patient selection, device size selection, technique, and complications from two institutions with high-volume endovascular and microsurgical aneurysm treatment experience.

Posterior Inferior Cerebellar Artery Aneurysms: Comparison of Results of Surgical and Endovascular Managements at One Single Center.

The objective of this article is to report our experience with the two treatment approaches in patients with PICA aneurysms and find predictive factors for treatment-related complications. Between January 2011 and December 2015, patients with PICA aneurysm who underwent surgical and endovascular treatment were retrospectively collected and reviewed. Patients' demographic features, treatment-related complications, and long-term angiographic and clinical outcomes (modified Rankin Scale [mRS]) between the two groups were compared. Multivariable logistic analysis was used to find statistically significant predictive factors for treatment-related complications. A total of 55 PICA aneurysms were identified, 13 were ruptured, and 42 unruptured. Endovascular treatment was performed in 26 patients and surgical clipping in 29 patients. Treatment-related complications occurred in one patient in the embolization group compared with 9 in the microsurgical surgery group (3.8% vs. 31.0%, P = 0.010). Multivariate logistic analysis showed that treatment modality was the only predictor for treatment-related complications. A lower recurrence rate was found in the microsurgical surgery group compared with the embolization group (3.4% vs. 7.7%, P = 0.493). Clinical follow-up showed that endovascular treatment achieved better outcomes (mRS ≤2) compared with surgical treatment (96.2% vs. 89.7%, P = 0.359). This study of PICA aneurysms demonstrates that results of both treatment modalities are comparable. To obtain the best treatment outcomes, cooperation between interventional neuroradiologist and endovascular neurosurgeons in deciding the optimal treatment is essential.

36. All headaches are not GCA

IntroductionVasculitis is a heterogeneous group of autoimmune disorders having multisystem involvement. In many cases, the neurological disorders have an atypical clinical course or even an early onset, and the healthcare professionals should be aware of them.Case descriptionWe report a case of 57-year-old Asian male without any significant past medical history admitted under the urology department. He had presented with abdominal pain and fever and was being treated for presumptive pyelonephritis (on antibiotics). He was referred to rheumatology when he developed severe unilateral headache on right side with significant scalp tenderness. Headache involved temporal and fronto-parietal-occipital area with no jaw claudication or any significant visual disturbance. There was no limb claudication or polymyalgia symptoms. On examination he had new onset hypertension (BP:174/94mmHg), rest of the systemic examination was normal with no bruit. Musculoskeletal and skin examination was normal.Investigations included CRP of 204, hemoglobin 133, white cell count 15.2 (neutrophils: 12.06), creatinine 118 (eGFR 59). Liver function: normal. Urine dip: Normal and blood/urine culture: negative. Immunological profile and viral screen was negative. Urgent CT head was done for severe headache which was normal. Patient was referred to rheumatology with provisional diagnosis of giant cell arteritis due to headache and raised inflammatory markers. On reviewing his CT abdomen, the renal parenchyma showed symmetrical well demarcated bilateral involvement which was more in favor of renal infarct rather than pyelonephritis. CT angiography of abdomen was requested which showed multiple vessel involvement including mesenteric artery and bilateral renal arteries with beaded appearance and stenosis. MR angiogram showed 6mm aneurysm of PICA with stenosis of P1 segment of PCA. Currently he is being screened for ADA2 deficiency. During his stay his renal function deteriorated, not responding previously to antibiotics. He was started on methylprednisolone pulse and antibiotics stopped in view of worsening liver function. On day 3 of methylprednisolone pulse he had significant improvement of his headache with stabilization of renal and liver function. Our plan is to start him on steroid sparing therapy based on the ADA2 levels.DiscussionThe classification of vasculitis is still unsatisfactory as the patho-genetic mechanisms have not been fully understood. Existing criteria classify based on predominant vessel involvement but there is still some overlap between them. The prevalence of CNS involvement in medium vessel vasculitis ranges as widely as 2-10% and does not usually occur until late in the course of the disease. The most commonly reported CNS manifestation is diffuse encephalopathy, followed in frequency by focal deficits and seizures. Intracranial aneurysms are rare with around 15 reported cases usually multiple and located in supra- as well as infra-tentorial compartments. Most of the cases presented with subarachnoid or parenchymal hemorrhage. Treatment guidelines are still not clear and most are treated conservatively by medical management. Repeat hemorrhages or re-bleed in spite of medical treatment have also been reported Deficiency of ADA2 (DADA2) has been recently recognized first molecularly described monogenic vasculitis having biallelic hypomorphic mutation in ADA2 gene. CNS involvement is one of the main features of DADA2 which presents with a wide spectrum of clinical manifestations ranging from systemic inflammation to cutaneous or visceral PAN like vasculopathy and early onset stroke.Our patient had presented with primary CNS and renal involvement with impending rupture aneurysm. Timely control of inflammation is pertinent in such cases with remission induction and maintenance to prevent stroke. Although cyclophosphamide is still used in such cases DADA2 usually require anti-TNF therapy. Our patient had good response to primary steroid therapy.Key learning pointsAcute GCA-like neurological presentation of medium vessel vasculitis with cerebral involvement is rare. If not recognised in a timely fashion, it can lead to sub-arachnoid haemorrhage which is the most common presentation of such cases. DADA2 is a recently recognised entity that presents with stroke and vasculitis/vasculopathy and responds to anti-TNF therapy.Conflicts of interestThe authors have declared no conflicts of interest.

