Characteristics of distal posteroinferior cerebellar artery aneurysms

OBJECTIVE: Distal posteroinferior cerebellar artery (PICA) aneurysms are rare and have not been well investigated previously. We report our series of 24 patients with 27 distal PICA aneurysms. METHODS: All patients with distal PICA aneurysms that were surgically treated at Shinshu University Hospital and its affiliated hospitals between 1983 and 2001 were reviewed retrospectively. Data relating to clinical, radiological, and intraoperative findings were analyzed. RESULTS: In our series, distal PICA aneurysms reached an incidence of 0.28 and 0.38% of all intracranial aneurysms and ruptured aneurysms, respectively. There were 23 ruptured and 4 unruptured distal PICA aneurysms. Of these, 74.1% were saccular, 7.4% fusiform, and 18.5% dissecting aneurysms. Primarily the telovelotonsillar segment of the PICA was affected. Usually, the surgical outcome was favorable and was influenced by the obstructive hydrocephalus and the preoperative grade. It was sometimes difficult to detect the ruptured distal PICA aneurysm on the initial angiogram, and an extracranial origin of the PICA was sometimes observed. CONCLUSION: This review summarizes the presentation and outcome of a large series of 24 patients with 27 distal PICA aneurysms, and we conclude that distal PICA aneurysms are benign entities compared with vertebral artery-PICA aneurysms. Characteristics that should be considered in the treatment of distal PICA aneurysms are discussed.     

Surgical management of ruptured and unruptured symptomatic posterior inferior cerebellar artery aneurysms

This retrospective study analyses the outcome of posterior inferior cerebellar artery aneurysms treated surgically. Thirteen consecutive ruptured and unruptured PICA aneurysm patients from January 1998 to January 2004 were reviewed retrospectively. The mean age was 49.1 +/- 7.4 years. Three were unruptured aneurysms and ten presented with acute subarachnoid haemorrahge. Surgery was performed immediately after completed 4 vessel angiograms using the far lateral approach. Eight were fusiform while five were saccular aneurysms. The saccular aneurysms were clipped. Treatment of the fusiform aneurysms included 3 trappings and three proximal clippings. One patient refused surgery and had endovascular occlusion of a giant PICA aneurysm. Eight out of ten (80%) operated patients needed CSF shunting for hydrocephalus. All check angiograms during follow up demonstrated adequate exclusion of the aneurysms from the circulation. None developed the PICA syndrome clinically or showed infarction on brain scans. All good grade patients recovered without neurological deficits. Our experience showed that early surgery for ruptured PICA aneurysm carries a good prognosis with low morbidity. In aneurysms that cannot be clipped, sacrifice of the PICA without revascularisation procedures in proximally located PICA aneurysms may still be feasible if the occlusion is done distal to the perforators.     

Surgical and endovascular management of symptomatic posterior circulation fusiform aneurysms

OBJECT: Patients with fusiform aneurysms can present with subarachnoid hemorrhage (SAH), mass effect, ischemia, or unrelated symptoms. The absence of an aneurysm neck impedes the direct application of a clip and endovascular coil deployment. To evaluate the effects of their treatments, the authors retrospectively analyzed a consecutive series of patients with posterior circulation fusiform aneurysms treated at Stanford University Medical Center between 1991 and 2005. METHODS: Forty-nine patients (mean age 53 years, male/female ratio 1.2:1) treated at the authors' medical center form the basis of the analysis. Twenty-nine patients presented with an SAH. The patients presenting without SAH had cranial nerve dysfunction (five patients), symptoms of mass effect (eight patients), ischemia (six patients), or unrelated symptoms (one patient). The aneurysms were located on the vertebral artery (VA) or posterior inferior cerebellar artery (PICA) (21 patients); vertebrobasilar junction (VBJ) or basilar artery (BA) (18 patients); and posterior cerebral artery (PCA) (10 patients). Pretreatment clinical grades were determined using the Hunt and Hess scale; for patients with unruptured aneurysms (Hunt and Hess Grade 0) functional subgrades were added. Outcome was evaluated using the Glasgow Outcome Scale (GOS) score during a mean follow-up period of 33 months. Overall long-term outcome was good (GOS Score 4 or 5) in 59%, poor (GOS Score 2 or 3) in 16%, and fatal (GOS Score 1) in 24% of the patients. In a univariate analysis, poor outcome was predicted by age greater than 55 years, VBJ location, pretreatment Hunt and Hess grade in patients presenting with SAH, and incomplete aneurysm thrombosis after endovascular treatment. In a multivariate analysis, age greater than 55 years was the confounding factor predicting poor outcome. Stratification by aneurysm location removed the effect of age. Of 13 patients with residual aneurysm after treatment, five (38%) subsequently died of SAH (three patients) or progressive mass effect/brainstem ischemia (two patients). CONCLUSIONS: Certain posterior circulation aneurysm locations (PCA, VA-PICA, and BA-VBJ) represent separate disease entities affecting patients at different ages with distinct patterns of presentation, treatment options, and outcomes. Favorable overall long-term outcome can be achieved in 90% of patients with PCA aneurysms, in 60% of those with VA-PICA aneurysms, and in 39% of those with BA-VBJ aneurysms when using endovascular and surgical techniques. The natural history of the disease was poor in patients with incomplete aneurysm thrombosis after treatment.     

