Dissecting aneurysms of the posterior inferior cerebellar artery: Retrospective evaluation of management and extended follow-up review in 6 patients
ABSTRACT The authors report the management protocol and successful outcomes in 6 patients with dissecting aneurysms of the posterior inferior cerebellar artery (PICA).
Medical records and neuroimaging studies of 6 patients who underwent surgical treatment of dissecting PICA aneurysms were reviewed. The mean follow-up duration was 1.8 years. No patient was lost to follow-up review.
Four patients presented with acute subarachnoid hemorrhage and 2 with PICA ischemia. All patients underwent surgery, which entailed proximal occlusion with distal revascularization in 3 cases and circumferential wrap/clip reconstruction in 3 cases. The revascularization techniques used were occipital artery-PICA bypass and PICA-PICA anastomosis. Delayed follow-up angiography was performed in all cases. In patients treated with proximal occlusion, delayed angiography showed minimal retrograde opacification of the dissected segments. The 3 patients treated with wrap/clip reconstruction showed unexpectedly significant normalization of their lesions on angiographic studies. Outcome was good in all cases.
Dissecting PICA aneurysms are rare lesions with an apparent propensity for bleeding. Individualized management including distal revascularization with PICA sacrifice or circumferential wrap/clip reconstruction to reinforce the dissected segment produced good outcomes. Patients treated with aneurysm wrapping may show dramatic angiographic improvement of the dissected segment.
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- "When possible, preservation of the parent artery is preferred to mitigate the risk of brainstem infarction by preserving flow through proximal perforators. When proximal occlusion or trapping are used, we have advocated for the use of combined distal revascularization techniques to prevent permanent ischemic damage of the brainstem and cerebellar hemisphere due to unpredictable collateral supply. "
ABSTRACT: Only a limited number of dissecting aneurysms of the peripheral cerebellar arteries have been previously described, and very few of these cases involve the superior cerebellar artery (SCA). Due to the rarity of these lesions, there is little consensus regarding prognosis and management. We describe our experience with two cases of complex peripheral SCA dissecting aneurysms and review the existing literature on this fascinating entity. Two patients, both with SCA dissecting aneurysms not amenable to endovascular treatment underwent microsurgical clipping, one with the associated removal of a tentorial meningioma. In each procedure a combined subtemporal, presigmoidal approach was performed. Surgical clips were utilized to reconstruct the aneurysms, and both patients were discharged without complication. Surgical management of complex distal SCA fusiform aneurysm is challenging and options include wrap/clip reconstruction, proximal occlusion, trapping, and distal outflow occlusion. When possible, preservation of the parent artery is preferred to mitigate the risk of brainstem infarction. If proximal occlusion or trapping are employed, we have advocated for the use of combined distal revascularization techniques to prevent permanent ischemic damage of the brainstem and cerebellar hemisphere. Peripherally dissecting aneurysm of the SCA is an uncommon entity. Management of these lesions is best handled by an experienced neuro-endovascular team combined with a neurovascular surgeon skilled in skull base approaches.Surgical Neurology International 05/2011; 2:69. DOI:10.4103/2152-7806.81731 · 1.18 Impact Factor
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ABSTRACT: The authors report the management and outcomes of 55 patients with 60 intracranial aneurysms arising distal to the major branch points of the circle of Willis and vertebrobasilar system. Between July 1997 and December 2006, the authors' neurovascular service treated 2021 intracranial aneurysms in 1850 patients. The database was reviewed retrospectively to identify peripherally located intracranial aneurysms. Aneurysms that were mycotic and aneurysms that were associated with either an arteriovenous malformation or an atrial myxoma were excluded from review. The authors encountered 60 peripheral intracranial aneurysms in 55 patients. There were 42 small, 7 large, and 11 giant lesions. Forty-one (68%) were unruptured, and 19 (32%) had bled. Fifty-three aneurysms were treated surgically by using direct clip reconstruction in 26, trapping or proximal occlusion with distal revascularization in 21, excision with end-to-end anastomosis in 3, and circumferential wrap/clip reconstruction in 3. Coils were used to treat 6 aneurysms, and 1 was treated by endovascular parent artery occlusion. Overall, 49 patients had good outcomes, 4 were left with new neurological deficits, and 2 died. Peripherally situated intracranial aneurysms are rare lesions that present unique management challenges. Despite the fact that in the authors' experience these lesions were rarely treatable with simple clipping of the aneurysm neck or endovascular coil occlusion, preservation of the parent artery was possible in most cases, and the majority of patients had a good outcome.Journal of Neurosurgery 11/2008; 110(1):7-13. DOI:10.3171/2008.6.JNS0814 · 3.74 Impact Factor
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ABSTRACT: To review recent advances in understanding supraaortic arterial dissections and their diagnosis and management. Dissection of the supraaortic arteries, including the extracranial carotid and vertebral arteries and intracranial arteries, is increasingly identified as an important cause of stroke and subarachnoid hemorrhage. The most common cause likely involves minor trauma with preexisting arteriopathy. The imaging diagnosis of dissection is complicated by the wide range of pathological changes that occur after dissection. Modalities include ultrasound, magnetic resonance imaging and angiography, computed tomography angiography, and digital subtraction angiography. The choice of method is best tailored to each patient individually. Similarly, treatments may vary from antiplatelet medications to complex endovascular techniques. There are limited data to guide treating patients with strokes due to arterial dissections. Conservative management is likely optimal for most patients with cervical dissections, endovascular treatments being reserved for the rapidly deteriorating patient only. However, patients with subarachnoid hemorrhage due to rupture of a dissecting aneurysm require urgent endovascular or surgical treatment of the aneurysm. The diagnosis and management of supraaortic arterial dissections is complex, and a variable multidisciplinary approach will likely yield the best outcome.Current opinion in neurology 03/2009; 22(1):80-9. DOI:10.1097/WCO.0b013e328320d2b2 · 5.31 Impact Factor