Posterior Communicating Artery Aneurysm Research Articles

Subdural hematoma of the posterior fossa due to posterior communicating artery aneurysm rupture

Background:We describe an unusual presentation of a ruptured aneurysm of the posterior communicating artery with an acute subdural hematoma (SDH) located in the posterior fossa. We also reviewed the literature, focusing on the location of this intracranial hematoma.Case Description:An 83-year-old woman was admitted to our institution with recent sudden headache and dizziness. Magnetic resonance imaging showed a thin collection of blood in the subdural space adjacent to the clivus, along the wall of the posterior fossa, and at the cervical spine level. A right posterior communicating artery aneurysm was diagnosed using computed tomography angiography and digital subtraction angiography. The aneurysm had two lobes, one of which was attached to the right dorsum sellae. The aneurysm was occluded by stent-assisted coil embolization. The patient was discharged 3 weeks after admission with absence of neurological deficit.Conclusion:A ruptured aneurysm of the posterior communicating artery may cause an acute SDH.

真の後交通動脈瘤の2例

真の後交通動脈瘤の2例

Pupil-Sparing Oculomotor Nerve Palsy Caused by Upward Compression of a Large Posterior Communicating Artery Aneurysm

A 69-year-old woman without diabetes or hypertension presented with a large posterior communicating artery aneurysm projecting beneath the oculomotor nerve manifesting as a 2-week history of progressive diplopia. Neurological examination revealed external ophthalmoplegia and blepharoptosis without pupil involvement. Neuroimaging showed a large aneurysm in the left internal carotid artery projecting postero-inferiorly. Craniotomy and neck clipping of the aneurysm revealed the origin at the junction of the internal carotid artery and posterior communicating artery, and elevation of the oculomotor nerve. Pupil-sparing oculomotor nerve palsy is often assumed to be caused by ischemic injury such as hypertension and diabetes mellitus. Sometimes compressive lesion can cause pupil-sparing oculomotor nerve palsy with a short interval from the onset of symptoms to diagnosis. Despite the 2-week interval from the onset of symptoms, this patient presented with pupil-sparing oculomotor nerve palsy caused by compressive lesion. Involvement or sparing of the pupil is often considered to be the most important criterion in the diagnosis of isolated oculomotor nerve palsy. This unique case demonstrated that unusual compressive lesions must be taken into consideration in the diagnosis of pupil-sparing oculomotor nerve palsy.

未破裂脳動脈瘤治療適応と日本の役割

In this study, we discuss the indications for surgery for unruptured cerebral aneurysm and the role of Japan, with special reference to the features of the Japanese medical system based on the data of ruptured cerebral aneurysm. We investigated 506 clipping cases of cerebral aneurysms from 1999 to 2011 in Shimane Prefectural Central Hospital: 182 unruptured cerebral aneurysms and 324 ruptured cerebral aneurysms. There were four cases (2.2%) of postoperative major complications of unruptured cerebral aneurysm, including two hemiparesis of symptomatic internal carotid artery aneurysm and two visual disturbance of paraclinoid aneurysms. There were two minor complications of transient memory disturbance and two complications of olfactory disturbance of anterior communicating artery aneurysms. There were 13 (7.1%) transient neurological deficits. Postoperative parenchymal abnormality on CT and/or MRI was seen in 14 (7.7%). Data show ruptured aneurysms occur most frequently in males in their 50’s and in females in their 70’s. The mean size of ruptured cerebral aneurysm according to site was 7±3.4 mm, 6.9±4.0 mm, and 5.7±2.5 mm in internal carotid artery posterior communicating artery aneurysms, middle cerebral artery aneurysms and anterior communicating artery aneurysms, respectively. Small aneurysms under 5 mm were 101 (31.1%). According to the OECD health data, Japan had the most acute care beds per 1,000 population and the most CT scan and Magnetic Resonance Imaging Units per million population. The treatment indication of unruptured cerebral aneurysm should be considered more precisely based on sex, age and site. In Japan, we have the most follow-up data on unruptured cerebral aneurysms and should share that data with the world.