Multiple peripheral aneurysms of the posterior inferior cerebellar artery

Peripheral aneurysms of the posterior inferior cerebellar artery (PICA) are rare. The authors describe a case in which five distinct peripheral aneurysms of the PICA were diagnosed and microsurgically clipped while preserving the parent vessel. One of the aneurysmal sacs was excised and examined pathologically, and no evidence of an infectious etiology was found. The surgical approach to peripheral PICA aneurysms is discussed and the literature concerning these unusual aneurysms is reviewed.     

Fenestration of the posteroinferior cerebellar artery: case report

OBJECTIVE AND IMPORTANCE: Fenestrations of cerebral arteries are rare, but very important to diagnose given their high association with saccular aneurysms. We present the first reported case of a fenestration of the posteroinferior cerebellar artery (PICA). CLINICAL PRESENTATION: A 62-year-old man who presented with a subarachnoid hemorrhage underwent repeated four-vessel cerebral angiography. An isolated right PICA abnormality consistent with a dissection or fenestration was revealed. INTERVENTION: The patient underwent surgical exploration of his PICA, which confirmed a PICA fenestration without an associated saccular aneurysm. The fenestration was wrapped with cotton. CONCLUSION: Our case report illustrates the novel anatomic finding of a fenestration of the PICA. Knowledge of this entity would be helpful in the differential diagnosis of a posterior fossa subarachnoid hemorrhage.     

Multiple,peripheral aneurysms of the anterior inferior cerebellar artery

Summary In this case report, a 49-year-old woman developed subarachnoid hemorrhage in the right cerebellopontine angle cistern and blood into the fourth ventricle from a ruptured peripheral aneurysm of the anterior inferior cerebellar artery (AICA) located at the meatal loop. Concomitantly, a contralateral peripheral aneurysm was found in the posterior inferior cerebellar artery (PICA). A second peripheral aneurysm, not identified by previous angiography, was found in the caudomedial branch of AICA. We describe this diagnostic dilemma, management, and review the clinical presentation and location of 84 other peripheral AICA aneurysms reported in the literature.     

内脏动脉瘤的外科治疗

目的 总结腔内技术和外科手段治疗内脏动脉瘤的疗效.方法 回顾性分析10例内脏动脉瘤患者的临床资料.男4例,女6例,年龄28～74岁,平均(56 ±13)岁.其中脾动脉真性动脉瘤5例,脾动脉假性动脉瘤1例,肠系膜上动脉瘤2例,腹腔干结核性假性动脉瘤1例,肾动脉瘤1例.结果 1例腹腔干假性动脉瘤行支架型人工血管腔内修复术,1例脾动脉瘤行支架型人工血管腔内修复术失败,改为开腹手术治疗,另外8例直接行开腹手术治疗.手术均获成功,康复出院.术后住院时间7～18 d,平均(10±5)d,本组所有患者获随访,随访时间3个月至6年,平均(27 ±12)个月.无死亡病例,无动脉瘤复发,无胃肠道、肝脏、脾脏、肾脏缺血梗死及其他严重并发症发生.结论 内脏动脉瘤开放手术治疗疗效可靠,而腔内治疗则是一种有前途的微创治疗手段.

