NEUROSURGERY 46:1 | JANUARY 2000 | 196-200
DOI: 10.1093/neurosurgery/46.1.196
Subarachnoid Hemorrhage from Vertebral Artery Dissecting Aneurysms Involving the
Origin of the Posteroinferior Cerebellar Artery: Report of Two Cases and Review of the
Literature
Toshihiro Yasui, M.D., Masaki Komiyama, M.D., Misao Nishikawa, M.D., Hideki Nakajima, M.D.
Department of Neurosurgery, Osaka City General Hospital, Miyakojima, Osaka, Japan
Abstract
OBJECTIVE AND IMPORTANCE:
Few reports have been published on ruptured vertebral artery dissecting
aneurysms in which the posteroinferior cerebellar artery (PICA) arises
from the aneurysm wall, and there is ongoing debate as to the proper
management of this type of aneurysm. This article describes two
patients.
CLINICAL PRESENTATION:
Both patients presented with subarachnoid hemorrhage and were
admitted to our institution on the day of rupture. Computed tomography
revealed that the subarachnoid hemorrhage was located mainly in the
posterior fossa. Cerebral angiography demonstrated a vertebral
dissecting aneurysm involving the origin of the PICA. In one patient,
the PICA was very large.
INTERVENTION:
One patient was treated by trapping, with the PICA involved in the
trapped segment. Postoperatively, the patient experienced transient mild
hoarseness and dysphasia but recovered completely. The other patient,
whose PICA was very large, was initially treated by endovascular
In patients with a dissecting aneurysm of the vertebral artery
resulting in subarachnoid hemorrhage, either proximal occlusion or
trapping of the lesion is commonly advocated to prevent subsequent
rupture. Although proximal occlusion is regarded as the standard
surgical treatment, postoperative rebleeding sometimes occurs (9, 16).
Thus, trapping should be considered the primary treatment of
choice. When trapping this type of lesion, however, an attempt must
be made to spare the posteroinferior cerebellar artery (PICA) from
clipping, because ischemic symptoms of the brainstem or
cerebellum may occur and lead to serious complications. This makes
therapeutic management very difficult when the PICA is
incorporated into the sac. This report presents two patients with a
ruptured dissecting aneurysm of the vertebral artery in which the
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CASE REPORTS
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proximal occlusion. This resulted in marked enlargement of the distal
part of the aneurysm, indicating a need for surgical treatment. A clip
was applied to the origin of the PICA after anastomosis of the occipital
artery to the PICA. The patient recovered well and was discharged with
no neurological deficits.
CONCLUSION:
The ideal method of treatment for patients with dissecting aneurysms of
the vertebral artery involving the PICA origin is complete isolation of
the aneurysm by trapping, with revascularization of the PICA. However,
trapping alone is one possible treatment option. If proximal clipping
alone is carried out, follow-up angiography is mandatory to observe any
changes in the aneurysm.
Key words: Anastomosis, Dissecting aneurysm, Posteroinferior cerebellar
artery, Vertebral artery
Received: May 17, 1999
Accepted: August 20, 1999
PICA arose from the wall and examines the problems accompanying
the treatment of such patients.
CASE REPORTS
Patient 1
A 44-year-old hypertensive woman experienced sudden onset of
headache and vomiting followed by loss of consciousness.
Clinical presentation
At admission 6 hours after the onset of symptoms, the patient was
somnolent but otherwise normal neurologically. A computed
tomographic scan demonstrated diffuse subarachnoid hemorrhage,
especially in the posterior fossa, and also showed ventricular
dilation. Cerebral angiography on the day of admission
demonstrated a dissecting aneurysm of the right vertebral artery
with complete occlusion of the artery just beyond the aneurysm.
Fusiform dilation started from near the origin of the right PICA. A
left vertebral angiogram revealed retrograde filling of only the short
segment of the distal portion of the right vertebral artery (Fig. 1).
FIGURE 1.
Vertebral angiograms, anteroposterior view. A, typical angiographic
"pearl and string" sign of a right vertebral artery dissection. The
right PICA arises from the aneurysm itself. The right vertebral artery
has been occluded just distal to the aneurysm. B, retrograde filling
of the distal portion of the right vertebral artery is visible.
FIGURE 2.
A, schematic drawing of the operation showing that the vertebral
artery (VA) and the origin of the PICA are occluded using Sugita
clips (Mizuho America, Inc., Beverly, MA). B, intraoperative
Doppler sonogram revealing retrograde flow velocity in the PICA.
Intervention
The patient was considered at significant risk of hemorrhage,
because there was a possibility of recanalization of the occluded
vertebral artery and subsequent rerupture of the aneurysm. Surgical
treatment using a right suboccipital approach was performed on the
day of rupture. The distal right vertebral artery showed a dark
purplish sausage-like swelling. The right PICA was involved in the
proximal portion of the aneurysm. For this reason, the right vertebral
artery was clipped proximal to the right PICA. An additional clip
was also applied to the origin of the right PICA to prevent a possible
retrograde flow from the left vertebral artery into the right PICA
through the recanalized right vertebral artery. After the clip was
applied to the origin of the artery, existence of blood flow in the
right PICA was confirmed with a microprobe by means of the
intraoperative Doppler method (Fig. 2).
Postoperatively, the patient seemed to be recovering well, but within
a few hours, she developed hoarseness, dyspnea, and right cerebellar
incoordination. Reintubation was required. The patient's clinical
197
state did not change during the next 10 days. Two weeks after the
operation, extubation was performed. Although the patient
displayed normal consciousness, she experienced mild right ataxia.
Cerebral angiography 3 weeks after the operation revealed complete
obliteration of the right vertebral dissecting aneurysm and good
collateral flow in the right PICA territory through the right
anteroinferior cerebellar artery and the right vertebral artery (Fig. 3).
Vasospasm and hydrocephalus did not occur. At the time of
discharge approximately 6 weeks after the operation, the patient had
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recovered completely.
FIGURE 3.
Postoperative vertebral angiograms obtained 3 weeks after surgery.
A, the right vertebral artery has been occluded; the vermian branch
of the right PICA is visualized through the right vertebral artery. B,
the territory of the tonsillohemispheric branch of the right PICA is
supplied by a good collateral flow through the right anteroinferior
cerebellar artery.
FIGURE 4.
Pre-embolization vertebral angiograms showing an extensive
dissecting aneurysm. A, anteroposterior; B, lateral. The PICA arises
from the aneurysm wall.
Patient 2
A 51-year-old woman in normal health complained of a headache.
Four days later, the headache rapidly intensified, followed by a loss
of consciousness.
Clinical presentation
At admission, the patient was in a semicomatose state. A computed
tomographic scan demonstrated blood in the basal cisterns, mainly
in the left cerebellopontine cistern. Angiography revealed a
dissecting aneurysm of the left vertebral artery. The origin of the
large left PICA was incorporated into the sac (Fig. 4).
Intervention
Trapping of an aneurysm when the large PICA is included in the
trapped segment carries a substantial risk of morbidity. Therefore,
endovascular proximal occlusion was used instead of surgical
trapping. Aggressive treatments for vasospasm, such as induced
hypertension, hypervolemia, and administration of antiplatelet
agents, were not adopted for fear of rebleeding. Care was taken to
avoid hypovolemia and to maintain normal blood pressure to
prevent vasospasm. A spinal drain was inserted to release bloody
cerebrospinal fluid and to control the intracranial pressure.
The patient demonstrated steady improvement and was extubated 3
days postoperatively. No signs of vasospasm and hydrocephalus
aneurysm and that the occipital-PICA anastomosis was still patent
(Fig. 6).
FIGURE 6.
Postoperative angiograms obtained 2 weeks after surgery. A, right
vertebral angiogram, anteroposterior view; showing that the
aneurysm has disappeared. B, left external carotid angiogram, lateral
view, demonstrating the patency of the anastomosis of the occipital
artery to the PICA with filling of the hemispheric branches of the

