J Cerebrovasc Endovasc Neurosurg.  2012 Sep;14(3):223-227. 10.7461/jcen.2012.14.3.223.

Bilateral Approach for Stent-assisted Coiling of Posterior Inferior Cerebellar Artery Aneurysms: Two Cases

Affiliations
  • 1Department of Neurosurgery, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea.
  • 2Department of Radiology, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea. bjkwon74@gmail.com
  • 3Department of Neurosurgery, Eulji Hospital, Eulji University, Seoul, Korea.

Abstract

Aneurysms of the posterior inferior cerebellar artery (PICA) are rarely encountered. In particular, due to frequent anatomic complexity and the presence of nearby critical structures, PICA origin aneurysms are difficult to treat. However, recent reports of anecdotal cases using advanced endovascular instruments and skills have made the results of endovascular treatment rather outstanding. PICA preservation is the key to a successful endovascular treatment, based on the premise that a PICA origin aneurysm is well occluded. To secure PICA flow, stenting into the PICA would be the best method, however, it is nearly impossible technically via the ipsilateral vertebral artery (VA) if the PICA arose at an acute angle from the sac. In such a case, a bilateral approach for stent-assisted coiling can be a creative method for achievement of two goals of both aneurysm occlusion and PICA preservation: ipsilateral approach for coil delivery and contralateral cross-over approach for stent delivery via a retrograde smooth path into the PICA.

Keyword

Posterior inferior cerebellar artery; Intracranial aneurysm; Endovascular treatment

MeSH Terms

Achievement
Aneurysm
Arteries
Intracranial Aneurysm
Pica
Stents
Vertebral Artery

Figure

  • Fig. 1 A 71-year-old female patient with subarachnoid hemorrhage (Case 1). Computed tomography (CT) scan shows acute left premedullary subarachnoid hemorrhage (A). Posterior view of three-dimensional (3D) volume-rendered CT angiography shows a ruptured left posterior inferior cerebellar artery (PICA) aneurysm (B). Digital subtraction angiogram (C) and 3D volume rendered image (D) of the left vertebral angiography show a left PICA origin aneurysm measuring 7 mm in length, giving rise to the PICA from the sac (open arrow) (C, D). On a left vertebral angiogram, a microcatheter is shown in the right vertebral artery, vertebrovertebral junction, left vertebral artery, aneurysm neck, and left PICA, in order (black arrows). In this manner, a wire can easily select the PICA retrograde through a smooth path at the aneurysm neck after cross-over at the vertebrovertebral junction (E). A self expanding stent is barely identified on a left vertebral angiogram due to subtraction (arrowheads) and a coil delivery microcatheter via the ipsilateral vertebral artery is shown in the PICA aneurysm (white arrows) (F). Completion angiogram obtained after stent-assisted coiling shows good occlusion of the aneurysm and PICA preservation (G). Digital subtraction lateral view (H) and 3D volume rendered image (I) obtained at four months show good occlusion of the aneurysm (H, I).

  • Fig. 2 A 43-year-old male patient with subarachnoid hemorrhage (case 2). Volume-rendered 3D image shows a ruptured aneurysm with a large PICA arising from the sac (A). A delayed angiogram obtained 30 minutes after intra-arterial (IA) infusion of tirofiban shows active PICA flow, though residual small clots remain at the aneurysm neck (arrowheads) (B).


Cited by  1 articles

Coil Embolization of Ruptured Proximal Posterior Inferior Cerebellar Artery Aneurysm with Contralateral Retrograde Approach for LVIS Jr. Intraluminal Support Deployment
Dong Sub Kim, Jae Hoon Sung, Dong Hoon Lee, Ho Jun Yi
J Cerebrovasc Endovasc Neurosurg. 2018;20(4):235-240.    doi: 10.7461/jcen.2018.20.4.235.


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