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Technical considerations and challenges in treatment of a ruptured PICA aneurysm in a morbidly obese patient
Interdisciplinary Neurosurgery 20 (2020) 100680
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery journal homepage: www.elsevier.com/locate/inat
Technical notes & surgical techniques
Technical considerations and challenges in treatment of a ruptured PICA aneurysm in a morbidly obese patient Daniel M.S. Rapera, Mariam Ishaqueb, Christopher Nealc, Min S. Parkb,
T
⁎
a
Department of Neurological Surgery, University of California San Francisco, CA, USA Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA c Department of Neurosurgery, Mary Washington Hospital, Fredericksburg, VA, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Endovascular Onyx Posterior inferior cerebellar artery Subarachnoid haemorrhage
Morbid obesity presents unique challenges in the treatment of many neurosurgical conditions. In ruptured posterior circulation aneurysms, endovascular treatment has emerged as the safest and most efficacious treatment modality in the majority of cases. We present a technical report of a patient with extensive subarachnoid hemorrhage from a ruptured distal PICA aneurysm. The patient was taken to the hybrid OR with biplane fluoroscopy, utilizing a unique operative set-up to enable safe endovascular treatment. The PICA aneurysm was treated via a transradial approach with distal PICA occlusion using Onyx liquid embolysate. The patient remained neurologically intact and was discharged home after 14 days. This case illustrates a number of technical adjustments that may be made in the safe treatment of patients in whom obesity otherwise limits treatment options.
1. Introduction Posterior inferior cerebellar artery (PICA) aneurysms account for 0.5–3% of intracranial aneurysms [8], and can present unique challenges for surgical and endovascular treatment depending on location and aneurysm morphology. Patient factors such as medical comorbidities and coagulation status can alter the balance in decision-making between surgical and endovascular approaches. Morbid obesity, however, presents a particular challenge for both open and minimally invasive approaches. Prone or semi-prone positioning may be limited in patients in which excess mass limits the anesthetist’s ability to ventilate the patient adequately; excess tissue over the shoulder and neck can severely limit the operative corridor from a far lateral approach; and a deep-seated femoral artery may be impossible to palpate, visualize with an ultrasound, or even access with standard arterial puncture needles. We present a case of a patient with a ruptured distal PICA aneurysm, in whom a constellation of innovative approaches was used to successfully overcome the challenges posed by the patient’s body habitus. 2. Technical case report A 47-year old lady presented to the hospital with progressive headache, nausea and vomiting, and was found to have a Hunt-Hess grade 1, Fisher grade 4 subarachnoid hemorrhage with associated ⁎
intracerebral hemorrhage (ICH) within the cerebellar vermis and intraventricular hemorrhage (IVH) in the fourth, third and lateral ventricles (Fig. 1). She was morbidly obese, with a weight of 235 kg (519 lb) and body mass index of 86.4. Prior medical history included congestive heart failure, pulmonary disease and prior deep vein thrombosis and pulmonary embolus. An external ventricular drain was placed, but she experienced neurological decline on the evening of presentation and required intubation. CT angiogram revealed a 4 × 4 mm fusiform aneurysm in the distal right posterior inferior cerebellar artery (PICA) (Fig. 1). The patient was considered for endovascular treatment; however, the procedural table in the angiography suite was operational only up to a patient weight of 225 kg. Therefore, the patient was taken to the hybrid operating room, equipped with biplane fluoroscopy. The built-in operating table was likewise operational only up to a patient weight of 225 kg and could not be used. Therefore, a regular operating table rated for patient weight up to 450 kg, was brought into the room and positioned next to the built-in table in order to allow access to the biplane unit. The set-up of the operating room was arranged to facilitate endovascular treatment, within the limitations imposed by the hybrid table, which was built into the hybrid suite. The set-up primarily allowed use of the A-plane of the biplane unit, but with the ability to maneuver the fluoroscopic arm through a wide range of angulation. Due to the patient’s habitus, a transradial approach was utilized.
Corresponding author at: Department of Neurosurgery, P.O. Box 800212, Charlottesville, VA 22908, USA. E-mail address: [email protected] (M.S. Park).
https://doi.org/10.1016/j.inat.2020.100680 Received 2 October 2019; Accepted 2 February 2020 2214-7519/ © 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Interdisciplinary Neurosurgery 20 (2020) 100680
D.M.S. Raper, et al.