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were detected. Right vertebral angiography 10 days after proximal PICA. A clip occluding the origin of the left PICA is visible.
occlusion of the left vertebral artery demonstrated retrograde filling
of the left PICA by the right vertebral artery via a residual part of
the aneurysm distal to the left PICA. Part of the aneurysm proximal
to the left PICA was not visualized (Fig. 5 A). The patient was
discharged 1 month after admission with no neurological deficits.

FIGURE 5.

Postembolization right vertebral angiograms, anteroposterior view.

A, angiogram 10 days after surgery showing retrograde filling of the
left PICA and a distal residual part of the aneurysm. The proximal
part of the aneurysm is not visualized. B, angiogram 3 months later
showing a marked enlargement of the distal part of the aneurysm.
Readmission
DISCUSSION
Most previously reported cases of ruptured vertebral artery
dissecting aneurysm were treated by proximal occlusion. Although
the results were generally excellent, this procedure does not
guarantee prevention of rebleeding (6, 9, 10). Therefore, trapping the
lesion should be considered the primary treatment to ensure its
obliteration. However, trapping an aneurysm with the PICA
involved in its sac carries a substantial risk of morbidity. If proximal
clipping alone is performed, retrograde flow from the contralateral
vertebral artery into the preserved PICA is maintained. This may
retard thrombosis and organization of the dissected lumen, leading
to the possibility of postoperative rebleeding.

