Surgical Neurology International

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1 Surgil Neurology Interntionl OPEN ACCESS For entire Editoril Bord visit : Editor: Jmes I. Ausmn, MD, PhD University of Cliforni, Los Angeles, CA, USA Originl Artile True posterior ommuniting neurysms: Three ses, three strtegies Breno Nery, Rirdo Arujo, Bruno Burjili, Timothy R. Smith 1, Jose Crlos Rodrigues Junior, Mrelo Nery Silv Deprtment of Neurosurgery, Hospitl Heliópolis, São Pulo, Brzil, 1 Deprtment of Neurosurgery, Brighm nd Women s Hospitl, Hrvrd University Shool of Mediine, Boston, MA, USA E mil: *Breno Nery renonery84@gmil.om; Rirdo Arujo rirdomlrujo@uol.om.r; Bruno Burjili runourj@yhoo.om.r; Timothy R. Smith timothy smith 0@fsm.northwestern.edu; Jose Crlos Rodrigues Junior joserlosnr@gmil.om; Mrelo Nery Silv mrelonr@gmil.om *Corresponding uthor Reeived: 02 Septemer 15 Aepted: 24 Novemer 15 Pulished: 05 Jnury 16 Astrt Bkground: The uthors provide review of true neurysms of the posterior ommuniting rtery (PCoA). Three ses dmitted in our hospitl re presented nd disussed s follows. Cse Desriptions: First ptient is 51 yer old femle presenting with Fisher II, Hunt Hess III (hedhe nd onfusion) surhnoid hemorrhge (SAH) from ruptured true neurysm of the right PCoA. She underwent suessful ipsilterl pterionl rniotomy for neurysm lipping nd ws dishrged on postopertive dy 4 without neurologil defiit. Seond ptient is 53 yer old femle with Fisher I, Hunt Hess III (hedhe, mild hemipresis) SAH nd multiple neurisms, one from left ophthlmi rotid rtery nd one (true) from right PCoA. These lesions were pprohed nd suessfully treted y single pterionl rniotomy on the left side. The ptient ws dishrged 4 dys fter surgery, with omplete reovery of musle strength during follow up. Third ptient is 69 yer old mle with Fisher III, Hunt Hess III (hedhe nd onfusion) SAH, from true PCoA on the right. He hd left sulvin rtery olusion with flow theft from the right verterl rtery to the left verterl rtery. The ptient underwent endovsulr tretment with ngioplsty nd stent plement on the left sulvin rtery tht resulted in neurysm olusion. Conlusion: In onlusion, despite their seldom ourrene, true PCoA neurysms n e suessfully treted with different strtegies. Aess this rtile online Wesite: DOI: / Quik Response Code: Key Words: Etiology, physiopthology, tretment, true posterior ommuniting rtery neurysms INTRODUCTION Twenty five perent of intrrnil neurysms rise from the internl rotid rtery (ICA) t the posterior ommuniting rtery (PCoA) origin, mking this site the seond most ommon lotion fter nterior ommuniting rtery (ACoA) neurysms. [4] True PCoA neurysms represent out 1.3% of ll intrrnil This is n open ess rtile distriuted under the terms of the Cretive Commons Attriution-NonCommeril-ShreAlike 3.0 Liense, whih llows others to remix, twek, nd uild upon the work non-ommerilly, s long s the uthor is redited nd the new retions re liensed under the identil terms. For reprints ontt: reprints@medknow.om How to ite this rtile: Nery B, Arujo R, Burjili B, Smith TR, Rodrigues JC, Silv MN. "True" posterior ommuniting neurysms: Three ses, three strtegies. Surg Neurol Int 2016;7:2. True -posterior-ommuniting-neurysms:- Three-ses,-three-strtegies/ 2016 Surgil Neurology Interntionl Pulished y Wolters Kluwer - Medknow

2 Surgil Neurology Interntionl 2016, 7:2 neurysms nd 6.8% of ll PCoA neurysms. [4] The so lled true PCoA neurysm ws first desried y Yoshid et l. [12] in He ttempted to formlize the nomenlture of neurysms originting diretly from the PCoA, 2 3 mm distl to the juntion of ICA with PCoA. The PCoA vsulr regionl ntomy is treherous due to the numerous perfortors rising from the posterior hlf of the rteril wll extending from the ommuniting segment of the rotid rtery, tht terminte on the opti hism nd trt, the floor of the third ventrile, the infundiulum, the posterior perforted sustne, nd the medil temporl loe. [3,12] Vritions of the irle of Willis re well desried nd ould hve primordil role in the development of erry neurysms long with other risk ftors