Multiple peripheral aneurysms of the posterior inferior cerebellar artery associated with a cerebellar arteriovenous malformation: case report

The authors describe a rare case of multiple peripheral aneurysms of the posterior inferior cerebellar artery found in association with a midline cerebellar arteriovenous malformation. Successful trapping of the aneurysms and excision of the arteriovenous malformation was accomplished with an excellent clinical result. The literature concerning aneurysms of the posterior inferior cerebellar artery, cerebellar arteriovenous malformations, and combined intracranial vascular abnormalities is discussed.     

Distal aneurysms of the superior cerebellar artery and posterior inferior cerebellar artery feeding an associated arteriovenous malformation: case report.

The authors report a case of two distal aneurysms of the cerebellar arteries, one arising from the vermian branch of the posterior inferior cerebellar artery, the other arising from the hemispheric branch of the superior cerebellar artery, and both feeding an associated arteriovenous malformation (AVM). The aneurysm of the distal posterior inferior cerebellar artery was considered the source of a cerebellar hemorrhage because of the location of a hematoma in the cerebellar vermis. The life-threatening hematoma was evacuated in an emergency operation 6 hours after the acute onset of symptoms. The cerebellar aneurysms and the AVM were clipped or extirpated successfully after the patient's condition improved. The association of two rare types of aneurysms with an AVM strongly supports the theory that increased hemodynamic stress derived from the AVM plays an important role in aneurysm formation. The authors think that one should operate on the symptomatic lesion first or both the aneurysm and the AVM in the same operative procedure.     

Growth of multiple peripheral high flow aneurysms of the posterior inferior cerebellar artery associated with a cerebellar arteriovenous malformation

A case of three high flow peripheral aneurysms of the posterior inferior cerebellar artery (PICA) associated with a left cerebellar arteriovenous malformation is presented. This rare association is of further interest because the patient had been diagnosed as harboring an arteriovenous malformation 3 years before her most recent subarachnoid hemorrhage. Repeat angiography revealed enlargement of the malformation with new growth of three peripheral PICA aneurysms at the telovelotonsillar segment. Successful excision of the malformation and obliteration of all three aneurysms were accomplished. The causal mechanism of increased cerebral blood flow in the generation of the peripheral cerebral aneurysms is demonstrated.     

Posterior inferior cerebellar artery aneurysm associated with arteriovenous malformation fed by the same artery

A 37-year-old man presented with a peripheral aneurysm of the left posterior inferior cerebellar artery associated with a more peripheral arteriovenous malformation fed by the same artery. Recurrent subarachnoid hemorrhage occurred from rupture of the aneurysm. Review of the pertinent literature indicates that the aneurysm of the posterior inferior cerebellar artery originates from the peripheral portion of the artery, when associated with arteriovenous malformation.     

Distal anterior inferior cerebellar artery aneurysms: report of three cases and literature review

Aneurysm at the distal portion of the anterior inferior cerebellar artery (AICA) is uncommon and only 55 cases have been documented in the literature. Here we report an additional three cases with review of the literature. All three patients presented with subarachnoid hemorrhage. The ruptured aneurysms were located at the meatal loop of the AICA in all three patients and one patient had another unruptured aneurysm at the lateral branch distal to the meatal loop. Two patients underwent surgical trapping of the aneurysms, and the other patient was treated with endovascular coiling because of poor clinical condition. Increase of hearing disturbance was found in two patients who underwent surgery or endovascular coiling, respectively. Clinical features and treatment of these rare lesions are discussed with reference to the 7th and 8th nerve impairments as preoperative symptoms and postoperative complications.     

Association of two saccular aneurysms of the posterior inferior cerebellar artery with a cerebellar arteriovenous malformation fed by the same artery. Case report

Coexistence of posterior fossa aneurysms and AVMs on the same feeding artery is very rare; the case of an association of two saccular aneurysms of the posterior inferior cerebellar artery with a cerebellar arteriovenous malformation of the same artery is reported. Theories concerning etiology are reported as well.     