Abstract：

Objective To analyse the management of splanchnic artery aneurysms by open surgery and endoluminal therapy. Methods The clinical data of 10 splanchnic artery aneurysm patients (four male, six female) hospitalised from January 2002 were analysed retrospectively. The average age was (56 ± 13) years (28 - 74). Surgical or endoluminal treatment for six cases of splenic artery aneurysms or pseudoaneurysms were applied, among which multiple splenic artery aneurysms was found in one, and aberrant aneurysms at the proximal section of the splenic artery originating from a spleno-mesenteric trunk was found in three, splenic artery pseudoaneurysm in one and single aneurysm with normal splenic artery in anatomy in one. Besides, there were two superior mesenteric artery aneurysm, one of tuberculous celiac artery pseudoaneurysm and one renal artery aneurysm. Results The tuberculous celiac artery pseudoaneurysm was successfully managed by deploying a stent-graft endoluminally. One case was converted to open surgery after the splenic artery aneurysm was only paitially covered by a stent-graft. The other 8 cases were successfully treated by open surgery. All of the operations are successful. All patients were followed up from three months to six years, during which no death or other severe complications occurs. Conclusions The splanchnic artery varies from one to another anatomically. Preoperative CT scan or digital substraction angiology are helpful for the diagnosis of the splanchnic arterial aneurysms and choosing an appropriate management. Conventional open surgery is effective and reliable, while endoluminal therapy is a minimally invasive alternative.     

Surgical management of renal artery aneurysms

PURPOSE: This retrospective review describes the surgical management and clinical outcome for renal artery aneurysms (RAAs) in 62 consecutive patients. METHODS: From January 1987 through July 2003, 804 patients had operative renal artery (RA) repair involving 1206 kidneys at our center. A subgroup of 62 patients (42 women, 20 men; mean age 46 +/- 18 years) received repair of 72 RAAs. Demographic data, comorbidity, and surgical technique were examined. Blood pressure and renal function response were determined. Patency of repair was evaluated by renal duplex sonography. Primary patency and patient survival were estimated by life-table methods. Tests of association were performed using chi(2) and the Student t tests. RESULTS: Seventy-two RAs were repaired for RAA with a mean diameter of 2.6 cm (range, 1.3 to 5.5 cm). Bilateral RAAs were present in 21 patients. Associated conditions included fibromuscular dysplasia, atherosclerosis, and arteritis in 54%, 35%, and 7%, respectively. Hypertension was present in 89% (mean blood pressure, 171 +/- 35/95 +/- 19 mm Hg; mean medications, 2.2 +/- 1.2 drugs) and renal insufficiency was present in 8% (mean serum creatinine, 1.9 +/- 0.6 mg/dL). RAA repair included bypass (67%), aneurysmorrhaphy (15%), or a combination (17%). One planned nephrectomy (1%) was performed for un-reconstructable disease. Branch RA reconstruction in 78% used ex vivo cold perfusion in 50%, in situ cold perfusion in 29%, and warm in situ repair in 21%. Of 9 bilateral RAA repairs, 7 (78%) were staged and 2 (22%) were simultaneous. Combined aortic reconstruction was required in 6 (10%) patients. Perioperative death occurred in 1 patient (1.6%), and significant morbidity was observed in 8 patients (12%). Hypertension was considered improved in 54%, cured in 21%, and unchanged in 25% at mean follow-up of 48 months (range, 1-156 months). Among patients with renal insufficiency, renal function was improved in 3 (60%), unchanged in 1 (20%), and declined in 1 (20%). Follow-up patency (mean, 33 months; range, 1-118 months) was determined for 64 (91%) RA reconstructions. Product-limit estimate of primary patency at 48 months was 96%. Product-limit estimate of survival was 91% at 120 months. CONCLUSION: RAAs were repaired with low morbidity and mortality. Complex branch RAA repair using cold perfusion preservation and ex vivo techniques resulted in no unplanned nephrectomy, with an estimated primary patency of 96% at 48 months. Beneficial blood pressure response was observed in the majority of hypertensive patients. These results support selective surgical management of RAA.     

