Neuroendoscopy in microsurgical clipping for ruptured posterior communicating artery aneurysms via keyhole approaches / 中华显微外科杂志

Objective:To explore the value of application and manipulation technique of neuroendoscope in microsurgical clipping of ruptured posterior communicating artery(PCoA)aneurysms via keyhole approaches.Methods:From January 2018 to December 2020, the clinical data of 52 patients who received microsurgical clipping for ruptured via keyhole approach were retrospectively analysed. Forty-one patients had the intraoperative endoscopic monitoring. The supraorbital keyhole approach or pterional keyhole approach was applied based on the characteristics of the aneurysms. According to the in-surgery requirement, a 30° rigid neuroendoscope was used before and/or after clipping. All patients entered postoperative follow-up in outpatient clinic and were evaluated with the modified Rankin Scale(mRS).Results:All 52 patients had 52 ruptured PCoA aneurysms. Eighteen of the patients were treated via supraorbital keyhole approach and 34 via pterion keyhole approach. Pre-and post-clipping endoscopic observation were carried out in 12 cases and 29 only with post-clipping endoscopic observation. Residual aneurysmal neck was detected in 3 patients. Missed clipping of perforators was found in 2 patients and followed by proper adjustment of clips. All patients received follow-up angiographic examinations. Total obliteration of the aneurysm and an intact of internal carotid artery and PCoA were found in 41 patients by the intraoperative endoscopic observation. Two residual aneurysmal neck were detected in 11 patients without intraoperative endoscopic observation. After 11 to 45 months of follow-up, all patients had good recovery(mRS 0-1).Conclusion:It is a safe and effective method with endoscopic observation during microsurgical clipping procedure for ruptured PCoA aneurysms via keyhole approaches. It can effectively make up for the insufficient visual angle of microscope, realise the anatomical relationship between the aneurysm and adjacent structures, and avoid residual aneurysmal neck and an iatrogenic injury to the parent artery and perforators.

Evaluación morfológica y variaciones del circulo arterial cerebral: un estudio con material cadavérico en una muestra de población colombianas / Morphological evaluation and variations of the cerebral arterial circle: a study with cadaveric material in a Colombian population sample

RESUMEN: El círculo arterial cerebral (CAC) mencionado también como polígono de Willis es una red de anastomosis vascular situado en la base del cerebro, constituido por ramas de la arteria carótida interna (ACI) y del sistema vertebro-basilar. Este estudio evaluó la morfología de las arterias que conforman el CAC en una muestra de individuos colombianos. Previa canalización de la ACI y de la arteria vertebral (AV), se perfundió con resina poliéster (palatal 85 % y estireno 15 %) los lechos vasculares del CAC de 70 encéfalos extraídos de cadáveres a quienes se les practicó necropsia en el Instituto de Medicina Legal de Bucaramanga, Colombia. La arteria comunicante anterior (ACoA) se observó en 68 encéfalos (97,1 %), con ausencia en 2 de las muestras (2,9 %); en promedio su diámetro fue de 1,91?1,04 mm y su longitud 2,21?0,97 mm respectivamente. Asimismo, se encontró hipoplasia en 6 muestras (8,4 %). La arteria comunicante posterior (ACoP) estuvo ausente en 2 de las muestras (5,7 %); su longitud fue 11,63?2,12 mm, mientras que su calibre fue de 1,21?0,58 mm, siendo ligeramente mayor en el lado derecho, sin diferencias estadísticamente significativas con relación al lado de presentación (p= 0,763). Se encontró hipoplasia de la ACoP en forma bilateral en 19 de las muestras (27,1 %) y unilateral en 15 muestras (21,4 %). En 8 muestras (20 %) de 35 CAC evaluados se observó configuración fetal. La incidencia de hipoplasia de la ACoP y de configuración fetal encontrados en el presente estudio, se ubican en el segmento superior de lo reportado en la literatura. Estas expresiones morfológicas han sido consideradas como coadyuvantes en el desarrollo de accidentes cerebro-vasculares (ACV).