Fig. 1. (A) A 47-year old, morbidly obese lady presented to the hospital with progressive headache, nausea and vomiting, and was found to have a Hunt-Hess grade 1, Fisher grade 4 subarachnoid hemorrhage with associated intracerebral hemorrhage (ICH) within the cerebellar vermis and intraventricular hemorrhage (IVH) in the fourth, third and lateral ventricles with hydrocephalus. (B) CTA demonstrating 4 × 4 mm fusiform distal right PICA aneurysm. (C) Right VA digital subtraction angiogram redemonstrates the distal PICA aneurysm. (D) Postembolization of the distal PICA with Onyx-18 liquid embolysate, demonstrating no further filling of the distal PICA or aneurysm.
3. Discussion
Angiogram further characterized the fusiform right PICA aneurysm, which due to its distal location was not able to be primarily treated with coiling. Therefore, a distal PICA sacrifice was performed. Briefly, a Benchmark guide catheter (Penumbra, Alameda, CA) was positioned in the distal right cervical vertebral artery. Next, under roadmap guidance, an Apollo microcatheter (EV3, Irvine, CA) was taken out over a microwire (Synchro 010, Stryker, Fremont, CA) into the distal telovelotonsillar segment of the right PICA. Superselective angiography demonstrated two main distal PICA branches, one which supplied the lateral cerebellar territory and a medial branch towards the aneurysm. We attempted to navigate into the distal most branch to the aneurysm. However, this resulted in prolapse of the catheter into the distal vertebral artery. Therefore, we re-navigated into position and elected to perform the vessel sacrifice from this position. Embolization was then performed to occlude the distal PICA using Onyx 18 liquid embolysate. Using blank roadmap guidance, Onyx was injected slowly under continuous fluoroscopic monitoring until a plug had formed within the vessel proximal to the aneurysm. The microcatheter was then removed without difficulty. Control angiography revealed good filling of the proximal segments of the right PICA to the telovelotonsillar segment, with no evidence of ongoing filling of the aneurysm. There was excellent retrograde collateral flow to the inferior lateral portion of the cerebellum originally served by the PICA. The patient was brought back to the neurointensive care unit, and was extubated the following day (post-bleed day 2). No procedural complications were encountered. The patient remained neurologically intact and was discharged from the hospital on post-bleed day 14.
In the past two decades, endovascular therapy has emerged as the primary treatment modality for posterior circulation aneurysms in the majority of cases [5,10]. Despite this paradigm shift in treatment approach, certain patients present ongoing challenges in planning and executing endovascular treatment. Morbid obesity is a commonly encountered impediment to routine care, and in its extreme form may require significant alterations in approach. Morbid obesity, but not mild obesity, has been linked to worse outcomes after aneurysmal subarachnoid hemorrhage in population-level analysis [4]. The technical adjustments that were made in this case in relation to the patient’s body habitus were: 1) treatment in the biplane-equipped hybrid operating room; 2) use of the regular OR table in combination with the built-in biplane fluoroscopy unit; 3) use of transradial access; and 4) deconstructive treatment using Onyx. Endovascular treatment has been used for both proximal and distal PICA aneurysms [2]. Naturally, deconstructive techniques are more commonly necessary for distal PICA aneurysms [2,9], in which the small caliber of the distal PICA and tortuosity of its course limit the ability to navigate the vessel with a microcatheter and to treat adequately with coiling or adjunctive techniques. In the largest reported series of endovascularly treated PICA aneurysms, endovascular treatment failed in over 13% of distal aneurysms [2], and a deconstructive technique was required in 32% of distal aneurysms that were treated. Onyx has been reported in select cases as a means of treating distal PICA aneurysms, either for proximal deconstruction or with the aim of 2
Interdisciplinary Neurosurgery 20 (2020) 100680
D.M.S. Raper, et al.
