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Microsurgical management of aneurysms of the superior cerebellar artery - lessons learnt: An experience of 14 consecutive cases and review of the literature.

Nair P, Panikar D, Nair AP, Sundar S, Ayiramuthu P, Thomas A - Asian J Neurosurg (2015 Jan-Mar)

Bottom Line: At 6 months follow-up, 10/14 (71%) patients had mRS of 0-2, and 2 (14%) had mRS of 5.They commonly present with SAH.The EDTP approach avoids complication caused by temporal lobe retraction and injury to the vein of Labbe.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India.

ABSTRACT

Objective: This is a retrospective study from January 2002 to December 2012 analyzing the results of microsurgical clipping for aneurysms arising from the superior cerebellar artery (SCA).

Materials and methods: All patients with SCA were evaluated with computerized tomography angiography and/or digital subtraction angiography (DSA) prior to surgery. All patients in our series underwent microsurgical clipping and postoperative DSA to assess the extent of aneurysm occlusion. The Glasgow outcome scale (GOS) and the modified Rankin's scale (mRS) were used to grade their postoperative neurological status at discharge and 6 months, respectively.

Results: Fourteen patients had SCA aneurysms (ruptured-9, unruptured-5). There were 10 females and 4 males with the mean age of 47.2 years (median - 46 years, range = 24-66 years). Subarachnoid hemorrhage (SAH) was seen in 11 patients. The mean duration of symptoms was 2.5 days (range = 1-7 days). The WFNS score at presentation was as follows: Grade 1 in 10 cases, II in 2 cases, III in 1 case and IV in 1 case. In the 9 cases with ruptured SCA aneurysm, average size of the ruptured aneurysms was 7.3 mm (range = 2.5-27 mm, median = 4.9 mm). The subtemporal approach was used in the first 7 cases. The extradural temporopolar (EDTP) approach was used in the last 5 cases. Complications include vasospasm (n = 6), third nerve palsy (n = 5) and hydrocephalus (n = 3). Two patients died following surgery. At mean follow-up 33.8 months (median - 25 months, range = 19-96 months), no patient had a rebleed. At discharge 9 (64%), had a GOS of 4 or 5 and 3 (21%) had a GOS of 3. At 6 months follow-up, 10/14 (71%) patients had mRS of 0-2, and 2 (14%) had mRS of 5.

Conclusions: Aneurysms of the SCA are uncommon and tend to rupture even when the aneurysm size is small (<7 mm). They commonly present with SAH. The EDTP approach avoids complication caused by temporal lobe retraction and injury to the vein of Labbe.

No MeSH data available.


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(a) CTA and (b and c) DSA of a 66-year-old female with Grade 3 SAH showing a 4.9 mm aneurysm arising from the left SCA, directed upward and posteriorly. The right PCA and SCA are seen arising from a single common trunk. The aneurysm was clipped using a temporopolar approach. (d) The aneurysm arising from the SCA, distal to its origin. (e) And the final clip placement across the aneurysm neck. (f) Postoperative angiogram shows complete occlusion of the aneurysm and flow across the patent SCA)
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Figure 5: (a) CTA and (b and c) DSA of a 66-year-old female with Grade 3 SAH showing a 4.9 mm aneurysm arising from the left SCA, directed upward and posteriorly. The right PCA and SCA are seen arising from a single common trunk. The aneurysm was clipped using a temporopolar approach. (d) The aneurysm arising from the SCA, distal to its origin. (e) And the final clip placement across the aneurysm neck. (f) Postoperative angiogram shows complete occlusion of the aneurysm and flow across the patent SCA)

Mentions: The SCA arises from the basilartrunk. Cadaveric studies have found that it is one of the most constant posterior fossa arteries, however, the pattern of origin from the BA may vary, and Yasargil has classified them into 7 patterns.[89] Cadaveric studies by Hardy et al. have demonstrated unilateral duplication of the SCA (pattern G) in 7/50 cases.[8] In case 10 [Tables 1, 2 and Figure 4a–f] the aneurysm was seen arising from duplicated SCA, 1.9 mm from its origin from the basilar trunk. To the best of our knowledge, an aneurysm arising from an accessory SCA has not been reported. Another anatomical variation we noted was in case 12, where the aneurysm was seen on the left SCA, and the right SCA and PCA appeared to arise from a common trunk, this matched pattern D according to Yasargil's classification [Figure 5a–e]. This aberrant origin of the SCA has been seen very rarely in cadaveric studies.[89] We also the noticed the development of a de novo aneurysm in one patient with an associated AVM (case 15), where the SCA aneurysm developed in the follow-up angiogram taken a year after clipping of preexisting flow related MCA aneurysm. In the above cases, vascular anomalies and AVM probably contributed to the altered dynamics of blood flow and the development of the aneurysms.


