Predicting Arachnoid Membrane Descent in the Chiasmatic Cistern in the Treatment of Pituitary Macroadenoma

Objective@#: Preoperative prediction of the arachnoid membrane descent in pituitary surgery is useful for achieving gross total removal and avoiding cerebrospinal fluid leakage resulting from tearing of the arachnoid membrane in the chiasmatic cistern. In this study, we analyzed the patterns of arachnoid membrane descent during or after pituitary tumor surgery and identified the factors related to this descent. @*Methods@#: Analysis was restricted to pituitary macroadenomas not extending into the third ventricle or over the internal carotid artery. To minimize confounding factors, patients who underwent revision surgery, those who had a torn arachnoid during operation or small medial diaphragma sellae (DS) opening, and subtotal resections were excluded. We enrolled 41 consecutive patients in this retrospective analysis. The degree of arachnoid descent was categorized using intraoperative videos. Preoperative magnetic resonance findings, including tumor height, suprasellar extension, and variables including DS area and medial opening size, tumor composition, and displacement of the pituitary stalk and gland were evaluated to determine their correlations with arachnoid membrane descent. @*Results@#: Arachnoid membrane descent was significantly correlated with DS area and medial opening size. Based on T2-weighted images (T2WI) magnetic resonance (MR) images, tumor composition was significantly associated with arachnoid membrane descent. Other factors were not significantly correlated with arachnoid membrane descent. @*Conclusion@#: T2WI of tumor composition and preoperative MR imaging of DS area and medial opening provided valuable information regarding arachnoid membrane descent. These parameters may serve as fundamental measures to facilitate complete resection of pituitary macroadenomas.

Endovascular Treatments Performed Collaboratively by the Society of Korean Endovascular Neurosurgeons Members: A Nationwide Multicenter Survey

OBJECTIVE: Since less invasive endovascular treatment was introduced to South Korea in 1994, a considerable proportion of endovascular treatments have been performed by neuroradiology doctors, and endovascular treatments by vascular neurosurgeons have recently increased. However, few specific statistics are known regarding how many endovascular treatments are performed by neurosurgeons. Thus, authors compared endovascular treatments collaboratively performed by vascular neurosurgeons with all cases throughout South Korea from 2013 to 2017 to elucidate the role of neurosurgeons in the field of endovascular treatment in South Korea.METHODS: The Society of Korean Endovascular Neurosurgeons (SKEN) has issued annual reports every year since 2014. These reports cover statistics on endovascular treatments collaboratively or individually performed by SKEN members from 2013 to 2017. The data was requested and collected from vascular neurosurgeons in various hospitals. The study involved 77 hospitals in its first year, and 100 in its last. National statistics on endovascular treatment from all over South Korea were obtained from the Healthcare Bigdata Hub website of the Health Insurance Review & Assessment Service based on the Electronic Data Interchange (EDI) codes (in the case of intra-arterial (IA) thrombolysis, however, statistics were based on a combination of the EDI and I63 codes, a cerebral infarction disease code) from 2013 to 2017. These two data sets were directly compared and the ratios were obtained.RESULTS: Regionally, during the entire study period, endovascular treatments by SKEN members were most common in Gyeonggi-do, followed by Seoul and Busan. Among the endovascular treatments, conventional cerebral angiography was the most common, followed by cerebral aneurysmal coiling, endovascular treatments for ischemic stroke, and finally endovascular treatments for vascular malformation and tumor embolization. The number of endovascular treatments performed by SKEN members increased every year.CONCLUSION: The SKEN members have been responsible for the major role of endovascular treatments in South Korea for the recent 5 years. This was achieved through the perseverance of senior members who started out in the midst of hardship, the establishment of standards for the training/certification of endovascular neurosurgery, and the enthusiasm of current SKEN members who followed. To provide better treatment to patients, we will have to make further progress in SKEN.

