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Table of Contents    
ORIGINAL ARTICLE
Year : 2011  |  Volume : 59  |  Issue : 1  |  Page : 6-11

Characteristics and endovascular treatment of aneurysms of posterior cerebral artery


1 The Affiliated Hospital of Inner Mongolia National University, Tongliao, Inner Mongolia, China
2 The Affiliated Hospital of Inner Mongolia National University, Tongliao, Inner Mongolia;The Third Hospital of Jilin University, Changchun, Jilin, China
3 The First Hospital of Jilin University, Changchun, Jilin, China

Date of Submission04-Jan-2010
Date of Decision26-Jan-2010
Date of Acceptance22-Jun-2010
Date of Web Publication18-Feb-2011

Correspondence Address:
Zhigang Sun
1742 HuoLinHe St, TongLiao, Inner Mongolia, 028007
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.76849

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 ╗ Abstract 

Background : Aneurysms of the posterior cerebral artery (PCA) are a distinct rarity and present with some peculiar morphologic features and specific clinical findings. These aneurysms can be managed endovascularly with good results. Objective : To evaluate the clinical features and endovascular management of PCA aneurysms. Material and Methods : Between 2000 and 2008, we treated 24 patients (14 male and 10 female; mean age: 36 years) with PCA aneurysms. Clinical presentations, radiologic images, and endovascular management were reviewed. Results : There were 11 saccular aneurysms, including 4 giant or large aneurysms, and 13 dissecting aneurysms, including 11 giant or large aneurysms. Of the 24 patients, 13 presented with hemorrhage and 6 with neurologic deficits. Five patients presented with headaches without any neurologic deficits. Parent vessel occlusion was performed in 12 patients, selective coil embolization was performed in 11 patients, and 1 patient conservatively. Eighteen patients had a good recovery, 5 had a moderate disability (one with 1 visual deficit after the treatment) related to hemorrhage, vasospasm, or infarction before aneurysm trapping, and 1 patient died because of rebleeding. The conservatively treated patient made a good recovery. Conclusion : PCA aneurysms have specific clinical characteristics compared with aneurysms located elsewhere. Endovascular technique can achieve good outcomes despite the aneurysmal site and size.


Keywords: Aneurysm, endovascular therapy, posterior cerebral artery


How to cite this article:
Wang J, Sun Z, Bao J, Zhang B, Jiang Y, Lan W. Characteristics and endovascular treatment of aneurysms of posterior cerebral artery. Neurol India 2011;59:6-11

How to cite this URL:
Wang J, Sun Z, Bao J, Zhang B, Jiang Y, Lan W. Characteristics and endovascular treatment of aneurysms of posterior cerebral artery. Neurol India [serial online] 2011 [cited 2020 Apr 1];59:6-11. Available from: http://www.neurologyindia.com/text.asp?2011/59/1/6/76849



 ╗ Introduction Top


Aneurysms of the posterior cerebral artery (PCA) are a distinct rarity with an incidence of 0.7%-2.3%. [1],[2],[3],[4] Nevertheless, they have been recognized as an important cause of bleeding. These aneurysms have some peculiar morphologic features and present with specific clinical findings that distinguish them from aneurysms occurring at other anatomic locations of cerebral circulation. [3],[5] Aneurysms of the PCA are also an important cause of stroke in younger patients. [4],[6] Also, there is a higher incidence of large and giant aneurysms. Compared with aneurysms located elsewhere, the site, size, and surgical techniques used do not significantly affect the prognosis of patients with PCA aneurysms, because, unlike aneurysms at other sites, there is rich collateral flow in areas fed by the PCA. [7],[8] However, recent data confirm good results when these aneurysms are treated by endovascular techniques. [4],[6],[9],[10],[11],[12],[13] We review our 8-year experience with these relatively rare aneurysms involving the PCA and discuss the specific clinical characteristics and endovascular management used to treat PCA aneurysms.


 ╗ Material and Methods Top


During the 8-year period from 2000 to 2008, of the 1956 patients with aneurysms seen at Beijing Tiantan Hospital, 24 patients (1.2%) were with PCA aneurysms, 14 men and 10 women, in the age range from 4 to 65 years (mean, 36 years) [Table 1]. Diagnosis was based on clinical presentations and radiologic findings, including computed tomography (CT) scanning, magnetic resonance imaging (MRI), and cerebral angiography. Intramural thrombus on T1-weighted images and intimal flaps on T2-weighted images were the major findings indicating dissecting aneurysm. All the patients underwent cerebral digital subtraction angiography (DSA), which demonstrated such typical results as double lumen, tapered narrowing, or occlusion with or without aneurysm dilation, and retention of contrast medium. A sequential change in luminal configuration also supported a diagnosis of dissection. Of the 24 aneurysms, 11 were saccular, including 4 giant or large aneurysms, and 13 were dissecting aneurysms, including 11 giant or large aneurysms. Of the 24 patients, subarachnoid hemorrhage (SAH) was the presenting feature in 12 and cerebral hemorrhage in 1 patient. Six patients presented with neurologic deficits and 5 with headache without any neurologic deficits. In 1 patient, SAH due to rupture of aneurysm at another site, was an incidental finding. The Hunt and Hess grade at admission was grade 0: 10; grade 1: 10; grade 2: 3; and grade 3: 1. Each segment of the PCA was classified according to the classification of Kaweshima and Rhoton. [8] The aneurysm location was P1 segment in 5 patients, P2 segment in 17 patients, P2-P3 junction in 1 patient, and P3 segment in 1 patient. The outcome was assessed using modified Rankin Scale (mRS).
Table 1: Demographic features of 24 PCA aneurysms

