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Management of posterior inferior cerebellar artery aneurysms: What factors play the most important role in outcome?

  • Original Article - Vascular
  • Published:
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Abstract

Background

Posterior inferior cerebellar artery (PICA) aneurysms are an uncommon, heterogeneous group of aneurysms with poorer clinical outcomes compared to other intracranial aneurysms. We performed a multicenter retrospective study to analyze the outcome in a large series of patients treated with modern microsurgical and endovascular techniques.

Methods

Records of 94 patients treated for PICA aneurysms between 2000 and 2015 at three large tertiary referral centers were retrospectively reviewed.

Results

Eighty-three patients met inclusion criteria and of these, two died before treatment, leaving 81 treated patients (43 underwent endovascular and 38 surgical treatment). Among patients treated endovascularly, procedure-related complications occurred in four cases (11.8%). Six patients (19.4%) suffered from complications directly associated with surgery. Recurrences occurred in 0% of surgical and in 16.3% of endovascularly treated patients, requiring treatment. Patients with unruptured asymptomatic aneurysms had good outcomes. In the group of 67 ruptured aneurysms, 16 endovascularly (47.1%) and 15 surgically (48.4%) treated patients had modified Rankin scale (mRS) scores of 3–6. Of patients in poor neurological condition (Hunt & Hess (H&H) IV–V at admission), 84.6% suffered a poor clinical outcome. Fifty percent of patients with distal and 31.9% patients with proximal ruptured PICA aneurysms suffered a poor neurological outcome.

Conclusions

This study of PICA aneurysms demonstrates that results of both treatment modalities are comparable. However, endovascular treatment is associated with higher risks of recurrence, requiring additional treatment. Outcomes were mostly impacted by clinical state at admission.

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Authors and Affiliations

  1. Neurosurgery Department, J.E. Purkynje University, Masaryk Hospital, Sociální péče 3316/12A, 400 11, Ústí nad Labem, Czech Republic

    Alena Sejkorová, Aleš Hejčl & Martin Sameš

  2. Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA

    Alena Sejkorová & Giuseppe Lanzino

  3. Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria

    Ondra Petr, Miriam Mulino & Claudius Thomé

  4. Department of Mathematics, Faculty of Science, J.E. Purkynje University, Ústi nad Labem, Czech Republic

    Jiří Cihlář

  5. International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic

    Aleš Hejčl

Authors
  1. Alena Sejkorová
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  2. Ondra Petr
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  3. Miriam Mulino
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  4. Jiří Cihlář
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  5. Aleš Hejčl
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  6. Claudius Thomé
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  7. Martin Sameš
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  8. Giuseppe Lanzino
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Corresponding author

Correspondence to Alena Sejkorová.

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Funding

Operational Programme Research and Development for Innovation provided financial support in the form of European Regional Development Fund - Project FNUSA-ICRC (No. CZ.1.05/1.1.00/02.0123). The sponsor had no role in the design or conduct of this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Comments