Endovascular Treatments Performed Collaboratively by the Society of Korean Endovascular Neurosurgeons Members: A Nationwide Multicenter Survey

OBJECTIVE: Since less invasive endovascular treatment was introduced to South Korea in 1994, a considerable proportion of endovascular treatments have been performed by neuroradiology doctors, and endovascular treatments by vascular neurosurgeons have recently increased. However, few specific statistics are known regarding how many endovascular treatments are performed by neurosurgeons. Thus, authors compared endovascular treatments collaboratively performed by vascular neurosurgeons with all cases throughout South Korea from 2013 to 2017 to elucidate the role of neurosurgeons in the field of endovascular treatment in South Korea. METHODS: The Society of Korean Endovascular Neurosurgeons (SKEN) has issued annual reports every year since 2014. These reports cover statistics on endovascular treatments collaboratively or individually performed by SKEN members from 2013 to 2017. The data was requested and collected from vascular neurosurgeons in various hospitals. The study involved 77 hospitals in its first year, and 100 in its last. National statistics on endovascular treatment from all over South Korea were obtained from the Healthcare Bigdata Hub website of the Health Insurance Review & Assessment Service based on the Electronic Data Interchange (EDI) codes (in the case of intra-arterial (IA) thrombolysis, however, statistics were based on a combination of the EDI and I63 codes, a cerebral infarction disease code) from 2013 to 2017. These two data sets were directly compared and the ratios were obtained. RESULTS: Regionally, during the entire study period, endovascular treatments by SKEN members were most common in Gyeonggi-do, followed by Seoul and Busan. Among the endovascular treatments, conventional cerebral angiography was the most common, followed by cerebral aneurysmal coiling, endovascular treatments for ischemic stroke, and finally endovascular treatments for vascular malformation and tumor embolization. The number of endovascular treatments performed by SKEN members increased every year. CONCLUSION: The SKEN members have been responsible for the major role of endovascular treatments in South Korea for the recent 5 years. This was achieved through the perseverance of senior members who started out in the midst of hardship, the establishment of standards for the training/certification of endovascular neurosurgery, and the enthusiasm of current SKEN members who followed. To provide better treatment to patients, we will have to make further progress in SKEN.

Characteristic Signs on T2*-Based Imaging and Their Relationship with Results of Reperfusion Therapy for Acute Ischemic Stroke: A Systematic Review and Evidence to Date / 신경중재치료의학

PURPOSE: Characteristic signs – the susceptibility vessel sign (SVS) and the prominent hypointense vessel sign (PHVS) – on T2*-based magnetic resonance imaging (T2*MRI) can be seen for acute ischemic stroke with large artery occlusion. In this study, we investigated the evidence to support our hypothesis that these findings may help to predict outcomes after reperfusion therapy. MATERIALS AND METHODS: We searched for papers describing SVS and PHVS in patients treated with reperfusion therapy for acute ischemic stroke, and their functional/radiologic outcomes were systematically reviewed. RESULTS: Nine studies on the SVS and six studies on the PHVS were included. The pooled odds ratio (OR) of recanalization after intravenous thrombolysis or mechanical thrombectomy was not significantly different with the presence of SVS (OR, 0.615; 95% confidence interval [CI], 0.335–1.131 and OR, 0.993; 95% CI, 0.629–1.567). The OR of favorable functional outcome after reperfusion therapy in terms of the presence of PHVS varied (0.083 to 1.831) by study. CONCLUSION: Our meta-analysis of the published data showed that a SVS was not a predictive factor for recanalization after reperfusion therapy for acute ischemic stroke. Currently, the data available on T2*MRI are too limited to warrant reperfusion therapy in routine practice. More data are needed from studies with randomized treatment allocation to determine the role of T2*MRI.

Alberta Stroke Program Early CT Score in the Prognostication after Endovascular Treatment for Ischemic Stroke: A Meta-analysis / 신경중재치료의학

PURPOSE: The Alberta Stroke Program Early CT Score (ASPECTS) was devised to quantify the extent of early ischemic changes in the middle cerebral artery territory on brain CT. We performed a systematic review and meta-analysis of studies that presented clinical outcomes and baseline ASPECTS in ischemic stroke patients managed with endovascular methods to validate the use of ASPECTS for risk prognostication. MATERIALS AND METHODS: We searched the MEDLINE, EMBASE, and Cochran databases for observational or interventional studies that reported clinical outcomes and baseline ASPECTS in ischemic stroke patients treated with endovascular methods. Data were pooled to perform a meta-analysis for comparisons of clinical outcomes between high and low ASPECTS patients. RESULTS: A meta-analysis of 13 studies (six observational and seven interventional) revealed favorable outcomes (mRS sore 0-2 at 90 days) for high baseline ASPECTS (odds ratio=2.22; 95% CI: 1.74-2.86). CONCLUSION: High ASPECTS is a predictor of favorable outcome after endovascular therapy for ischemic stroke.