filling the aneurysm dome [2,10–12]. Procedure-related complications for distal PICA aneurysms treated endovascularly occur in approximately 10% of cases [2,10–12]. Generally, distal PICA sacrifice is well tolerated without a high risk of neurological deficit. Surgical options for distal PICA aneurysms include suboccipital craniotomy and microsurgical clipping, wrapping, or bypass, usually consisting of an excision of the affected segment of vessel and re-anastomosis [3]. In an analysis of 102 PICA aneurysms treated over a 12year period, endovascular therapy was less likely to cause postoperative neurological deficit, although long-term functional outcomes were significantly predicted only by severity of presenting symptoms and increasing age, rather than treatment modality [6]. The transradial approach has been used successfully in stroke thrombectomy [1], and is particularly useful in patients with tortuous or folded aortic arche. Vascular tortuosity has been associated with obesity [7], often complicating access to the intracranial vasculature for endovascular procedures. The transradial approach, particularly for access to the ipsilateral vertebral artery, can avoid the necessity of introducing bulky coaxial support systems that can increase the possibility of thromboembolic complications and iatrogenic vascular injury. Finally, our case illustrates how creative use of space in the operating theatre may be used to overcome weight limitations of certain endovascular equipment. In extreme cases, a C-arm may be used to perform fluoroscopy in a single plane in a regular operating room, utilizing an operative table designed for morbidly obese patients. Such deviations from standard protocols require the cooperation of all team members including OR and interventional staff, as well as the surgical and anaesthetic teams, in order to develop a creative solution to what can seem like an otherwise insurmountable problem.
influence the work reported in this paper. References [1] S. Sur, B. Snelling, P. Khandelwal, J.M. Caplan, E.C. Peterson, R.M. Starke, D.R. Yavagal, Transradial approach for mechanical thrombectomy in anterior circulation large-vessel occlusion, Neurosurg. Focus 42 (4) (2017) E13. [2] N. Chalouhi, P. Jabbour, R.M. Starke, S.I. Tjoumakaris, L.F. Gonzalez, S. Witte, R.H. Rosenwasser, A.S. Dumont, Endovascular treatment of proximal and distal posterior inferior cerebellar artery aneurysms, J. Neurosurg. 118 (2013) 991–999. [3] A.A. Abla, C.M. McDougall, J.D. Breshears, M.T. Lawton, Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients, J. Neurosurg. 124 (2016) 1275–1286. [4] H.H. Dasenbrock, M.O. Nguyen, K.U. Frerichs, D. Guttieres, W.B. Gromley, M.A. Aziz-Sultan, R. Du, The impact of body habitus on outcomes after aneurysmal subarachnoid hemorrhage: a nationwide inpatient sample analysis, J. Neurosurg. 127 (2017) 36–46. [5] B.A. Coert, S.D. Chang, H.M. Do, M.P. Marks, G.K. Steinberg, Surgical and endovascular management of symptomatic posterior circulation fusiform aneurysms, J. Neurosurg. 106 (2007) 855–865. [6] B.N. Bohnstedt, M. Ziemba-Davis, G. Edwards, J. Brom, T.D. Payner, T.J. Leipzig, J.A. Scott, A.J. DeNardo, E. Palmer, A.A. Cohen-Gadol, Treatment and outcomes anong 102 posterior inferior cerebellar artery aneurysms: a comparison of endovascular and microsurgical clip ligation, World Neurosurg. 83 (2015) 784–793. [7] M. Mochida, H. Sakamoto, Y. Sawada, H. Yokoyama, M. Sato, H. Sato, Y. Oyama, M. Kurabayashi, J. Tamura, T. Sakamaki, Visceral fat obesity contributes to the tortuosity of the thoracic aorta on chest radiograph in poststroke Japanese patients, Angiology 57 (2006) 85–91. [8] J.P. Peluso, W.J. van Rooij, M. Sluzewski, G.N. Beute, C.B. Majoie, Posterior inferior cerebellar artery aneurysms: incidence, clinical presentation, and outcome of endovascular treatment, AJNR Am. J. Neuroradiol. 29 (2008) 86–90. [9] J.R. Mascitelli, K. Yaeger, D. Wei, C.P. Kellner, T.J. Oxley, R.A. De Leacy, J.T. Fifi, A.B. Patel, T.P. Naidich, J.B. Bederson, J. Mocco, Multimodality treatment of posterior inferior cerebellar artery aneurysms, World Neurosurg. 106 (2017) 493–503. [10] H. Ishihara, S. Tateshima, R. Jahan, N. Gonzalez, G. Duckwiler, F. Vinuela, Endovascular treatment of ruptured dissecting aneurysms of the posterior inferior cerebellar artery, J. Neurointerv. Surg. 5 (2013) 557–561. [11] A.S. Puri, F. Massari, S.Y. Hou, J.D. Lozano, M. Howk, M. Perras, et al., Onyx embolization in distal dissecting posterior inferior cerebellar artery aneurysms, J. Neuorinterv. Surg. 8 (2016) 501–506. [12] F. Xu, Y. Hong, Y. Zheng, Q. Xu, B. Leng, Endovascular treatment of posterior inferior cerebellar artery aneurysms: a 7-year single-center experience, J. Neurointerv. Surg. 9 (2016) 45–51.
Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to
3
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery journal homepage: www.elsevier.com/locate/inat
Technical notes & surgical techniques
Technical considerations and challenges in treatment of a ruptured PICA aneurysm in a morbidly obese patient Daniel M.S. Rapera, Mariam Ishaqueb, Christopher Nealc, Min S. Parkb,
T
⁎
a
Department of Neurological Surgery, University of California San Francisco, CA, USA Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA c Department of Neurosurgery, Mary Washington Hospital, Fredericksburg, VA, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Endovascular Onyx Posterior inferior cerebellar artery Subarachnoid haemorrhage
Morbid obesity presents unique challenges in the treatment of many neurosurgical conditions. In ruptured posterior circulation aneurysms, endovascular treatment has emerged as the safest and most efficacious treatment modality in the majority of cases. We present a technical report of a patient with extensive subarachnoid hemorrhage from a ruptured distal PICA aneurysm. The patient was taken to the hybrid OR with biplane fluoroscopy, utilizing a unique operative set-up to enable safe endovascular treatment. The PICA aneurysm was treated via a transradial approach with distal PICA occlusion using Onyx liquid embolysate. The patient remained neurologically intact and was discharged home after 14 days. This case illustrates a number of technical adjustments that may be made in the safe treatment of patients in whom obesity otherwise limits treatment options.
1. Introduction Posterior inferior cerebellar artery (PICA) aneurysms account for 0.5–3% of intracranial aneurysms [8], and can present unique challenges for surgical and endovascular treatment depending on location and aneurysm morphology. Patient factors such as medical comorbidities and coagulation status can alter the balance in decision-making between surgical and endovascular approaches. Morbid obesity, however, presents a particular challenge for both open and minimally invasive approaches. Prone or semi-prone positioning may be limited in patients in which excess mass limits the anesthetist’s ability to ventilate the patient adequately; excess tissue over the shoulder and neck can severely limit the operative corridor from a far lateral approach; and a deep-seated femoral artery may be impossible to palpate, visualize with an ultrasound, or even access with standard arterial puncture needles. We present a case of a patient with a ruptured distal PICA aneurysm, in whom a constellation of innovative approaches was used to successfully overcome the challenges posed by the patient’s body habitus. 2. Technical case report A 47-year old lady presented to the hospital with progressive headache, nausea and vomiting, and was found to have a Hunt-Hess grade 1, Fisher grade 4 subarachnoid hemorrhage with associated ⁎
intracerebral hemorrhage (ICH) within the cerebellar vermis and intraventricular hemorrhage (IVH) in the fourth, third and lateral ventricles (Fig. 1). She was morbidly obese, with a weight of 235 kg (519 lb) and body mass index of 86.4. Prior medical history included congestive heart failure, pulmonary disease and prior deep vein thrombosis and pulmonary embolus. An external ventricular drain was placed, but she experienced neurological decline on the evening of presentation and required intubation. CT angiogram revealed a 4 × 4 mm fusiform aneurysm in the distal right posterior inferior cerebellar artery (PICA) (Fig. 1). The patient was considered for endovascular treatment; however, the procedural table in the angiography suite was operational only up to a patient weight of 225 kg. Therefore, the patient was taken to the hybrid operating room, equipped with biplane fluoroscopy. The built-in operating table was likewise operational only up to a patient weight of 225 kg and could not be used. Therefore, a regular operating table rated for patient weight up to 450 kg, was brought into the room and positioned next to the built-in table in order to allow access to the biplane unit. The set-up of the operating room was arranged to facilitate endovascular treatment, within the limitations imposed by the hybrid table, which was built into the hybrid suite. The set-up primarily allowed use of the A-plane of the biplane unit, but with the ability to maneuver the fluoroscopic arm through a wide range of angulation. Due to the patient’s habitus, a transradial approach was utilized.
Corresponding author at: Department of Neurosurgery, P.O. Box 800212, Charlottesville, VA 22908, USA. E-mail address: [email protected] (M.S. Park).
https://doi.org/10.1016/j.inat.2020.100680 Received 2 October 2019; Accepted 2 February 2020 2214-7519/ © 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Interdisciplinary Neurosurgery 20 (2020) 100680
D.M.S. Raper, et al.
