Endovascular Treatment for Ruptured Distal Anterior Inferior Cerebellar Artery Aneurysm
A 42-year-old woman with no underlying diseases was referred to our department for severe headache, nausea, and vomiting after coitus. She was drowsy with no neurologic deficit (Hunt and Hess grade 3). Computed tomography (CT) and magnetic resonance image (MRI) showed a subarachnoid hemorrhage (SAH) on the cerebellopontine angle cistern, and a small vermian intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) in the fourth ventricle (Fisher grade 4) (). There was no evidence of head injury. Digital subtraction angiography revealed an aneurysm arising on the branching point between the caudomedial and rostrolateral branch of the left distal AICA, located distally from the meatal loop. The aneurysm was associated with fenestration () and was 2.7×2.8 mm with a neck of 1.5 mm directed caudo-laterally. The diameter of AICA proximal to aneurysm was 0.8 mm on 3D rotational angiogram ().\nUnder general anesthesia, a 6F Envoy guiding catheter (Cordis Neurovascular, Bridgewater, NJ, United States) was placed on the right vertebral artery (VA) at the level of C2 vertebra. An Excelsior SL-10 microcatheter (Boston Scientific, Natick, MA, United States) and X-pedion-14 microwire (ev3 Endovascular, Inc., Plymouth, MN, United States) were advanced to the right VA and the basilar artery. Under the roadmap guidance, aneurysm selection was tried. Even though the superselection of the AICA orifice was not difficult, aneurysm selection was very difficult due to the tortuous course of AICA and relatively small diameter of the AICA for accommodation of the microcatheter ().\nAfter failed multiple trials of selecting the aneurysm with Excelsior SL-10 microcatheter and X-pedion-14 microwire, we changed the microwire to X-pedion-10, resulting in successful distal AICA aneurysm selection. The aneurysmal sac was then obliterated completely without compromise of the AICA branch even though the second coil was extruded from the aneurysmal sac during coiling (). Postoperative CT showed slightly increased cerebellar hemorrhage, but there was no evidence of obstructive hydrocephalus. She was alert without motor weakness or brain stem sign. However, she complained of hearing loss and tinnitus despite the patent flow to left AICA. She was discharged home at two weeks with remaining sensorineural hearing loss.