Surgical Management and Outcomes of Aneurysms of Posterior Inferior Cerebellar Artery: Location-Based Approaches with Review of Literature

Abstract

Background Posterior inferior cerebellar artery (PICA) is a tortuous, variable, and uncommon site for aneurysms. Surgical management of PICA aneurysms involves careful selection of approach based on the location of the aneurysm and meticulous dissection of the neurovascular structures and perforators. Materials and Methods We did a retrospective review of all the PICA aneurysms operated at our institute in the past 10 years along with the site, presentation, and approach used for the same. Preoperative World Federation of Neurosurgical Society scores and follow-up modified Rankin scores (mRS) were also evaluated. During the same period, data for intervention cases of PICA aneurysm were also collected with follow-ups for a comparative analysis. Results A total of 20 patients with 21 PICA aneurysms were reviewed. All the reviewed cases presented with subarachnoid hemorrhage, and the most common location was the lateral medullary segment and vertebral artery (VA)–PICA junction. Midline approaches were used for distal PICA cases, with far-lateral approach reserved for anterior medullary/VA–PICA junction. No lower cranial nerve palsies were recorded at follow-up. Four cases needed cerebrospinal fluid diversion and two developed cerebellar infarcts. All cases were mRS 0 to 2 at follow-up. Conclusion Our series compares well with some of the larger surgical series of PICA aneurysms. This may be due to early referral patterns and early surgery (<24 hours) policy at our institution. Anatomical knowledge of PICA anatomy and sound perioperative management are keys to good outcomes in these cases.

Microsurgical Clipping of a Posterior Inferior Cerebellar Artery Aneurysm Following Failed Pipeline Stent

“…Recently, placement of the PED in the PICA itself has also been shown to be successful [ 5 ]. However, some have also shown in the literature that surgery can be an effective first-line management option for these aneurysms as well [ 9 , 14 - 15 ]. Furthermore, as shown in this case, sometimes PEDs are not effective in completely occluding an aneurysm.…”

Microsurgical treatment of posterior inferior cerebellar aneurysms based on angioarchitecture supplemented by high-resolution vessel wall MRI: a case series report

“…Therefore, microsurgical treatment may be required for the treatment of complex PICA aneurysms. This approach can be challenging because of anatomic variability, interference of lower cranial nerves, diverse aneurysmal morphology and size, and presence of atherosclerosis, calcification, and intraluminal thrombosis, all of which must be assessed preoperatively 4 8–16. However, previously developed angioarchitecture-based surgical algorithms do not take aneurysmal wall structure into account despite its impact on treatment selection.…”

“…High-resolution vessel wall MRI (HR-VW MRI) has shown promise in identifying aneurysmal wall inflammatory reaction and atherosclerosis and may be useful in surgical planning 17. Therefore, We have developed tailored operative techniques for PICA aneurysms that are based on digital subtraction angiography (DSA) angioarchitecture characteristics, including morphology, location and wall structure 12 14 18 19. This study describes our evaluation process, surgical strategy and outcomes.…”

Pipeline embolization of distal posterior inferior cerebellar artery aneurysms

“…1–3 As such, a variety of open and endovascular treatments can be considered when treating these aneurysms. 3–6…”

“…[1][2][3] As such, a variety of open and endovascular treatments can be considered when treating these aneurysms. [3][4][5][6] Flow diverting stents are a promising endovascular treatment for intracranial aneurysms. The most widely used flow diverter, the Pipeline Embolization Device (PED), has demonstrated high levels of safety and efficacy when used for aneurysm treatment in approved regions of the internal carotid artery.…”