Surgical treatment of a double origin posterior inferior cerebellar artery aneurysm and insights from embryology: Case report and literature review

Abstract

BACKGROUND AND IMPORTANCE: Aneurysms affecting double origin (DO) posterior inferior cerebellar artery (PICA) variants are rare. Most reports describe endovascular occlusion of the affected branch to treat the aneurysm, but we describe a patient in which open surgical sacrifice of 1 branch resulted in insufficient perfusion. This case and our review of PICA embryology provide insight into treatment of aneurysms affecting duplicated intracranial vessels. CLINICAL PRESENTATION: We report the only case of open surgical treatment of an aneurysm affecting a leg of a DOPICA. A 42-year-old woman presenting with the worst headache of her lifewas found to have a DOPICA aneurysmand initially treated by trapping the aneurysm. Intraoperative indocyanine green imaging revealed insufficient perfusion through the caudal branch,which was remediated by end-to-end anastomosis to preserve flow through both origins. The patient made a full recovery. CONCLUSION: Treating aDOPICA aneurysmby sacrificing 1 of the origins is not possible for all patients. This first report of open surgical treatment of a DOPICA leg aneurysmsuggests that 1 or both branches may be required for sufficient perfusion, and the unique embryology of DOPICA development suggests a possible mechanism.