SUMMARY: The cerebral arterial circle (CAC), also referred to as the polygon of Willis is a network of vascular anastomoses located at the base of the brain, consisting of branches of the internal carotid artery (ICA) and the vertebrobasilar system (VBS). This study evaluated the morphology of the arteries forming the CAC in a sample of Colombian individuals. After cannulation of the ICA and the vertebral artery (VA), the vascular beds of the ACC of 70 brains extracted from cadavers at the Institute of Legal Medicine of Bucaramanga, Colombia, were perfused with polyester resin (85 % palatal and 15 % styrene). The anterior communicating artery (ACoA) was observed in 68 brains (97.1 %), with absence in 2 of the samples (2.9 %); on average its diameter was 1.91?1.04mm and its length 2.21?0.97mm respectively. Likewise, hypoplasia was found in 6 samples (8.4 %). The posterior communicating artery (ACoP) was absent in 2 of the samples (5,7 %); its length was 11.63?2.12mm, while its caliber was 1.21?0.58mm, being slightly larger on the right side, with no statistically significant differences in relation to the side of presentation (p= 0.763). Hypoplasia of the ACoP was found bilaterally in 19 of the samples (27.1 %) and unilaterally in 15 samples (21.4 %). Fetal configuration was observed in 8 samples (20 %) of 35 CACs evaluated. The incidence of ACoP hypoplasia and fetal configuration found in the present study are in the upper segment of those reported in the literature. These morphological expressions have been considered as coadjuvants in the development of cerebrovascular accidents (CVA).

Clinical efficacy of endovascular treatment of posterior communicating artery aneurysms with fetal posterior cerebral artery / 中国脑血管病杂志

Objective To evaluate the safety and efficacy of endovascular treatment of posterior communicating artery (PCoA) aneurysms with fetal posterior cerebral artery (fPCA). Methods From January 2015 to December 2017,55 consecutive patients with PCoA aneurysm with fPCA (57 aneurysms) treated at the Department of Neurosurgery, First Hospital Affiliated to Naval Military Medical University were enrolled retrospectively. All aneurysms were treated with endovascular treatment, including 27 aneurysms treated with coils alone and 30 treated with stent-assisted embolizatioa The immediate degree of embolization after procedure was assessed according to the Raymond grade. Imaging follow-up was performed using DSA or MR angiography, and the clinical prognosis was followed up by the outpatient and/or telephone. The prognosis was assessed using the modified Rankin scale (MRS) score. Results Of the 55 patients ,41 (74. 5% ) had subarachnoid hemorrhage. Immediate post-operative angiography revealed that 21 aneurysms (36. 8% ) were Raymond grade 1,11 aneurysms (19. 3% ) were Raymond grade E ,and 25 aneurysms (43. 9% ) were Raymond grade HI. All the PCoAs were patent Three patients (5.5%) had perioperative complications, they were operation-related bleeding.no ischemic events occurred,and 3 patients died. Thirty-nine patients with 41 aneurysms were followed up with imaging, of which 26 (63. 4% ) were cured, 1 (2. 4% ) were improved,8 ( 19. 5% ) were stable, and 6 (14. 6% ) recurred ( all treated with coils alone). All PCoAs with fPCA remained patent during the follow-up. Of the 52 patients who were clinically followed up,2 died and the aneurysm of 1 ease reruptured one year after procedure. The follow-up MRS score was 0-2 in 47 cases (90.4% ) ,3 in 1 case,4 in 1 case,5 in 1 case,and 6 in 2cases. Conclusion Endovascular treatment of PCoA aneurysms with fPCA is feasible and effective.

Surgery of a Posterior Communicating Artery Aneurysm with Fetal-Type Circulation

Inadvertent occlusion of a fetal-type posterior communicating artery in aneurysm surgery could result in posterior circulation infarction and neurological morbidity. The case of a patient with an unruptured posterior communicating artery aneurysm with lateral projection and a fetal-type posterior communicating artery is presented. The utility of the carotid-oculomotor window as a surgical corridor to safely find the fetaltype posterior communicating artery is discussed.

A oclusão da artéria comunicante posterior do tipo fetal em cirurgia de aneurisma pode resultar em infarto da circulação posterior e morbidade neurológica. Apresentamos o caso de um paciente com aneurisma não roto da artéria comunicante posterior com projeção lateral e uma artéria comunicante posterior do tipo fetal. Discutimos a utilidade da janela carótida-oculomotora como um corredor cirúrgico para encontrar com segurança a artéria comunicante posterior do tipo fetal.

