Multiple Aneurysms of the Distal Posterior Inferior Cerebellar Artery: Two Case Reports

Abstract

Introduction: The distal segment of the PICA (posterior inferior cerebellar artery) is a very rare localization for the occurrence of intracranial aneurysms. They are almost always presented with SAH (subarachnoid hemorrhage). Hydrocephalus often develops following intraventricular hemorrhage (IVH). The distal PICA segment is a quite difficult localization for neurosurgical procedures. The authors could not find any case report presenting multiple aneurysms on a distal segment of PICA in the literature.

Case 1: A 62-year-old male patient was admitted to the emergency room with complaints of sudden headache, vomiting and blackout of consciousness. Early CT scans demonstrated SAH and intraventricular hemorrhage (IVH). In his medical history, SAH had been determined in our clinic 3 month previously. He had carried out conservative treatment ever since the distal located PICA aneurysm had been determined. There was no determined symptom except for moderate neck stiffness in his physical examination. In his neurological examination, he was stuporous and he localized the pain in his left arm. A ventriculo-atrial shunt operation was performed after the external ventricular drainage which was applied at the acute period of hydrocephalus in his previous SAH. Both of the left distal PICA aneurysms were clipped via a left lateral suboccipital craniotomy. The patient was discharged from the hospital without neurological deficit in the seventh day postoperatively. His control examination was normal and there was not any fixed pathological filling in the control cerebral digital subtraction angiography (DSA).

Case 2: A 49-year-old female patient was admitted to the emergency service with the complaint of headache, dizziness and vomiting. She was neurologically intact except for neck stiffness. A cranial CT demonstrated triventricular hydrocephalus and a hemispheric cerebellar hematoma, which was about 1×1.5 cm in diameter. The cerebellar DSA was normal. The patient was discharged with no neurological impairment. In the examination of the control cerebral DSA, two aneurysmatic fillings were determined in the distal segments of right posterior inferior cerebellar artery (PICA). Both of the aneurysms were clipped through a microsurgical approach. No neurological deficit was determined in the postoperative early and late stages. In the control cerebral DSA, no aneurysmatic filling was seen.

Discussion: Distal PICA aneurysms constitute only 0.28–1.4% of all intracranial aneurysms. Most of the patients present with SAH and along with this; intraventricular hemorrhage is seen and later on, hydrocephalus develops. As for treatment, surgery and endovascular interference methods can be applied.

