A case of ruptured peripheral aneurysm of the anterior inferior cerebellar artery associated with an arteriovenous malformation : a less invasive image-guided transcortical approach

Abstract

A 47-year-old man presented with a subarachnoid hemorrhage (SAH) and right cerebellar hematoma was referred for evaluation. Cerebral angiography revealed a distal anterior inferior cerebellar artery (AICA) aneurysm associated with an arteriovenous malformation (AVM). Successful obliteration and complete removal of the aneurysm and AVM were obtained using transcortical approach under the guidance of neuronavigation system. The association of a peripheral AICA aneurysm and a cerebellar AVM by the same artery is unique. The reported cases of conventional surgery for this disease complex are not common and their results are variable. Less invasive surgery using image-guided neuronavigation system would be helpful and feasible for a peripheral aneurysm combining an AVM of the posterior fossa in selective cases.

Keywords: Aneurysm; Anterior inferior cerebellar artery; Arteriovenous malformation; Neuronavigation.

Fig. 1

Computed tomography at admission showing a subarachnoid hemorrhage under the falcotentorium (A), subdural (arrow) and subcortical (arrowhead) hematoma in the right cerebellum (B).

Fig. 2

Axial T1-weighted (A) and T2-weighted (B) magnetic resonance image showing tangled signal voids (arrows) near the right cerebellar hematoma.

Fig. 3

Right vertebral angiogram anteroposterior (A) and lateral (B) image revealing a distal anterior inferior cerebellar artery (AICA) aneurysm (arrow) associated with an arteriovenous malformation (AVM) nidus (arrowhead) with a draining vein (broken arrow) into the sigmoid sinus that was located distal to the AICA aneurysm. Note the clear relationship between a flow-related AICA aneurysm and cerebellar AVM shown by the reconstruction image of 3D rotational angiogram (C).

Fig. 4

Right vertebral angiogram during the endovascular neurointervention showing a severe vasospasm (arrows) in the proximal part of the anterior inferior cerebellar artery due to the heavy tension caused by microcatheter manipulations.

Fig. 5

The photograph obtained during the image-guided neurosurgery showing the target entry to the vascular pathology in the right cerebellum pointed out by a navigation wand (dotted cross to the skull and cross to the malformation).

Fig. 6

Postoperative right vertebral angiogram anteroposterior (A) view and lateral (B) none-subtracted view showing neither distal anterior inferior cerebellar aneurysm nor an associated arteriovenous malformation. Arrow in (B) indicates a surgical clip.