![]() ![]() In cases of multiple aneurysms, the site of rupture was decided based on CT findings, size and irregularity of the aneurysm, or findings in surgery or at an autopsy or both. Aneurysm location and anatomy with respect to the management strategy and postoperative neurological complications were analyzed in light of their location on DSA. Data were collected from patient records under the following heads: demography, presentation, World Federation of Neurosurgical Society (WFNS) grade, and computed tomography (CT) findings. All aneurysms were identified using digital subtraction angiography (DSA). Aneurysms from PICA can originate from one of its six segments and two loops (based on its relationship with the medulla oblongata and the cerebellum) that include (a) the VA-PICA junction, (b) the anterior medullary segment extending from VA-PICA’s origin to the inferior olivary prominence, (c) the lateral medullary segment extending till the origin of IX-X-XI cranial nerves (CNs) from the brain stem, (d) the tonsillomedullary segment extending till the caudal portion of tonsil (including the caudal loop), (e) the telovelotonsillar segment which extends from the midportion of its ascent along the medial surface of tonsil to the cortical cerebellar surface (including the cranial loop), and (f) the cortical segment, extending till the cerebellar vermis and hemisphere (Īll operated cases of PICA aneurysm from February 2012 to May 2017 were retrospectively reviewed. PICA usually originates from the V4 segment, while extracranial origin from V3 has been described. ![]() In recent years, the trend of treatment of posterior circulation aneurysms has tilted toward the endovascular arm. In 1947, Rizzoli and Hayes trapped and excised a PICA aneurysm. The first ligation of cervical VA due to an intracranial aneurysm was reported by Dandy in 1928. Microsurgical approach is limited by anatomical corridors of brain stem, petrous occipital bone, and multiple neurovascular structures occupying the cerebellomedullary and cerebellopontine cisterns.Īdding to our misery is the fact that PICA is the most variable artery in terms of its course among all arteries of the posterior circulation. Furthermore, re-bleeding rates are high (78%) primarily due to their relatively thin aneurysm wall and dissecting nature. They, however, pose a significant risk because of their high morbidity, mortality, and rupture rate. Aneurysms of the posterior inferior cerebellar artery (PICA) comprise 0.5 to 3% of all intracranial aneurysms. Posterior circulation aneurysms arise from vertebral arteries (VAs), basilar arteries (BAs), or their branches. Personalized Approach to the Treatment of Posterior Inferior Cerebellar Artery Aneurysms Anatomical knowledge of PICA anatomy and sound perioperative management are keys to good outcomes in these cases. This may be due to early referral patterns and early surgery (<24 hours) policy at our institution. Our series compares well with some of the larger surgical series of PICA aneurysms. Four cases needed cerebrospinal fluid diversion and two developed cerebellar infarcts. No lower cranial nerve palsies were recorded at follow-up. Midline approaches were used for distal PICA cases, with far-lateral approach reserved for anterior medullary/VA–PICA junction. All the reviewed cases presented with subarachnoid hemorrhage, and the most common location was the lateral medullary segment and vertebral artery (VA)–PICA junction. During the same period, data for intervention cases of PICA aneurysm were also collected with follow-ups for a comparative analysis.Ī total of 20 patients with 21 PICA aneurysms were reviewed. Preoperative World Federation of Neurosurgical Society scores and follow-up modified Rankin scores (mRS) were also evaluated. We did a retrospective review of all the PICA aneurysms operated at our institute in the past 10 years along with the site, presentation, and approach used for the same. Surgical management of PICA aneurysms involves careful selection of approach based on the location of the aneurysm and meticulous dissection of the neurovascular structures and perforators. Posterior inferior cerebellar artery (PICA) is a tortuous, variable, and uncommon site for aneurysms. ![]()
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