suh s vsulr genetis, hnges in wll sher stress, smoking, hypertension, nd gender. [7] CASE REPORTS Cse report 1 L.M.S is 51 yer old who experiened proxysml, severe hedhe long with onfusion nd presented to seondry hospitl emergeny deprtment within few hours of onset. She hd medil history of poorly ontrolled hypertension, nd signifint smoking history (40 igrettes/dy for 20 yers). A omputed tomogrphy (CT) sn demonstrted surhnoid hemorrhge (SAH) with the preponderne of hemorrhge entered in the right Sylvin fissure. A linil dignosis of neurysml SAH (Hunt nd Hess Grde III, Fisher Grde II) ws mde. Four vessel digitl sutrtion ngiogrphy (DSA) reveled smll, true sulr neurysm with fetl type right PCoA. The neurysm ws 3 mm 4 mm in size, with postero superiorly direted 2 mm nek [Figure 1]. Figure 1: Lterl view of right internl rotid rtery ngiogrphy performed on June 18, Smll true sulr neurysm (white rrow) of the right posterior ommuniting rtery, 3 mm 4 mm size, nek dimeter of 2 mm, postero-superiorly direted, nd fetl pttern of ipsilterl posterior ommuniting rtery The ngiogrm lso reveled hypoplsi A1 segment of the right nterior ererl rtery. She ws trnsferred to our hospitl 30 dys fter her initil presenttion, nd her neurologil exm ws nonfol with mild meningismus (Hunt nd Hess Grde I). The ptient underwent n uneventful nd suessful mirosurgil lipping of the sulr neurysm through pterionl pproh [Figure 2]. The ptient developed postopertive mild presis of the ipsilterl oulomotor nerve, whih resolved y postopertive dy 3. A postopertive hed CT reveled no ovious omplitions. The ptient ws dishrged from the hospitl 4 dys fter surgery without ny neurologil defiits. Cse report 2 M.C.S., 53 yer old femle, with previous history of hypertension nd smoke (20 igrettes/dy for 30 yers), presented hedhe of moderte intensity for 5 dys, in the oiptoervil region, prtilly responsive to nonsteroidl nti inflmmtory drugs, followed y sudden inrese in pin intensity, long with right sided hemipresis, when she ws dmitted in seondry hospitl. The hed CT ws norml, ut lumr punture demonstrted SAH (Hunt nd Hess Grde III, Fisher Grde I). The four vessel DSA then reveled true sulr neurysm of the right PCoA, 6 mm 3 mm in size, inferiorly oriented, with 2 mm nek, nd sulr neurysm of the left ophthlmi segment of ICA, 12 mm 10 mm in size, superiorly oriented, with 5 mm nek [Figure 3]. We performed the surgil lipping of oth lesions with single pterionl pproh, on the left side, inluding n intrdurl linoidetomy [Figure 4]. Postopertive physil exmintion nd CT sn reveled no further omplitions nd she ws dishrged 4 dys fter the surgery with omplete reovery of musle strength during follow up. Cse report 3 A 69 yer old mle ptient presented to seondry hospitl emergeny deprtment with sudden hedhe followed y momentry loss of onsiene nd rnil nerve presis. After 18 dys of the initil symptoms, he ws trnsferred to our hospitl. By physil exmintion fter dmission, the ptient presented with slight hedhe nd nek stiffness, lood pressure on left rm of 140 mmhg 110 mmhg nd right rm of 170 mmhg 100 mmhg. Neurologil exm showed onsious nd oriented ptient with right oulomotor (III) nd trohler (IV) presis. The CT sn reveled Fisher Grde III SAH [Figure 5]. The susequent four vessel DSA reveled right true PCoA neurysm [Figure 5 nd ], olusion of the left sulvin rtery [Figure 6], right verterl rtery steel phenomen to the left verterl rtery [Figure 6] nd >80% right ICA stenosis. The therpeuti disussion ws sed on the ft tht the steel ws so importnt tht no enhnement of the superior segment of the silr rtery nd its