Incomplete Clipping Resulting from Scissoring of the Clip Blades during Treatment of a Large Atheromatous Aneurysm

The cerebral aneurysm 'clip scissoring' phenomenon resulting from clip blade twisting is an unpredictable surgical complication. Additionally, incomplete clipping resulting from the presence of an atherosclerotic wall in the neck of the aneurysm can also cause unforeseen problems. Here, the authors present an unusual case of incomplete clipping of a large, atheromatous aneurysm resulting from clip scissoring, which was treated with additional endovascular coiling.

Extended Pneumocephalus after Drainage of Chronic Subdural Hematoma Associated with Intracranial Hypotension : Case Report with Pathophysiologic Consideration

Chronic subdural hematoma (SDH) is a well-known disease entity and is traditionally managed with surgery. However, when associated with spontaneous intracranial hypotension (SIH), the treatment strategy ought to be modified, as classical treatment could lead to unwanted consequences. A 59-year-old man presented with a case of SIH that manifested as a bilateral chronic SDH. He developed fatal extensive pneumocephalus and SDH re-accumulation as a complication of burr-hole drainage. Despite application of an epidural blood patch, the spinal cerebrospinal fluid leak continued, which required open spinal surgery. Chronic SDH management should not be overlooked, especially if the exact cause has not been determined. When chronic SDH assumed to be associated with SIH, the neurosurgeon should determine the exact cause of SIH in order to effectively correct the cause.

Giant Intrathoracic Meningocele and Breast Cancer in a Neurofibromatosis Type I Patient

Intrathoracic meningoceles are relatively rare entities found in patients with neurofibromatosis type I (NF1). Given that both the BRCA1 and NF-1 genes are located on the same long arm of chromosome 17, one would expect concurrence of neurofibromatosis and breast cancer. However, incidence of such co-disorders is very rare in the literature. Here, the authors report a case of a 50-year-old female patient with NF-1 and concurrent cancer of the left breast, who had a huge bilobulated intrathoracic meningocele with thoracic dystrophic scoliosis, treated surgically via a posterior-only approach for the meningocele and spinal deformity in the same setting.

Analyses Using Micro-CT Scans and Tissue Staining on New Bone Formation and Bone Fusion According to the Timing of Cranioplasty via Frozen Autologous Bone Flaps in Rabbits : A Preliminary Report

OBJECTIVE: The timing of cranioplasty and method of bone flap storage are known risk factors of non-union and resorption of bone flaps. In this animal experimental study, we evaluated the efficacy of cranioplasty using frozen autologous bone flap, and examined whether the timing of cranioplasty after craniectomy affects bone fusion and new bone formation. METHODS: Total 8 rabbits (male, older than 16 weeks) were divided into two groups of early cranioplasty group (EG, 4 rabbits) and delayed cranioplasty group (DG, 4 rabbits). The rabbits of each group were performed cranioplasty via frozen autologous bone flaps 4 weeks (EG) and 8 weeks (DG) after craniectomy. In order to obtain control data, the cranioplasty immediate after craniectomy were made on the contralateral cranial bone of the rabbits (control group, CG).The bone fusion and new bone formation were evaluated by micro-CT scan and histological examination 8 weeks after cranioplasty on both groups. RESULTS: In the micro-CT scans, the mean values of the volume and the surface of new bone were 50.13+/-7.18 mm3 and 706.23+/-77.26 mm2 in EG, 53.78+/-10.86 mm3 and 726.60+/-170.99 mm2 in DG, and 31.51+/-12.84 mm3 and 436.65+/-132.24 mm2 in CG. In the statistical results, significant differences were shown between EG and CG and between DG and CG (volume : p=0.028 and surface : p=0.008). The histological results confirmed new bone formation in all rabbits. CONCLUSION: We observed new bone formation on all the frozen autologous bone flaps that was stored within 8 weeks. The timing of cranioplasty may showed no difference of degree of new bone formation. Not only the healing period after cranioplasty but the time interval from craniectomy to cranioplasty could affect the new bone formation.