Therapeutic strategy for isolated dissecting aneurysms of the posterior inferior cerebellar artery: report of three cases and review of literature

Dissecting aneurysm of the posterior inferior cerebellar artery (PICA) is a relatively rare disease and its treatment has not been well established. The authors analyzed the clinical and anatomical features of 38 reported lesions and three of our cases to clarify the "best therapeutic modality". The average age was 45.0 years old and 27 patients were male. Left-sided predominance (26 cases) was noted. As to the mode of onset, 23 cases were subarachnoid hemorrhage, 16 were ischemia, and 6 were Wallenberg's syndrome. Anatomically, the sites of dissection were located in the proximal segment of PICA in 31 lesions (75.6%). Review of the cases show that 30 (75%) patients underwent surgical therapy, and 7 (17.5%) patients underwent endovascular treatment. Twenty six patients who took surgical therapy and 5 patients who took endovascular treatment had excellent or good outcome. The critical point in therapeutic procedure is the preservation of perforating branches arising from PICA, therefore surgical trapping with the revascularization of PICA (usually extracranial-PICA anastomosis), in which these tiny branches are secured under microscopic manipulation, has the advantage in principle.     

Posterior fossa arteriovenous malformation associated with persistent primitive trigeminal artery--case report

A 21-year-old female presented with an unusual case of posterior fossa arteriovenous malformation (AVM) associated with ipsilateral persistent primitive trigeminal artery (PPTA), manifesting as intraparenchymal hemorrhage involving both the brain stem and the left cerebellar hemisphere. The presenting symptoms were compatible with Wallenberg's syndrome and Foville's syndrome on the left side. She was initially treated conservatively, and subsequently with transarterial embolization followed by stereotactic radiosurgery. This case combined the rare association of posterior fossa AVM and PPTA, with the clinical presentation of intraparenchymal hemorrhage causing both Wallenberg's syndrome and Foville's syndrome.     

Arteriovenous malformation associated with multiple aneurysms in the posterior fossa: a case report with a review of the literature

The association of two aneurysms on the distal posteroinferior cerebellar artery with an arteriovenous malformation fed by the same artery is reported. A one-stage operation was performed. The other cases in the literature are analyzed with particular regard to the origin of the subarachnoid hemorrhage and the location of the aneurysms.     

Anterior inferior cerebellar artery aneurysms: six cases and a review of the literature

Aneurysms of the anterior inferior cerebellar artery are rare. Six cases of anterior inferior cerebellar artery (AICA) aneurysms treated at one center are presented. The six cases of AICA aneurysms were surgically treated. The clinical features, surgical process, complications, and follow-up are demonstrated. Six patients with six AICA aneurysms were presented including one AVM accompanied aneurysm and one giant aneurysm. Five aneurysms had ruptured, one was unruptured. Five patients presented with subarachnoid hemorrhage (SAH) including two with intraventricular hemorrhaging and one with an intraparenchymal hematoma. One aneurysm was proximal, two were distal, and three were meatal. All cases were treated surgically. Retrosigmoid and far-lateral craniectomy were included. Navigation was accomplished through intraoperative ultrasound and fluorescent angiography. Resection of the aneurysm after clipping was significant. The most common postoperative deficit involved the cranial nerves in four patients. Follow-up was available for all patients for a mean of 68 months. SAH is the most common presentation. The relationship between the aneurysms and the meatus is an important factor for neurological dysfunction. 3D-CTA and MRA may be considered as diagnostic adjuncts. Several special surgical techniques used in our cases are worth noting. Endovascular therapy for AICA aneurysms is in the process of development and should be reserved for special cases.     