The authors present pooled data from a multicenter study about the management and treatment (43 endovascular vs. 38 surgical) of 81 posterior inferior cerebellar artery (PICA) aneurysms. The matter is interesting because only few data from small series are reported in the literature about PICA aneurysm management. The retrospective analysis of data show that patients’ outcomes do not significantly differ between microsurgery and endovascular approaches; conversely, the residual aneurysms/recurrence rate requiring retreatment significantly differs between the two treatment groups. The authors presented a large series of patients, treated in high-volume centers, with a “true” multidisciplinary approach, and with a particularly “aggressive” patient-management policy (38.8% of treated SAH-patients were presenting a H&H grade IV–V, aneurysm treatment on > 75-year-old patients). However, even though data arising from the study highlight the good outcome of surgically treated patients (albeit treatment selection bias represents a main limitation, see “clinical state”), we think that the design of the study does not allow the authors to suggest to prefer “surgical treatment in case both modalities are considered feasible”. The matter is quite more complex. We think that we should distinguish between bleeding and unruptured PICA aneurysms. When we deal with an unruptured aneurysm, a PICA aneurysm in particular and a cerebral aneurysm in general, we must keep in mind that we do not have at present evidence of which is the best treatment. Surgeon expertise, aneurysm features, and patient characteristics must be carefully considered. The higher recurrence rate of an endovascularly treated aneurysm is a critical issue because operating on a coiled aneurysm represents a potential further concern for patient, particularly in this critical area; for this reason, the age of a patient could be crucial in the decision-making process, since a young patient could benefit from potentially higher and longer time efficacy of clipping. Conversely, when we are dealing with a bleeding PICA aneurysm, all randomized studies support coiling embolization over surgical clipping: differently, the matter is questionable for anterior circulation aneurysms [1]. The issue of aneurysm recurrence after coiling must be clearly presented to the readers because previous reports did not show a significant higher re-bleeding rate in this patient subset. In addition, it is still unclear when to treat a recurrent aneurysm, even being different the endovascular from surgeon perspective. The authors asked: “What factors play the most important role in outcome?” We learned from the authors that in the bleeding subgroup, 10.8% of patients re-bleed before treatment; that patients affected by a proximally located PICA aneurysm presented a worse prognosis; that more than 25% of patients developed shunt-dependent hydrocephalus. However, the next question should be “What factors play the most important role in treatment modality choice? Actually, at present, we do not know whether aneurysm location along PICA, age of patients, and aneurysm size are really crucial for treatment modality choice. Again, neurophysiological monitoring could further improve outcome data as compared to the already available literature on surgical treatment of such patients. We should probably investigate in these directions. In our opinion, modern management of PICA aneurysms, and in general of all intracranial aneurysms, should aim to make out the best treatment based on aneurysm and patient features. We think that to aprioristically prefer one technique over another is incorrect. The so-called “tailored treatment” is crucial in vascular surgery as in other different fields of neurosurgery. A multidisciplinary approach is essential to this attitude. We think that the present study well shows treatment modality spectrum and patient outcome data of modern multidisciplinary management of PICA aneurysm.

1.Spetzler RF, McDougall C, Zabramski J, Albuquerque F, Hills N, Russin J, Partovi S, Nakaji P, Wallace R (2015) The Barrow Ruptured Aneurysm Trial: 6-year results. J Neurosurg 123:609–617

Domenico d’Avella and Alessandro Della Puppa

Padova, Italy

The authors present a relatively large multi-center series of PICA aneurysms where 83 patients (67 ruptured) were evaluated. The results are remarkable for a higher rate of aneurysm recurrence and re-treatment in the endovascular group as expected. Also, the outcome is directly related to the initial clinical grade in SAH patients. The complication rate, although slightly higher in the surgical group, did not reach statistical significance between the endovascular and surgical arms. This study highlights that PICA aneurysms, whether ruptured or unruptured, are a distinct subgroup of posterior fossa aneurysms for which surgical treatment has still a major role in management. The risk of recurrence is relatively high after endovascular treatment and this should be factored in before decision-making, especially in younger patients. There is undeniably a higher risk of cranial nerve deficit with open surgery, but this can be improved with skull base approaches and experience. For distal segment PICA aneurysms, revascularization should be considered if direct endovascular coiling or surgical clipping is not an option and the aneurysm is located on one of the first three segments of PICA. Endovascular treatment is also limited in terms of stent application in this location due to vessel size, navigation issue, and higher risk associated with stent placement. This article fails to identify the precise characteristics of each PICA aneurysm location (anteromedullary, lateromedullar, tonsilomedullary, telovelotonsilar, and cortical) with regard to surgical treatment modality and outcome. Aneurysms located at the 4th and 5th segment of the PICA can usually be sacrificed endovascularily along with the distal vessel with no major concern for ischemia. Unfortunately, this article does not dissect this important detail, as the Drake classification is less specific. However, the manuscript highlights the current limitation of endovascular treatment in this subset of patients and emphasizes a robust multidisciplinary approach to PICA aneurysms.

Amir Dehdashti

NY, USA

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Sejkorová, A., Petr, O., Mulino, M. et al. Management of posterior inferior cerebellar artery aneurysms: What factors play the most important role in outcome?. Acta Neurochir 159, 549–558 (2017). https://doi.org/10.1007/s00701-016-3058-z

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