Endovascular treatment of ruptured intracranial aneurysms during pregnancy: Is this the best way forward? Case report and review of the literature

Objective and importanceSubarachnoid haemorrhage in pregnancy has traditionally been treated by surgical clipping however lately cases of successful coiling have been reported. Nevertheless, the long-term outcome of coiling is not well known in pregnant women. Mortality due to rebleeding of an incompletely treated aneurysm remains high. Only 15 cases of successful endovascular coiling during pregnancy have been reported so far. Clinical presentationWe report the case of a pregnant woman who presented with aneurysmal subarachnoid hemorrhage (WFNS Grade III) due to rupture of a right posterior communicating artery aneurysm. InterventionThe patient underwent endovascular coiling successfully followed by an elective caesarian section and delivery of a healthy baby. However, during the course of a 2-year follow up the patient had suffered two relapses of the coiled aneurysm which required additional treatment. These events have affected her choice of extending her family. ConclusionThe small risk of recurrence and the potential impact on future pregnancies should be explicitly communicated to patients in cases of endovascular coiling.

Tuberothalamic Artery Infarctions following Coil Embolization of Ruptured Posterior Communicating Artery Aneurysms with Posterior Communicating Artery Sacrifice

Ischemic complications after coil embolization of the PcomA aneurysms are not thoroughly understood, especially in cases in which the PcomA is sacrificed. Our purpose was to examine the preoperative angiographic features and pattern of postoperative cerebral infarctions exhibited by patients who underwent embolization of ruptured PcomA aneurysms with PcomA sacrifice. A retrospective review identified 14 patients with ruptured PcomA aneurysms who underwent embolization of the aneurysms in combination with PcomA sacrifice. Preoperative angiographic data, including the Allcock test, postoperative DWI, and neurologic status, were examined. Elimination of the aneurysm was complete in all cases. Postoperative DWI indicated 7 cases with infarctions (infarction group) and 7 cases without infarctions (noninfarction group). All patients in the infarction group developed infarctions in the vicinity of the tuberothalamic artery. In all 14 cases, a preoperative Allcock test demonstrated a retrograde filling of the PcomA through the P1 segment. The incidence of negative visualizations of the P1 segment on vertebral angiograms was significantly higher in the infarction group (100%) than in the noninfarction group (0%; P = .00058). The mean PcomA diameters, PcomA/P1 ratios, and aneurysm sizes observed in the infarction group were significantly greater than those in the noninfarction group (P < .05, P < .01, and P < .02, respectively). Tuberothalamic artery infarction caused hemiparesis and memory disturbance, which were associated with unfavorable outcomes. After the coil occlusion of ruptured PcomA aneurysms with PcomA sacrifice, tuberothalamic artery infarctions tended to occur in cases exhibiting negative visualization of the P1 segment, even when collateral flow was observed with the Allcock test.

Oculomotor Nerve Palsy Caused by Posterior Communicating Artery Aneurysm: Evaluation of Symptoms after Endovascular Treatment

We report the outcome of endovascular treatment in a series of patients presenting with posterior communicating artery aneurysm causing ocular motor nerve palsy. A retrospective study was made of ten patients who were treated by coil embolization of posterior communicating artery aneurysm caused by oculomotor nerve palsy. The assessed parameters were as follows: patient's age, presence of subarachnoid hemorrhage, aneurysm size, preoperative severity of symptoms, and timing of treatment after onset of symptoms. Improvement of oculomotor nerve palsy after treatment was noted in eight patients (80.0%). Complete recovery was noted in seven patients (70.0%), partial recovery in one patient (10.0%), and no recovery in two patients (20%). Clinical presentations with early management (≤2 days) were significant in influencing recovery. Complete recovery from ocular motor nerve palsy was significantly higher in patients with initial incomplete palsy compared with initial complete palsy patients (6/6 versus 1/4). Early treatment and initial partial palsy are relevant to improving prognoses. Endovascular treatment is favored method for treating oculomotor palsy.

Interdural Hematoma Extending From the Clivus to the Spinal Epidural Space in an Intracranial Aneurysm Case

Interdural Hematoma Extending From the Clivus to the Spinal Epidural Space in an Intracranial Aneurysm Case

Detached Coil Migration that Assisted Stent Migration, during Stent Assisted Coiling of a Recurrent Aneurysm