Endovascular Treatment of Vertebral Artery Dissecting Aneurysms That Cause Subarachnoid Hemorrhage : Consideration of Therapeutic Approaches Relevant to the Angioarchitecture

OBJECTIVE: Intracranial ruptured vertebral artery dissecting aneurysms (VADAns) are associated with high morbidity and mortality when left untreated due to the high likelihood of rebleeding. The present study aimed to establish an endovascular therapeutic strategy that focuses specifically on the angioarchitecture of ruptured VADAns. METHODS: Twenty-three patients with ruptured VADAn received endovascular treatment (EVT) over 7 years. The patient group included 14 women (60.9%) and 9 men (39.1%) between the ages of 39 and 72 years (mean age 54.2 years). Clinical data and radiologic findings were retrospectively analyzed. RESULTS: Four patients had aneurysms on the dominant vertebral artery. Fourteen (61%) aneurysms were located distal to the posterior inferior cerebellar artery (PICA). Six (26%) patients had an extracranial origin of the PICA on the ruptured VA, and 2 patients (9%) had bilateral VADAns. Eighteen patients (78%) were treated with internal coil trapping. Two patients (9%) required an adjunctive bypass procedure. Seven patients (30%) required stent-supported endovascular procedures. Two patients experienced intra-procedural rupture during EVT, one of which was associated with a focal medullary infarction. Two patients (9%) exhibited recanalization of the VADAn during follow-up, which required additional coiling. No recurrent hemorrhage was observed during the follow-up period. CONCLUSION: EVT of ruptured VADAns based on angioarchitecture is a feasible and effective armamentarium to prevent fatal hemorrhage recurrence with an acceptable low risk of procedural complications. Clinical outcomes depend mainly on the pre-procedural clinical state of the patient. Radiologic follow-up is necessary to prevent hemorrhage recurrence after EVT.

Rebleeding of Ruptured Intracranial Aneurysms in the Immediate Postoperative Period after Coil Embolization

OBJECTIVE: Early rebleeding after coil embolization of ruptured intracranial aneurysms is rare, however serious and fatal results of rebleeding have been reported. We studied the incidence and angiographic and clinical characteristics of rebleeding of ruptured aneurysms occurring in the immediate postoperative period after coil embolization. MATERIALS AND METHODS: We analyzed patients who had aneurysmal subarachnoid hemorrhage and underwent coil embolization. Patients with dissecting aneurysms, blood blister-like aneurysms, fusiform aneurysms, and pseudoaneurysms were excluded. This study included 330 consecutive patients. The clinical and radiological data of 7 of these patients with acute rebleeding after coil embolization were reviewed. RESULTS: The incidence of rebleeding of ruptured aneurysms after coil embolization was 2.1% (7/330), and all cases of rebleeding occurred in the immediate postoperative period within 3 days after coiling. The radiological characteristics were as follows: anterior communicating artery (ACoA) aneurysm (71.4%, 5/7); presence of intracerebral hemorrhage (ICH, 71.4%, 5/7); dome-to-neck ratio < 2 (42.9%, 3/7); presence of bleb (42.9%, 3/7); and subtotal occlusion of aneurysm after coiling (14.3%, 1/7). A thrombolytic agent was administered in 1 patient and continued anticoagulation was performed in 2 patients. Rebleeding patients showed a very poor outcome (Glasgow Outcome Scale 1, 85.7%, 6/7). CONCLUSION: The prognosis of early rebleeding was very poor. Location of aneurysms on ACoA, the unilateral hypoplasia of A1 segment, presence of ICH and bleb, and adverse events during the procedure were probably associated with early rebleeding of ruptured intracranial aneurysms in the immediate postoperative period after coil embolization.

Spontaneous Occluded Anterior Communicating Artery Aneurysm during Coil Embolization Treated with One Coil Insertion into Remaining Stump

Spontaneous thrombosis of a ruptured aneurysm during coil embolization is a rare event, and some reports on recanalization of a spontaneous occluded ruptured aneurysm have been published. We report on a case of a 54-year-old male who presented with a subarachnoid hemorrhage due to rupture of a small aneurysm of the anterior communicating artery (ACoA). Cerebral angiography confirmed the presence of the ACoA aneurysm, but, during coil embolization, the aneurysm was near completely occluded with a remaining small neck. A small coil was inserted into the remaining stump of the neck to prevent recanalization, and the angiographic result at 1 year after coil embolization showed complete obliteration of the aneurysm.