Efficacy analysis of ruptured posterior communicating artery aneurysms with stent-assisted vs.non-stent-assisted coil embolization / 中国脑血管病杂志

Objective To compare the safety and efficacy of stent-assisted coil and non-stent-assisted coil for the treatment of ruptured posterior communicating artery aneurysms.Methods A total of 121 consecutive patients with ruptured posterior communicating artery aneurysm treated at the Department of Neurosurgery,Heze Municipal Hospital between June 2014 and June 2017 were enrolled retrospectively.They divided into either a stent group (n =63) or non-stent group (n =58) according to whether they used stent treatment or not.The two groups were compared,and their clinical data,surgical related complications,the degree of embolism immediately after aneurysm surgery,and the follow-up results of clinical and imaging were analyzed.Results Interventional embolization therapy was successfully performed in all the patients.(1) The proportion of wide-necked aneurysms of the stent group was higher than that of the non-stent group.There was significant difference (92.1％ [58/63] vs.8.6％ [5/58],x2 =84.249,P ＜ 0.01).There were no significant differences in age,aneurysm size,sex,and HuntHess grade (all P ＞ 0.05).(2) The incidences of intraoperative aneurysm rupture of the stent group and non-stent group were 4.8％ (3/63) and 3.4％ (2/58) respectively.There was no significant difference (x2 =0.132,P =0.717).The incidence of thromboembolie complication was 12.7％ (8/63) and 5.2％ (3/58)respectively.There was no significant difference (x2 =2.070,P =0.150).In the stent group,1 patient disabled and 1 died,and in the non-stent group,there were no cases with surgical related disability,and 1 died.(3) The comparison of immediate results after procedure between the stent group and non-stent group:there were no significant differences in the complete embolic rate (39.7％ [25/63] vs.37.9％[22/58],x2 =0.039),aneurysm neck residual rate (25.4％ [16/63] vs.39.7％ [23/58],x2 =2.811],and residual rate of aneurysm (34.9％ [22/63] vs.22.4％ [13/58],x2 =2.298,all P ＞ 0.05).(4) The recurrence rate of aneurysms (4.3％ [2/46]) of the stent group was lower than that of the non-stent group (31.8％ [14/44]).There was significant difference between the two groups (x2 =112.610,P =0.01).No rebleeding occurred in all aneurysms after procedure.Conclusion Compared with the non-stent-assisted coil embolization,the stent assisted embolization of ruptured posterior communicating artery aneurysms in acute phase may reduce the recurrence rate of aneurysms and without significantly increasing the incidence of surgery-related complications.

A tiny bleb at Junctional Dilatation of the Posterior Communicating Artery as a Predisposing Factor for Development of a De Novo Aneurysm / 신경중재치료의학

Formation of de novo aneurysm from a junctional dilatation at the origin site of the posterior communicating artery (PcomA) has been rarely reported. In this case report, three females in sixth decades of age developed a de novo aneurysm from the junctional dilatation of the PComA with a tiny bleb-like lesion over 5 years after initial presentation.

Efficacy analysis of endovascular treatment of ruptured aneurysm of fetal posterior communicating artery / 中国脑血管病杂志

Objective To investigate the feasibility and effectiveness of endovascular treatment of posterior communicating artery aneurysm (PcoAA)in keeping the fetal posterior cerebral artery (FPCA) patency. Methods Form January 2014 to December 2015,14 patients with ruptured PcoAA enrolled retrospectively were treated with endovascular embolization. Six of them were treated with simple coil embolization,3 with stent-assisted coil embolization,3 with double catheter-assisted coil embolization,1 with stent-assisted coil embolization + double catheter technique,and 1 with Y-stent in Yijishan Hospital, Wannan Medical College. The immediate embolization rate of PcoAA (using Raymond grade),prognosis of the patients (the modified Rankin scale score at 6 months after procedure),complications,and imaging follow-up results were analyzed. Results The success rate of coil and stenting was 100% . All the stents were accurately released in place without displacement. The immediate Raymond grading of the aneurysms displayed that Raymond grade Ⅰ was in 8 cases,Raymond grade Ⅱ was in 4 cases,and Raymond grade Ⅲ was in 2 cases. All FPCA were kept patent. A coil protruded into internal carotid artery in one case during the procedure. Others did not have any complications,such as intraoperative cerebral vasospasm,in-stent thrombosis,and rupture. All 14 patients were followed up for 3 -24 months after procedure. Two had recurrence. Both were aneurysms embolized with coils only. No rebleeding and ischemic complications were observed. The modified Rankin scale scores in 13 cases were 0 -2 at 6 months after procedure,1 was 4. Conclusions Endovascular embolization for the treatment of PcoAA and keeping FPCA patency are safe and feasible. A variety of endovascular treatment modalities are necessary in order to keep FPCA patency.