Surgical management of ulnar artery aneurysms

In a ten-year review (1978 to 1988), ten ulnar artery aneurysms in nine male patients were studied. Blunt trauma led to 70%, penetrating trauma to 20%, and 10% had no history of trauma. Three cases were seen as asymptomatic palmar masses with brief antecedent histories of 4 weeks or less. Seven patients with aneurysms had persistent vascular hand symptoms for 6 weeks or longer. All seven symptomatic lesions proved to be sources of emboli. Diagnostic arteriography was done in all cases. Intraoperative digital plethysmography aided in operative decisions regarding the necessity for microvascular reconstruction. Five aneurysms were resected with end-to-end ulnar artery microvascular repairs, four resected without repair, and a single case treated with long-term anticoagulants. Follow-up, averaging 40 months, showed uniform improvement in vascular symptoms, with no loss of jeopardized tissues. Ulnar artery aneurysms, well studied preoperatively and intraoperatively, can be treated successfully with selective microvascular reconstruction.     

Bilateral mirror aneurysms at the origin of the posteroinferior cerebellar artery: case report and review of the literature

We report an exceptional case of symmetrical mirror aneurysms at the origin of the posterior inferior cerebellar arteries treated by endovascular occlusion. Questions related to a correct diagnosis and treatment at this localization are discussed.     

椎动脉-小脑后下动脉梭形动脉瘤的手术治疗

目的 探讨手术治疗椎动脉-小脑后下动脉梭形动脉瘤的方法.方法 回顾性分析2007年12月至2010年2月收治的5例椎动脉-小脑后下动脉梭形动脉瘤患者的临床特点、手术方法及疗效.5例患者均为男性,年龄40～55岁,平均47岁.其中动脉瘤破裂出血4例,1例表现为后枕部阵发性头痛.所有患者均采用远外侧入路,翻开皮肌瓣后,先于枕部肌群内分离枕动脉,开颅后显露同侧小脑后下动脉尾襻,并于此处行枕动脉-小脑后下动脉吻合重建小脑后下动脉血流,再行动脉瘤孤立术或切除术.术后进行随访,观察疗效.结果 5例患者术后1例无神经功能缺失;3例有后组脑神经功能障碍;1例出现颅内血肿,二次手术后并发对侧肢体偏瘫.行数字减影血管造影或CT血管造影检查,吻合口通畅,动脉瘤不显影.随访2～29个月,平均18个月,4例预后良好,1例对侧肢体轻偏瘫.结论 枕动脉-小脑后下动脉搭桥+动脉瘤孤立或切除术是治疗椎动脉-小脑后下动脉梭形动脉瘤的有效方法,但需结合实际情况,选择个体化的治疗方案.     

Surgical management of extracranial carotid artery aneurysms

Between 1982 and 1991 we performed eight operations on seven patients with carotid artery aneurysms. Their mean age was 52.8 years (range: 20–67 years). Five aneurysms were atherosclerotic, one was associated with Marfan's syndrome, and two were pseudoaneurysms, one occurring after Dacron patch angioplasty and the other due to tuberculosis. Seven aneurysms were treated electively; one patient underwent an emergency surgical procedure. In one case, the internal carotid artery was ligated. Seven operations were reconstructive. No intraluminal shunt was used. No perioperative deaths occurred. Regressive hemiparesis and ipsilateral Horner's syndrome developed in one patient. The follow-up period ranged from six months to nine and a half years. One patient died of myocardial infarction three months after surgery.     

Surgical management of extracranial carotid artery aneurysms

Extracranial carotid artery aneurysms are uncommon and not much is known about them. The purpose of this study is to report the authors’ surgical experience and present a review of this entity. This single institution experience shows that resection of these aneurysms and restoration of flow can be accomplished using a number of surgical techniques with relatively low morbidity and mortality. Endovascular techniques are also increasingly being considered in the repair of these aneurysms, although long‐term data from such techniques are not currently available.     