Fig. 1. (A) A 47-year old, morbidly obese lady presented to the hospital with progressive headache, nausea and vomiting, and was found to have a Hunt-Hess grade 1, Fisher grade 4 subarachnoid hemorrhage with associated intracerebral hemorrhage (ICH) within the cerebellar vermis and intraventricular hemorrhage (IVH) in the fourth, third and lateral ventricles with hydrocephalus. (B) CTA demonstrating 4 × 4 mm fusiform distal right PICA aneurysm. (C) Right VA digital subtraction angiogram redemonstrates the distal PICA aneurysm. (D) Postembolization of the distal PICA with Onyx-18 liquid embolysate, demonstrating no further filling of the distal PICA or aneurysm.
3. Discussion
Angiogram further characterized the fusiform right PICA aneurysm, which due to its distal location was not able to be primarily treated with coiling. Therefore, a distal PICA sacrifice was performed. Briefly, a Benchmark guide catheter (Penumbra, Alameda, CA) was positioned in the distal right cervical vertebral artery. Next, under roadmap guidance, an Apollo microcatheter (EV3, Irvine, CA) was taken out over a microwire (Synchro 010, Stryker, Fremont, CA) into the distal telovelotonsillar segment of the right PICA. Superselective angiography demonstrated two main distal PICA branches, one which supplied the lateral cerebellar territory and a medial branch towards the aneurysm. We attempted to navigate into the distal most branch to the aneurysm. However, this resulted in prolapse of the catheter into the distal vertebral artery. Therefore, we re-navigated into position and elected to perform the vessel sacrifice from this position. Embolization was then performed to occlude the distal PICA using Onyx 18 liquid embolysate. Using blank roadmap guidance, Onyx was injected slowly under continuous fluoroscopic monitoring until a plug had formed within the vessel proximal to the aneurysm. The microcatheter was then removed without difficulty. Control angiography revealed good filling of the proximal segments of the right PICA to the telovelotonsillar segment, with no evidence of ongoing filling of the aneurysm. There was excellent retrograde collateral flow to the inferior lateral portion of the cerebellum originally served by the PICA. The patient was brought back to the neurointensive care unit, and was extubated the following day (post-bleed day 2). No procedural complications were encountered. The patient remained neurologically intact and was discharged from the hospital on post-bleed day 14.
In the past two decades, endovascular therapy has emerged as the primary treatment modality for posterior circulation aneurysms in the majority of cases [5,10]. Despite this paradigm shift in treatment approach, certain patients present ongoing challenges in planning and executing endovascular treatment. Morbid obesity is a commonly encountered impediment to routine care, and in its extreme form may require significant alterations in approach. Morbid obesity, but not mild obesity, has been linked to worse outcomes after aneurysmal subarachnoid hemorrhage in population-level analysis [4]. The technical adjustments that were made in this case in relation to the patient’s body habitus were: 1) treatment in the biplane-equipped hybrid operating room; 2) use of the regular OR table in combination with the built-in biplane fluoroscopy unit; 3) use of transradial access; and 4) deconstructive treatment using Onyx. Endovascular treatment has been used for both proximal and distal PICA aneurysms [2]. Naturally, deconstructive techniques are more commonly necessary for distal PICA aneurysms [2,9], in which the small caliber of the distal PICA and tortuosity of its course limit the ability to navigate the vessel with a microcatheter and to treat adequately with coiling or adjunctive techniques. In the largest reported series of endovascularly treated PICA aneurysms, endovascular treatment failed in over 13% of distal aneurysms [2], and a deconstructive technique was required in 32% of distal aneurysms that were treated. Onyx has been reported in select cases as a means of treating distal PICA aneurysms, either for proximal deconstruction or with the aim of 2
Interdisciplinary Neurosurgery 20 (2020) 100680
D.M.S. Raper, et al.
filling the aneurysm dome [2,10–12]. Procedure-related complications for distal PICA aneurysms treated endovascularly occur in approximately 10% of cases [2,10–12]. Generally, distal PICA sacrifice is well tolerated without a high risk of neurological deficit. Surgical options for distal PICA aneurysms include suboccipital craniotomy and microsurgical clipping, wrapping, or bypass, usually consisting of an excision of the affected segment of vessel and re-anastomosis [3]. In an analysis of 102 PICA aneurysms treated over a 12year period, endovascular therapy was less likely to cause postoperative neurological deficit, although long-term functional outcomes were significantly predicted only by severity of presenting symptoms and increasing age, rather than treatment modality [6]. The transradial approach has been used successfully in stroke thrombectomy [1], and is particularly useful in patients with tortuous or folded aortic arche. Vascular tortuosity has been associated with obesity [7], often complicating access to the intracranial vasculature for endovascular procedures. The transradial approach, particularly for access to the ipsilateral vertebral artery, can avoid the necessity of introducing bulky coaxial support systems that can increase the possibility of thromboembolic complications and iatrogenic vascular injury. Finally, our case illustrates how creative use of space in the operating theatre may be used to overcome weight limitations of certain endovascular equipment. In extreme cases, a C-arm may be used to perform fluoroscopy in a single plane in a regular operating room, utilizing an operative table designed for morbidly obese patients. Such deviations from standard protocols require the cooperation of all team members including OR and interventional staff, as well as the surgical and anaesthetic teams, in order to develop a creative solution to what can seem like an otherwise insurmountable problem.