Early Lessons Learned From the WEB Device: Feasibility, Technique and Complications—A Real-Life Experience

Abstract INTRODUCTION Wide-neck bifurcation cerebral aneurysms have always posed a treatment challenge and have historically required either clip ligation, or stent vs balloon-assisted coil embolization. This predicament led to the development of the newly FDA-approved Woven EndoBridge (WEB) Aneurysm Embolization System (Sequent Medical Inc, Aliso Viejo, California), which is a self-expanding mesh that achieves intrasaccular flow disruption and does not require antithrombotic medications. In this study, we report our experience with the first 29 consecutive aneurysms treated via WEB embolization at 2 high-volume institutions. METHODS We reviewed our first 27 consecutive patients with 29 cerebral aneurysms who underwent WEB embolization from February to April 2019. We collected data on patient demographics and clinical presentation, aneurysm characteristics, device and procedural details, and functional outcomes. RESULTS A total of 29 aneurysms were included in our study. Seven patients (24.1%) presented with acutely ruptured aneurysm while the rest were unruptured. The majority of patients (82.8%) required only 1 attempt for successful device deployment, while a stent was necessary as an adjunct treatment in 4 patients (13.7%) due to WEB herniation. Two patients had residual aneurysm that had to undergo additional treatment; one of them underwent second WEB embolization and one underwent clip ligation. One patient with a PICA aneurysm had device dislodgment with injury to the parent vessel Onyx and coils were used to deconstruct the vertebral artery. CONCLUSION The advent of the WEB device has significantly impacted the surgical decision-making for the treatment of bifurcation, wide-neck aneurysms. We discuss in detail the lessons learned from patient selection, device size selection, technique, and complications from 2 institutions with a high-volume endovascular and microsurgical aneurysm treatment experience.

Clipping of a PICA aneurysm located on the contralateral side of its parent vertebral artery in front of the brainstem: how I do it.

Vertebro-PICA aneurysms may be challenging because of their relationship with the brainstem and the lower cranial nerves, especially when the vertebral artery is tortuous and the aneurysm is located in front of the brainstem, contralaterally to the parent vertebral artery. We describe the surgical technique for safe approach. Cadaveric dissection performed by the authors, provided comprehensive understanding of relevant anatomy. Intraoperative photos and videos show clipping of the aneurysm using a combined midline and far-lateral suboccipital craniotomy with a para-condylar extension. The literature reviews potential complications. This combined approach allows safe clipping of such PICA aneurysms.

Endovascular treatment of ruptured pica aneurysms and association with its extradural origin: A single-center experience.

