Posterior Communicating Artery Aneurysm Research Articles

Intraprocedural retrieval of migrated coils during endovascular aneurysm treatment with the Trevo Stentriever device

Coil migration during endovascular treatment of intracranial aneurysms occurs in 2–6% of cases. As endovascular coiling of aneurysms has become increasingly popular and as endovascular technology continues to rapidly evolve, the prevalence of intraprocedural coil migration will invariably rise. Since coil masses are highly thrombogenic, migration out of the aneurysm sac into the parent artery may result in large territory infarcts which subsequently manifest as significant neurological morbidity. Therefore safe and timely retrieval of migrated coils is essential to avoiding poor angiographic and clinical outcomes. A 66-year-old woman with an unruptured 5×3mm, wide-necked posterior communicating artery aneurysm was referred for endovascular treatment. During coiling with the dual catheter technique, both initially deployed coils dislodged from the aneurysm sac and migrated distally into the middle cerebral artery. After failed retrieval with an Alligator device (Chestnut Medical Technologies, Menlo Park, CA, USA), we used two Trevo devices (Concentric Medical, Mountain View, CA, USA) in succession to successfully retrieve the migrated coils. The aneurysm was then occluded with stent-assisted coil embolization. There were no post-procedural angiographic or clinical complications. The patient was subsequently discharged home without neurological deficit. This case illustrates the first use of the Trevo device for retrieval of migrated coils during endovascular treatment of an intracranial aneurysm to our knowledge. Due to the lack of guidelines defining the standard management of intraprocedural coil migration, current strategies are based on retrospective review of published reports and expert opinion. We present a unique and effective method for endovascular retrieval of displaced coils using a Trevo Stentriever device.

Morphological and clinical risk factors for posterior communicating artery aneurysm rupture

Recent studies have shown that posterior circulation aneurysms, specifically posterior communicating artery (PCoA) aneurysms, are more likely to rupture than other aneurysms. To date, few studies have investigated the factors contributing to PCoA aneurysm rupture. The authors aimed to identify morphological and clinical characteristics predisposing to PCoA aneurysm rupture. The authors retrospectively reviewed 134 consecutive patients with PCoA aneurysms managed at their facility between July 2003 and December 2012. The authors divided patients into groups of those with aneurysmal rupture (n = 39) and without aneurysmal rupture (n = 95) and compared morphological and clinical characteristics. Morphological characteristics were mainly evaluated by 3D CT angiography and included diameter of arteries (anterior cerebral artery, middle cerebral artery, and internal carotid artery), size of the aneurysm, dome-to-neck ratio, neck direction of the aneurysmal dome around the PCoA (medial, lateral, superior, inferior, and posterior), aneurysm bleb formation, whether the PCoA was fetal type, and the existence of other intracranial unruptured aneurysm(s). Patients with ruptured PCoA aneurysms were significantly younger (a higher proportion were < 60 years of age) and a significantly higher proportion of patients with ruptured PCoA aneurysms showed a lateral direction of the aneurysmal dome around the PCoA, had bleb formation, and the aneurysm was > 7 mm in diameter and/or the dome-to-neck ratio was > 2.0. Multivariate logistic regression analysis showed age < 60 years (OR 4.3, p = 0.011), history of hypertension (OR 5.1, p = 0.008), lateral direction of the aneurysmal dome around the PCoA (OR 6.7, p = 0.0001), and bleb formation (OR 11, p < 0.0001) to be significantly associated with PCoA aneurysm rupture. The present results demonstrated that lateral projection of a PCoA aneurysm may be related to rupture.

