J Cerebrovasc Endovasc Neurosurg.  2023 Dec;25(4):452-461. 10.7461/jcen.2023.E2022.10.011.

Endovascular treatment for anterior inferior cerebellar artery-posterior inferior cerebellar artery (AICA-PICA) common trunk variant aneurysms: Technical note and literature review

• Ku JC
• Chavda V
• Palmisciano P
• Pasarikovski CR
• Yang VX
• Kiwan R
• Priola SM
• Chaurasia B

• KMID: 2549452
• DOI: http://doi.org/10.7461/jcen.2023.E2022.10.011

Abstract

The Anterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery (AICA-PICA) common trunk is a rare variant of cerebral posterior circulation in which a single vessel originating from either the basilar or vertebral arteries supplies both cerebellum and brainstem territories. We present the first case of an unruptured right AICA-PICA aneurysm treated with flow diversion using a Shield-enhanced pipeline endovascular device (PED, VANTAGE Embolization Device with Shield Technology, Medtronic, Canada). We expand on this anatomic variant and review the relevant literature. A 39-year-old man presented to our treatment center with vertigo and right hypoacusis. The initial head CT/CTA was negative, but a 4-month follow-up MRI revealed a 9 mm fusiform dissecting aneurysm of the right AICA. The patient underwent a repeat head CTA and cerebral angiogram, which demonstrated the presence of an aneurysm on the proximal portion of an AICA-PICA anatomical variant. This was treated with an endovascular approach that included flow diversion via a PED equipped with Shield Technology. The patient’s post-procedure period was uneventful, and he was discharged home after two days with an intact neurological status. The patient is still asymptomatic after a 7-month follow-up, with MR angiogram evidence of stable aneurysm obliteration and no ischemic lesions. Aneurysms of the AICA-PICA common trunk variants have a high morbidity risk due to the importance and extent of the territory vascularized by a single vessel. Endovascular treatment with flow diversion proved to be both safe and effective in obliterating unruptured cases.

Keyword

Aneurysm; AICA-PICA variant; Coiling; Endovascular treatment; Posterior fossa; Stenting

Figure

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  Fig. 1. Head CT/CTA scan done after emergency admission for vertigo and right hypoacusis. No signs of intracranial bleeding, vascular malformations, neoplasm or other relevant conditions. Specifically, no aneurysms or dissections can be seen arising from the basilar artery and right AICA (black arrow). CTA, computed tomography angiogram; AICA, anterior inferior cerebellar artery

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  Fig. 2. Repeat head CT/CTA now showing a 9 mm fusiform aneurysm arising from the presumed AICA vessel (black arrow). CTA, computed tomography angiogram; AICA, anterior inferior cerebellar artery

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  Fig. 3. Diagnostic cerebral angiogram of the left vertebral artery, oblique view (A) and 3D reconstruction (B) showing the lack of PICA vessels bilaterally, with the AICA bifurcating and supplying both AICA and PICA territories bilaterally. There is a 9 mm fusiform aneurysm involving the proximal part of the AICA-PICA at its origin from the basilar artery. PICA, posterior inferior cerebellar artery; AICA, anterior inferior cerebellar artery

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  Fig. 4. Planning of stent deployment (A and B). Selective cannulation of the right AICA-PICA variant (C) and stent deployment covering the fusiform aneurysm on its entire length (D). AICA, the anterior inferior cerebellar artery; PICA, posterior inferior cerebellar artery

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  Fig. 5. Cerebral angiogram pre (A) and post (B) stent deployment showing the stent covering the entire neck of the aneurysm, with parent vessel patency.

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  Fig. 6. 7-month follow-up MRI showing no evidence of cerebellar or brainstem parenchymal ischemia on T1 (A) and T2 weighted images of the AICA or PICA territory (B), with follow-up T1 post contrast MR angiography axial image (C) and coronal image (D) showing opacification of the AICA-PICA vessel distal to the stent (white arrow) and no residual aneurysm filling. MRI, magnetic resonance imaging; AICA, anterior inferior cerebellar artery; PICA, posterior inferior cerebellar artery

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