distal posterior inferior cerebellar artery - aneurysm - multiple aneurysms

References

• 1 Tamano Y, Kobayashi T, Hagiwara S. et al . Aneurysm of the distal posterior inferior cerebellar artery originating from the extracranial and extradural vertebral artery.  Neurol Med Chir (Tokyo). 2003;  43 301-303
• 2 Ishikawa T, Suzuki A, Yasui N. Distal posterior inferior cerebellar aneurysms – report of 12 cases.  Neurol Med Chir (Tokyo). 1990;  30 100-108
• 3 Bertalanffy H, Seeger W. The dorsolateral, suboccipital, transcondylar approach to the lower clivus and anterior portion of the craniocervical junction.  Neurosurgery. 1991;  19 29
• 4 Liew D, Ng PY, Ng I. Surgical management of ruptured and unruptured symptomatic posterior inferior cerebellar artery aneurysms.  Br J Neurosurg. 2004;  18 608-612
• 5 Lister JR, Rhoton Jr AL, Matsushima T. et al . Microsurgical anatomy of the posterior inferior cerebellar artery.  Neurosurgery. 1982;  10 170-199
• 6 Margolis MT, Newton TH. The posterior inferior cerebellar artery. In: Newton TH, Potts DG, eds. Radiology of the Skull and Brain. St Louis: Mosby 1974 Vol. 2 Bk 2 1719-1775
• 7 Osborn AG. Introduction to cerebral angiography. Philadelphia: Harper & Row 1980: 379-427
• 8 Sen CN, Sekhar LN. An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum.  Neurosurgery. 1990;  27 197-204
• 9 Horiuchi T, Tanaka Y, Hongo K. et al . Characteristics of distal posteroinferior cerebellar artery aneurysms.  Neurosurgery. 2003;  53 589-595 , ; discussion 595–596
• 10 Lister JR, Rhoton Jr AL, Matsushima T. et al . Microsurgical anatomy of the posterior inferior cerebellar artery.  Neurosurgery. 1982;  10 170-199
• 11 Orakcioglu B, Schuknecht B, Otani N. et al . Distal posterior inferior cerebellar artery aneurysms: Clinical characteristics and surgical management.  Acta Neurochir (Wien). 2005;  147 1131-1139
• 12 Todaka T, Hamada J, Yano S. et al . Successful clipping of a distal posterior inferior cerebellar artery aneurysm located on the anterior surface of the medulla oblongata – case report.  Neurol Med Chir (Tokyo). 2002;  42 158-161
• 13 Dinichert A, Rufenacht DA, Tribolet N. Dissecting aneurysms of the posterior inferior cerebellar artery: report of four cases and review of the literature.  J Clin Neurosci. 2000;  6 515-520
• 14 Jamjoom A. Recurrent subarachnoid haemorrhage from an angiographically occult large distal pica aneurysm.  Br J Neurosurg. 1991;  5 393-398
• 15 Ikeda A, Yamaguchi T, Yamaguchi T. et al . Excision and end-to-end anastomosis of a fusiform aneurysm of the distal posterior inferior cerebellar artery associated with ischemia – case report.  Neurol Med Chir (Tokyo). 1991;  31 351-355
• 16 Nishino A, Sakurai Y, Satoh H. et al . Aneurysms of the distal posterior inferior cerebellar artery; the report of 10 cases.  No Shinkei Geka. 1991;  19 925-932
• 17 Yamaura A, Isobe K, Nakamura T. et al . Posterior inferior cerebellar aneurysm in the fourth ventricle.  Surg Neurol. 1980;  13 297-299
• 18 Hudgins RJ, Day AL, Quisling RG. et al . Aneurysms of the posterior inferior cerebellar artery. A clinical and anatomical analysis.  J Neurosurg. 1983;  58 381-387
• 19 Kaptain GJ, Lanzino G, Do HM. et al . Posterior inferior cerebellar artery aneurysms associated with posterior fossa arteriovenous malformation: report of five cases and literature review.  Surg Neurol. 1999;  51 146-152
• 20 Mukonoweshuro W, Laitt RD, Hughes DG. Endovascular treatment of PICA aneurysms.  Neuroradiology. 2003;  45 188-192
• 21 Salcman M, Rigamonti D, Numaguchi Y. et al . Aneurysms of the posterior inferior cerebellar artery-vertebral artery complex: variations on a theme.  Neurosurgery. 1990;  27 12-20 , ; discussion 20–21
• 22 Nussbaum ES, Mendez A, Camarata P. et al . Surgical management of fusiform aneurysms of the peripheral posteroinferior cerebellar artery.  Neurosurgery. 2003;  53 831-834
• 23 Tawk RG, Bendok BR, Qureshi AI. et al . Isolated dissections and dissecting aneurysms of the posterior inferior cerebellar artery: topic and literature review.  Neurosurg Rev. 2003;  26 180-187
• 24 Yamamoto I, Tsugane R, Ohya M. et al . Peripheral aneurysms of the posterior inferior cerebellar artery.  Neurosurgery. 1984;  15 839-845
• 25 Tikkakoski T, Leinonen S, Siniluoto T. et al . Isolated dissecting aneurysm of the left posterior inferior cerebellar artery: endovascular treatment with a Gugliemi detachable coil.  AJNR Am J Neuroradiol. 1997;  18 936-938
• 26 Fujimura M, Nishijima M, Midorikawa H. et al . Fatal rupture following intra-aneurysmal embolization for the distal posterior inferior cerebellar artery aneurysm with parent artery preservation.  Clin Neurol Neurosurg. 2003;  117-120
• 27 Dinichert A, Rufenacht DA, Tribolet N. Dissecting aneurysms of the posterior inferior cerebellar artery: report of four cases and review of the literature.  J Clin Neurosci. 2000;  7 515-520
• 28 Beyerl BD, Heros RC. Multiple peripheral aneurysms of the posterior inferior cerebellar artery.  Neurosurgery. 1986;  19 285-289

Correspondence