Safety and long-term efficacy of endovascular treatment of small posterior communicating artery aneurysms by coiling with or without stent: A single center retrospective study

ObjectivesEndovascular stents have been widely used in intracranial aneurysm embolization. In this work, we compared the safety and long-term efficacy of stent-assisted coiling with those of conventional coiling for small posterior communicating artery aneurysms, aiming at a better understanding of the related safety and efficacy profiles. MethodsBetween January 2008 and December 2011, 114 small PcomA aneurysms (defined as 3mm≤maximum diameter<10mm in this study) in 108 patients were treated by endovascular treatment in our department. Patient demographics, aneurysm characteristics, angiographic results (initial and follow-up), and procedural complications were assessed. ResultsEmbolization was successfully performed in all the patients. Complications occurred in 7.4% of patients in both groups. There was no associated mortality. Based on initial post-procedural angiography, the rate of complete aneurysm occlusion, neck remnant and residual sac in the stented group were 37.9%, 24.1%, and 37.9%, while in the conventional group the figures were 42.9%, 48.2%, and 8.9%, respectively. The initial angiographic results were significantly better in the conventional group, compared with the stented group (P=0.038). The follow-up results showed that the rate of improvement in the stented group was significantly higher (53.3% vs. 14.0%; P<0.001) and the recurrence rate was significantly lower than that in the conventional group (4.4% vs. 3.02%; P=0.001). ConclusionCompared with conventional coiling, stent-assisted coiling of the small posterior communicating artery aneurysms does not increase the risk. Stents bear an advantage in reducing the recurrence rate, increasing progressive occlusion rate, and improving long-term prognosis in endovascular treatment of intracranial aneurysms.

Predominant intraventricular hemorrhage from a ruptured posterior communicating artery aneurysm.

A 45-year-old woman presented with acute onset of headache and confusion. A computed tomography (CT) of the brain showed predominant intraventricular hemorrhage (IVH) without significant subarachnoid hemorrhage (Figure 1A and B). A CT angiography showed a laterally oriented, left posterior communicating artery (PCOM) aneurysm (Figure 1C). This aneurysm, confirmed by cerebral angiography (Figure 1D), was successfully coil embolized. The ventriculostomy was placed in the right lateral ventricle to treat the obstructive hydrocephalus. The patient survived without major neurological deficits. Although ruptured cerebral aneurysms rarely present as isolated IVH, laterally oriented PCOM aneurysms can rupture through the medial temporal lobe, causing predominant IVH without subarachnoid hemorrhage. This case highlights the importance of urgent vascular imaging for optimal IVH evaluation and management.

Effect of surgical clipping versus endovascular coiling on recovery from oculomotor nerve palsy in patients with posterior communicating artery aneurysms: A retrospective comparative study and meta-analysis

Background:Oculomotor nerve palsy (OMNP) is a well-recognized complication of posterior communicating artery (PCOM) aneurysms. Only a few comparative studies have assessed the effect of clipping versus coiling on recovery from OMNP in PCOM aneurysms. A retrospective review and meta-analysis was conducted to assess the relationship between PCOM aneurysm treatment and OMNP.Materials and Methods:Medical records of all patients presenting between January 2000 and February 2013 with intracranial aneurysm were searched. All patients with OMNP secondary to PCOM aneurysm were included for analysis. Patients undergoing surgical clipping or endovascular coiling were compared with respect to complete resolution of OMNP after aneurysm surgery (i.e., primary outcome). A meta-analysis of published studies of OMNP associated with PCOM aneurysm was performed after a MEDLINE search.Results:Seventeen patients with OMNP secondary to PCOM aneurysms met the inclusion criteria. Surgical clipping (seven of eight patients, or 87.5%) resulted in greater complete resolution of OMNP compared with endovascular coiling (four of nine patients, or 44.4%), P = 0.13. A meta-analysis of similar studies revealed that complete resolution of OMNP was more commonly associated with surgical clipping (36 of 43 patients, or 83.7%) than with endovascular coiling (29 of 55 patients, or 52.7%), yielding an adjusted odds ratio (OR) of 6.04 [confidence interval (CI) =1.88-19.45, P = 0.003]. Multivariate analysis found that the degree of pre-operative OMNP (OR = 0.07, CI = 0.02-0.28, P = 0.001) and surgical clipping (OR = 6.37, CI = 1.73-23.42, P = 0.005) were significant factors that affected the complete recovery of OMNP.Conclusion:Complete recovery of OMNP with PCOM aneurysms is more commonly associated with surgical clipping than with endovascular coiling. Also, the degree of pre-operative OMNP and the treatment modality are significant factors that affect the complete recovery of OMNP.