This is a pictorial case report of previously unreported intra-procedural complication of an intra-procedural migrated stent-coil complex. It shows fluoroscopic detail of the migration of a stent with the help of a migrated coil with subsequent retrieval of coil and deployment of a second stent proximally. It also briefly covers postulated mechanisms for this in the discussion. In our clinical practice we experienced an unusual case during stent assisted coiling of a right Posterior Communicating Artery Aneurysm (PCOM) where a coil migrated through a deployed stent into the parent artery and become ensnared into a distal stent strut. This caused stent migration distally. Studies have shown that stent assisted coiling of cerebral aneurysms is an effective treatment that lowers the risk of recurrence. There are several complications associated with both coiling and stent deployment. Multiple cases of individual coil migration and stent misplacement have been described in the literature, such as coil protrusion through a stent with open cell designs and a single case of delayed coil migration through a deployed stent. Various aetiologies are described for these, which we cover, and we postulate on the factors relevant to our case and suggest the biggest contributing factor was an open side stent design. We believe this is a rare documented acute case of a migrated coil that has assisted stent migration. We suggest caution particularly when small coils need to be deployed alongside open cell and side design stents.

Unilateral Contrast Neurotoxicity as a Stroke Mimic After Cerebral Angiogram

Contrast neurotoxicity (CN) following exposure to iodinated contrast is uncommon, and usually presents as cortical blindness due to bilateral occipital lobe involvement. Unilateral cortical dysfunction due to CN could mimic an acute stroke and has been rarely described. We report the case of an 89-year-old female who developed a transient dense/complete left homonymous-hemianopsia and left-sided tactile extinction after undergoing a right internal carotid (ICA) artery rotational angiogram with a standard high-volume iodinated contrast injection for 3D visualization a 6×4-mm right posterior communicating artery aneurysm with a fetal posterior cerebral artery (PCA) incorporated in the neck. This was associated with transient fullness and loss of gray-white matter differentiation in the right occipital and parietal lobes. The potential mechanism of CN in our case was the injection of a high volume of contrast in the ICA for the rotational angiogram. The presence of a right fetal PCA possibly allowed the contrast to reach the right occipital lobe. CN manifesting as an acute focal neurologic syndrome should be considered in the setting of recent iodinated contrast exposure.

Ultra - early microsurgical management for patients with ruptured aneurysms of anterior circlulation combined with intracerebral hematoma

Objective To explore ultra - early microsurgical management in patients with ruptured aneurysms of anterior circlulation combined with intracerebral hematoma. Method The imaging characteristics and operation methods of 27 cases of ruptured aneurysms of anterior circlulation combined with intracerebral hematoma underwent surgery within 24 hours were collected. Results The surgical outcomes indicated that the intraoperative diagnoses were consistent with preoperative diagnoses in all cases. The rupture aneurysms include 6 cases of anterior communicating artery aneurysms,8 posterior communicating artery aneurysms,and 13 middle cerebral artery aneurysms. There were 3 patients harbored two aneurysms,2 in homolateral anterior circulation clipped at the same time, 1 in contralateral middle artery clipped in another operation. The aneurysms were all middle or small size. The postoperative Glasgow Outcome Scales (GOS) were grade Ⅴ in 14 patients,grade Ⅳ in 9, grade Ⅲ in 2, grade Ⅰ in 2. Conclusions For patients with ruptured aneurysms of anterior circlulation combined with intracerebral hematoma, favorable outcome chould be achieved through ultra - early microsurgical management Key words: Intracranial aneurysm; Anterior circulating; Ruptured; Microsurgery; Hematoma; Ultra early

Intracranial Aneurysm with Concomitant Rupture of an Undiagnosed Visceral Artery Aneurysm

Concomitant intracranial and visceral artery aneurysms are a rare occurrence. We report the case of a patient who underwent surgical repair of a ruptured intracranial aneurysm but subsequently experienced a ruptured hepatic artery aneurysm in the immediate postoperative period. A 59-year-old woman presented with a ruptured posterior communicating artery aneurysm and was treated with coil occlusion. On postoperative day 3, she became hypotensive with a rigid abdomen and was found to have a ruptured hepatic artery aneurysm. Rapid transfusion of packed red blood cells was begun, and the patient was taken to the angiography suite where the hepatic artery aneurysm was identified and successfully occluded using detachable coils to prevent further hemorrhage. Recovery was complicated by an ileus and mild pulmonary edema. Over several weeks, neurological status and third nerve paresis improved, with eventual discharge to a subacute rehabilitation center. Subsequent follow-up is notable for recurrence of the intracranial aneurysm, and multiple strictures of right intrahepatic arteries and hepatic ducts. The patient is currently being evaluated for liver transplant, but continues to improve neurologically. Prior to this report, there have only been 2 documented cases of concomitant intracranial and visceral artery aneurysms. These reports serve to remind the clinician that intracranial aneurysms may be only part of a systemic pathology, which should be taken into account when unexpected complications arise postoperatively.

