Abstract
A 62-year-old female patient presented following a sudden severe headache, which occurred while playing recreational sport and which was followed by a period of confusion. CT confirmed a basal subarachnoid hemorrhage (SAH) graded Fisher IV and CTA was suspicious for an aneurysm of the left posterior communicating artery (PcomA). DSA showed an infundibulum of the PcomA bilaterally, and additionally, on the left-hand side a small aneurysm (<2 mm fundus diameter) was located on the surface of the infundibulum. Selective coil occlusion of the small aneurysm appeared hazardous. Coil occlusion of the entire infundibulum would probably have been possible but may have necessitated the implantation of a stent in order to keep the coil(s) in place. Given the wide neck of the infundibulum and a hesitation to use dual antiplatelet medication in the acute phase after SAH, the decision was made to treat this patient with microsurgical clipping. The operation was well-tolerated and the patient recovered from the SAH. The expected result of surgery was the complete exclusion of the aneurysm from the circulation. A follow-up DSA 3 weeks after the operation revealed residual perfusion of the partially clipped aneurysm. The neck of the aneurysm, however, was now stenosed by the applied clip. Endovascular treatment was performed 7 weeks after the initial SAH. The attempt to catheterize the residual aneurysm fundus to permit coil occlusion failed, mainly related to the elongated proximal ICA. A high risk of vessel- and aneurysm perforation during this procedure was anticipated, so a p64 flow diverter was deployed into the concerning segment of the left supraclinoid ICA. Upon detachment of this flow diverter, instantaneous contrast stagnation in the aneurysm fundus was observed. The procedure was well-tolerated and follow-up DSA was scheduled to be performed 3 months later. The significance of infundibula of the PcomA as a source of SAH is the main topic of this chapter.
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Donauer, E., Jedi, F., Jangid, N., Juergens, M., Terstegge, K., Henkes, H. (2019). Posterior Communicating Artery Aneurysm: Subarachnoid Hemorrhage from a Small Aneurysm Located on an Infundibulum of the Posterior Communicating Artery; Partial Clipping of the Aneurysm, Followed by Endovascular Flow Diversion, with Good Clinical Outcome. In: Henkes, H., Lylyk, P., Ganslandt, O. (eds) The Aneurysm Casebook. Springer, Cham. https://doi.org/10.1007/978-3-319-70267-4_96-1
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