Tuberothalamic Artery Infarction following Coil Embolization of a Ruptured Posterior Communicating Artery Aneurysm Belonging to a Transitional Type Posterior Cerebral Artery

There are many potential anatomical variations in the connection between the internal carotid artery and the posterior circulation through the posterior communicating artery (PCoA). We describe the endovascular treatment of an aneurysm arising near the origin of the PCoA belonging to a transitional type posterior cerebral artery. Coil embolization subsequently resulted in thrombo-occlusion of the adjacent PCoA causing thalamic infarction even though sufficient retrograde flow had been confirmed pre-operatively by Allcock's test.

Sudden headache, third nerve palsy and visual deficit: thinking outside the subarachnoid haemorrhage box

A 75-year-old lady presented with sudden severe headache and vomiting. Examination was normal, and CT and lumbar puncture not convincing for subarachnoid haemorrhage. Shortly thereafter, she developed painless diplopia. Examination confirmed right third cranial nerve palsy plus homonymous left inferior quadrantanopia. Urgent cerebral MRI with angiography was requested to assess for a possible posterior communicating artery aneurysm, but revealed an unsuspected pituitary mass. Pituitary adenoma with pituitary apoplexy was diagnosed. Pituitary apopolexy is a syndrome comprising sudden headache, meningism, visual and/or oculomotor deficits, with an intrasellar mass. It is commonly due to haemorrhage or infarction within a pituitary adenoma. Treatment includes prompt steroid administration, and potentially surgical decompression. While subarachnoid haemorrhage is an important, well-recognised cause of sudden severe headache, other aetiologies, including pituitary apoplexy, should be considered and sought.

Perforated Oculomotor Nerve After Endovascular Coiling: Complete Regeneration After Microsurgical Repair. Case Report

We describe a patient who developed complete right oculomotor nerve palsy after endovascular coiling for a ruptured posterior communicating artery aneurysm caused by migration of the coils outside the aneurysm. A 50-year-old woman was admitted with an acute subarachnoid hemorrhage. She underwent, on the day of admission, endovascular coiling of a ruptured posterior communicating artery aneurysm. Four hours postcoiling, complete right oculomotor nerve palsy developed because of extrusion of the coils outside the aneurysm. The patient recovered completely after surgical exploration with removal of the migrated coils and microsurgical repair of the oculomotor nerve. This report illustrates that oculomotor nerve palsy is a rare complication after coiling of a posterior communicating artery aneurysm, and it should serve as a reminder to encourage neurovascular teams to consider surgical exploration in cases of third nerve palsy after endovascular coiling.

Endovascular treatment of ruptured tiny, wide-necked posterior communicating artery aneurysms using a modified stent-assisted coiling technique

The endovascular treatment of patients with tiny, wide-necked aneurysms is technically challenging, due to the small volume for microcatheterization and coil stabilization inside the aneurysm sac. We performed a retrospective study to evaluate the feasibility, effectiveness, and safety of stent-assisted embolization for patients with ruptured, tiny, wide-necked posterior communicating artery (PcomA) aneurysms. Between January 2007 and August 2011, 17 tiny, wide-necked PcomA aneurysms that had ruptured were treated at our institution using a modified stent-assisted technique, with delivery of the first coil inside the aneurysm followed by placement of a self-expanding stent via a second microcatheter. All patients were treated successfully using this modified stent-assisted coiling technique. Initial results showed aneurysm occlusion of Raymond Class 1 in 10 patients, Class 2 in four patients, and Class 3 in three patients. The angiographic follow-up results for 13 patients (mean, 12.5months) showed that all aneurysms remained stable or improved, without any in-stent stenosis or recurrence. Of the other four patients, three refused angiography for economic or personal reasons, and one was lost in follow-up. Clinical follow-up of 16 patients for a mean of 23.8months showed no death or rebleeding. These results imply that endovascular treatment of ruptured tiny, wide-necked PcomA aneurysms using our modified stent-assisted coiling technique is safe and feasible. This technique improves the long-term outcomes of these aneurysms by increasing the packing density and diverting the intra-aneurysmal blood flow.