Follow-up angiography 3 months after endovascular proximal Table 1.

occlusion demonstrated that the residual part of the aneurysm distal
to the large left PICA had enlarged markedly (Fig. 5B).
Reexamination revealed that the patient was neurologically intact.
Surgery was planned to arrest the growth of the aneurysm and to
eliminate the risk of hemorrhage.
Clinical Summary of 10 Patients with Vertebral Artery Dissecting
Aneurysms Involving the Origin of the Posteroinferior Cerebellar
Arterya

Left suboccipital exploration was performed. The left vertebral

artery was identified at its dural entrance and found to have no blood
flow. Part of the aneurysm proximal to the PICA was atrophic and
white, but the enlarged distal part of the aneurysm continued to
pulsate strongly, as did the large left PICA, which still fed through
the enlarged aneurysm via the distal left vertebral artery. End-to-
side anastomosis of the left occipital artery to the caudal loop of the
left PICA was performed, and then a clip was applied to the origin
of the large left PICA. The left vertebral artery distal to the aneurysm
was identified intraoperatively; however, a clip could not be applied
to this distal segment of the left vertebral artery because of
insufficient working space. Complete isolation of the vertebral Reports of ruptured vertebral artery dissecting aneurysms involving
dissecting aneurysm therefore could not be obtained. The patency of the PICA are rare. Only 10 patients have been reported, including
the anastomosis was confirmed by a microprobe by means of the the two patients described here (Table 1) (2, 5, 6, 8, 9, 14, 15). The 10
intraoperative Doppler method. patients include 3 men and 7 women, with ages ranging from 38 to
The postoperative course was unremarkable, and the patient was 58 years (average, 47.5 yr). One of the eight previously reported
discharged 30 days after surgery. Postoperative angiography 2 patients was treated by trapping without PICA revascularization (2),
weeks after surgery demonstrated that there was no filling of the four were treated by proximal occlusion (6, 9, 15), and three were
treated by trapping with PICA reconstruction (5, 8, 14).

