CASE 15621 Published on 11.05.2018

Endovascular treatment of PICA Aneurysm

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Nersesyan N, Gil-Romero J, Sanchis-Garcia JM, Bosca-Ramon A, Rengel-Ruiz M, Lorente-Martinez E.

Hospital Clínico Universitario de Valencia,
Department of Radiology,
Avenida Blasco Ibañez 17
46010 Valencia, Spain
Email:nerses90@gmail.com
Patient

24 years, female

Categories
Area of Interest Neuroradiology brain, Interventional vascular ; Imaging Technique CT, CT-Angiography, Catheter arteriography, Image manipulation / Reconstruction
Clinical History
A 24-year-old unconscious female patient was admitted to the emergency department after having a severe headache followed by seizures. The patient had not previously reported neurological conditions.
Imaging Findings
In the unenhanced brain CT scan (Fig. 1) the presence of intraventricular haemorrhage, primarily in the 3rd, and 4th ventricles were noted. Also, foci of subarachnoid haemorrhage and blood in the cerebellomedullary cistern could be seen.

In the consecutive CT-angiography slices (Fig. 2) a small, 5 mm in diameter, left PICA aneurysm can be appreciated.

Diagnostic DSA shows a narrow-neck saccular aneurysm arising from the left PICA (Fig. 3 a and b).
Endovascular treatment with coil embolisation of the aneurysm is noted in the DSA images of the Fig. 3 c and d.

3D reconstructions (Fig. 4 a and b) were performed to clarify the location and relations of the aforementioned aneurysm. In the Fig. 4c a 3D reconstruction after treatment with coil embolisation can be observed.
Discussion
Posterior Inferior Cerebellar Artery (PICA) are rare, making up for almost 3% of intracranial aneurysms. [1]
The patients most frequently present with symptoms related to subarachnoid haemorrhage. However, its close relation with the medulla and IX, X and XI cranial nerves might warrant the presentation as nerve palsies. [2]

The rebleeding without treatment remains high. The likelihood of recurrence is still unclear, although several studies showed no significant difference between anterior and posterior circulation. [3]

Nowadays, several approaches are available for the treatment of the PICA aneurysms.

Removal of the blood clot and identification of the bleeding sources are the two main advantages of the open surgery. However, the manipulation of posterior fossa structures increases the incidence of lower cranial nerve palsies. [4]

Endovascular treatment presents a versatile approach having in mind the location and morphology of the aneurysm: [2]
- saccular narrow-neck aneurysms: selective embolisation of the lesion with preservation of the parent artery [5]
- wide-neck or, when the PICA originates from the aneurysm sac, ballon remodelling or stent-assisted coiling [5]
- distally located saccular aneurysms: parent artery occlusion with coil embolisation [6]

Catheterisation of the aneurysm may be very difficult because most PICA aneurysms project upward facilitating for the catheter to be transferred upward during pushing, which may result in the rupture of the aneurysm dome. Besides, PICA's tortuous anatomy strengthens the technical complications of endovascular treatment more than in other intracranial aneurysms. [2]

In our patient, the following procedure was implemented. A percutaneous approach through the right common femoral artery was performed with selective catheterisation of left vertebral arteries. A small left proximal PICA aneurysm was appreciated. A 6F guide catheter was then placed in the left V2 segment, and Excel SL10 (Stryker) micro with Synchro 14'' (Stryker) guide was used to microcatheterise the aneurysm. The procedure was done with the adminitration of 5.000 UI/ml of heparin sodium.
Embolisation with four coils was performed with a satisfactory morphological result, observing complete exclusion of the lesion in subsequent control series.

In our case, the patient's clinical evolution was favourable afterwards. However, given both anatomical and procedural difficulties that arise from the treatment of the PICA aneurysms, a multimodality approach tailored to the specific aneurysm in the particular patient seems the most appropriate management. [1]
Differential Diagnosis List
PICA Aneurysm treated with coil embolisation.
PICA aneurysm
Vertebral artery aneurysm
Final Diagnosis
PICA Aneurysm treated with coil embolisation.
Case information
URL: https://eurorad.org/case/15621
DOI: 10.1594/EURORAD/CASE.15621
ISSN: 1563-4086
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