Tratamiento endovascular de un aneurisma «verdadero» de la arteria comunicante posterior

True posterior communicating artery aneurysms originate exclusively from the wall of this artery and should be differentiated from aneurysms of the posterior communicating segment of the distal carotid artery. As these lesions are rare, their anatomical relationships have been poorly described; likewise, reports concerning their endovascular treatment are extremely rare and the technical aspects poorly detailed. A case of a patient with a true aneurysm of the left posterior communicating artery treated by endovascular coiling is presented. A literature review was also conducted to illustrate the anatomical and technical details relevant to achieving its successful treatment.

E-028 Intracranial Stenting without Angioplasty for Cerebral Aneurysms with Adjacent Vessel Stenoses

IntroductionIntracranial stenting is currently not routinely recommended for intracranial stenotic disease based on recent clinical trial results. However, wide-necked cerebral aneurysms with adjacent vascular stenoses may require stent placement to...

Dissecting aneurysms of posterior communicating artery itself: anatomical, diagnostic, clinical, and therapeutical considerations

Posterior communicating artery (PCoA) itself is an unusual location for intracranial aneurysms in that isolated dissections or dissecting aneurysms are extremely rare. In the way of correct diagnosis of dissecting aneurysms of PCoA itself, a proper understanding of (1) the anatomy of the PCoA and its perforator branches, (2) some particular diagnostic features, and (3) related clinical aspects is of significant importance. Although there are no established treatment strategies for this particular type of aneurysms, the endovascular approach might be considered as a plausible one. In this paper, our scope was to report five cases with dissecting aneurysm of the PCoA itself and to discuss this rare vascular pathology from anatomical, diagnostic, clinical, and therapeutical perspectives.

Analysis of Morphologic and Hemodynamic Parameters for Unruptured Posterior Communicating Artery Aneurysms with Oculomotor Nerve Palsy

Posterior communicating artery aneurysms with oculomotor nerve palsy may imply sudden enlargement of the aneurysm sac and have a high risk of rupture. Our aim was to identify the morphologic and hemodynamic parameters in this special period of aneurysm progression and to assess related rupture risk indices. We analyzed the morphologic and hemodynamic parameters of 9 unruptured posterior communicating artery aneurysms with oculomotor nerve palsy and 9 ruptured ones. The morphologic parameters were measured and calculated from patient-specific 3D rotational angiographic images, and pulsatile computational fluid dynamic simulation was then performed for hemodynamic parameters. There was no significant statistical difference between the 2 groups in size, aspect ratio, size ratio, aneurysm angle, or vessel angle; analysis only demonstrated a significantly lower wall shear stress of the aneurysm wall in the symptomatic unruptured group in hemodynamics (P = .024), whereas there were no differences in wall shear stress of the parent artery, low wall shear stress area, and oscillatory shear index. From morphologic and hemodynamic perspectives, we demonstrated that posterior communicating artery aneurysms with oculomotor nerve palsy had characteristics similar to those of ruptured ones, except for lower wall shear stress on the aneurysm wall, which might indicate an important role in aneurysm rupture.

Arteriovenous fistula after ventriculostomy in aneurysmal subarachnoid hemorrhage

A 66-year-old woman was found unresponsive after complaining of severe headache several days prior. She was comatose upon initial evaluation and a cranial CT revealed diffuse subarachnoid hemorrhage. A right posterior communicating artery aneurysm (figure, A, arrow) was successfully treated with endovascular embolization. Conventional angiography performed 7 days following ventriculostomy placement for hydrocephalus demonstrated interval development of a traumatic arteriovenous fistula (AVF) filling by the middle meningeal artery (figure, C and D, arrows). The AVF was treated with intra-arterial embolization. Ventriculostomy-associated AVF has rarely been reported.1 Outcomes of untreated iatrogenic AVF are unknown, but could lead to hemorrhagic complications.

