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 »  Abstract
 » Introduction
 » Case Report
 » Discussion
 » Acknowledgment
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CASE REPORT
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 228-230

Posterior cerebral artery-posterior communicating artery (PCA-PComA) aneurysms: Report of five cases and literature review


1 Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
2 Department of Neurology, Changhai Hospital, Second Military Medical University, Shanghai, China

Date of Submission12-Dec-2011
Date of Decision30-Dec-2011
Date of Acceptance11-Mar-2012
Date of Web Publication19-May-2012

Correspondence Address:
Jianmin Liu
Department of Neurosurgery, Changhai Hospital, Changhai Road 168, Shanghai 200433
China
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Source of Support: This work was partly supported by the National Natural Science Foundation of China (81000494) and dawn project of Shanghai (11CG043), Conflict of Interest: None


DOI: 10.4103/0028-3886.96409

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 » Abstract 

Posterior cerebral artery-posterior communicating artery aneurysms are rare and not well documented. In this article, we report five such cases and review four similar cases by searching the PubMed database through the years 1980-2011 to study the occurrence and treatment of this rare entity.


Keywords: Cerebral aneurysms, internal carotid artery, occlusion, posterior cerebral artery, posterior communicating artery


How to cite this article:
Zhou Y, Yang P, Zhang Y, Liu J. Posterior cerebral artery-posterior communicating artery (PCA-PComA) aneurysms: Report of five cases and literature review. Neurol India 2012;60:228-30

How to cite this URL:
Zhou Y, Yang P, Zhang Y, Liu J. Posterior cerebral artery-posterior communicating artery (PCA-PComA) aneurysms: Report of five cases and literature review. Neurol India [serial online] 2012 [cited 2023 Dec 10];60:228-30. Available from: https://www.neurologyindia.com/text.asp?2012/60/2/228/96409



 » Introduction Top


Posterior communicating artery (PComA) aneurysms are not rare, constituting about 25% of all intracranial aneurysms. [1] Usually, "PComA aneurysm" refers to internal carotid artery (ICA)-PComA aneurysms originating from the ICA-PComA junction and less frequently refers to the aneurysms of the PComA itself. [1],[2] However, PComA aneurysm may also occur at the other junction of posterior cerebral artery (PCA) and PComA, which is extremely rare and not well documented. [3],[4],[5],[6] To the best of our knowledge, only four cases have been reported earlier and this report presents five additional cases.


 » Case Report Top


From August 1998 to November 2011, five patients, two males and three females, aged between 53 and 82 years (mean age 67.8 years), with PCA-PComA aneurysms were admitted to our institution. Their clinical characteristics, treatments, and follow-up information are summarized in [Table 1]. Two cases, case 6 and case 8, presented with subarachnoid hemorrhage (SAH), two aneurysms were found incidentally, and the other one presented with oculomotor nerve palsy. Of the five, four were on the right side in location. All these five patients were associated with unilateral ICA occlusion (ipsilateral to the PCA-PComA aneurysm); in four patients the cause of ICA occlusion could not be determined and in the remaining patient it was iatrogenic occlusion using a balloon to treat a giant carotid artery aneurysm 15 years ago (case 7) [Figure 1]. All of them were confirmed by digital subtraction angiography (DSA). Collateral circulation from PCA due to occluded ICA through PComA was noticed in all of them, and the PComAs were all hypertrophied on the side of PCA-PComA aneurysms [Figure 2]. Four of these PCA-PComA aneurysms were small, 3.6-7 mm in size, while the other one was 16.1 mm in size (case 5) [Figure 3]. The shapes of the aneurysms were irregular in all the patients. Three patients were treated endovascularly; stent was used in case 5 to assist the coiling due to wide neck of the aneurysm. The initial embolization results, according to Raymond's classification, were Grade 2 in one and Grade 3 in two. No peri-procedural complications occurred, and all of them recovered well. Case 8 and case 9 were not treated as they have not opted for any form of treatment. Angiographic follow-up from 2 to 27 months was available in four patients. Two patients, followed up by DSA, achieved complete occlusion. In case 5, follow-up magnetic resonance angiography (MRA) did not show any residual aneurysm. No patient experienced new neurological deficit during a follow-up of 1-34 months (mean, 15.2 months).
Figure 1: Angiogram of case 7 (a) MRA image showed occluded right ICA. (b) and (c) Angiography revealed a PCA-PComA aneurysm (white arrow) and a concurrent P1 segment aneurysm on the right side. (d) and (e) the aneurysm was completely occluded by coiling. (f) seven-month DSA showed the aneurysms remain stable. Black arrow indicated the marker of the balloon which was used to treat a giant ICA cavernous aneurysm 15 years ago.

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Figure 2: Angiogram of case 6 (a) Preoperative angiography indentified occlusion of right ICA. (b) and (c), a giant PCA-PComA aneurysm on the right side. (d) the aneurysm was treated by coiling, resulting in a residual sac. (e) six-month DSA showed the aneurysm was completely occluded and the parent artery was patent.