Microsurgical management of aneurysms of the superior cerebellar artery - lessons learnt: An experience of 14 consecutive cases and review of the literature.

Nair P, Panikar D, Nair AP, Sundar S, Ayiramuthu P, Thomas A - Asian J Neurosurg (2015 Jan-Mar)

(a) CTA and (b and c) DSA of a 66-year-old female with Grade 3 SAH showing a 4.9 mm aneurysm arising from the left SCA, directed upward and posteriorly. The right PCA and SCA are seen arising from a single common trunk. The aneurysm was clipped using a temporopolar approach. (d) The aneurysm arising from the SCA, distal to its origin. (e) And the final clip placement across the aneurysm neck. (f) Postoperative angiogram shows complete occlusion of the aneurysm and flow across the patent SCA)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4352632&req=5

Figure 5: (a) CTA and (b and c) DSA of a 66-year-old female with Grade 3 SAH showing a 4.9 mm aneurysm arising from the left SCA, directed upward and posteriorly. The right PCA and SCA are seen arising from a single common trunk. The aneurysm was clipped using a temporopolar approach. (d) The aneurysm arising from the SCA, distal to its origin. (e) And the final clip placement across the aneurysm neck. (f) Postoperative angiogram shows complete occlusion of the aneurysm and flow across the patent SCA)
Mentions: The SCA arises from the basilartrunk. Cadaveric studies have found that it is one of the most constant posterior fossa arteries, however, the pattern of origin from the BA may vary, and Yasargil has classified them into 7 patterns.[89] Cadaveric studies by Hardy et al. have demonstrated unilateral duplication of the SCA (pattern G) in 7/50 cases.[8] In case 10 [Tables 1, 2 and Figure 4a–f] the aneurysm was seen arising from duplicated SCA, 1.9 mm from its origin from the basilar trunk. To the best of our knowledge, an aneurysm arising from an accessory SCA has not been reported. Another anatomical variation we noted was in case 12, where the aneurysm was seen on the left SCA, and the right SCA and PCA appeared to arise from a common trunk, this matched pattern D according to Yasargil's classification [Figure 5a–e]. This aberrant origin of the SCA has been seen very rarely in cadaveric studies.[89] We also the noticed the development of a de novo aneurysm in one patient with an associated AVM (case 15), where the SCA aneurysm developed in the follow-up angiogram taken a year after clipping of preexisting flow related MCA aneurysm. In the above cases, vascular anomalies and AVM probably contributed to the altered dynamics of blood flow and the development of the aneurysms.

Bottom Line: At 6 months follow-up, 10/14 (71%) patients had mRS of 0-2, and 2 (14%) had mRS of 5.They commonly present with SAH.The EDTP approach avoids complication caused by temporal lobe retraction and injury to the vein of Labbe.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India.

ABSTRACT

Objective: This is a retrospective study from January 2002 to December 2012 analyzing the results of microsurgical clipping for aneurysms arising from the superior cerebellar artery (SCA).

Materials and methods: All patients with SCA were evaluated with computerized tomography angiography and/or digital subtraction angiography (DSA) prior to surgery. All patients in our series underwent microsurgical clipping and postoperative DSA to assess the extent of aneurysm occlusion. The Glasgow outcome scale (GOS) and the modified Rankin's scale (mRS) were used to grade their postoperative neurological status at discharge and 6 months, respectively.

Results: Fourteen patients had SCA aneurysms (ruptured-9, unruptured-5). There were 10 females and 4 males with the mean age of 47.2 years (median - 46 years, range = 24-66 years). Subarachnoid hemorrhage (SAH) was seen in 11 patients. The mean duration of symptoms was 2.5 days (range = 1-7 days). The WFNS score at presentation was as follows: Grade 1 in 10 cases, II in 2 cases, III in 1 case and IV in 1 case. In the 9 cases with ruptured SCA aneurysm, average size of the ruptured aneurysms was 7.3 mm (range = 2.5-27 mm, median = 4.9 mm). The subtemporal approach was used in the first 7 cases. The extradural temporopolar (EDTP) approach was used in the last 5 cases. Complications include vasospasm (n = 6), third nerve palsy (n = 5) and hydrocephalus (n = 3). Two patients died following surgery. At mean follow-up 33.8 months (median - 25 months, range = 19-96 months), no patient had a rebleed. At discharge 9 (64%), had a GOS of 4 or 5 and 3 (21%) had a GOS of 3. At 6 months follow-up, 10/14 (71%) patients had mRS of 0-2, and 2 (14%) had mRS of 5.

Conclusions: Aneurysms of the SCA are uncommon and tend to rupture even when the aneurysm size is small (<7 mm). They commonly present with SAH. The EDTP approach avoids complication caused by temporal lobe retraction and injury to the vein of Labbe.

No MeSH data available.


Related in: MedlinePlus