Controversy: Clipping of Asymptomatic Intracranial Aneurysm That is &lt;7 mm

The second (prospective) International Study of Unruptured Intracranial Aneurysms (ISUIA), published in 2003 in The Lancet ,1 suggested that the risk of hemorrhage from an unruptured intracranial aneurysm <7 mm is extremely low, and that present microsurgical or endovascular treatment for patients harboring these lesions carries a far greater risk of incurring a neurological deficit than the natural history. This has led to a much more conservative approach toward managing such patients. However, considerable controversy remains on whether or not to offer therapy (surgical or endovascular) to these patients. We recall that the first (retrospective) ISUIA study, published in New England Journal of Medicine in 1998,2 demonstrated that asymptomatic intracranial aneurysms ≤10 mm had a very low rupture rate (0.05%/yr for group 1, no previous bleeding from another aneurysm; 0.5%/yr for group 2, previous bleeding from another aneurysm). The authors concluded that 10 mm should be the cutoff for considering treatment of these aneurysms, particularly in group 1 patients. This study also promoted a major change in clinical practice, so that many patients with aneurysms <10 mm were not treated. Was this a reasonable response? Probably not, especially in view of the more recent ISUIA data indicating that aneurysms that are 7 to 12 mm carry a considerable risk of bleeding. Should we significantly alter our practice on the basis of a single nonrandomized study, such as the 2003 ISUIA study? A closer examination of the 2003 ISUIA study reveals that some aneurysms <7 mm have a significant risk of bleeding (Table). Five-year cumulative risks of hemorrhage were 2.5% for posterior communicating artery aneurysms in group 1; 1.5% for anterior communicating (AC), middle cerebral (MC), and internal carotid aneurysms in group 2; and 3.4% for posterior communicating artery aneurysms in group 2. All patients with these asymptomatic aneurysms …

Stent-Assisted Coil Embolization of Posterior Communicating Artery Aneurysms

Use of protective stents may not be effective in coil embolization of wide-neck aneurysms involving the posterior communicating artery. Successful implementation depends on the caliber of the vessel, its angle of origin, and the manner in which its orifice is incorporated into the aneurysm. Presented here are the results (clinical and radiographic) of coil embolization in aneurysms of the ICA-posterior communicating artery junction, variably aided by stents. The primary focus is angiographic configurations that impact stent placement. From a prospective data repository, we retrieved records of 32 consecutive patients with 33 posterior communicating artery aneurysms, all of which were treated by stent-assisted coil embolization between June 2008 and August 2012. Outcomes were analyzed in terms of aneurysm configuration and clinical status. Stents were positioned entirely in the ICA (n = 26), from the ICA to the posterior communicating artery (n = 2), in the posterior communicating artery only (n = 3), and retrograde from the posterior communicating artery to the ICA terminus (n = 2). Procedure-related complications occurred in 3 patients (9.1%), but only 1 (3.0%) had mild neurologic sequelae (Glasgow Outcome Score 4). Using coil embolization, we achieved successful occlusion in 24 aneurysms (72.7%), and in 9 others, subtotal occlusion was conferred. During a mean follow-up of 15.7 ± 10.7 months, imaging of 27 aneurysms documented stable occlusion in 19 (70.4%), whereas angiography of 15 aneurysms (39.5%) disclosed 2 instances of in-stent stenosis (13.3%) and a solitary occurrence of stent migration (6.7%). In posterior communicating artery aneurysms, stent protection during coil embolization is feasible by adjusting the procedural strategy to accommodate differing configurations of the aneurysm and its vascular source.

Acute Subdural Hematoma without Subarachnoid Hemorrhage or Intraparenchymal Hematoma Caused by Rupture of a Posterior Communicating Artery Aneurysm: Case Report and Review of the Literature

BackgroundAcute subdural hematoma without subarachnoid hemorrhage or intraparenchymal hematoma is rare. Case ReportWe report on a 47-year-old women without previous trauma who presented with an acute subdural hematoma without subarachnoid hemorrhage. The hematoma was evacuated immediately. Further evaluation with a cerebral four-vessel angiography revealed a left-sided posterior communicating artery aneurysm that was occluded by endovascular embolization. The patient recovered without neurological deficit. ConclusionsRuptured intracranial aneurysm should be considered as a cause of nontraumatic subdural hematoma. Immediate subdural hematoma removal after aneurysm coiling can be performed in such patients, even those in poor neurological condition.