Retrograde Stent-assisted Coil Embolization of Wide-neck or Branch-incorporated Posterior Communicating Artery Aneurysm

Endovascular coil embolization using a balloon- or stent-assisted technique for the treatment of wide-necked posterior communicating artery (PcomA) aneurysms is well established. However, complete aneurysm occlusion with preservation of the PcomA can be difficult in case of wide-neck aneurysms with a PcomA incorporation. We present two cases of stent-assisted coil embolization using a retrograde approach through the posterior circulation for wide-neck or branch-incorporated PcomA aneurysms. Retrograde stenting was successful without periprocedural complications. These aneurysms were completely occluded. The patency of the PcomA was maintained in all cases.

Microsurgical Anatomy of Supraclinoid ICA in North West Indian Population: A Cadaveric Study.

Background: To study the microsurgical anatomy of supraclinoid ICA, the size and number of perforators, any anomalies in normal anatomy of ICA, its branches and surrounding structures in North West Indian population. Materials and Methods: Twenty cadaveric brain dissections were performed under operating microscope (Carl ZeissNC31). Sylvian fissure was meticulously dissected from distal to proximal. Anterior clinoid process (ACP) was drilled intradurally using M-80 pneumatic drill. Vessels, their branches and perforators were dissected with measurement of their length, diameter and number. Supraclinoid ICA was dissected till its bifurcation into anterior and middle cerebral arteries. The length of falciform ligament was also measured. Results: The length of ophthalmic segment was largest varying from 5.5 to 13.0 mm (average 9.75mm).The communicating segment was the shortest varying from 1.5 to 6.0 mm (average 3.2mm). The number of perforating arteries excluding the OphA, PComA and AChA arising from C4 varied from 3-10(average 6). The maximum perforators were from Cho Seg and least from Com Seg. Conclusion: The overall anatomical details of supraclinoid ICA in North West Indian population were comparable to existing literature.

Analysis of the shape and hemodynamic characteristics of the ruptured posterior communicating artery minimal aneurysms / 中国脑血管病杂志

Objective To investigate the shape and hemodynamic characteristics of the ruptured posterior communicating artery minimal aneurysms. Methods The clinical data of 42 patients with ruptured posterior communicating artery minimal aneurysm (the maximum diameter < 3 mm,11 ruptured aneurysms and 31 unruptured aneurysms)were collected retrospectively. Three-dimensional DSA shapes of the aneurysms were assessed,and the hemodynamic parameters of the aneurysms were calculated according to their computer simulation models. Results (1)The multiple aneurysms were more common in the unruptured group than those in the ruptured group (58. 1% [18/ 31]vs. 9. 1% [1/ 11]). There was significant difference,P = 0. 006 ). (2 )The complex flow pattern was more common in the ruptured group (63. 6%[7 / 11]vs. 6. 5% [2 / 31],P < 0. 01)and also the changed flow pattern (45. 5% [5 / 11]vs. 3. 2% [1 / 31),P = 0. 003). (3)The median aneurysm wall shear stress of the ruptured group was 0. 74 (0. 52,0. 86)and that of the unruptured group was 1. 03(0. 83,3. 64). There was significant difference between the 2 groups (P =0. 008). Conclusion The unruptured minimal aneurysms are common in patients with multiple aneurysms. Active surgical intervention is recommended for the posterior communicating artery minimal aneurysms with low wall shear stress,complex and change flow.

