Orakcioglu B, Schuknecht B, Otani N, Khan N, Imhof H G, Yonekawa Y
Department of Neurosurgery, Universitätsspital Zurich, Switzerland.
Acta Neurochir (Wien). 2005 Nov;147(11):1131-9; discussion 1139. doi: 10.1007/s00701-005-0599-y. Epub 2005 Aug 1.
Aneurysms located on the distal posterior inferior cerebellar artery (PICA) are rare, and their underlying clinical features and surgical management are poorly understood. We report our series of 16 patients with 18 distal PICA aneurysms.
All patients with distal PICA aneurysms were treated between March 1996 and August 2004. We excluded all PICA aneurysms that involved the vertebral artery. Patients were analysed in the light of their clinical profiles, radiological studies, intraoperative findings and outcomes. All patients underwent non-enhanced and contrast enhanced CT scans followed by 4-vessel cerebral angiography on admission. The hemorrhagic patterns on initial CT scans were assessed using the Fisher Grading Score. The outcomes were documented using the Glasgow Outcome Scale at time of discharge and at three or twelve months follow-up.
The series included 6 men and 10 women. Massive intraventricular haemorrhage was found in 13 patients with proven CT subarachnoid haemorrhage, one patient revealed SAH without intraventricular components, one presented with only intraventricular blood in the occipital horns and 3 aneurysms were found incidentally without presence of blood. Fourteen aneurysms were saccular and four were fusiform. Nine cases were associated with another cerebrovascular lesion. A lateral transcondylar or a median suboccipital approach was used to secure the aneurysms in 15 patients, either by direct clipping (14 lesions) or vessel sacrifice (3 lesions). One aneurysm was treated by an endovascular approach. At long-term follow up, an excellent or good outcome was achieved in 75% of cases. One patient died due to pre-existing cardiopulmonary complications.
Most of our cases of ruptured distal PICA aneurysms presented with haematocephalus. These were frequently associated with another vascular abnormality and 22% were fusiform or multilobulated. These specific features require special management strategies entailing an appropriate surgical approach to the aneurysm, clipping method, haematoma removal, ventricular drainage and when suitable choice of endovascular interventions.
位于小脑后下动脉（PICA）远端的动脉瘤较为罕见，其潜在的临床特征及手术治疗方法尚不明确。我们报告了16例患者共18个PICA远端动脉瘤的病例系列。
所有PICA远端动脉瘤患者于1996年3月至2004年8月期间接受治疗。我们排除了所有累及椎动脉的PICA动脉瘤。根据患者的临床资料、影像学检查、术中发现及预后情况进行分析。所有患者入院时均接受了非增强及增强CT扫描，随后进行四血管脑血管造影。初始CT扫描的出血模式采用Fisher分级评分进行评估。出院时及术后3个月或12个月随访时，使用格拉斯哥预后量表记录预后情况。
该病例系列包括6名男性和10名女性。在13例经CT证实为蛛网膜下腔出血的患者中发现大量脑室内出血，1例患者显示为无脑室内成分的蛛网膜下腔出血，1例仅枕角有脑室内血液，3个动脉瘤为偶然发现且无出血。14个动脉瘤为囊状，4个为梭形。9例与另一脑血管病变相关。15例患者采用外侧经髁或枕下正中入路来处理动脉瘤，其中14个病变采用直接夹闭，3个病变采用血管牺牲。1个动脉瘤采用血管内治疗。长期随访时，75%的病例获得了良好或优秀的预后。1例患者因原有心肺并发症死亡。
我们大多数PICA远端动脉瘤破裂病例表现为脑积水。这些病例常与另一血管异常相关，22%为梭形或多叶形。这些特殊特征需要特殊的管理策略，包括针对动脉瘤的适当手术入路、夹闭方法、血肿清除、脑室引流以及在合适时选择血管内干预措施。