Far lateral suboccipital approach for the treatment of proximal posteroinferior cerebellar artery aneurysms: surgical results and long-term outcome

OBJECTIVE: Proximal posteroinferior cerebellar artery (PICA) aneurysms are challenging to treat surgically, with high reported perioperative complication rates. We describe the perioperative course and long-term clinical outcomes obtained via a far lateral suboccipital approach in 20 consecutive proximal PICA aneurysms. METHODS: Data were collected prospectively on the first 20 proximal PICA aneurysms treated surgically by a single surgeon (ESC) between December 1997 and April 2003. All aneurysms were clipped via a far lateral approach. Patients with unruptured aneurysms were assessed at 3 and 12 months after surgery. For all subarachnoid hemorrhage patients, a battery of outcome tests was performed at 3- and 12-month intervals. Outcomes were then compared with those of a contemporaneously managed population of ruptured right-sided posterior communicating artery aneurysms. RESULTS: The far lateral suboccipital approach achieved adequate exposure in all cases. There were no intraoperative complications or intraoperative aneurysm ruptures. All patients with unruptured aneurysms were fully functional at long-term follow-up. At 3 months of follow-up, 93% of the subarachnoid hemorrhage patients achieved a Glasgow Outcome Scale score of 1 to 2. At 12 months of follow-up, 92% achieved a Glasgow Outcome Scale score of 1 to 2. Compared with the patients with a ruptured right-sided posterior communicating artery aneurysm, no difference could be found in quality of life or activities of daily living at either time point. CONCLUSION: The favorable outcomes and low postoperative morbidity in this subset of patients argues that clipping via this approach be considered a first-line therapeutic option. When performed in this manner, PICA aneurysm surgery seems to have no greater morbidity than right-sided posterior communicating artery aneurysm surgery.     

Surgical options for the management of visceral artery aneurysms

Visceral artery aneurysm (VAA) is a rare entity but increased use of abdominal imaging has led to an increased prevalence. Rupture is related to a high mortality rate. Open repair, endovascular treatment and laparoscopic techniques have been described as treatment options. In this systematic review we describe the surgical options for treating VAA. A literature search identified articles focussing on the key issues of visceral artery aneurysms and surgical options using the Pubmed and Cochrane databases. Case reports dominate the literature about VAA. Twenty-seven small case series and ten review articles have been published in the last 20 years concerning the surgical options for VAA. The evidence does not exceed level 3. Surgical treatment is dictated by both patient and aneurysm characteristics. Whether VAA should be treated largely depends upon age, gender, presence of hypertension (e.g. in renal aneurysm), aneurysm size and presentation. Aneurysm size and characteristics, anatomical location and presence of collateral circulation dictate the surgical option to be chosen. The mortality and morbidity rates after elective open repair are low. Literature about surgical options for treating VAA remains scarce. Only a few clinical trials have shown the possibilities and results of open surgical repair. In general, there is no consensus on the surgical treatment of VAA and the highest level of evidence is based upon expert opinions.     

Double giant fusiform aneurysms of the posterior cerebral artery

Subarachnoid hemorrhage in a patient with two giant fusiform aneurysms arising from the posterior cerebral artery was treated by clipping the P2 segment of the artery, proximal to the first aneurysm. This combination of aneurysms has not previously been reported.     

脾动脉瘤的手术及微创治疗

目的 探讨脾动脉瘤的治疗方法及中远期疗效.方法 1999-2011年收治18例脾动脉瘤患者,对18例的治疗方法及预后等临床资料进行回顾性分析.结果 18例患者中男7例,女11例.平均年龄53.8±7.3岁.8例患者无临床症状于体检中发现,7例表现为左上腹疼痛,3例因动脉瘤破裂于急诊首诊.14例经三维血管造影(3DCTA)、3例经数字减影血管造影(DSA)、1例经磁共振血管造影(MRA)确诊.手术治疗11例,其中脾动脉瘤破裂行急诊手术3例,择期性手术8例.手术包括脾动脉瘤及脾切除4例,同时切除胰尾5例,脾动脉瘤切除、断端吻合1例,脾动脉瘤切除加脾及结肠脾区切除1例.另外,行脾动脉瘤介入栓塞治疗3例.本组中,4例无临床症状、且瘤体直径＜2 cm者行随访观察中.围手术期无死亡.随访16例平均3.2年.失访2例,1例于术后4年死于脑溢血.结论 脾动脉瘤发病率低,症状多隐匿,脾动脉瘤破裂多有致死的危险.开腹手术及腔内微创治疗预后良好.