Early endovascular embolization treatment for the ruptured posterior communicating artery aneurysm:analysis of the mid-term and long-term effects / 介入放射学杂志

Objective To evaluate the mid-term and long-term effects of early endovascular emboli-zation in treating ruptured posterior communicating artery aneurysm. Methods Early endovascular embolization therapy was carried out in 36 patients with ruptured posterior communicating artery aneurysm (36 aneurysms in total), and the effects of embolization therapy were evaluated by using Raymond grading method. The unified imaging review program was formulated, and the mid-term and long-term effects were evaluated at half, 1, 2, 3 and 5 years after the treatment. Results The technical success rate was 100% in 36 patients (36 aneurysms in total). Raymond grading evaluation showed that gradeⅠwas seen in 32 patients, gradeⅡ in 2 patients, and grade Ⅲ in 2 patients. Recurrence of aneurysm was found in 5 patients (13.89%) at half (n=1), 2 (n=1), 3 (n=1) and 5 years (n=2) after the treatment. Re-rupture of the recurrent aneurysm was seen in one patient (2.78%). No death occurred during the following-up period. Conclusion Early endovascular embolization for ruptured posterior communicating artery aneurysm can effectively improve the prognosis of subarachnoid hemorrhage, and regular imaging examination can promptly detect the recurrence of aneurysm. Effective interventions are helpful for preventing deterioration and rupture of aneurysm.

Analysis of the therapeutic effect of interventional embolization and surgical clipping for the treatment of posterior communicating artery aneurysms / 介入放射学杂志

Objective To analyze the complications and clinical effects of interventional embolization and surgical clipping for the treatment of posterior communicating artery aneurysms, and to compare the results between the two methods.Methods A total of 90 patients with confirmed posterior communicating artery aneurysm, who were admitted to the Second Affiliated Hospital of Zhengzhou University during the period from August 2013 to March 2015, were enrolled in this study. Of the 90 patients, 49 received interventional embolization therapy (interventional embolization group) and 41 underwent surgical clipping treatment (surgical clipping group). Before the treatment the patient's condition was evaluated according to Hunt-Hess classification, after the treatment the therapeutic effect was assessed with Glasgow prognosis scale (GOS). The postoperative GOS scores and complications in patients with different Hunt-Hess classification were compared between the two groups. Results In patients of Hunt-Hess 0-Ⅲ grade, no statistically significant differences in postoperative GOS scores existed between the interventional embolization group and the surgical clipping group (t=0.842,P>0.05), while the postoperative GOS scores in patients of Hunt-HessⅣgrade of the interventional embolization group was remarkably higher than that in patients of Hunt-HessⅣgrade of the surgical clipping group, the difference was statistically significant (t=1.713,P<0.05). The incidence of complications in the interventional embolization group was significantly lower than that in the surgical clipping group (x2=1.036,P<0.05). Conclusion For the treatment of Hunt-Hess 0-Ⅲgrade posterior communicating artery aneurysms, the interventional embolization and the surgical clipping show no difference in their therapeutic effects; while for the treatment of Hunt-Hess Ⅳ grade posterior communicating artery aneurysms, the interventional embolization in superior to the surgical clipping, as the interventional embolization carries lower operation risk and complication incidence, and it also has reliable effect.

Application effect analysis of anterior clinoid process drilled off via epidural approach in posterior communicating artery aneurysm clipping / 中国脑血管病杂志

Objective To investigate the application effect of anterior clinoid process drilled off via epidural approach in posterior communicating artery aneurysm ( PCoAA) clipping. Methods The clinical data of 42 patients with PCoAA who underwent craniotomy from January 2012 to January 2014 were analyzed retrospectively,including 22 patients performed anterior clinoid process drilled off and 20 did not. The difficult or easy degree of intraoperative aneurysm clipping and postoperative efficacy were analyzed. Results The aneurysms in 22 patients underwent anterior clinoid process were clipped satisfactorily. The brain retractor was not used during the procedure. Only one patient had cerebral infarction after procedure. No patients had oculomotor nerve paralysis and incomplete clipping of aneurysms. Of the 20 patients without the anterior clinoid process drilled off,3 aneurysms were clipped incompletely because it was difficult to implant aneurysm clips, 2 had cerebral infarction, and 1 had oculomotor nerve paralysis. Conclusion Removing the anterior clinoid process drilled off via extradural approach may bring convenience for PCoAA clipping. It can effectively avoid the difficulty of implanting aneurysm clips during the procedure. Its application is safe and can reduce postoperative complications.

