A review of the management of posterior communicating artery aneurysms in the modern era

Abstract

Background:Technical advancements have significantly improved surgical and endovascular treatment of cerebral aneurysms. In this paper, we review the literature with regard to treatment of one of the most common intra-cranial aneurysms encountered by neurosurgeons and interventional radiologists.Conclusions:Anterior clinoidectomy, temporary clipping, adenosine-induced cardiac arrest, and intraoperative angiography are useful adjuncts during surgical clipping of these aneurysms. Coil embolization is also an effective treatment alternative particularly in the elderly population. However, coiled posterior communicating artery aneurysms have a particularly high risk of recurrence and must be followed closely. Posterior communicating artery aneurysms with an elongated fundus, true posterior communicating artery aneurysms, and aneurysms associated with a fetal posterior communicating artery may have better outcome with surgical clipping in terms of completeness of occlusion and preservation of the posterior communicating artery. However, as endovascular technology improves, endovascular treatment of posterior communicating artery aneurysms may become equivalent or preferable in the near future. One in five patients with a posterior communicating artery aneurysm present with occulomotor nerve palsy with or without subarachnoid hemorrhage. Factors associated with a higher likelihood of recovery include time to treatment, partial third nerve deficit, and presence of subarachnoid hemorrhage. Both surgical and endovascular therapy offer a reasonable chance of recovery. Based on level 2 evidence, clipping appears to offer a higher chance of occulomotor nerve palsy recovery; however, coiling will remain as an option particularly in elderly patients or patients with significant comorbidity.

Failure of the Pipeline Embolization Device in Posterior Communicating Artery Aneurysms Associated with a Fetal Posterior Cerebral Artery

“…Its incidence is estimated between 4 and 29% of patients and bilateral fetal PCOM variants occur in 1–9% of patients [6, 7]. Because fetal PCOM arteries are the only supply to the PCA, care must be taken not to compromise flow to this artery during clipping or coiling of PCOM artery aneurysms [8]. The aneurysm neck originates from the PCOM artery in 0.1–2.8% of all aneurysms and 4.6–13% of PCOM artery aneurysms [8, 9].…”

Imaging Vascular Anatomy and Pathology of The Posterior Fossa

“…28.9), or by superior cerebellar artery or posterior cerebral artery aneurysms as the oculomotor nerve passes in between these vessels (Ciceri et al 2001;Rhoton 2002;Al-Khayat et al 2005a;Peluso et al 2007b). An acute presentation of oculomotor palsy suggests a morphological change in the aneurysm, and can herald impending rupture (Golshani et al 2010). Similarly facial or vestibulocochlear nerve palsy may occur with AICA aneurysms, and lower cranial nerve palsies with PICA aneurysms (Peluso et al 2007a(Peluso et al , 2008.…”

“…An oculomotor palsy, occurring in 20% of PCOM aneurysms (Golshani et al 2010), may also be caused by posteriorly directed BT aneurysms compressing the oculomotor nerve as it enters the interpeduncular fossa (Fig. 28.9), or by superior cerebellar artery or posterior cerebral artery aneurysms as the oculomotor nerve passes in between these vessels (Ciceri et al 2001;Rhoton 2002;Al-Khayat et al 2005a;Peluso et al 2007b).…”

“…Most commonly, the posterior communicating artery arises from the base of the aneurysm (Golshani et al 2010). Because the number of perforators from the PCOM is relatively constant, both microsurgery and coiling aim to preserve this vessel regardless of caliber (Baskaya 2005).…”

“…Notably, ruptured PCOM aneurysms may present with nontraumatic subdural hemorrhage (1.3-7.9%), typically if they point toward the sphenoid ridge. Rarely, superiorly and posterolaterally directed PCOM aneurysms may present with temporal lobe intra-parenchymal hemorrhage (Golshani et al 2010). These cases may require open evacuation with concomitant microsurgical aneurysm treatment.…”