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Figure 3: Angiogram of case 5 (a) Preoperative angiography indentified occlusion of right ICA. (b) and (c) a giant PCA-PComA aneurysm on the right side;a hypertrophied PcomA was also presented on the right side, indicating increased blood supply. (d) and (e), the aneurysm was treated by stent assisted coiling, resulting in a residual sac (f) three-month MRA showed the aneurysm was completely occluded

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Table 1: Clinical data, treatment, and outcome of nine PCA-PComA aneurysms

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 » Discussion Top


Though reports about the P1-P2 junction aneurysms are not uncommon, seldom cases can be defined as PCA-PComA aneurysms; [7],[8] it is hard to make sure that the aneurysms are located at the PCA-PComA junction since the PComAs are invisible in most cases. We summarized the clinical data and treatment of the nine cases of PCA-PComA aneurysms including the present five cases in [Table 1]. From the data, the PCA-PComA aneurysms seem to occur mainly in old people and predominantly on the right side. Also, most importantly, all of them were associated with ipsilateral ICA occlusion, which may be the reason for the formation of PCA-PComA aneurysms. Usually, because of the impact of the blood flow, aneurysms are prone to occur at the ICA-PComA junction. However, following unilateral or bilateral ICA occlusion, the blood would flow retrogradely from PCA to ICA territory via PComA. Increased blood velocity and existed turbulence may lead to degeneration of the endothelial basement membrane and subendothelial connective tissue in the blood vessel wall, leading to the occurrence of PCA-PComA aneurysms. [2] In all of our patients, retrograde blood flow from posterior circulation to anterior circulation via PComA artery was noticed. The hypertrophied PComAs indicate increased blood flow and added hemodynamic stress. Therefore, the formation of these aneurysms is probably the result of hemodynamic changes caused by ipsilateral ICA occlusion.

Most of the PCA-PComA aneurysms (5/9) presented with SAH. The high rate of bleeding, associated with location of posterior circulation, irregular shape, and continuing blood flow impact, [9] makes these aneurysms quite dangerous, and therefore they should be treated as early as possible. Both clipping and coiling can be the treatment options. If clipping is chosen, aneurysms at this location can be accessed via pterional or subtemporal approach. [7],[8] However, caution should be taken since the surgical access is still challenging due to the deep location, complexity, and importance of the perforating branches, and their close relationship with the cranial nerve and brain stem. [7],[10] In our review, only two cases were treated by clipping. However, with the development of endovascular techniques, we prefer to coil these lesions, especially considering the difficulty of clipping these aneurysms. Since the PCA-PComA aneurysms are associated with bilateral or ipsilateral ICA occlusion, the goal of treating these aneurysms is to pack the aneurysm as well as preserve the PComA. In this series, four aneurysms were successfully coiled. No peri-operative complications were observed. However, sometimes, endovascular treatment may not be successful due to the tortuous vasculature or for other reasons; then clipping should be considered, as in the case reported by Sameš et al.[6]


 » Acknowledgment Top


Yu Zhou and Pengfei Yang have contributed equally to this paper.

 
 » References Top

1.Brisman JL, Song JK, Newell DW. Cerebral aneurysms. N Engl J Med 2006;355:928-39.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Kaspera W, Majchrzak H, Kopera M, £adzin´ski P. "True" aneurysm of the posterior communicating artery as a possible effect of collateral circulation in a patient with occlusion of the internal carotid artery. A case study and literature review. Minim Invasive Neurosurg 2002;45:240-4.  Back to cited text no. 2
    
3.Kataoka K, Taneda M. [Cerebral aneurysm with bilateral carotid occlusion. Report of two cases]. Neurol Med Chir (Tokyo) 1982;22:744-50.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Shibuya T, Hayashi N. A case of posterior cerebral artery aneurysm associated with idiopathic bilateral internal carotid artery occlusion: case report. Surg Neurol 1999;52:617-22.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Yousaf I, Gray WJ, McKinstry CS, Choudhari KA. Development of posterior circulation aneurysm in association with bilateral internal carotid artery occlusion. Br J Neurosurg 2003;17:471-2.  Back to cited text no. 5
[PUBMED]    
6.Sameš M, Orlický M, Vachata P, Hejcl A. P Com - P1 Aneurysm Formation in a Patient with Bilateral Internal Carotid Occlusion. Cen Eur Neurosurg 2011 [In Press].  Back to cited text no. 6
    
7.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. 7
    
8.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. 8
    
9.Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD, Jr., Piepgras DG, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362:103-10.  Back to cited text no. 9
    
10.Kocaeli H, Chaalala C, Abruzzo TA, Zuccarello M. Results of surgical management for posterior cerebral artery aneurysms: 7-year experience in the endovascular era. Acta Neurochirurgica 2009;151:1583-91.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  


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    Tables

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