Selection and application of aneurysm clip in posterior communicating artery aneurysm clipping / 中国脑血管病杂志

Objective: To investigate the selection and application of aneurysm clips for microsurgical clipping of posterior communicating artery aneurysms (PCoAA). Methods: The clinical data of 46 patients with PCoAA whom underwent microsurgical clipping in Peking University First Hospital from January 2007 to June 2011 were analyzed retrospectively. The aneurysms were classified according to the relationship between the aneurysm neck and its parent artery. The locations of aneurysm necks, the types of aneurysm clip and the placement of aneurysm clips were analyzed. The patients were followed up by outpatient department examination, telephone inquiry and DSA for 4 months to 4 years. Results: Circled digit oneThe 46 patients with PCoAA were divided into 3 types according to the site of aneurysmal necks in parent artery; internal carotid artery (n = 19), PCoAA (n = 5) proper, and bifurcation (n = 22). Circled digit twoThe bent clip, straight clip, angled fenestrated clip, and bayonet-shaped clip were used in 37, 6, 2, and 1 patients, respectively. The clip length was 6-7 mm in 54.3% patients, and was 5-7 mm in 21.7% patients. In the PCoAA type and bifurcation type aneurysms, the clips were parallel to the direction of the vessels, while in the internal carotid type aneurysms were placed vertically the clips to the internal carotid artery in 13 patient, and parallel to the direction of the vessels in 6 patients. Circled digit threeThe postoperative follow-up showed that the patients did not have the clinical manifestations of aneurysm recurrence and rupture. Twelve patients were followed up with DSA, and it revealed that their aneurysm necks were occluded completely and no residual aneurysms seen. Conclusion: In the PCoAA clipping, confirming the location of aneurysm necks and identifying the relationship between the aneurysm and its surrounding vessels are critical for selecting and placing aneurysm clips. The first choice of bent aneurysm clip may improve the success rate for complete occlusion of PCoAA.

Transposition of Anterior Choroidal Artery and Posterior Communicating Artery Origin

The anterior choroidal artery has several kinds of variations. Among them, the transposition of anterior choroidal artery and posterior communicating artery origins has been extremely rare. We report a case with cerebral aneurysm arising from posterior communicating artery which origin was distal to the anterior choroidal artery and review the relevant literature.

Endovascular Embolization of a de Novo True Posterior Communicating Artery Aneurysm 23 years After Surgical Clipping of an Ipsilateral Posterior Communicating Artery-internal Carotid Artery Aneurysm: A Case Report / 대한뇌혈관외과학회지

We describe a true posterior communicating artery (PCoA) aneurysm, which is an uncommon variant of intracranial aneurysm that was treated by endosaccular embolization. A 64-year-old woman was admitted for management of an unruptured left PCoA aneurysm. She had undergone microsurgical clipping of an ipsilateral internal carotid artery (ICA)-PCoA aneurysm 23 years prior to the current presentation. Angiography showed a saccular aneurysm 3 mm distal to the junction of the ICA and the fetal-type PCoA arising on the opposite side of the vessel to that of the previous clipping. Endovascular embolization was performed to occlude the lumen of the aneurysm while preserving the patency of the PCoA. Based on angiograms, hemodynamic stress seems to be the most feasible explanation for the de novo development of an aneurysm at the first acute bend within the PCoA in our patient. For this anatomical reason, endosaccular coil deployment was possible without the use of a balloon or stent.