3 Surgil Neurology Interntionl 2016, 7:2 Figure 2: () From the left to the right, opti nerve, nterior ererl rtery, internl rotid rtery nd third rnil nerve. () Opti nerve nd internl rotid rtery slightly retrted to expose the opti rotid tringle with the neurysm inside it. () Clip in the nek of the neurysm Figure 3: () Contrlterl olique view of left internl rotid rtery ngiogrphy, with sulr neurysm of the ophthlmi segment, 12 mm 10 mm, 5 mm nek. () Lterl nd () nteroposterior views of right internl rotid rtery ngiogrphy, with true sulr neurysm of the posterior ommuniting rtery, 6 mm 3 mm, 2 mm nek Figure 4: () Intropertive view (pterionl ontrlterl pproh) of the posterior ommuniting rtery with its true neurysm, efore lipping. () During nd () fter lipping rmi were seen on posterior irultion ngiogrm, nd were minly supplied y the right PCoA. In this mnner we elieved tht the neurysm might e relted to the high flow through the PCoA, despite the importnt stenosis in right ICA. Our hypothesis ws tht norml flow restortion due to orretion of the left sulvin rtery ostrution would orret the steel phenomenon, diminishing the high flow through the PCoA, with possile neurysml exlusion. The ptient underwent renliztion nd stent plement on the left sulvin rtery [Figure 7], resulting in restortion of flow through the left verterl rtery [Figure 7]. Full replenishment of the verter silr irultion nd posterior ererl rteries (PCAs) [Figure 7] ws oserved. The flow through the PCoA ws lowered nd ontrst stgntion inside the neurysm ws oserved [Figure 7]. Lte ontrol ngiogrm of the orti rh nd right ICA showing dequte flow through the left sulvin rtery nd neurysm s irultion exlusion [Figure 8]. DISCUSSION True PCoA neurysms re rre with pooled dt reveling tht they represent 1.3% (95% onfidene intervl [CI] %) of ll intrrnil neurysms, nd 6.8% (95% CI %) of ll PCoA neurysms. [4] In reent systemti review nd met nlysis of individul ptient dt, the men ptient ge of symptom onset ws 53.5 yers, (53.5

4 Surgil Neurology Interntionl 2016, 7:2 Figure 5: () Axil omputed tomogrphy sn showing Fisher III surhnoid hemorrhge. ( nd ) Right internl rotid rtery ngiogrm showing the sulr true posterior ommuniting rtery neurysm (lk rrows) Figure 6: () Aorti rtery ngiogrm showing left sulvin rtery olusion (lk rrow). () Right verterl rtery ngiogrm showing steel phenomenon from the right verterl rtery to the left verterl nd silr nd posterior ererl rteries low flow (lk rrows) Figure 8: () Lte ontrol ngiogrm of the orti rh nd right internl rotid rtery showing dequte flow through the left sulvin rtery (lk rrow). () Aneurysm s irultion exlusion Figure 7: () Aorti rh ngiogrm showing the rterioplsty proedure nd stent pling on the left sulvin rtery (lk rrow). () Left verterl ngiogrm fter rterioplsty with dequte filling of the verterosilr irultion nd posterior ererl rteries. () Right internl rotid rtery fter rterioplsty nd diminished flow on the posterior ommuniting rtery with ontrst stgntion inside the neurysm (empty lk rrow) ± 15.4 yers), nd rnged from 23 to 79 yers. [4] At the time of this pulition, 49 ptients with true PCoA hve een reported in the literture, with the mjority presenting with rupture (89.8%). There hve een no signifint reported differenes in ruptured sttus etween ge of ourrene (P = 0.321), left versus right neurysm (P = 0.537) nd shpe of neurysm (P = 0.408). There is puity of literture regrding the pthophysiology of true PCoA neurysm. Aneurysms of the PCoA n our t the juntion with the ICA, PCA or the proximl PCoA itself. [5] It is well known tht the suprlinoid rotid rtery, fter the emergene of the superior hypophysel rtery, turns upwrd towrd the nterior perforted sustne to form urve tht is onvex posteriorly. [3] The most ommon vriety of rotid rtery neurysm rises t the ommuniting segment of the ICA. [3] This epidemiology supports the four priniples of the opertive tretment of intrrnil neurysms: (1) They rise t rnhing points on the prent rtery; (2) they our t urve or turn in the rtery; (3) sullr neurysms point in the diretion of the proximl segment hemodynmi vetor; (4) there is onsistent group of perforting rteries situted t eh neurysm site tht need to e preserved to hieve n optiml ptient outomes. [3] These neurysms rise from the posterior wll of the rotid rtery ner the pex of this turn, immeditely ove the distl edge of the origin of the PCoA. [12] Hemodynmi stressors ontriute to neurysm formtion nd my e ssoited with prent vessel size nd neurysm lotion. [5] Morphometri nlysis hs een performed using CT ngiogrphy to determine the ext origin of true PCoA neurysms. [5] In totl of 77 PCoA neurysms nlyzed, 10 (13%) were found to e true PCoA neurysms. The ipsilterl PCoA/P1 rtio (1.77 ± 0.44 vs ± 0.46, P = ) nd ipsilterl P2/P1 rtio (1.73 ± 0.40 vs ± 0.41, P = ) were signifintly higher in true PCoA neurysms, suggesting tht true PCoA neurysms hve lrger PCoA reltive to the ipsilterl P1 segment. Juntionl neurysms hd lrger size thn true PCoA neurysms (P = 0.03), ut the

