gms | German Medical Science

Objective: Aneurysms of the posterior inferior cerebellar artery (PICA) are relatively uncommon and often difficult to treat due to complex morphology and location nearby the brainstem and lower cranial nerves. We present our experience in treating ruptured PICA aneurysms with clip ligation or endovascular techniques.

Method: Patients with aneurysmal SAH were entered into a prospectively collected database. Over the period from September 2009 until September 2013 we selected patients with a ruptured PICA aneurysm and analyze clinical presentation, radiological features, treatment, procedure-related complications and outcome. Outcome was assessed by the modified Rankin Scale (mRS) into favourable (0-2) and poor (3-6) at 6-12 months.

Results: Fourteen (10 women, 4 men, range 41-69 years) out of 200 patients (7.0%) with aneurysmal subarachnoid hemorrhage (SAH) from ruptured PICA aneurysm were identified. Eleven patients presented in a poor clinical condition (grade 4-5 Hunt and Hess) at admission, 3 patients in a good condition (grade 1-2 Hunt and Hess). All patients were classified Fisher III. Acute hydrocephalus occurred in 12 patients. In 10 patients the aneurysm was located on the left side, in 4 patients on the right. Aneurysm size was 6.7 mm on average (range 2-17 mm). Twelve aneurysms were saccular, two fusiform. The ruptured PICA aneurysms were secured in 7 patients by endovascular techniques and by clip ligation in 6 patients. No treatment option existed in one patient with a persistent bilateral mesencephalic syndrome. In 2 patients treated with coil embolization an intraprocedural rupture of the aneurysm with consecutive hemorrhage occurred leading to death in one patient. One patient with a fatal outcome rebleeded from a remnant after clipping. The patency of PICA could not be preserved in 2 patients after clip ligation and in one patient after coil embolization resulting in territorial infarction of PICA. Seven patients developed chronic hydrocephalus with consecutive shunt insertion. In summary, 5 patients had a favourable outcome (mRS 0-2), 9 patients showed a poor outcome (mRS 3-6), while 7 patients died.

Conclusions: In our series the majority of patients with ruptured PICA aneurysms predominantly located on the left side presented in a poor clinical condition and with acute hydrocephalus. The aneurysms were amenable to secure by endovascular techniques or clip ligation. Due to the initial poor condition burdened to brainstem affection the majority had rather a poor outcome.