Background: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 surgical clipping of PICA aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies; however, the use of endovascular therapy as an alternative treatment to surgery has been increasing. We present our experience of last 5 years in treating the ruptured PICA aneurysms.Materials and Methods:A total of 11 patients with PICA aneurysms, out of them 7 were at proximal PICA, 2 at the vertebral-PICA junction, and 1 each at mid and distal PICA, underwent endovascular treatment at our institution between 2011 and 2016.Results:All the patients presented with an acute intracranial hemorrhage, confirmed on CT head. Most of the aneurysms were at proximal PICA (anterior and lateral medullary segments) with the partial incorporation of PICA origin in the sac. Low origin of PICA was seen in 7 (out of 11) cases, out of these cases, 5 had proximal PICA, aneurysm, and one (n = 1) had VA-PICA, junction aneurysm (1/7) and. one distal PICA aneurysm. There were seven proximal PICA aneurysms, and out of them, parent vessel occlusion was done in six and selective coiling in one (n = 1) case. From seven (n = 7) proximal PICA aneurysms, there were five cases of low origin and rests showed normal course and origin. Two (n = 2) junctional aneurysms were treated with simple coiling. Low origin was seen in right VA-PICA junction aneurysm. Endovascular treatment of all the 11 aneurysms was successful. The treatment consisted of selective aneurysm coiling in four (36.3%) patients and aneurysm with parent vessel trapping in seven patients (63.6%). Out of these seven patients, in one (n = 1) patient where aneurysm was distal PICA, glue embolization was done. There was no intra-procedural rupture/contrast extravasation or any thrombo-embolic complications. Follow-up studies ranged from 6 months to 5 years.Conclusion: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.

Decision Making in Surgery for Nonsaccular Posterior Inferior Cerebellar Artery Aneurysms With Special Reference to Intraoperative Assessment of Collateral Blood Flow and Neurophysiological Function.

Posterior inferior cerebellar artery (PICA) aneurysms represent a challenging pathology. PICA sacrifice is often necessary, due to the high proportion of nonsaccular aneurysms that can be found in this location. Several treatments are available, but the infrequency of these aneurysms and the increasing number of endovascular techniques have limited the development of a standardized algorithm for cases in which open surgery is indicated. We present our series of nonsaccular PICA aneurysms, in the attempt to define an algorithm for their surgical management. We retrospectively reviewed the operation database, identifying patients harboring nonsaccular PICA aneurysms who were surgically treated at our institution from 2007 to 2016. During a 9-yr period, 17 patients harboring 18 nonsaccular PICA aneurysms were surgically treated at our institution. Fourteen (7.7%) aneurysms were located within the proximal PICA (including those located at the vertebral artery-PICA junction), and 4 were located distally. We performed PICA revascularization in 8 (57.1%) cases of proximal aneurysms (n = 4, PICA-PICA bypass; n = 4, occipital artery-PICA bypass). We based our decision whether to perform bypass on intraoperative test occlusion with indocyanine green (ICG) videoangiography and neurophysiological monitoring. In no cases, bypass was necessary for distal aneurysms. For nonsaccular PICA aneurysms, in which vessel occlusion is often necessary, it is possible to adopt a selective use of revascularization techniques. Intraoperative occlusion test with ICG videoangiography and neurophysiological monitoring provides reliable indications, allowing real-time assessment of collateral circulation.

Posterior Inferior Cerebellar Artery Aneurysm: Surgical or Endovascular Treatment in a Case Report

Introduction: PICA aneurysms answer for 3% of all intracranial aneurysms. The patients generally present Hunt- Hess I or II and have intraventricular hemorrhage needing treatment. Case presentation: This is a case study about an elderly woman complaining about a sudden headache. She had an aneurysm in the distal segment of the PICA, which was treated by clipping. The woman progressed well despite her hydrocephalus. Discussion: Information about the aneurysm positioning and anatomy guided the therapeutic decisions. Age and clinical presentation are the most prominent factors in positive clinical evolution. An interdisciplinary team should choose between surgical and endovascular treatment.