Asymptomatic Penetration of the Oculomotor Nerve by a De Novo Aneurysm Associated with Severe Atherosclerotic Stenosis of the Supraclinoid Internal Carotid Artery

A 70-year-old woman presented with headaches and recurrent stroke symptoms. During five years, the patient has been treated for cerebral infarction associated with severe atherosclerotic stenosis of the internal carotid artery. Three-year follow-up magnetic resonance angiography showed a tiny de novo aneurysm arising from the distal part of atherosclerotic internal carotid artery. And 5-year follow-up three-dimensional CT angiogram demonstrated a definite aneurysm enlargement as large as requiring treatment. During dissection of aneurysm, the oculomotor nerve was found to be penetrated with the growing de novo aneurysm. The authors report a case of a de novo aneurysm, which resulted from atherosclerotic stenosis of the internal carotid artery at the supraclinoid portion, that was found to be penetrating the oculomotor nerve with no ocular palsy.

Clinical Analysis and Surgical Considerations of Atherosclerotic Cerebral Aneurysms: Experience of a Single Center

OBJECTIVE: Atherosclerotic cerebral aneurysms are known to increase occurrence of thromboembolic events and occlusion of perforator vessels intraoperatively due to pathological changes in the vessels themselves. In the current study, we analyzed the points to be considered during surgery for atherosclerotic cerebral aneurysms and the postoperative results. MATERIALS AND METHODS: We retrospectively reviewed the medical records, radiological results, and surgical records, including intraoperative video recordings and photographs, of 262 patients who underwent cerebral aneurysm surgery. We then performed a detailed analysis of aneurysm features, surgical methods, and clinical outcomes. RESULTS: Among 278 aneurysms in 262 patients, 73 aneurysms in 67 patients showed atherosclerotic features (atherosclerotic group, AG), and 205 aneurysms in 195 patients showed no evidence of atherosclerosis (non-atherosclerotic group, NAG). In the AG, clipping with multiple permanent clips was performed in 14 aneurysms, and clip slippage was found in four cases. Six AG cases had a remnant neck after clipping, which was significantly more frequent than in the NAG (p < 0.05). Clinical outcomes and surgery-related complications did not differ significantly between the two groups. CONCLUSION: In the surgical repair of aneurysms, the incidence of ischemia, which is irreversible or severe, might be greater in atherosclerotic than in non-atherosclerotic aneurysms. In addition, multiple clips might be applied to atherosclerotic aneurysms for effective obliteration and an aneurysm neck might be left to avoid a region of atheroma.

Decompressive Surgery in Patients with Poor-grade Aneurysmal Subarachnoid Hemorrhage: Clipping with Simultaneous Decompression Versus Coil Embolization Followed by Decompression

OBJECTIVE: In addition to obliterating the aneurysm using clipping or coiling, decompressive surgery for control of rising intracranial pressure (ICP) is thought to be crucial to prevention of adverse outcomes in patients with poor grade aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the clinical characteristics of patients with poor-grade aSAH, and compared outcomes of aneurysmal clipping with simultaneous decompressive surgery to those of coil embolization followed by decompression. MATERIALS AND METHODS: In 591 patients with aSAH, 70 patients with H-H grade IV and V underwent decompressive surgery including craniectomy, lobectomy, and hematoma removal. We divided the patients into two groups according to clipping vs. coil embolization (clip group vs. coil group), and analyzed outcomes and mortality. RESULTS: Aneurysmal clipping was performed in 40 patients and coil embolization was performed in 30 patients. No significant differences in demographics were observed between the two groups. Middle cerebral artery and posterior circulation aneurysms were more frequent in the clip group. Among 70 patients, mortality occurred in 29 patients (41.4%) and 61 patients (87.1%) had a poor score on the Glasgow outcome scale (scores I-III). No significant difference in mortality was observed between the two groups, but a favorable outcome was more frequent in the coil group (p < 0.05). CONCLUSION: In this study, despite aggressive surgical and endovascular management for elevated ICP, there were high rates of adverse outcomes and mortality in poor-grade aSAH. Despite poor outcomes overall, early coil embolization followed by decompression surgery could lead to more favorable outcomes in patients with poor-grade aSAH.

