Dissecting aneurysms of the posterior inferior cerebellar artery: Retrospective evaluation of management and extended follow-up review in 6 patients

National Brain Aneurysm Center, St. Joseph's Hospital, St. Paul, Minnesota 55416, USA.
Journal of Neurosurgery (Impact Factor: 3.74). 08/2008; 109(1):23-7. DOI: 10.3171/JNS/2008/109/7/0023
Source: PubMed


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.[911] "
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    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.
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