Operative Treatment of a Superior Cerebellar Artery Perforator Dissecting Aneurysm

Abstract

BACKGROUND AND IMPORTANCE Superior cerebellar artery (SCA) perforator aneurysms are extremely rare, with only one other case published in the literature. There is no conclusive management strategy for these aneurysms, although endovascular treatment, open surgical treatment with clipping, and antifibrinolytic administration with spontaneous thrombosis have all been discussed. CLINICAL PRESENTATION A 61-yr-old male presented with intraventricular hemorrhage (IVH) primarily in the posterior fossa. He was found to have a dissecting left SCA perforator aneurysm lying on the floor of the fourth ventricle. The aneurysm was not amenable to endovascular treatment, and antifibrinolytic therapy failed to spontaneously thrombose the aneurysm. We performed a suboccipital craniotomy and used a supracerebellar transvermian approach to resect the aneurysm. There was total obliteration of the aneurysm on postoperative cerebral angiogram. CONCLUSION SCA perforator aneurysms represent an extremely uncommon subset of intracranial aneurysms. The best therapeutic strategy has yet to be definitively proven. When pursuing surgical treatment, the supracerebellar transvermian navigated approach can be a useful and safe option, as described and illustrated in this video.

Woven Endobridge device for treatment of dissection-related PICA aneurysm

“…3 Endovascular treatment is often favored because of the higher risk of cranial nerve or brainstem injury associated with surgical clipping. 4,5 Proximal occlusion, coil or stent-assisted coil embolization, and flow diversion are the primary endovascular options available for the treatment of dissecting aneurysms. 1,2,6 Vessel sacrifice is the most durable option but is also associated with a high risk of ischemic stroke.…”

Orbitozygomatic Approach for a Ruptured P1 Perforator Aneurysm: 2-Dimensional Operative Video

“…Perforator aneurysms are a rare cause of subarachnoid hemorrhage that are challenging to diagnose and treat. The posterior circulation is prone to perforator aneurysms, with reported cases including 57 basilar artery perforator aneurysms, 1-26 3 superior cerebellar artery aneurysms, 22,27,28 and 2 posterior choroidal artery aneurysms. 22,28 Approximately half of perforator aneurysms are diagnosed on the first diagnostic imaging, 29 and described management strategies include open treatment, endovascular treatment, or conservative management.…”