influence the work reported in this paper. References [1] S. Sur, B. Snelling, P. Khandelwal, J.M. Caplan, E.C. Peterson, R.M. Starke, D.R. Yavagal, Transradial approach for mechanical thrombectomy in anterior circulation large-vessel occlusion, Neurosurg. Focus 42 (4) (2017) E13. [2] N. Chalouhi, P. Jabbour, R.M. Starke, S.I. Tjoumakaris, L.F. Gonzalez, S. Witte, R.H. Rosenwasser, A.S. Dumont, Endovascular treatment of proximal and distal posterior inferior cerebellar artery aneurysms, J. Neurosurg. 118 (2013) 991–999. [3] A.A. Abla, C.M. McDougall, J.D. Breshears, M.T. Lawton, Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients, J. Neurosurg. 124 (2016) 1275–1286. [4] H.H. Dasenbrock, M.O. Nguyen, K.U. Frerichs, D. Guttieres, W.B. Gromley, M.A. Aziz-Sultan, R. Du, The impact of body habitus on outcomes after aneurysmal subarachnoid hemorrhage: a nationwide inpatient sample analysis, J. Neurosurg. 127 (2017) 36–46. [5] B.A. Coert, S.D. Chang, H.M. Do, M.P. Marks, G.K. Steinberg, Surgical and endovascular management of symptomatic posterior circulation fusiform aneurysms, J. Neurosurg. 106 (2007) 855–865. [6] B.N. Bohnstedt, M. Ziemba-Davis, G. Edwards, J. Brom, T.D. Payner, T.J. Leipzig, J.A. Scott, A.J. DeNardo, E. Palmer, A.A. Cohen-Gadol, Treatment and outcomes anong 102 posterior inferior cerebellar artery aneurysms: a comparison of endovascular and microsurgical clip ligation, World Neurosurg. 83 (2015) 784–793. [7] M. Mochida, H. Sakamoto, Y. Sawada, H. Yokoyama, M. Sato, H. Sato, Y. Oyama, M. Kurabayashi, J. Tamura, T. Sakamaki, Visceral fat obesity contributes to the tortuosity of the thoracic aorta on chest radiograph in poststroke Japanese patients, Angiology 57 (2006) 85–91. [8] J.P. Peluso, W.J. van Rooij, M. Sluzewski, G.N. Beute, C.B. Majoie, Posterior inferior cerebellar artery aneurysms: incidence, clinical presentation, and outcome of endovascular treatment, AJNR Am. J. Neuroradiol. 29 (2008) 86–90. [9] J.R. Mascitelli, K. Yaeger, D. Wei, C.P. Kellner, T.J. Oxley, R.A. De Leacy, J.T. Fifi, A.B. Patel, T.P. Naidich, J.B. Bederson, J. Mocco, Multimodality treatment of posterior inferior cerebellar artery aneurysms, World Neurosurg. 106 (2017) 493–503. [10] H. Ishihara, S. Tateshima, R. Jahan, N. Gonzalez, G. Duckwiler, F. Vinuela, Endovascular treatment of ruptured dissecting aneurysms of the posterior inferior cerebellar artery, J. Neurointerv. Surg. 5 (2013) 557–561. [11] A.S. Puri, F. Massari, S.Y. Hou, J.D. Lozano, M. Howk, M. Perras, et al., Onyx embolization in distal dissecting posterior inferior cerebellar artery aneurysms, J. Neuorinterv. Surg. 8 (2016) 501–506. [12] F. Xu, Y. Hong, Y. Zheng, Q. Xu, B. Leng, Endovascular treatment of posterior inferior cerebellar artery aneurysms: a 7-year single-center experience, J. Neurointerv. Surg. 9 (2016) 45–51.
Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to
3