Dissecting aneurysms of the posterior inferior cerebellar artery: report of four cases and review of the literature

doi:10.1054/jocn.2000.0757

Journal of Clinical Neuroscience

Volume 7, Issue 6, November 2000, Pages 515-520

https://doi.org/10.1054/jocn.2000.0757 Get rights and content

Abstract

Dissecting aneurysms frequently involve the vertebral arteries and their branches, but those exclusively on the posterior inferior cerebellar artery (PICA) represent only 24 cases in the literature, including the four cases discussed in this article. The clinical diagnosis lacks pathognomonic signs or symptoms, with presentations such as subarachnoid haemorrhage or ischaemia of the brain stem or the cerebellum, and the management is controversial. Wrapping, clipping and embolisation of the aneurysms were tried in this series with different outcomes. Exclusion of the pathological segment should be performed, as shown by rebleeding from our case which was wrapped or by progression of the vascular disease in cases where treatment was delayed. Surgical or endovascular occlusion are well tolerated in our cases and in those reported from the literature, which implies the absence of normal perforating branches to the brain stem arising from the proximal dissected segment of the PICA and a good collateral circulation. A revascularisation procedure using the occipital artery can be performed in order to prevent infarction if an endovascular test occlusion is not tolerated.

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Cited by (46)

Isolated posterior inferior cerebellar artery dissection with ischaemic stroke: evaluating the radiological features and diagnostic feasibility of high-resolution vessel wall imaging
2022, Clinical Radiology
Citation Excerpt :
The parameters for each sequences were as follows1: PDWI: 2,000 ms repetition time)TR)/31 ms echo time (TE), 10 cm field of view (FOV), 200 × 200 matrix size, 2 mm section thickness, 22 sections, no intersection gap, number of excitations (NEX) = 2, 6 minutes acquisition time,2 T2WI: 2,000 ms TR/100 ms TE, 10 cm FOV, 200 × 200 matrix; 2 mm section thickness, 22 sections, no intersection gap, number of excitations (NEX) = 4; 6 minutes 36 seconds acquisition time3; T1WI: 1,000 ms TR/7.9 ms TE, 10 cm; 200 × 200; 2 mm section thickness, 22 sections, no intersection gap, NEX = 2, 5 minutes 40 seconds acquisition time4; time of flight (TOF) imaging: 25 ms TR/3.45 ms TE; 20° flip angle, 20 × 25 cm FOV, 880 × 267 matrix, 1.2 mm section thickness, 160 sections. The black-blood technique with pre-regional saturation pulses of 80 mm thickness to saturate incoming arterial flow was used for 2D HR-VWI.5 3D CE-MSDE-T1WI: 450 ms TR/18 ms TE, echo train length ETL of 18, flow velocity encoding of 2 cm/s for gradient pulses; 170 × 170 × 44 mm FOV, 0.7 × 0.7 × 1.0 voxel size, 44 mm section thickness, reformatted images in axial, coronal, sagittal planes with 1 mm thickness; 4 minutes 50 seconds acquisition time.
To evaluate the radiological features of isolated posterior inferior cerebellar artery dissection (PICAD) and the feasibility of using high-resolution vessel-wall imaging (HR-VWI) for diagnosing PICAD.
Three hundred and nine patients with arterial dissection involving the posterior cerebral circulation, who underwent HR-VWI between March 2012 and July 2019 were reviewed retrospectively. Among them, 44 patients (14.2%) were diagnosed with isolated PICAD in consensus among a neuroradiologist, a neurointerventionist, and a neurologist. Two neuroradiologists reviewed the vessel wall images independently for evidence of dissection (dissection flap, outer diameter enlargement on T2-weighted imaging [WI], mural haematoma). Diagnostic confidence was also scored on a five-point scale. Intra- and interobserver agreement for diagnosing PICAD and detecting evidence of dissection were evaluated.
Dissection flaps were seen on T2WI in all cases (100%) and on contrast-enhanced T1WI in 34 patients (79.1%). Outer diameter enlargement of the steno-occlusive lesions on angiography was detected in most cases (97.7%). A mural haematoma was detected on three-dimensional (3D) contrast-enhanced motion-sensitised driven-equilibrium T1WI in 97.1% of the cases. The mean diagnostic confidence score derived by two neuroradiologists was 4.72. The two reviewers showed substantial to almost perfect agreement (weighted kappa coefficient: 0.62–0.97).
Use of HR-VWI as a diagnostic tool for PICAD is feasible, and a dissection flap with outer wall enlargement on HR-T2WI allows confident dissection diagnosis. The present data suggest that PICAD might be considered as a stroke aetiology in patients with unexplained ischaemic stroke in the PICA territory, and that PICA evaluation with HR-VWI is both necessary and feasible.
Treatment Strategy for Isolated Posterior Inferior Cerebellar Artery Dissection
2017, World Neurosurgery
Citation Excerpt :
The most appropriate treatment for dissecting PICA aneurysms is controversial. Most patients have been reported to undergo surgical occlusion or trapping with revascularization, direct clipping, and wrapping.1,6,10,29 The endovascular procedures used have included coil or liquid material embolization of the aneurysmal portion of the dissection, with preservation of the PICA and endovascular PICA sacrifice.3,8,28,30,31
Isolated dissections that develop on the posterior inferior cerebellar artery (PICA) require intensive treatment because of their potential fatality. However, because of the rarity of these dissections, the optimal treatment has not yet been established.
We retrospectively reviewed the clinical records of all patients who underwent any PICA dissection treatment in our institute over the last 4 years. Ten patients were enrolled, including 7 patients with subarachnoid hemorrhage (SAH) and 3 with PICA territory infarction. Dissection was seen at the proximal portion in 8 patients, whereas the remaining 2 patients showed distal PICA dissecting aneurysms.
Among the 7 patients with hemorrhage, 5 were actively treated (trapping and bypass, 2 patients; surgical clipping, 1 patient; coil embolization, 2 patients). Conservative management was performed in the other 2 patients. Among the 3 patients with infarction, 2 received conservative treatment. Endovascular treatment was performed in 1 patient, who showed rapid progression, aneurysm formation, and conversion to massive SAH within 10 days after the initial attack. Although 7 patients showed relatively good outcomes (modified Rankin Scale score, ≤2) after 30 days of follow-up, 1 patient had a final modified Rankin Scale score of 3. In addition, the other 2 patients (1 in each group) died as a result of major SAH.
Given the dynamic clinical course and potential fatality of PICA dissection, meticulous evaluation, intensive treatment with a diverse range of modalities, and proper follow-up are required for patients with PICA dissection to achieve favorable outcomes.
Temporary occlusion test using a microcatheter
2012, World Neurosurgery
Citation Excerpt :
When the diseased segment of the proximal PICA is occluded or trapped, the perforating vessels of the first three segments of the PICA that are associated with the risk of brain stem ischemia are sacrificed in both surgical and endovascular treatment. Dinichert et al. (4) considered aneurysmal dilations of the dissected arterial segments that may be associated with the absence of normal perforating branches, and occlusion of these segments can, thus, be performed without further damage to perforating territories. Isokangas et al. (5) reviewed the literature and their own experience and proposed that the risk for brain stem ischemia seems to be relatively low, though potentially carrying a high risk for morbidity.
The balloon occlusion test (BOT) is a well-accepted technique for the treatment of large or complex aneurysms. However, this procedure may not be feasible for small arteries such as the posterior inferior cerebellar artery (PICA). We report our experience with endovascular treatment of a fusiform PICA aneurysm employing a microcatheter occlusion test.
A 46-year-old male had a fusiform Type I aneurysm with irregular wall in the lateral medullary segment of left PICA. Because the BOT cannot be safely performed in the PICA, we performed a temporary occlusion test using a microcatheter.
The microcatheter occlusion test was successfully performed, and endovascular treatment was performed afterward. The patient remained symptom free after the embolization and at one-year follow-up.
The microcatheter occlusion test is an excellent option for performing an occlusion test for vessels that cannot accommodate a balloon because of their diminutive size.
Clinical presentation and treatment of distal posterior inferior cerebellar artery aneurysms: report on 5 cases
2008, Surgical Neurology
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).
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.
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.
Dissecting aneurysm of the posterior cerebellar artery
2007, Neurocirugia
Los aneurismas disecantes que afectan de forma exclusiva a la arteria cerebelosa posteroinferior (PICA) son muy raros. Su manifestación clínica dependerá del lugar de la pared arterial en que se produzca la disección, produciendo hemorragia subaracnoidea (HSA) o bien oclusión del vaso e isquemia. El diagnóstico del aneurisma se realiza en el estudio angiográfico mostrándose como una dilatación fusiforme de la arteria o como grados variables de estrechamiento y dilatación del vaso. La resonancia magnética (RM) puede ser de gran ayuda detectando el hematoma intramural.
Presentamos un enfermo de 47 años que sufrió una HSA que toleró bien. El estudio angiográfico mostró una dilatación fusiforme de la porción anterobulbar de la PICA. El paciente fue intervenido realizándose una exclusión del segmento de la PICA afecto, colocando un clip proximal y otro distal al aneurisma. El postoperatorio transcurrió sin incidencias a pesar de presentar en la angiografía de control un vasoespasmo muy notable de todo el territorio vertebrobasilar.
Los aneurismas disecantes de la PICA y fundamentalmente los que se presentan con HSA deben se tratados a fin de prevenir el resangrado. Tanto los procedimientos quirúrgicos como los endovasculares se han revelado eficaces y con buenos resultados.
Dissecting aneurysms affecting exclusively to the posterior inferior cerebellar artery (PICA) are rare entities. Depending on the dissecting plane of the arterial wall, the clinical manifestations are subarachnoid hemorrhage (SAH) due to rupture or ischemia caused by stenosis or occlusion. Angiographic findings are fusiform dilatation with a narrowing of various degrees proximal to and distal to the fusiform lesion. Magnetic resonance imaging (MRI) can be useful demonstrating the intramural hematoma.
We report a 47-year-old man who suffered from SAH. He was neurologicaly intact and vertebral angiography demonstrated and fusiform aneurysm at the origin of the left PICA.
He was operated by trapping of the dissecting segment. The patient's postoperative course was uneventful despite of severe vasospasm showed in follow up angiography.
Aggressive treatment has been recommended for dissecting aneurysms of the PICA and specially for those presenting with SAH. Both the surgical and endovascular procedures are effective and with good results.
Overlapping Pure LIVS Jr. Stents for Isolated Ruptured Dissecting Aneurysm of the Proximal Posterior Inferior Cerebellar Artery
2022, Medicina (Lithuania)

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Clinical studyDissecting aneurysms of the posterior inferior cerebellar artery: report of four cases and review of the literature

Abstract

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