Microsurgical Clipping of a Complex PICA Aneurysm

Patient Presentation

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This segment presents the background information surrounding the specific surgerical case for a complex PICA Aneurysm.

Keywords

  • Posterior inferior cerebellar artery
  • Complex aneurysm
  • Hypoglossal triangle
  • Hypoglossal nerve
  • Spinal accessory nerve
  • Vertebral artery
  • Intraoperative angiography

About this video

Author(s)
Katherine Elizabeth Wagner
Amir Reza Dehdashti
First online
26 April 2019
DOI
https://doi.org/10.1007/978-3-030-20172-2_1
Online ISBN
978-3-030-20172-2
Publisher
Springer, Cham
Copyright information
© The Author(s) 2019

Video Transcript

Here, we describe the microsurgical clipping of a complex PICA aneurysm. This aneurysm was diagnosed in a 65-year-old woman, who presented to the emergency with headache and some dizziness. There was no evidence of a stroke. The patient underwent a brain MRI and MRA as evidenced here, showing a left broad-based PICA aneurysm on the left side with the left PICA coming from the base of the aneurysm.

The neurologist then referred a patient to us. We performed a CT angiogram showing a calcification at the base and a little bit on the dome of the aneurysm. The PICA is coming from the base of the aneurysm itself. There is a relatively hypoplastic right vertebral artery. We further continue the investigation with a cerebral angiogram, showing the aneurysm measuring about 1.4 centimeters in diameter. There is a dominant left vertebral artery as mentioned before. And in the 3D picture as you can see how the aneurysm as relationship with the PICA itself coming from the base of the aneurysm, incorporating the base.

The right vertebral artery is hypoplastic, however, ends on the VB junction as well. This aneurysms is on a relatively high VB junction and relatively distal PICA. The right carotid also shows a right cavernous segment aneurysm, which is irrelevant in this case. Now, the question would be whether to treat this patients or observe. The patient is very healthy 65-year-old. And considering the size of the aneurysm and the fact that the aneurysm is in the posterior fossa, we considered that the natural history of these aneurysms are not that benign and over the next five years could have a risk of bleed of up to 15% over the five years. And, therefore, after discussion of treatment versus observation, we decided for treatment.

The concern for endovascular treatment here was the incorporation of the PICA at the base of the aneurysm and, as we know these, are quite often surgical aneurysms as there is a risk of occlusion of the PICA with endovascular treatment. However, an incomplete treatment of the aneurysm could be performed with coiling followed by a stent, but we felt that the surgery in this particular patient with this particular angio anatomy is the best option with very high chance of complete occlusion of the aneurysm and, basically, curing the aneurysm. And the patient also favored surgical treatment after discussion of treatment.