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Treatment strategies

Our basic treatment strategy for PCA aneurysms was endovascular. Early embolization within 48 h after SAH was performed in 1 patient with Hunt and Hess grade 1 and the remaining patients underwent delayed embolization.

  1. Dissecting and wide-necked saccular aneurysms were treated with stent-coil embolization (n = 1), "remodeling technique" (n = 2) or parent artery obliteration (n = 12).
  2. Small-neck saccular aneurysms were selectively occluded, while preserving the parent artery (n = 9).
  3. In the patient with P3 segment aneurysm, the aneurysm and the parent artery were occluded with n-butyl-cyanoacrylate at the same sitting.


Outcomes

Of the 24 patients, 18 (75%) made a good recovery (mRS = 0) and 5 had a moderate disability (mRS = 1-2) related to hemorrhage, vasospasm, or infarction. The patient who was managed conservatively had spontaneous thrombosis of aneurysm and made a good recovery. There was one death among the patients with ruptured aneurysms because of incomplete embolization and rebleeding. Of the 12 patients who underwent PCA sacrifice, the patients who underwent parent vessel occlusion demonstrated no homonymous hemianopsia.

Illustrative cases

Case 9

A 21-year-old woman was admitted on the previous day at another hospital for SAH. At admission she was alert with no neurologic deficit. DSA revealed a small broad-neck saccular aneurysm in the P1 segment of the left PCA [Figure 1]a. She was transferred to our hospital for further evaluation and treatment [Figure 1]b-d. On the next day, stent-coil embolization was performed and her postoperative course was uneventful. She was neurologically intact at 3 months of follow-up.
Figure 1: (a)Patient 9 - Anteroposterior angiogram of the left vertebral artery shows a small wide-necked aneurysm at the left P1 portion (arrow). Perforating branches are visible near the aneurysm
Figure 1b: Patient 9 - Lateral angiogram of the left carotid artery obtained before treatment shows the open posterior communicating artery (arrowheads)
Figure 1c: Patient 9 - Unsubtracted image in the anteroposterior projection demonstrating a 3 × 15-mm neuroform stent in place across the aneurysm neck demarcated by 2 sets of 4 radiopaque markers at the proximal and distal ends of the stent (arrows), the coil mass (black arrowhead) and the tip of the microcatheter is out of the aneurysm (white arrowhead)
Figure 1d: Patient 9 - Anteroposterior angiogram of the left vertebral artery obtained after treatment shows the occlusion of the aneurysm and the left P1 portion with preserving perforating arteries


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Case 24

A 25-year-old woman underwent CT for acute onset of left hemiparesis, which revealed a mass lesion measuring 30 mm in diameter compressing the right cerebral peduncle [Figure 2]a-c. Cerebral angiography revealed a dissecting aneurysm at the right P2a segment [Figure 2]d. The aneurysm was treated with parent vessel occlusion. At 6-month follow-up, the patient showed no neurologic deficits.
Figure 2: (a)Patient 24 - Preoperative CT scan shows a posterior cerebral artery (PCA) aneurysm with thrombosis
Figure 2b: Patient 24 - Axial MRI scan, T1-weighted, shows a large mass with a "bull's eye" in the right ambient cistern, which compressed the right cerebral peduncle
Figure 2c: Patient 24 - MRI scan (coronal view) demonstrates a highpositioned P2a aneurysm in the right ambient cistern, which protrudes into the choroidal fissure
Figure 2d: Patient 24 - left vertebral angiogram (anteroposterior view) reveals a fusiform aneurysm arising from the right P2a
Figure 2e: Patient 24 - Right carotid angiogram shows the retrograde filling of the cortical branches of the PCA
Figure 2f: Patient 24 - Postoperative left vertebral angiogram (anteroposterior view) demonstrates no residual aneurysm. The main trunk of the PCA was occluded
Figure 2g: Patient 24 - Postoperative right carotid angiogram (lateral view) shows the retrograde filling of the cortical branches of the PCA Figure 2h: Patient 24 - Follow-up angiogram


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 ╗ Discussion Top


Aneurysms arising from the PCA frequently affect young patients. [12] The average age in our series was 36 years, a much younger age than the patients (range, 50-60 years) with aneurysms at other anatomic sites. PCA aneruysms tend to be large or giant dissecting aneurysms. [3] In our series, of the 24 aneurysms, 15 (62.5%) were either large or giant, a higher frequency than frequently reported by others. The location of aneurysms at various segments of PCA in our series was similar to the reported findings in other series. [1],[3],[4],[6],[11],[12] The frequently found location was P2 segment.