5 Surgil Neurology Interntionl 2016, 7:2 rupture rte ws not sttistilly different etween oth groups (~80%, P = not signifint). This suggests tht true PCoA neurysms might e more prone to rupture thn juntionl neurysms, lthough needs further nlysis to onfirm those onlusions. It is well known tht hemodynmi ltertions within the ICA from either ntomi/pthologi hypoplsti segments or itrogeni olusion n diretly influene the development of intrrnil neurysms. [1,6,11] There is lso evidene tht de novo neurysms n rise in the ACoA or ontrlterl ICA fter oiling or lipping of intrrnil neurysms. [2,10] Ksper et l. [8] demonstrted, through Doppler ultrsonogrphy, tht there is oth inresed veloity nd turulene of lood flow in PCoA when ptients re sumitted to ICA olusion. These n susequently led to the development of true PCoA neurysms. Mirosurgil understnding of this unique ntomy is lso essentil for minimizing moridity ssoited with surgil lipping. It is ritil to note tht for true PCoA neurysms, the nek rises distl to the origin of the PCoA, nd therefore resides in wht is trditionlly onsidered n intr opertive lind spot. The PCoA must e followed posteriorly to visulize the neurysm nek for mirosurgil lipping. [9] CONCLUSION In onlusion, true PCoA neurysms re rre. Muh is still unler regrding its pthophysiology. Preopertive ntomil understnding nd mirosurgil fility re prmount for tretment, nd speil onsidertion must e pid to the perforting rteries. The seldom ourrene of suh lesion does not imply tht tretment will hve poor outome, nd different strtegies my e used. Finnil support nd sponsorship Nil. Conflits of interest There re no onflits of interest. REFERENCES 1. de Gst AN, Sprengers ME, vn Rooij WJ, Lvini C, Sluzewski M, Mjoie CB. Long term 3T MR ngiogrphy follow up fter therpeuti olusion of the internl rotid rtery to detet possile de novo neurysm formtion. AJNR Am J Neurordiol 2007;28: Ferns SP, Sprengers ME, vn Rooij WJ, vn den Berg R, Velthuis BK, de Kort GA, et l. De novo neurysm formtion nd growth of untreted neurysms: A 5 yer MRA follow up in lrge ohort of ptients with oiled neurysms nd review of the literture. Stroke 2011;42: Gio H, Lenkey C, Rhoton AL Jr. Mirosurgil ntomy of the suprlinoid portion of the internl rotid rtery. J Neurosurg 1981;55: He W, Gndhi CD, Quinn J, Krimi R, Prestigiomo CJ. True neurysms of the posterior ommuniting rtery: A systemti review nd met nlysis of individul ptient dt. World Neurosurg 2011;75: He W, Huptmn J, Psupuleti L, Setton A, Frrow MG, Ksper L, et l. True posterior ommuniting rtery neurysms: Are they more prone to rupture? A iomorphometri nlysis. J Neurosurg 2010;112: Jou LD, Lee DH, Morsi H, Mwd ME. Wll sher stress on ruptured nd unruptured intrrnil neurysms t the internl rotid rtery. AJNR Am J Neurordiol 2008;29: Juvel S, Pouss K, Porrs M. Ftors ffeting formtion nd growth of intrrnil neurysms: A long term follow up study. Stroke 2001;32: Ksper W, Mjhrzk H, Koper M, Ldzinski P. True neurysm of the posterior ommuniting rtery s possile effet of ollterl irultion in ptient with olusion of the internl rotid rtery. A se study nd literture review. Minim Invsive Neurosurg 2002;45: Kuzmik GA, Bulsr KR. Mirosurgil lipping of true posterior ommuniting rtery neurysms. At Neurohir (Wien) 2012;154: Miller CA, Hill SA, Hunt WE. De novo neurysms. A linil review. Surg Neurol 1985;24: Ogswr K, Numgmi Y, Kithr M. A se of ruptured true posterior ommuniting rtery neurysm thirteen yers fter surgil olusion of the ipsilterl ervil internl rotid rtery. No Shinkei Gek 1995;23: Yoshid M, Wtne M, Kurmoto S. True posterior ommuniting rtery neurysm. Surg Neurol 1979;11: