Posterior Communicating Artery Aneurysm Research Articles

Single-centre comparison of procedural complications, clinical outcome, and angiographic follow-up between coiling and stent-assisted coiling for posterior communicating artery aneurysms

Aneurysm recurrence is a principle limitation of endovascular coiling procedures, especially in posterior communicating artery aneurysms, with reported recurrence rates of >30%. The adjunctive use of self-expandable stents has revolutionised the treatment of intracranial aneurysms, especially for complex morphologies, wide necks, or unfavourable dome-to-neck ratios. However, there are limited data concerning a direct comparison between simple coiling and stent-assisted coiling in posterior communicating artery aneurysms. This study aimed to compare the durability and outcomes of coiling versus stent-assisted coiling procedures. Imaging data of patients with posterior communicating artery aneurysms treated with coiling or stent-assisted coiling between January 2008 and October 2012 were retrospectively analysed. The initial angiographic results, procedural complications, and clinical outcomes were assessed at discharge. Imaging follow-up was performed with cerebral angiography. Complete aneurysm occlusion was achieved on initial angiography in 23/56 (41.1%) stent and 83/235 (35.3%) non-stent patients. At the latest follow-up (mean follow-up 14.3±10.4months for stent and 13.2±9.5months for non-stent patients), aneurysms had recurred in 5/47 (10.6%) stent and 57/203 (28.1%) non-stent patients (p=0.014). Procedural complications occurred in 6/56 (10.7%) stent and 27/235 (11.5%) non-stent aneurysms. No rebleeding occurred during clinical follow-up (mean duration, 46.7months). Recurrence rates at the latest follow-up were significantly lower in patients undergoing stent-assisted coiling than those undergoing simple coiling. Thus, use of the stent-assisted neck remodelling technique in the treatment of wide-necked posterior communicating artery intracranial aneurysms appears to improve the long-term clinical outcome.

O-020 Modifying Flow in the ICA Bifurcation: Pipeline Deployment from the supraclinoid ICA Extending into the M1 Segment: Clinical and Anatomical Results

BackgroundUtility of the pipeline embolization device (PED) extending to the M1 segment as well as its clinical and flow consequences at the ICA bifurcation, has not clearly described. We describe...

P-003 Endovascular Concurrent Use of Coils and Pipeline Embolization Device for Intracranial Aneurysms: Clinical and Angiographic Results

BackgroundThe utility of the pipeline embolization device (PED) has been described as the sole device for treatment of brain aneurysms. The benefit using concurrent coils with limited number of PEDs...

Endovascular coil embolization of unruptured posterior communicating artery aneurysm

The patient is a 60-year-old woman who presented to her primary care physician with new onset of headache. She was neurologically intact without cranial nerve deficit. An outpatient CT angiogram (CTA) revealed no subarachnoid hemorrhage, but showed a right-sided posterior communicating artery aneurysm measuring 11 mm by 10 mm. Digitally subtracted cerebral angiography confirmed these measurements and showed that the aneurysm was amenable to endovascular coil embolization. The patient underwent aneurysm coiling without complication and was discharged to home on postoperative Day 1. The video can be found here: http://youtu.be/MjOc3Zpv2K8 .

E-032 Retrograde Stent-Assisted Coil Embolization of Posterior Communicating Artery Aneurysms

Introduction/purposeEndovascular coil embolization with or without stenting for the treatment of posterior communicating artery (PcommA) aneurysms is well established. However, if the PcommA originates from the base of the aneurysm,...

Third nerve palsy caused by compression of the posterior communicating artery aneurysm does not depend on the size of the aneurysm, but on the distance between the ICA and the anterior–posterior clinoid process

ObjectiveThird nerve palsy (TNP) caused by a posterior communicating artery (PCoA) aneurysm is a well-known symptom of the condition, but the characteristics of unruptured PCoA aneurysm-associated third nerve palsy have not been fully evaluated. The aim of this study was to analyze the anatomical features of PCoA aneurysms that caused TNP from the viewpoint of the relationship between the ICA and the skull base. MethodsForty-eight unruptured PCoA aneurysms were treated surgically between January 2008 and September 2013. The characteristics of the aneurysms were evaluated. ResultsThirteen of the 48 patients (27%) had a history of TNP. The distance between the ICA and the anterior–posterior clinoid process (ICA–APC distance) was significantly shorter in the TNP group (p<0.01), but the maximum size of the aneurysms was not (p=0.534). ConclusionRelatively small unruptured PCoA aneurysms can cause third nerve palsy if the ICA runs close to the skull base.

Anterior petroclinoid fold fenestration: an adjunct to clipping of postero-laterally projecting posterior communicating aneurysms.

Proximally located posterior communicating artery (PCoA) aneurysms, projecting postero-laterally in proximity to the tentorium, may pose a technical challenge for microsurgical clipping due to obscuration of the proximal aneurysmal neck by the anterior petroclinoid fold. We describe an efficacious technique utilizing fenestration of the anterior petroclinoid fold to facilitate visualization and clipping of PCoA aneurysms abutting this aspect of the tentorium. Of 86 cases of PCoA aneurysms treated between 2003 and 2013, the technique was used in nine (10.5 %) patients to allow for adequate clipping. A 3 mm fenestration in the anterior petroclinoid ligament is created adjacent and lateral to the anterior clinoid process. This fenestration is then widened into a small wedge corridor by bipolar coagulation. In all cases, the proximal aneurysm neck was visualized after the wedge fenestration. Additionally, an adequate corridor for placement of the proximal clip blade was uniformly established. All cases were adequately clipped, with complete occlusion of the aneurysm neck and fundus with preservation of the PCoA. There were two intraoperative ruptures not related to creation of the wedge fenestration. One patient experienced post-operative partial third nerve palsy, which resolved during follow-up. We describe a technique of fenestration of the anterior petroclinoid fold to establish a critical and safe corridor for both visualization and clipping of PCoA aneurysms.

Anatomic and Radiologic Classification of Posterior Communicating Artery Aneurysms

One-quarter of all cerebral aneurysms affect the posterior communicating artery. The clinical course typically involves subarachnoid hemorrhage and oculomotor nerve palsy. The objective of this study was to apply the de Aguiar and colleagues’ anatomicosurgical classification of posterior communicating artery aneurysms to a series of ruptured and incidental aneurysms treated at a single center and ascertain whether correlations exist between this classification and surgical outcomes (successful or failed occlusion). A single-center, retrospective cohort study based on imaging data was carried out between 2005 and 2010. Patients were allocated into 2 groups depending on aneurysm presentation (acutely ruptured or incidental). In this series, posterior communicating artery aneurysms were 4 to 5 times more common in women than in men, and type II (temporal) aneurysms were those most frequently found. The worst prognosis in the acute bleeding group was seen in cases with fetal variant circulation. The overall prognosis was poorer for temporal aneurysms, particularly those with a higher Hunt and Hess scale grade. Unruptured aneurysms were associated with better outcomes after surgical treatment.

Morphological parameters associated with ruptured posterior communicating aneurysms.

The rupture risk of unruptured intracranial aneurysms is known to be dependent on the size of the aneurysm. However, the association of morphological characteristics with ruptured aneurysms has not been established in a systematic and location specific manner for the most common aneurysm locations. We evaluated posterior communicating artery (PCoA) aneurysms for morphological parameters associated with aneurysm rupture in that location. CT angiograms were evaluated to generate 3-D models of the aneurysms and surrounding vasculature. Univariate and multivariate analyses were performed to evaluate morphological parameters including aneurysm volume, aspect ratio, size ratio, distance to ICA bifurcation, aneurysm angle, vessel angles, flow angles, and vessel-to-vessel angles. From 2005–2012, 148 PCoA aneurysms were treated in a single institution. Preoperative CTAs from 63 patients (40 ruptured, 23 unruptured) were available and analyzed. Multivariate logistic regression revealed that smaller volume (p = 0.011), larger aneurysm neck diameter (0.048), and shorter ICA bifurcation to aneurysm distance (p = 0.005) were the most strongly associated with aneurysm rupture after adjusting for all other clinical and morphological variables. Multivariate subgroup analysis for patients with visualized PCoA demonstrated that larger neck diameter (p = 0.018) and shorter ICA bifurcation to aneurysm distance (p = 0.011) were significantly associated with rupture. Intracerebral hemorrhage was associated with smaller volume, larger maximum height, and smaller aneurysm angle, in addition to lateral projection, male sex, and lack of hypertension. We found that shorter ICA bifurcation to aneurysm distance is significantly associated with PCoA aneurysm rupture. This is a new physically intuitive parameter that can be measured easily and therefore be readily applied in clinical practice to aid in the evaluation of patients with PCoA aneurysms.

Extensive Proximal Migration of Posterior Communicating Artery Aneurysm Coil Presenting with a Transient Ischemic Attack (P5.127)

Extensive Proximal Migration of Posterior Communicating Artery Aneurysm Coil Presenting with a Transient Ischemic Attack (P5.127)

Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms: results after clipping versus coiling in a single-center series

Oculomotor nerve palsy (ONP) is a common clinical manifestation of ruptured or unruptured posterior communicating artery (PcomA) aneurysms. Although microsurgical clip ligation has been proven a safe and durable treatment, endovascular management is emerging as an increasingly popular alternative. The aim of our study is to compare the recovery rate from ONP and assess the safety and long-term durability of both techniques. We have reviewed the retrospective data concerning twenty-two patients treated at our institution between 2004 and 2012 for PcomA aneurysms with ONP. Seven patients were operated on via a standard pterional approach, and fourteen were treated by endovascular occlusion with coils. One patient was managed conservatively. Pre-treatment and post-treatment severity of ONP was recorded, as well as the duration of symptoms before admission and treatment-related complications. All seven patients who underwent surgery improved, with six total recoveries and one partial recovery. Among the fourteen patients treated by embolization, thirteen initially recovered, but long-term follow-up revealed three cases of exacerbation of ONP after refilling of the aneurysms. Two of them were clipped, and one embolized. Also, one partially resolved patient underwent a second embolization. No severe complications occurred in either group. Despite the small number of patients, our study suggests that both surgical clipping and embolization are safe and effective methods in regards to functional recovery (complete ONP recovery in about 85% of the cases). However, coiling may lead to delayed recurrence of third cranial nerve (CN) palsy at long-term follow-up, requiring additional treatment.

Augmented Reality in the Surgery of Cerebral Aneurysms

Augmented reality is the overlay of computer-generated images on real-world structures. It has previously been used for image guidance during surgical procedures, but it has never been used in the surgery of cerebral aneurysms. To report our experience of cerebral aneurysm surgery aided by augmented reality. Twenty-eight patients with 39 unruptured aneurysms were operated on in a prospective manner with augmented reality. Preoperative 3-dimensional image data sets (angio-magnetic resonance imaging, angio-computed tomography, and 3-dimensional digital subtraction angiography) were used to create virtual segmentations of patients' vessels, aneurysms, aneurysm necks, skulls, and heads. These images were injected intraoperatively into the eyepiece of the operating microscope. An example case of an unruptured posterior communicating artery aneurysm clipping is illustrated in a video. The described operating procedure allowed continuous monitoring of the accuracy of patient registration with neuronavigation data and assisted in the performance of tailored surgical approaches and optimal clipping with minimized exposition. Augmented reality may add to the performance of a minimally invasive approach, although further studies need to be performed to evaluate whether certain groups of aneurysms are more likely to benefit from it. Further technological development is required to improve its user friendliness.

Endovascular management of cerebral vasospasm following aneurysm rupture: Outcomes and predictors in 116 patients

ObjectiveTo retrospectively assess the safety and efficacy of endovascular treatment of cerebral vasospasm with different modalities and assess predictors of outcome. MethodsEndovascular treatment was indicated in the event of neurological deterioration refractory to medical therapy. Data were collected for 116 patients treated at our institution. ResultsVasospasm was treated with balloon angioplasty in 52.6%, intra-arterial nicardipine infusion in 19.8%, or both in 27.6%. Angiographic vasospasm was reversed in all but 4 (96.6%) patients. The complication rate was 0.9%. Twenty patients (17.2%) had incipient pre-procedure hypodensities; 3 (15%) hypodensities were reversed and neurological improvement occurred in 60% of these patients. Retreatment was required in 22 (19%) patients. Higher Hunt and Hess grades and treatment with nicardipine alone predicted retreatment. Neurological improvement was noted in 82%. Male gender, pre-procedure hypodensities, and posterior communicating artery aneurysm location negatively predicted neurological recovery. Favorable outcomes were noted in 73%. Higher Hunt and Hess grades, pre-procedure hypodensities, posterior circulation aneurysms, and no neurological recovery predicted poor outcome. ConclusionEndovascular therapy for vasospasm has an excellent safety-efficacy profile. Balloon angioplasty and nicardipine are equally effective but effects of nicardipine are less durable. Patients with incipient pre-procedure hypodensities benefit from endovascular intervention and should probably not be excluded from treatment.

外科的適応から外れ経過観察中に増大しくも膜下出血をきたした未破裂脳動脈瘤の3例

The UCAS Japan, the SUAVe Study, and the ISUIA have shown that the indications for surgical or endovascular treatment of unruptured small aneurysms and asymptomatic aneurysms in elderly patients require careful consideration. We describe three cases of intracranial aneurysms not indicated for surgical or endovascular treatment: a 3-mm middle cerebral artery aneurysm in a 36-year-old woman, a 4-mm pericallosal artery aneurysm in a 74-year-old woman, and an 8-mm posterior communicating artery aneurysm in an 83-year-old woman, which had all enlarged in the observation period and finally ruptured. All three patients had two or more risk factors for aneurysm growth or rupture identified by the UCAS Japan or SUAVe Study, indicating that careful follow-up monitoring for morphological changes in the aneurysm is mandatory, even for a small aneurysm, and especially in young patients with such multiple risk factors. However, surgical indications are limited for elderly patients, even after aneurysm enlargement, so the appropriate treatment for elderly patients requires careful consideration of the clinical condition of the individual patient.

