Extracranial aneurysms of the distal posterior inferior cerebellar artery: Resection and primary reanastomosis as the preferred management approach
A 76-year-old Hispanic female suddenly collapsed and was brought to the emergency room of an outside hospital where a head computed tomography (CT) revealed diffuse subarachnoid hemorrhage (SAH) with blood in the fourth, third and lateral ventricles. Upon arrival at our institution, she was a Hunt and Hess grade III SAH. Repeated CT showed the SAH and hydrocephalus [ and ] and right frontal external ventriculostomy drain (EVD) was placed emergently. A diagnostic cerebral angiogram demonstrated the presence of a right PICA aneurysm measuring approximately 2-2.5 mm in diameter with a broad neck []. Decision was made that due to its morphology, the aneurysm should be treated with microsurgical clipping.\nA SOC with C1 and partial C2 laminectomies was performed. The cisterna magna was found to be full of blood; it was explored and the hematoma evacuated. Both segments of the PICA, proximal and distal to the aneurysm, were identified. The caudal loop of the PICA was seen under the C2 lamina and the aneurysm itself projected under the lamina of C1, and was located on the tonsillomedullary segment. Under temporary clipping distal and proximal, the aneurysm neck was defined and the aneurysm was clipped. The dura was then closed at the more distal cervical region, and Duragen (Integra LifeSciences Corporation, NJ) was placed more cranially. Cervical fascia and skin were closed in the usual fashion.\nThe patient recovered well from the surgery and passed EVD challenge. CT on postoperative day (POD) 19 revealed resolution of the SAH, and no blood in the posterior fossa around the aneurysm clip. Postoperative skull X-ray (XR) showed the clip located below the foramen magnum []. The patient was scheduled to be discharged to an inpatient rehabilitation facility, and on POD 25, following a physical therapy session including active range of motion of bilateral upper extremities, was found unresponsive on the floor. Emergent CT scan of the head showed the presence of blood in the fourth, third and lateral ventricles, and right frontal EVD was placed. A repeat diagnostic angiogram revealed findings consistent with rebleed from the previously clipped right PICA aneurysm.