J Korean Neurosurg Soc.  2018 Sep;61(5):653-659. 10.3340/jkns.2017.0229.

Technical Consideration for Coiling of Ruptured Proximal Posterior Inferior Cerebellar Artery Aneurysm

• Kim JH
• Jeon IC
• Chang CH
• Jung YJ

• KMID: 2420075
• DOI: http://doi.org/10.3340/jkns.2017.0229

Abstract

OBJECTIVE
Surgical obliteration of ruptured aneurysm of the proximal posterior inferior cerebellar artery (PICA) is challenging because of limited surgical accessibility. In recent years, coil embolization is the first-choice treatment for these lesions. However, coil embolization is not always easy in ruptured PICA aneurysm owing to the variable anatomical diversity of its shapes, its relationship to the parent artery, its low incidence, and accordingly, lesser neurointerventionist experience.
METHODS
The parent artery and microcatheter for easier navigation and the embolization technique for stable coiling were identified.
RESULTS
This study aimed to identify the more appropriate approach route, microcatheter, and strategies for an easier and safer, and more durable coil embolization in the treatment of lesions in the proximal PICA.
CONCLUSION
Coil embolization for aneurysmal subarachnoid hemorrhage due to a ruptured proximal PICA remains a challenge, but with the appropriate coiling plan, it can be treated successfully.

Keyword

Subarachnoid hemorrhage; Proximal posterior inferior cerebellar artery; Embolization, Therapeutic

MeSH Terms

Aneurysm*
Aneurysm, Ruptured
Arteries*
Embolization, Therapeutic
Humans
Incidence
Parents
Pica
Subarachnoid Hemorrhage

Figure

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  Fig. 1. General relationship between the VA and the PICA. The PICA arises from the VA and travels posterolaterally around the medulla, and makes a characteristic loop appearance (A). Usually, aneurysms grow in the direction of bloodstream flow, so superior directed aneurysms are more common among proximal PICA aneurysms (B). Thus, we can navigate the microcatheter to the aneurysm according the ipsilateral VA (C). However, sometimes, aneurysms may grow to the opposite direction (D). In these cases, the contralateral approach via the opposite VA is easier than the ipsilateral approach (E). The contralateral approach is possible with the navigation on ipsilateral side with a J-shaped microcatheter, but it is easily pushed back to the parent artery during coil delivery (F). VA : vertebral artery, PICA : posterior inferior cerebellar artery.

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  Fig. 2. Usually, the VA shows an upward curved curvature in the lateral view, and the microcatheter within the VA may slightly droop along its normal curvature (A). The aneurysm on the proximal PICA arises at a superior direction. To navigate the superior directed aneurysm, an S-shaped microcatheter could be necessary (B). The type of S-shaped microcatheter can depend slightly on the angle between the parent artery and the aneurysm. As shown in (B), it is desirable to decide on the angle of an S-shaped microcatheter depending on the angle between the parent artery and the aneurysm. C-E : Show that the form of an S-shaped microcatheter also depends on the angle between the parent artery and the aneurysm. A more acutely angled S-shaped microcatheter is necessary for larger angled aneurysms (F). VA : vertebral artery, PICA : posterior inferior cerebellar artery.

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  Fig. 3. In cases of small neck aneurysm, coil embolization can be achieved with a single catheter, without other tools (A). However, if the aneurysm has a relative large neck or compromised the parent artery, an additional microcatheter may be useful for preventing the coil from coming out to the parent artery (B-D). In fusiform aneurysms or suspicious dissecting aneurysm, coil embolization can be performed with a stent-assisted technique (E-G).

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  Fig. 4. The 3-dimensional rotational digital subtraction angiogram shows a superior directed proximal PICA aneurysm, arising according the bloodstream flow (A). With the ipsilateral VA approach, the aneurysm is obliterated with a single microcatheter (B-D). The other 3-dimensional angiogram shows the inferolateral directed aneurysm growing opposite to the normal blood flow (E). The microcatheter is approached via the opposite side VA (F and G). Complete coil embolization of the aneurysm is achieved with a single microcatheter (H). PICA : posterior inferior cerebellar artery, VA : vertebral artery.

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  Fig. 5. The 3-dimensional rotational digital subtraction angiogram shows superior directed proximal PICA aneurysms arising according to the bloodstream flow (A and D). In case A, the angle between the aneurysm and the VA is lower than that in case D. After making a loose S-shaped microcatheter with steam, complete coil obliteration was achieved with a single microcatheter (B, C). Case D has a larger angle between the aneurysm and the VA; thus, a more angled S-shaped microcatheter with a double catheter technique was used (D-F). PICA : posterior inferior cerebellar artery, VA : vertebral artery.

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  Fig. 6. The 3-dimensional rotational digital subtraction angiogram shows an abnormal dilatation of the proximal PICA. The aneurysm arises at the proximal PICA, and the parent artery is compromised by the aneurysm neck (A). After two microcatheters are inserted in the aneurysm, the frame coil is made simultaneously with two pieces of coil while maintaining patency of the parent artery (B and C). PICA : posterior inferior cerebellar artery.

Reference

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