Iatrogenic rupture of undiagnosed blood blister-like aneurysm during aneurysmal neck clipping.

Iatrogenic rupture of undiagnosed blood blister-like aneurysm during aneurysmal neck clipping.

Ruptured Posterior Communicating Artery Aneurysm Associated with Aarskog Syndrome

A 44-year-old male with Aarskog syndrome (AS) presented with subarachnoid hemorrhage secondary to ruptured posterior communicating artery aneurysm. AS, also known as faciogenital dysplasia, is an X-linked, autosomal dominant or autosomal recessive congenital developmental disorder. This syndrome is characterized by short stature in association with a variety of multiple anomalies in musculoskeletal, neurological, and urogenital systems. Cerebrovascular abnormalities such as anomalous cerebral venous drainage, dysplastic internal carotid artery, and basilar artery malformation have been reported to be associated with AS. To our knowledge this represents the first case of a ruptured intracranial aneurysm in a patient with AS.

Endovascular treatment of ruptured true posterior communicating artery aneurysms

Although true posterior communicating artery (PCoA) aneurysms are rare, they are of vital importance. We reviewed 9 patients with this fatal disease, who were treated with endovascular embolization, and discussed the meaning of endovascular embolization for the treatment of true PCoA aneurysms. From September 2006 to May 2012, 9 patients with digital substraction angiography (DSA) confirmed true PCoA aneurysms were treated with endovascular embolization. Patients were followed-up with a minimal duration of 17 months and assessed by Glasgow Outcome Scale (GOS) score. All the patients presented with spontaneous subarachnoid hemorrhage from the ruptured aneurysms. The ratio of males to females was 1:2, and the average age of onset was 59.9 (ranging from 52 to 72) years. The preoperative Hunt-Hess grade scores were I to III. All patients had recovered satisfactorily. No permanent neurological deficits were left. Currently, endovascular embolization can be recommended as the top choice for the treatment of most true PCoA aneurysms, due to its advanced technique, especially the application of the stent-assisted coiling technique, combined with its advantage of mininal invasiveness and quick recovery. However, the choice of treatment methods should be based on the clinical and anatomical characteristics of the aneurysm and the skillfulness of the surgeon.

Rupture risks of posterior communicating artery aneurysms: morphological and hemodynamic analysis

Rupture risks of posterior communicating artery aneurysms: morphological and hemodynamic analysis

Recovery of oculomotor nerve palsy secondary to posterior communicating artery aneurysms

Background. Recent studies suggest more favourable recovery of oculomotor nerve palsy (ONP) caused by posterior communicating artery (PComA) aneurysms with microsurgical clipping compared to endovascular coiling. We describe a consecutive series of patients with ONP from PComA aneurysms treated by microsurgical clipping or endovascular coiling. Methods. We retrospectively reviewed medical records of all patients from 2005 to 2009 with complete or partial ONP from PComA aneurysms. Results. Twenty patients were identified, three with unruptured aneurysms. Two patients with ruptured aneurysms were unfit for treatment and therefore excluded. Of the 18 patients included (15 female), 9 underwent microsurgical clipping and 9 received endovascular coiling. Patients treated by surgical clipping were significantly younger compared to those treated by endovascular coiling (mean 52.3 vs. 67.9 years; p = 0.039). Five patients had incomplete ONP (3 clipped, 2 coiled) and thirteen had complete ONP. At 6 months, six of nine patients treated with clipping and five of nine patients treated with coiling had complete resolution of their ONP (p = 1.0); the remainder had partial improvement. There was no significant difference in duration of pre-treatment ONP, age, sex or status of aneurysm (ruptured or unruptured) between patients in the two groups or between those with full or partial recovery. However, all 5 patients with incomplete ONP at presentation recovered fully, compared with 6 of 13 patients who presented with complete ONP. Conclusions. We found no significant difference between clipping and coiling in the recovery of ONP due to PComA aneurysms. Patient who present with incomplete ONP are more likely to have a full recovery of ONP following either treatment modality than those who present with complete ONP.

True posterior communicating artery aneurysms with or without increased flow dynamical stress: Report of three cases

True posterior communicating artery (PCoA) aneurysm refers to n aneurysm that originates from the PCoA itself. These aneurysms re very rare lesions, representing 0.1–2.8% of all intracranial neurysms [1,2]. As indicated in a recent systematic review, 70 ases of true PCoA aneurysms were reported since 1951, includng those reported in non-English articles and meeting abstracts, nd only part of them had detailed information in sporadic singlease reports [1]. In this small case series, we describe three unique atients with ruptured true PCoA aneurysms that were successfully reated with surgical or endovascular procedures.