Changes of Motor Deactivation Regions in Patients with Intracranial Lesions

OBJECTIVE: There is a rich literature confirming the default mode network found compatible with task-induced deactivation regions in normal subjects, but few investigations of alterations of the motor deactivation in patients with intracranial lesions. Therefore, we hypothesized that an intracranial lesion results in abnormal changes in a task-induced deactivation region compared with default mode network, and these changes are associated with specific attributes of allocated regions. METHODS: Blood oxygenation level dependent (BOLD) functional magnetic resonance imaging (fMRI) during a motor task were obtained from 27 intracranial lesion patients (mean age, 57.3 years; range 15-78 years) who had various kinds of brain tumors. The BOLD fMRI data for each patient were evaluated to obtain activation or deactivation regions. The distinctive deactivation regions from intracranial lesion patients were evaluated by comparing to the literature reports. RESULTS: There were additive deactivated regions according to intracranial lesions: fusiform gyrus in cavernous hemangioma; lateral occipital gyrus in meningioma; crus cerebri in hemangiopericytoma; globus pallidus, lateral occipital gyrus, caudate nucleus, fusiform gyrus, lingual gyrus, claustrum, substantia nigra, subthalamic nucleus in GBM; fusiform gyrus in metastatic brain tumors. CONCLUSION: There is increasing interest in human brain function using fMRI. The authors report the brain function migrations and changes that occur in patients with intracranial lesions.

Safety and Efficacy of Mechanical Thrombectomy with Solitaire Stent Retrieval for Acute Ischemic Stroke: A Systematic Review / 신경중재치료의학

PURPOSE: In recent years, mechanical thrombectomy using Solitaire stent retrieval has been tried for treating acute ischemic stroke with a large artery occlusion. We systematically reviewed published articles to appraise the evidence that supports the safety and efficacy of the mechanical thrombectomy in acute strokes with Solitaire stent. MATERIALS AND METHODS: Systematic searches using Medline and Scopus were performed for studies evaluating mechanical thrombectomy using a Solitaire stent in acute ischemic stroke. Articles were included if they were published since 2008, contained at least 5 subjects, and provided clinical results. RESULTS: Thirteen articles (262 cases) were included in this review. The mean time of the procedures ranged from 37 to 95.6 minutes in 10 studies. The success of recanalization was achieved in 89.7% and the recanalization rate varied from 66.7% to 100% in all 13 studies. The overall rates of the symptomatic hemorrhagic complications and mortality were 6.8% and 11.1%, respectively. A favorable outcome of mRS 2 or under was 47.3%. Procedure-induced complications developed in 3.4%. CONCLUSION: The present review suggested that mechanical thrombectomy using a Solitaire stent in acute ischemic stroke was effective in recanalizing the occluded artery. The rate of procedural complications was small.

Coincidental Occurrence of Acute In-stent Thrombosis and Iatrogenic Vessel Perforation During a Wingspan Stent Placement: Management with a Stent In-stent Technique / 신경중재치료의학

We presented a case that an acute in-stent thrombosis after the deployment of a Wingspan stent was successfully managed with a stent in-stent technique. Because vessel perforation and subarachnoid hemorrhage were iatrogenically developed during the procedure, we were unable to use the thrombolytic agents to correct the in-stent thrombosis. When a thrombotic complication following an intracranial stent placement occurs with a coincidentally hemorrhagic complication, the stent in-stent technique should be considered as a treatment option.

Late Spontaneous Recanalization of Chronic Middle Cerebral Artery Occlusion / 신경중재치료의학

Early spontaneous recanalization of the middle cerebral artery in acute ischemic phase artery is not uncommon, whereas the late spontaneous recanalization of chronic occluded artery is a very rare phenomenon and exact incidence and the timing of this event have not been quantified. We present a case in which late spontaneous recanalization of long-lasting middle cerebral artery occlusion occurred in the absence of surgical, endovascular and thrombolytic treatments.

Dissecting Aneurysm Associated with a Double Origin of the Posterior Inferior Cerebellar Artery Causing Subarachnoid Hemorrhage

Two cases of the posterior fossa dissecting aneurysm associated with a double origin of the posterior inferior cerebellar artery (DOPICA) causing subarachnoid hemorrhage are presented. After observing a relationship between the aneurysm and DOPICA on a three dimensional rotational angiogram (3DRA), the dissecting aneurysms were successfully obliterated by surgical trapping and endovascular internal trapping, respectively. This report warrants suspecting DOPICA of an associating anomaly predisposing to dissecting aneurysm in the vertebral artery-posterior inferior cerebellar artery territory and highlights the role of 3DRA in pretreatment evaluation of unusual aneurysms accompanying a particular anatomical variation.