E-013 Comparison of initial results following dual aneurysm embolization with the new penumbra coil 400 and 10-size coils in a single patient treated by the same operator

PurposeThe recently available Penumbra Coil 400 has 400% the volume per unit length of a 10-size coil due to its 0.020″ primary diameter, double that of conventional 10-coils. The Penumbra...

Superciliary keyhole surgery for unruptured posterior communicating artery aneurysms with oculomotor nerve palsy: maximizing symptomatic resolution and minimizing surgical invasiveness

For oculomotor nerve palsy (ONP) induced by unruptured posterior communicating artery (PCoA) aneurysms, the authors performed surgical clipping via a superciliary keyhole approach as an optimal treatment modality with high efficiency and low invasiveness. In this study, they then evaluated the technical feasibility, safety, clinical outcomes, including recovery from ONP as well as cosmetic results, and durability of the procedure. Thirteen patients presenting with complete (7 patients) or incomplete (6 patients) ONP underwent surgery via a superciliary approach. The operative video record was used to evaluate the technical feasibility, neurological examinations and CT were performed to analyze the safety of the treatment, and neuroophthalmological examinations and 3D CT angiography were undertaken to determine the effectiveness and durability of the treatment. In all cases, the aneurysms were successfully clipped using a 3.5-cm eyebrow incision and supraorbital minicraniotomy. The mean operative time was 108 ± 24 minutes. Twelve (92.3%) of the 13 patients showed complete resolution of the ONP. All 6 patients (100%) with incomplete ONP recovered completely within 1-2 months after surgery, whereas 6 (85.7%) of the 7 patients with complete ONP recovered completely within 1-6 months after surgery. Cosmetic results for the operative wounds were excellent without frontalis palsy. The durability of the treatment was ascertained based on 3D CT angiograms obtained 1 year after surgery. Surgical clipping via a superciliary keyhole approach can be an optimal treatment modality for PCoA aneurysms inducing ONP because it is effective, safe, and durable.

Posterior Communicating Artery Aneurysm–Related Oculomotor Nerve Palsy: Influence of Surgical and Endovascular Treatment on Recovery: Single-Center Series and Systematic Review

Compression of the third nerve resulting in oculomotor nerve palsy (ONP) is a common initial symptom and in some cases the only neurological deficit in patients with posterior communicating artery (PcomA) aneurysms. To analyze the resolution of ONP after surgical or endovascular treatment in comparison with its spontaneous course. Between June 1999 and April 2008, 5 of 914 consecutive patients with ruptured and 10 of 344 with unruptured intracranial aneurysms causing ONP were treated at our institution. ONP was recorded at admission and at follow-up. The electronic database MEDLINE was searched for published studies of PcomA aneurysm-caused ONP. Two reviewers independently extracted data. Overall, 26 studies and 15 patients of the current series totaling 201 PComA aneurysms met the inclusion criteria. A total of 132 patients underwent surgical clipping, 54 patients were treated endovascularly, and 15 patients remained untreated. Surgical treatment was associated with a significantly higher rate of complete ONP resolution (55% vs 32%; P=.006; odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3-5.1) and ONP resolution of any degree (92% vs 74%; P=.001; OR, 4.3; 95% CI, 1.8-10.4) compared with endovascularly treated patients. In the multivariate analyses, surgical clipping was significantly associated with ONP resolution of any degree (P<.0001; OR, 12.2; 95% CI, 3-49) and of complete resolution (P=.006; OR, 7.1; 95% CI, 1.8-28). The present data indicate that ONP caused by PComA aneurysms resolves in a significantly higher portion of patients after surgical treatment compared with endovascular coiling and the spontaneous course.