The most common clinical presentation of PCA aneurysms is SAH as seen in our series. The overall morbidity and mortality in our series was 25%, similar to the morbidity and mortality seen in patients treated for aneurysms in the anterior circulation at our hospital. The reported rates of homonymous hemianopia following proximal P2 occlusion varied between 4.5% and 14%. [12] There were few associated vascular anomalies in our series: basilar fenestration and multiple intracranial aneurysms in one patient each. One of our patients had spontaneous thrombosis of the aneurysm. However, the natural history of thrombosed intracranial aneurysms is not well studied. Although our patient was neurologically stable at 2-year follow-up, we suggest long-term follow-up of such patients to define the natural history.

Endovascular surgery is associated with good results in aneurysms of the posterior circulation, including the PCA. [14] Aneurysms in the P2 segment are well suited for parent vessel occlusion with detachable coils because

the perforating branches are close to the cerebral peduncle. [11],[12],[15] We obliterated 2 small saccular aneurysms with coils and embolized 1 aneurysm arising from the branch of P3 segment with liquid material. We found that endovascular obliteration using coils is safe and effective in cases with small PCA aneurysms with a small neck.

 
 ╗ References Top

1.Ciceri EF, Klucznik RP, Grossman RG, Rose JE, Mawad ME. Aneurysms of the posterior cerebral artery: Classification and endovascular treatment. AJNR Am J Neuroradiol 2001;22:27-34.  Back to cited text no. 1
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2.Ferrante L, Acqui M, Trillò G, Lunardi P, Fortuna A. Aneurysms of the posterior cerebral artery: Do they present specific characteristics? Acta Neurochir (Wien) 1996;138:840-52.  Back to cited text no. 2
    
3.Hamada J, Morioka M, Yano S, Todaka T, Kai Y, Kuratsu J. Clinical features of aneurysms of the posterior cerebral artery: A 15-year experience with 21 cases. Neurosurgery 2005;56:662-70.  Back to cited text no. 3
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4.Li Y, Lv X, Jiang C, Liu A, Wu Z. Endovascular treatment of posterior cerebral artery aneurysms. Neuroradiol J 2008;21:128-36.  Back to cited text no. 4
    
5.Kawashima M, Rhoton AL Jr, Tanriover N, Ulm AJ, Yasuda A, Fujii K. Microsurgical anatomy of cerebral revascularization. Part II: Posterior circulation. J Neurosurg 2005;102:132-47.  Back to cited text no. 5
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6.Lempert TE, Malek AM, Halbach VV, Phatouros CC, Meyers PM, Dowd CF, et al. Endovascular treatment of ruptured posterior circulation cerebral aneurysms. Clinical and aniographic outcomes. Stroke 2000;31:100-10.  Back to cited text no. 6
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7.Terasaka S, Sawamura Y, Kamiyama H, Fukushima T. Surgical approaches for the treatment of aneurysms on the P2 segment of the posterior cerebral artery. Neurosurgery 2000;47:359-64.  Back to cited text no. 7
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8.Taylor CL, Kopitnik TA Jr, Samson DS, Purdy PD. Treatment and outcome in 30 patients with posterior cerebral artery aneurysms. J Neurosurg 2003;99:15-22.  Back to cited text no. 8
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9.Arat A, Islak C, Saatci I, Kocer N, Cekirge S. Endovascular parent artery occlusion in large-giant or fusiform distal posterior cerebral artery aneurysms. Neuroradiology 2002;44:700-5.  Back to cited text no. 9
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10.Brassel F, Rademaker J, Haupt C, Becker H. Intravascular stent placement for fusiform aneurysm of the posterior artery: Case report. Eur Radiol 2001;11:1250-3.  Back to cited text no. 10
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11.Hallacq P, Poitin M, Moret J. Endovascular occlusion of the posterior cerebral artery for the treatment of P2 segment aneurysms: Retrospective review of a 10-year series. AJNR Am J Neuroradiol 2002;23:1128-36.  Back to cited text no. 11
    
12.Lv X, Li Y, Jiang C, Yang X, Wu Z. Parent vessel occlusion for P2 dissecting aneurysms of the posterior cerebral artery. Surg Neurol 2009;71:319-25.  Back to cited text no. 12
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13.van Rooij WJ, Sluzewski M, Beute GN. Endovascular treatment of posterior cerebral artery aneurysms. AJNR Am J Neuroradiol 2006;27:300-5.  Back to cited text no. 13
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14.Coert BA, Chang SD, Do HM, Marks MP, Steinberg GK. Surgical and endovascular management of symptomatic posterior circulation fusiform aneurysms. J Neurosurg 2007;106:855-65.  Back to cited text no. 14
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15.Lv X, Li Y, Liu A, Jiang P, Lv M, Wu Z. Endovascular treatment of intracranial giant serpentine aneurysms. Neuroradiol J 2007;20:237-41.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]

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