"True" posterior communicating aneurysms: Three cases, three strategies

Abstract

Background: The authors provide a review of true aneurysms of the posterior communicating artery (PCoA). Three cases admitted in our hospital are presented and discussed as follows.

Case descriptions: First patient is a 51-year-old female presenting with a Fisher II, Hunt-Hess III (headache and confusion) subarachnoid hemorrhage (SAH) from a ruptured true aneurysm of the right PCoA. She underwent a successful ipsilateral pterional craniotomy for aneurysm clipping and was discharged on postoperative day 4 without neurological deficit. Second patient is a 53-year-old female with a Fisher I, Hunt-Hess III (headache, mild hemiparesis) SAH and multiple aneurisms, one from left ophthalmic carotid artery and one (true) from right PCoA. These lesions were approached and successfully treated by a single pterional craniotomy on the left side. The patient was discharged 4 days after surgery, with complete recovery of muscle strength during follow-up. Third patient is a 69-year-old male with a Fisher III, Hunt-Hess III (headache and confusion) SAH, from a true PCoA on the right. He had a left subclavian artery occlusion with flow theft from the right vertebral artery to the left vertebral artery. The patient underwent endovascular treatment with angioplasty and stent placement on the left subclavian artery that resulted in aneurysm occlusion.

Conclusion: In conclusion, despite their seldom occurrence, true PCoA aneurysms can be successfully treated with different strategies.

Keywords: Etiology; physiopathology; treatment; true posterior communicating artery aneurysms.

Figure 1

Lateral view of right internal carotid artery angiography performed on June 18, 2012. Small true saccular aneurysm (white arrow) of the right posterior communicating artery, 3 mm × 4 mm size, neck diameter of 2 mm, postero-superiorly directed, and fetal pattern of ipsilateral posterior communicating artery

Figure 2

(a) From the left to the right, optic nerve, anterior cerebral artery, internal carotid artery and third cranial nerve. (b) Optic nerve and internal carotid artery slightly retracted to expose the optic carotid triangle with the aneurysm inside it. (c) Clip in the neck of the aneurysm

Figure 3

(a) Contralateral oblique view of left internal carotid artery angiography, with a saccular aneurysm of the ophthalmic segment, 12 mm × 10 mm, 5 mm neck. (b) Lateral and (c) anteroposterior views of right internal carotid artery angiography, with a true saccular aneurysm of the posterior communicating artery, 6 mm × 3 mm, 2 mm neck

Figure 4

(a) Intraoperative view (pterional contralateral approach) of the posterior communicating artery with its true aneurysm, before clipping. (b) During and (c) after clipping

Figure 5

(a) Axial computed tomography scan showing Fisher III subarachnoid hemorrhage. (b and c) Right internal carotid artery angiogram showing the saccular true posterior communicating artery aneurysm (black arrows)

Figure 6

(a) Aortic artery angiogram showing left subclavian artery occlusion (black arrow). (b) Right vertebral artery angiogram showing steel phenomenon from the right vertebral artery to the left vertebral and basilar and posterior cerebral arteries low flow (black arrows)

Figure 7

(a) Aortic arch angiogram showing the arterioplasty procedure and stent placing on the left subclavian artery (black arrow). (b) Left vertebral angiogram after arterioplasty with adequate filling of the vertebrobasilar circulation and posterior cerebral arteries. (c) Right internal carotid artery after arterioplasty and diminished flow on the posterior communicating artery with contrast stagnation inside the aneurysm (empty black arrow)

Figure 8

(a) Late control angiogram of the aortic arch and right internal carotid artery showing adequate flow through the left subclavian artery (black arrow). (b) Aneurysm's circulation exclusion