Isolated dissections and dissecting aneurysms of the posterior inferior cerebellar artery: topic and literature review

Isolated dissections of the posterior inferior cerebellar artery (PICA) are rare. Thus, no large series of cases have been reported in the literature. Due to limited knowledge regarding the natural history of these lesions and the lack of high-quality evidence supporting various treatment options, management is controversial and practice parameters are ill defined. In order to offer a comprehensive reference for the diagnosis and management of isolated PICA dissections, the authors reviewed the National Library of Medicine from 1966 to October 2001. Twenty-seven patients averaging 43.6 years of age and including 14 males and 13 females were reported. Subarachnoid hemorrhage occurred in 20 patients, and two died. Dissections were located in the proximal PICA in 22 patients and were three times more common on the left side (left:right=3:1). Six patients were managed conservatively, and four with endovascular techniques. Seventeen had open surgery: five underwent resection, two went through trapping, and two had proximal clipping. Wrapping with muscle was performed in two patients, encasement with Sundt clips in two, and four had occipital artery (OA)-PICA bypass surgery. A meticulous analysis of reported cases with regard to clinical and pathological features, management strategies, and outcomes is presented.     

Isolated dissections and dissecting aneurysms of the posterior inferior cerebellar artery: topic and literature review

Isolated dissections of the posterior inferior cerebellar artery (PICA) are rare. Thus, no large series of cases have been reported in the literature. Due to limited knowledge regarding the natural history of these lesions and the lack of high-quality evidence supporting various treatment options, management is controversial and practice parameters are ill defined. In order to offer a comprehensive reference for the diagnosis and management of isolated PICA dissections, the authors reviewed the National Library of Medicine from 1966 to October 2001. Twenty-seven patients averaging 43.6 years of age and including 14 males and 13 females were reported. Subarachnoid hemorrhage occurred in 20 patients, and two died. Dissections were located in the proximal PICA in 22 patients and were three times more common on the left side (left:right=3:1). Six patients were managed conservatively, and four with endovascular techniques. Seventeen had open surgery: five underwent resection, two went through trapping, and two had proximal clipping. Wrapping with muscle was performed in two patients, encasement with Sundt clips in two, and four had occipital artery (OA)-PICA bypass surgery. A meticulous analysis of reported cases with regard to clinical and pathological features, management strategies, and outcomes is presented.     

Clinical presentation and treatment of distal posterior inferior cerebellar artery aneurysms: report on 5 cases

BACKGROUND: Aneurysms of the PICA are uncommon. Most of them arise at the PICA origin from the VA, whereas distal PICA aneurysms are exceptional. A retrospective analysis of 457 patients with SAH treated in our hospital found 5 patients with 6 distal PICA aneurysms (approximately 1% of SAHs). CASE DESCRIPTION: All patients were female, with a mean age of 54 years. A 4-vessel cerebral angiogram performed immediately after admission showed an aneurysm located on the distal PICA. One patient was treated by an endovascular approach, and 3 patients were treated by surgical approach. The last patient had 2 distal high-flow aneurysms located on the distal PICA, which was the main arterial feeder of an AVM. The patient refused surgery or endovascular therapy. All 4 treated patients had good outcome at 3-month clinical follow-up. CONCLUSIONS: Distal PICA aneurysms are exceptionally rare and may be treated successfully with surgical or endovascular techniques. The therapeutic strategy, either surgical or endovascular, should be selected according to the condition of the patient, the arterial and aneurysmal morphology, and the preference of the medical team.     

Coexistence of posterior inferior cerebellar artery aneurysm and arteriovenous malformation fed by the same artery

A saccular aneurysm of the posterior inferior cerebellar artery and an arteriovenous malformation in the cerebellum fed by the same artery are reported. Clipping of the neck of the aneurysm and total removal of the arteriovenous malformation were performed successfully in one operation.     

Dissecting aneurysms of the posterior inferior cerebellar artery

The authors present three cases of dissecting aneurysms of the posterior inferior cerebellar artery (PICA). A literature search revealed only three previous cases. Analysis of these six cases showed a unique clinical picture. Three patients developed subarachnoid hemorrhage, and the other three had ischemia. All patients complained of occipital headache or neck pain, regardless of the initial symptoms. Heralding episodes were recorded in four cases. Angiography showed a characteristic fusiform dilatation of the PICA and a narrowing proximal to and distal to the lesion. Various surgical treatments were performed in five cases. Intraoperative observation showed a sausage-like swelling of the PICA or one of its branches with various discoloration depending on the age of the intramural clot. The outcomes were favorable.     

Peripheral aneurysms of the posterior inferior cerebellar artery

Nonmycotic peripheral posterior inferior cerebellar artery (PICA) aneurysms are rare. The authors report six cases of peripheral PICA aneurysm. Two of these are unusual; one was fusiform and another was a double aneurysm arising from the peripheral PICA. The previously reported 40 cases of peripheral PICA aneurysm are reviewed.     

Cerebral revascularization performed using posterior inferior cerebellar artery-posterior inferior cerebellar artery bypass. Report of four cases and literature review

Cerebral revascularization is often required for the surgical treatment of complex intracranial aneurysms. In certain anatomical locations, vascular anatomy and redundancy make in situ bypass possible. The authors present four patients who underwent revascularization performed using the rarely reported posterior inferior cerebellar artery (PICA)-PICA in situ bypass after their aneurysms had been trapped. At Barrow Neurological Institute, between 1991 and the present, four male patients underwent PICA-PICA by-passes to treat aneurysms involving the vertebral artery, the PICA, or both. The mean age of these patients was 34 years (range 5-49 years). Follow-up studies revealed patent bypasses and no evidence of infarction. Patient outcomes were excellent or good. Multiple surgical techniques have been described for revascularization of at-risk cerebral territories. Often, the blood supply must be derived from extracranial sources through a mobilized pedicle or interposited graft. Certain anatomical locations such as the vertebrobasilar junction, the anterior circle of Willis, and the middle cerebral artery bifurcation are amenable to in situ bypass because there is vessel redundancy or proximity to the contralateral analogous vessel. The advantages of an in situ bypass include one suture line, a short bypass distance, and a close match with the caliber of the recipient graft. Although technically challenging, this technique can be successful and should be considered for appropriate candidates.     

Aneurysms of the distal posterior inferior cerebellar artery: experience with three cases and review of the literature

We report 3 surgically treated aneurysms of the distal posterior inferior cerebellar artery (PICA) and review 36 cases in the literature. More than half of the distal PICA aneurysms arose distal to the choroidal arch. These lesions often arose at a turning point (i.e., a hairpin curve) of an artery instead of at a junction of vessels. Distal PICA aneurysms are likely to be missed and it is necessary to investigate carefully with four-vessel angiography even if computed tomography is done. Eighty-two per cent of the surgically treated 39 patients had good recoveries and 8% had fair results. The mortality rate was 10%. Although clipping of the aneurysm neck is preferable, trapping is useful when neck clipping is impossible in segments distal to the choroidal arch.     

Ruptured aneurysms of the choroidal branches of the posterior inferior cerebellar artery: a review of the literature and a case report

Aneurysms of the choroidal branches of the posterior inferior cerebellar artery (PICA) are quite rare; only seven such cases have been reported thus far. In this study, we present a very rare case of a ruptured aneurysm of a choroidal branch of the PICA; the aneurysm was exposed by splitting the vermis and resected after proximal arterial ligation. We have also undertaken a thorough review of the literature on aneurysms in choroidal branches of the PICA, focusing on the clinical presentation, etiology, radiological findings, and surgical strategies. We found that the aneurysms in our patient and the aneurysms in seven published case reports were small, and frequently associated with vascular anomalies. Intraventricular hemorrhage (IVH) in the fourth ventricle was detected in all eight cases. The outcomes of surgical treatment were generally favorable, notwithstanding the high incidence of rebleeding after rupture of distal PICA aneurysms. The recognition of predominant fourth ventricular hemorrhage should raise the suspicion of the presence of an underlying aneurysm, and digital subtraction angiograms (DSAs) should be immediately obtained in order to detect small aneurysms of the choroidal branches of the PICA.