Acute Spinal Epidural Hematoma and Cranial Interdural Hematoma Due to a Rupture of a Posterior Communicating Artery Aneurysm: Case Report

We describe an unusual presentation of a ruptured aneurysm of the posterior communicating artery with an acute intracranial hematoma between the dural layers associated with an acute spinal epidural hematoma descending to L1. A 35-year-old woman presented 3 hours after ictus with a postcoital headache, neck stiffness, and bilateral abducens cranial nerve palsy. No other neurological deficits were present. Clinically, she had a subarachnoid hemorrhage World Federation of Neurosurgical Societies grade 1. CT scan demonstrates an acute subdural hematoma, extending from the right parasellar region, around the clivus, tentorium, and falx. Angio-CT showed a posterior communicating artery aneurysm and an anterior communicating artery aneurysm and an extension of the hematoma to the cervical spine. This justified a spinal and cerebral MRI that confirmed an extension of the hematoma to the epidural space at the cervical, thoracic, and lumbar levels. Three-dimensional digital subtraction angiography confirmed aneurysms on the right posterior communicating artery and on the anterior communicating artery. Both aneurysms were completely occluded by coiling. With reference to the concept of the cranial subdural compartment described in studies conducted using an electron microscope, this group of hematomas was classified as interdural. Ruptured aneurysm of the posterior communicating artery may cause cranial acute interdural hematoma with a typical subarachnoid hemorrhage clinical presentation, and it rarely can extend to spinal epidural space.

Cavernous Malformation of the Oculomotor Nerve Mimicking a Partially Thrombosed Posterior Communicating Artery Aneurysm: Report of Two Cases

Cavernous malformations of the cranial nerves are exceedingly rare. The classic radiographic appearance of cavernous malformations may not be obvious when located in a cranial nerve. We present 2 cases of acute oculomotor paresis caused by cavernous malformations of the oculomotor nerve that were mistaken for a thrombosed posterior communicating artery aneurysm on magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. Both patients underwent a craniotomy with exploration of the lesion. Both cavernous malformations were completely resected while the integrity of the third cranial nerve was maintained. One patient experienced complete resolution of the oculomotor palsy. Although rare, cavernous malformations should be included in the differential diagnosis of a partially thrombosed posterior communicating artery aneurysm. Exploration and complete lesional resection are possible with improvement of the cranial nerve function.

Simultaneous posterior communicating artery aneurysm clipping and selective amygdalohippocampectomy via direct lateral access through the mesial temporal lobe to the basal cisterns

We report a 23-year-old man with intractable epilepsy and an incidental posterior communicating artery aneurysm who was treated simultaneously for both pathologies. He was counseled regarding the potential to treat both pathologies with one procedure. He elected to undergo a simultaneous approach. The patient was doing well at his 5-month follow-up examination with no residual seizures or neurologic deficits. We conclude that access to aneurysms within the basal cisterns is viable with transchoroidal approaches through the temporal horn of the lateral ventricle. Anterior extension through portions of the amygdala further increases access. In our patient, selective amygdalohippocampectomy and posterior communicating artery aneurysm clipping were performed during the same surgical setting/approach. This directly lateral corridor allowed our young patient with an incidental aneurysm to undergo a less invasive combined operation rather than two separate procedures.

The role of circle of Willis anomalies in cerebral aneurysm rupture

Background and purposeLimited data exist to guide patient selection for preventive treatment of unruptured cerebral aneurysms. Cerebral aneurysms have been associated with circle of Willis anomalies but whether this association...

Microcatheter Neck Bridging and Incorporated Branch Vessel Protection for Coil Embolization of a Wide-Neck Ruptured Aneurysm: Technical Case Report

A novel technique in which microcatheter neck bridging of a ruptured wide-neck posterior communicating artery aneurysm was performed by intra-aneurysmal catheter navigation into a fetal configuration posterior cerebral artery (PCA) branch vessel arising from the sac. An 88-year-old woman with a Hunt and Hess grade 1 and Fisher grade 4 subarachnoid hemorrhage was identified as having a wide-neck posterior communicating artery aneurysm and an isolated fetal configuration PCA with origins from the aneurysm sac. Delivery of a bare platinum Guglielmi detachable coil within the aneurysm lumen resulted in persistent coil prolapse into the parent vessel with occlusion of the incorporated vital PCA origin. A microcatheter was then navigated through the aneurysm lumen and into the fetal configuration PCA. This was retained within the PCA with resultant aneurysm neck narrowing and branch vessel protection. A second microcatheter was placed in the aneurysm lumen for coil delivery. Complete aneurysm occlusion with patency of the PCA without coil loop prolapse into the parent vessel was achieved. The presence of normal branch vessels arising from the dome is a limitation for endovascular techniques. To the best of our knowledge, no prior description of a dual-microcatheter technique with selective catheter placement within an important intra-aneurysmal branch vessel has been published. The vital branch vessel was protected and the wide-neck aneurysm completely occluded. Novel placement of microcatheters further expands the range of complex configuration aneurysms amenable to endovascular coiling.