Rapid Enlargement of Aneurysmal Remnant as a Cause of Early Rebleed after Coil Embolization of Posterior Communicating Artery Aneurysm: A Case Report

Early rebleeding of an aneurysm following endovascular coiling is a serious complication and carries a high risk of mortality and morbidity. A 56-year-old woman was diagnosed with subarachnoid hemorrhage (SAH) due to rupture of a saccular aneurysm arising from the communicating segment (PComm) of the right internal carotid artery. She underwent an uneventful right pterional craniotomy and clipping of the aneurysm. On postoperative day 5, she lapsed into altered sensorium. Computed tomography (CT) of the head showed fresh subarachnoid bleed and digital subtraction cerebral angiography (DSA) demonstrated a relatively small (4.9 mm × 3.5 mm × 2.6 mm) left PComm saccular aneurysm with complete obliteration of the previously clipped right PComm aneurysm. She underwent coil embolization of this aneurysm, with a small remnant at the neck (>95% occlusion was achieved). On postcoiling day 9, she again lapsed into altered sensorium. CT of the head revealed fresh SAH. CT-angiography and DSA was performed, which showed significant enlargement of the residual left PComm aneurysm with coil impaction. Patient was subjected to a standard left pterional craniotomy and clipping of the residual aneurysm. She also underwent a subsequent ventriculoperitoneal shunt for the associated hydrocephalus. She gradually recovered and was able to return to work with minimal disability. Rapid enlargement and rupture of an aneurysmal remnant following endovascular coiling is a rare cause of an early rebleed, especially associated with "small" aneurysms. A more stringent postprocedural imaging strategy along with restrained anticoagulation in such "high-risk" cases is recommended.

Quantification of speed-up and accuracy of multi-CPU computational flow dynamics simulations of hemodynamics in a posterior communicating artery aneurysm of complex geometry

BackgroundTowards the translation of computational fluid dynamics (CFD) techniques into the clinical workflow, performance increases achieved with parallel multi-central processing unit (CPU) pulsatile CFD simulations in a patient-derived model of...

Morphological and Hemodynamic Analysis of Mirror Posterior Communicating Artery Aneurysms

Background and PurposeHemodynamic factors are commonly believed to play an important role in the pathogenesis, progression, and rupture of cerebral aneurysms. In this study, we aimed to identify significant hemodynamic and morphological parameters that discriminate intracranial aneurysm rupture status using 3-dimensional-angiography and computational fluid dynamics technology.Materials and Methods3D-DSA was performed in 8 patients with mirror posterior communicating artery aneurysms (Pcom-MANs). Each pair was divided into ruptured and unruptured groups. Five morphological and three hemodynamic parameters were evaluated for significance with respect to rupture.ResultsThe normalized mean wall shear stress (WSS) of the aneurysm sac in the ruptured group was significantly lower than that in the unruptured group (0.52±0.20 versus 0.81±0.21, P = .012). The percentage of the low WSS area in the ruptured group was higher than that in the unruptured group (4.11±4.66% versus 0.02±0.06%, P = .018). The AR was 1.04±0.21 in the ruptured group, which was significantly higher than 0.70±0.17 in the unruptured group (P = .012). By contrast, parameters that had no significant differences between the two groups were OSI (P = .674), aneurysm size (P = .327), size ratio (P = .779), vessel angle (P = 1.000) and aneurysm inclination angle (P = 1.000).ConclusionsPcom-MANs may be a useful disease model to investigate possible causes of aneurysm rupture. The ruptured aneurysms manifested lower WSS, higher percentage of low WSS area, and higher AR, compared with the unruptured one. And hemodynamics is as important as morphology in discriminating aneurysm rupture status.