Isolated, Contralateral Trochlear Nerve Palsy Associated with a Ruptured Right Posterior Communicating Artery Aneurysm

Trochlear nerve palsy associated with spontaneous subarachnoid hemorrhage (SAH) is known to be a rare malady. We report here on a patient who suffered with left trochlear nerve palsy following rupture of a right posterior communicating artery aneurysm. A 56-year-woman visited our emergency department with stuporous mental change. Her Hunt-and-Hess grade was 3 and the Fisher grade was 4. Cerebral angiography revealed a ruptured aneurysm of the right posterior communicating artery. The aneurysm was clipped via a right pterional approach on the day of admission. The patient complained of diplopia when she gazed to the left side, and the ophthalmologist found limited left inferolateral side gazing due to left superior oblique muscle palsy on day 3. Elevated intracranial pressure, intraventricular hemorrhage or a dense clot in the basal cisterns might have caused this trochlear nerve palsy.

A Occluded Posterior Communicating Artery Mimicking a Cerebral Aneurysm: A Case Report / 대한뇌혈관외과학회지

A 47-year-old man was admitted to the emergency department due to a sudden onset of headache during exercise. Brain computed tomography (CT) and CT angiography showed a subarachnoid hemorrhage (SAH) with a small sac in the left posterior communicating (pcom) artery and total obstruction in the proximal portion of the right middle cerebral artery (MCA). Catheter angiography revealed a protruding lesion in the left p-com artery and a total obstruction in the right MCA. It was difficult to differentiate the aneurysm from the occlusion of the pcom artery. We planned to confirm whether or not the protruded lesion was an aneurysm. Intraoperatively, the aneurysmal opacification seen on the preoperative catheter angiography proved it to be the occluded p-com artery filled with thrombus. The possibility of a vascular stump should be considered when diagnosing a protruding vascular lesion at the p-com artery.

The 3rd Cranial Nerve Palsy due to Posterior Communicating Artery Aneurism Mimicking Acute Vestibulopathy (Vestbular Neuritis) / 대한이비인후과학회지

We present a 66-year old woman complaining of dizziness and vomiting for the previous three days. Her symptoms were quite similar to vestibular neuritis except for mild headache. Spontaneous nystagmus recording, head shake test, and slow harmonic acceleration results were also similar to vestibular neuritis. But the caloric test was not consistent with the chair test results. During the neurologic examination, ptosis, mydriasis, and the diplopia in the left eye were detected, which was indicative of central organic pathology. Bilateral posterior communicating artery aneurysm that was compressing the left oculomotor nerve was detected by CT angiography. A careful and precise neurologic examination should never be neglected when examining a dizzy patient. It was also noticeable that, acute third nerve palsy may present as intermittent saccades which mimic spontaneous nystagmus in vestibular neuritis.

An Analysis of Prognostic Factors forRecovery from Oculomotor Nerve Palsy in Patients withPosterior CommunicatingArtery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: The aim of this study was to identify the prognostic factors for recovery from oculomotor nerve palsy in patients with a posterior communicating artery aneurysm after surgical intervention. METHODS: We retrospectively reviewed 16 patients with a ruptured or unruptured posterior communicating artery aneurysm that was associated with oculomotor nerve palsy and these patients were treated in our hospital between 2002 and 2006. Fifteen of the 16 patients were women, and the patients' ages ranged between 38 and 75 years (mean age: 52.6 years), and the follow up period was from 0.5 to 36 months (mean: 8.75 months). RESULTS: The total number of aneurysmal cases treated over the 5-year study period was 1135, and there were 223 patients (19.6%) with posterior communicating artery aneurysms. Among these 223 patients, 16 (7.2%) presented with third cranial nerve palsy (4 ruptured, 12 unruptured). Ptosis was presented in all cases (100.0%). Extraocular muscle palsy was presented to some degree by 10 cases (62.5%). The affected pupils were dilated and fixed in all patients (100.0%). The ptosis improved completely in 13 patients (81.3%), and incompletely in 3 patients (18.7%) within 6 months. The dilated and fixed pupils were improved in 10 of the 16 patients (62.5%). The extraocular muscle palsies recovered completely in 15 cases within 6 months. The mean interval between palsy onset and the time of surgery was 6.2 days for the complete recovery cases, and 22 days for the incomplete recovery cases. However, recovery of papillary function was unpredictable. CONCLUSIONS: The duration of symptoms and the degree of preoperative deficits are considered as prognostic factors for the postoperative recovery from third nerve palsy in patients with a posterior communicating artery aneurysm.