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

• Jeon SI
• Kwon BJ
• Seo DH
• Kang HI
• Park SC
• Choe IS

• KMID: 1808459
• DOI: http://doi.org/10.7461/jcen.2012.14.3.223

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).

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  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).

Reference

1. Al-khayat H, Al-khayat H, Beshay J, Manner D, White J. Vertebral artery-posteroinferior cerebellar artery aneurysms: clinical and lower cranial nerve outcomes in 52 patients. Neurosurgery. 2005. 01. 56(1):2–10. discussion 11.

2. Ates O, Ahmed AS, Niemann D, Baskaya MK. The occipital artery for posterior circulation bypass: microsurgical anatomy. Neurosurg Focus. 2008. 02. 24(2):E9.

3. Bragg TM, Duckworth EA. Contralateral far-lateral approach for clipping of a ruptured vertebral artery-posterior inferior cerebellar artery aneurysm. Neurosurg Focus. 2008. 12. 25(6):E9.

4. Coert BA, Chang SD, Do HM, Marks MP, Steinberg GK. Surgical and endovascular management of symptomatic posterior circulation fusiform aneurysms. J Neurosurg. 2007. 05. 106(5):855–865.

5. Cross DT 3rd, Moran CJ, Derdeyn CP, Mazumdar A, Rivet D, Chicoine MM. Neuroform stent deployment for treatment of a basilar tip aneurysm via a posterior communicating artery route. AJNR Am J Neuroradiol. 2005. Nov-Dec. 26(10):2578–2581.

6. Crowley RW, Evans AJ, Kassell NF, Jensen ME, Dumont AS. Endovascular treatment of a fusiform basilar artery aneurysm using multiple "in-stent stents". Technical note. J Neurosurg Pediatr. 2009. 06. 3(6):496–500.

7. D'Ambrosio AL, Kreiter KT, Bush CA, Sciacca RR, Mayer SA, Solomon RA, et al. Far lateral suboccipital approach for the treatment of proximal posteroinferior cerebellar artery aneurysms: surgical results and long-term outcome. Neurosurgery. 2004. 07. 55(1):39–50. discussion 50-4.

8. Doerfler A, Wanke I, Egelhof T, Stolke D, Forsting M. Double-stent method: therapeutic alternative for small wide-necked aneurysms. Technical note. J Neurosurg. 2004. 01. 100(1):150–154.

9. Ecker RD, Hanel RA, Levy EI, Hopkins LN. Contralateral vertebral approach for stenting and coil embolization of a large, thrombosed vertebral-posterior inferior cerebellar artery aneurysm. Case report. J Neurosurg. 2007. 12. 107(6):1214–1216.

10. Hudgins RJ, Day AL, Quisling RG, Rhoton AL Jr. , Sypert GW, Garcia-Bengochea F. Aneurysms of the posterior inferior cerebellar artery. J Neurosurg. 1983. 03. 58(3):381–387.

11. Jeon SG, Kwon DH, Ahn JS, Kwun BD, Choi CG, Jin SC. Detachable coil embolization for saccular posterior inferior cerebellar artery aneurysms. J Korean Neurosurg Soc. 2009. 09. 46(3):221–225.

12. Mocco J, Snyder KV, Albuquerque FC, Bendok BR, Alan SB, Carpenter JS, et al. Treatment of intracranial aneurysms with the Enterprise stent: a multicenter registry. J Neurosurg. 2009. 01. 110:35–39.

13. Moret J, Cognard C, Weill A, Castaings L, Rey A. [Reconstruction technique in the treatment of wide-neck intracranial aneurysms. Long-term angiographic and clinical results. Apropos of 56 cases]. J Neuroradiol. 1997. 06. 24(1):30–44. French.

14. Moret J, Ross IB, Weill A, Piotin M. The retrograde approach: a consideration for the endovascular treatment of aneurysms. AJNR Am J Neuroradiol. 2000. 02. 21(2):262–268.

15. Peluso JP, van Rooij WJ, Sluzewski M, Beute GN, Majoie CB. Posterior inferior cerebellar artery aneurysms: incidence, clinical presentation, and outcome of endovascular treatment. AJNR Am J Neuroradiol. 2008. 01. 29(1):86–90.

16. Rodriguez-Hernandez A, Lawton MT. Anatomical triangles defining surgical routes to posterior inferior cerebellar artery aneurysms. J Neurosurg. 2011. 04. 114(4):1088–1094.

17. Siddiqui MA, Bhattacharya J, Lindsay KW, Jenkins S. Horizontal stent-assisted coil embolisation of wide-necked intracranial aneurysms with the enterprise stent - a case series with early angiographic follow-up. Neuroradiology. 2009. 06. 51(6):411–418.

18. Song HH, Won YD, Kim YJ, Kim BS. The endovascular management of saccular posterior inferior cerebellar artery aneurysms. Korean J Radiol. 2008. Sep-Oct. 9(5):396–400.

19. Sundt TM Jr, Piepgras DG. Occipital to posterior inferior cerebellar artery bypass surgery. J Neurosurg. 1978. 06. 48:916–928.

20. Surdell DL, Hage ZA, Eddleman CS, Gupta DK, Bendok BR, Batjer HH. Revascularization for complex intracranial aneurysms. Neurosurg Focus. 2008. 02. 24(2):E21.

21. Wanke I, Gizewski E, Forsting M. Horizontal stent placement plus coiling in a broad-based basilar-tip aneurysm: an alternative to the Y-stent technique. Neuroradiology. 2006. 11. 48(11):817–820.

22. Yavuz K, Geyik S, Saatci I, Cekirge HS. WingSpan Stent System in the endovascular treatment of intracranial aneurysms: clinical experience with midterm follow-up results. J Neurosurg. 2008. 09. 109(3):445–453.