198
Postoperatively, the patient treated by trapping alone experienced a
cerebellar and brainstem infarction (2). One patient treated by
proximal occlusion developed rebleeding 18 days postoperatively
(9), and one of the three patients treated by trapping with PICA
revascularization developed a mild lateral medullary syndrome (14).
Sacrifice of the PICA at its origin cannot always be performed safely
without producing an ischemic insult in the brainstem or cerebellum.
In general, clipping of the PICA can be safely performed at a point
distal to the choroidal point. It is potentially dangerous if performed
proximal to the choroidal point, because important branches to the
brainstem and deep cerebellar nuclei are located proximal to the
choroidal point (3, 7, 10). The consequences of a PICA occlusion are
unpredictable and could range from a clinically silent occlusion to
infarction of portions of the brainstem or cerebellum with swelling,
hemorrhage, and death (13).
Three patients with a PICA aneurysm and four patients with
vertebral artery aneurysms involving the PICA origin have been
reported in whom reconstruction of the PICA was performed to
preserve PICA flow (1, 4, 5, 8, 11, 12, 14) (Table 2). Three patients were
diagnosed with vertebral dissecting aneurysms involving the origin
of the PICA (5, 8, 14). The PICA reconstruction techniques used in
these patients were end-to-end suture of the PICA in two patients (4,
11
), occipital artery-PICA anastomosis in two (8, 12), PICA-PICA
end-to-side anastomosis in one (1), PICA-PICA side-to-side
anastomosis in one (14), and reimplantation of the PICA to the
vertebral artery in one (5). However, clinical indications for PICA
reconstruction are not yet clearly defined. The reasons for PICA
reconstruction in the reported patients included unpredictable
outcome of PICA sacrifice in three patients (4, 5, 12), small ipsilateral
anteroinferior cerebellar artery in one (1), disappearance of PICA
pulsation after trapping in one (14), and location of the sacrifice of
the PICA proximal to the choroidal point in one (11). No detailed
description was given in one case (8). The ideal treatment method
for a vertebral dissecting aneurysm involving the PICA is complete
isolation of the aneurysm by trapping, with reconstruction of the
PICA. This technique can prevent both recurrent hemorrhage and
possible brainstem or cerebellar infarction. Reconstruction of the
PICA, however, especially with an intracranial interarterial bypass,
runs the risk of enlarging the infarction in the event of unsuccessful
anastomosis. The indications for PICA reconstruction are not yet
defined, and it should not be undertaken lightly (14). Therefore, the
surgeon should weigh the disadvantages of these procedures against
the risk of rebleeding if proximal occlusion alone is performed, as
well as the ischemic complications in the brainstem or cerebellum
that might develop using trapping without PICA recanalization.
Table 2.
Modes of Revascularization of the Posteroinferior Cerebellar
Arterya
199
CONCLUSION
The intraoperative Doppler method is not a quantitative technique
of measuring blood flow. However, trapping without PICA
reconstruction and confirmation of PICA blood flow using the
Doppler method, as described in Patient 1, may be one of the
treatment options for vertebral dissecting aneurysms involving the
PICA. If proximal occlusion alone is used, follow-up angiography
is mandatory to observe any changes in the aneurysm, as in Patient
2.
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COMMENTS
Yasui et al. report on the treatment of two patients with
subarachnoid hemorrhage from vertebral artery dissecting
aneurysms involving the origin of the posteroinferior cerebellar
artery (PICA). Patient 1 was treated by proximal clipping of the right
vertebral artery as well as proximal clipping of the origin of the
PICA. Blood flow in the distal PICA was confirmed intraoperatively
by a micro-Doppler probe. The patient had an uneven postoperative
course and a transient lateral medullary plate syndrome but
ultimately recovered fully. Why did the authors clip the proximal
PICA when the distal vertebral artery was known to be occluded,
and why did they not add an occipital artery bypass as in Patient 2?
As stated by the authors, the consequences of PICA sacrifice can be
extremely variable, and marginal collaterals can be further reduced
in the presence of significant vasospasm. Sacrificing the PICA
proximal to the choroidal point may carry substantial risks of
brainstem infarction without some adjunctive revascularization,
because of the numerous perforating vessels that arise from more
proximal segments of this vessel. This patient was quite fortunate to
have anteroinferior cerebellar artery collaterals that clearly
contributed to her recovery, and her close margin to infarction is
evidenced by the transient dysphagia, dysarthria, and right-sided
ataxia.
Patient 2 clearly demonstrates continued filling and late growth of
the dissection via retrograde flow from the contralateral vertebral
artery, despite successful proximal vertebral artery ligation near the
aneurysm origin. An extracranial-to-intracranial bypass from the
occipital artery to the caudal loop of PICA, combined with left PICA
clipping, ultimately cured the lesion without creating a neurological
deficit.
Vertebral artery dissecting aneurysms involving the PICA are
particularly problematic because the involved segment cannot be
trapped without risk to the PICA territory and cannot be proximally
ligated (sparing the PICA) without reconstitution or enlargement
risks from blood flow from contralateral sources. These case reports
and the literature review support the authors’ conjecture that the
ideal treatment for a vertebral artery dissecting aneurysm involving
200
reconstruction of the PICA.
Arthur L. Day
D. John Chang
Christopher G. Gaposchkin
Gainesville, Florida
The authors have nicely summarized the problems associated with
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vertebral artery dissections involving the PICA origin. These lesions
have failed proximal ligation historically, probably because of flow
demand coming across the vertebral confluens, which allows
persisting inflow into the diseased segment and may be associated
with distention and ultimately rupture.
I agree with the authors that, using conventional techniques, the
optimal form of therapy is trapping the diseased segment with
revascularization of the PICA unless more definitive means are
developed to determine whether adequate collateral flow exists. The
authors did not mention the potential for intracranial stents to
provide a unique therapeutic opportunity. Extracranially,
endovascular stents handle the problems associated with dissections
fairly well; the remaining question is whether PICA inflow could be
preserved through the matrix of an indwelling stent. Nevertheless,
short of a development of that type, I agree with the authors’
summary of the existing literature.
H. Hunt Batjer
Chicago, Illinois
This article reports subarachnoid hemorrhage from vertebral artery
dissecting aneurysms involving the origin of the PICA. In theory,
the ideal method of treating dissecting aneurysms of the vertebral
artery is to isolate the dissecting part of the vertebral artery or close
the entry of the dissecting point. Proximal occlusion or occlusion
distal to the PICA is widely performed; however, it carries some risk
of rebleeding.
The authors presented interesting and important reasons for
considering the optimal treatment of the vertebral artery dissecting
aneurysm, especially in relation to the PICA. Dissecting aneurysms
involving the PICA origin, as in the present patients, are difficult to
treat using conventional methods. In Patient 1, transient ischemic
change occurred in the territory of the PICA. In Patient 2, regrowth
of the aneurysm occurred after proximal occlusion. Isolation of the
involved vertebral artery is required; at the same time,
reconstruction of the PICA should be considered.
As the authors mention, one of the difficulties in treating vertebral
artery dissecting aneurysms is the lack of predictability as to
whether ischemic change caused by involvement of the PICA may
occur in the brainstem or the cerebellum. Measuring the stump
pressure of the PICA when trapping the vertebral artery may be one
method. Close follow-up with neurological and angiographic
examinations is essential. Further study is warranted as to whether
reconstruction of the PICA is needed when the involved vertebral
artery is isolated.
Shigeaki Kobayashi
Kazuhiro Hongo
Matsumoto, Japan