Ruptured Distal Posterior Inferior Cerebellar Artery Aneurysm Associated with an Arteriovenous Malformation Detected by Intraoperative Indocyanine Green Video angiography: Case Report and Literature Review

Mari Kusumi; Hidehiro Oka; Hamidreza Aliabadi; Koji Kondo; Toshihiro Kumabe

Mari Kusumi^1*, Hidehiro Oka¹, Hamidreza Aliabadi², Koji Kondo¹, Toshihiro Kumabe³

¹Department of Neurosurgery, Kitasato University Medical Center, Kitamoto, Japan

²Department of Spine and Neurosurgery Associates, California, USA

³Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan

^*Corresponding author: Mari Kusumi, Department of Neurosurgery, Kitasato University Medical Center, 100-6 Arai Kitamoto, Saitama 364-8501, Japan. Tel: +81485931212; Fax: +81427788855; Email: kusumi@med.kitasato-u.ac.jp

Received Date: 08 June, 2018; Accepted Date: 11 June, 2018; Published Date: 15 June, 2018

1. Abstract

1.1. Background: Distal Posterior Inferior Cerebellar (PICA) aneurysms are quite rare. The infrequency of distal PICA aneurysms has limited our understanding of their underlying pathology, natural history, and clinical management. Moreover, vascular anomalies are frequently noted in association with distal PICA aneurysms.

1.2. Case Description: We present a very unique case of a ruptured distal PICA aneurysm associated with an Arteriovenous Malformation (AVM) which was successfully identified by Intraoperative Indocyanin Green (ICG) video angiography. In the current era, we tend to perform Computed Tomographic Angiography (CTA) studies as the initial imaging for vascular lesions. CTA revealed the distal PICA aneurysm but failed to reveal the associated AVM. However, intraoperative ICG video angiography strongly suspected the existence of an AVM.

1.3. Conclusion: Intraoperative ICG video angiography is very useful in detecting small vessel anomalies. DSA should be considered for all distal PICA aneurysms even in the era of advanced CTA.

Keywords: Arteriovenous Malformation; Cerebral Aneurysm; Distal Posterior Inferior Cerebellar Artery; Indocyanin Green Video angiography; Intraventricular Hemorrhage

Figure 1: (A): Axial view, CT shows IVH of fourth ventricle. (B): Preoperative CTA demonstrates left distal PICA aneurysm without any other vascular anomalies.

Figure 2: (A-B): Intraoperative view of mid-line suboccipital craniotomy shows normal cerebellum surface without SAH and red veins, and the view via the tonsilomedullary and cerebellomedullary fissure (A: arrow line) shows the ruptured distal PICA aneurysm (B: arrow) which appeared to be connected via an abnormal vessel (B: arrow head). (C-D): ICG video angiography (C: early phase, D: delayed phase) demonstrate delayed flow on the abnormal vessel (arrow head). The aneurysm (arrow) appeared to be located at the branching point.

Figure 3: (A): Intraoperative view shows clip applied to the aneurysm and abnormal vessel suspected as feeding artery to AVM, with temporary clip (lower clip). (B): The next view shows final clip preserving branches of PICA. (C): ICG video angiography after clipping demonstrates disappearance of the aneurysm and abnormal vessel. Arrow: aneurysm, arrow head: abnormal vessel

Figure 4: (A-B): Postoperative conventional DSA shows a superior vermian AVM (arrow head, A: frontal view, B: lateral view). (C-D): Three dimensional DSA demonstrates AVM fed by PICA (C: arrow head), and complete clipping of the aneurysm (D: arrow) and abnormal vessel.

1. Locksley HB (1996) Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the cooperative study. Journal of neurosurgery 25: 219-239.

2. Hudgins RJ, Day AL, Quisling RG, Rhoton AL Jr, Sypert GW, et al. (1983) Aneurysms of the posterior inferior cerebellar artery. A clinical and anatomical analysis. Journal of neurosurgery 58: 381-387.

3. Lewis SB, Chang DJ, Peace DA, Lafrentz PJ, Day AL (2002) Distal posterior inferior cerebellar artery aneurysms: clinical features and management. Journal of neurosurgery 97: 756-766.

4. Ishikawa T, Suzuki A, Yasui N (1990) Distal posterior inferior cerebellar aneurysms--report of 12 cases. Neurologia medico-chirurgica 30: 100-108.

5. Rodriguez-Hernandez A, Zador Z, Rodriguez-Mena R, Lawton MT (2013) Distal aneurysms of intracranial arteries: application of numerical nomenclature, predilection for cerebellar arteries, and results of surgical management. World neurosurgery 80: 103-112.

6. Case D, Kumpe D, Cava L, Neumann R, Roark C, et al. (2016) Ruptured Distal Posterior Inferior Cerebellar Artery (PICA) Aneurysms Associated with Cerebellar Arterial Venous Malformations (AVMs): A Case Series and Review of the Literature Demonstrating the Need for Angiographic Evaluation and Feasibility of Endovascular Treatment. World neurosurgery 2016.

7. Kaptain GJ, Lanzino G, Do HM, Kassell NF (1999) Posterior inferior cerebellar artery aneurysms associated with posterior fossa arteriovenous malformation: report of five cases and literature review. Surgical neurology 51: 146-152.

8. Lister JR, Rhoton AL Jr, Matsushima T, Peace DA (1982) Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10: 170-199.

9. Lehto H, Harati A, Niemela M, Dashti R, Laakso A, et al. (2014) Distal posterior inferior cerebellar artery aneurysms: clinical features and outcome of 80 patients. World neurosurgery 82: 702-713.

10. Peluso JP, van Rooij WJ, Sluzewski M, Beute GN, Majoie CB (2008) Posterior inferior cerebellar artery aneurysms: incidence, clinical presentation, and outcome of endovascular treatment. AJNR American journal of neuroradiology 29: 86-90.

11. Tokimura H, Yamahata H, Kamezawa T, Yokoyama S, Haruzono A, et al. (2011) Clinical presentation and treatment of distal posterior inferior cerebellar artery aneurysms. Neurosurgical review 34: 57-67.

12. Hokari M, Kuroda S, Yasuda H, Iwasaki M, Abe S, et al. (2010) Ruptured aneurysms of the choroidal branches of the posterior inferior cerebellar artery: a review of the literature and a case report. Acta neurochirurgica 152: 515-518.