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Background: Brain aneurysms are mostly discovered during the investigation of subarachnoid hemorrhage (SAH). Some patients present neurological signs that may suggest the aneurysm’s topography, and the oculomotor nerve palsy (ONP) of the same side of the aneurysm is the most common sign. Only one case report of contralateral palsy was previously described in the medical literature. Case Description: Authors describe a patient who presented a classic manifestation of SAH associated with complete ONP, whose vascular investigation demonstrated a brain aneurysm located in the contralateral intracranial carotid. The patient was surgically treated with great neurologic outcome, and late angiography did not evidence other vascular abnormalities. Conclusion: The ipsilateral ONP is a common sign found in posterior communicating artery aneurysms; however, such aneurysm can have different presentations due to the elevation of intracranial pressure, and, in rarer cases, the ONP cannot be operated as a localizing sign.

Background: The treatment of internal carotid artery (ICA) – posterior communicating artery aneurysms (ICPC aneurysms) is challenging when a fetal posterior cerebral artery (PCA) arises from the saccular neck. This complex angioarchitecture renders endovascular approaches difficult. Giant thrombosed IC-PC aneurysms are also hard to treat by endovascular coiling because its flow-diversion effect is insufficient. Case Description: We report the first case of a ruptured giant thrombosed IC-PC aneurysm associated with a fetal PCA that was successfully treated by coil embolization with retrograde overlap horizontal stenting using low-profile stents introduced through the contralateral ICA. The aneurysm was completely occluded and follow-up MRI scans demonstrated the reduction of the aneurysmal size. Conclusion: Our technique is advantageous because low-profile stents can be used to treat lesions not accessible with flow-diverter stents due their presence in complex angioarchitectures, and overlap stenting may have flow-diversion effects that can result in the complete occlusion of giant thrombosed aneurysms.

Background: Subarachnoid hemorrhage with multiple aneurysms is very challenging because it is difficult to identify the ruptured aneurysm. We could not identify the ruptured aneurysm preoperatively, so we decided to treat all of the aneurysms as a single-stage surgery. Case Description: A 79-year-old woman was diagnosed with subarachnoid hemorrhage with multiple cerebral aneurysms at the right distal anterior cerebral artery, left middle cerebral artery, and right internal carotid artery- posterior communicating artery bifurcation. We could not identify the ruptured aneurysm preoperatively. We fixed her head using the Sugita head holding system (Mizuho Co., Ltd., Tokyo) and performed clipping for each aneurysm with bifrontal craniotomy and bilateral frontotemporal craniotomy as a single-stage operation. The last aneurysm seemed ruptured, and clipping for all the aneurysms was successful. She was discharged with a good postoperative course. The Sugita head holding system allowed turning the head of the patient toward the right and left with single fixation, leading to this single-stage operation. Conclusion: Several methods for identifying a ruptured aneurysm from multiple aneurysms have been reported, but under limited medical resources, this procedure would be one of the treatment strategies.

Background: Posterior cerebral artery aneurysms can frequently present with an ipsilateral cranial nerve III palsy. Case Description: We report the first case of a posterior cerebral artery aneurysm associated with a contralateral cranial nerve III palsy. A 64-year-old male presented with acute subarachnoid hemorrhage, Hunt and Hess grade 3, and a left-sided fixed and dilated pupil. Computed tomography scan showed hemorrhage, mainly within the left basal cisterns. Digital subtraction angiography revealed a right-sided P1–P2 junction aneurysm. Conclusions: This case demonstrates that, although the neurological exam can help pinpoint the location of a lesion, false localizing signs should be recognized.

Background Pure subdural hematoma (without subarachnoid, intraventricular, or intraparenchymal hemorrhage) due to a ruptured intracranial aneurysm is rare. Most reported cases involve an aneurysm along the internal carotid artery, posterior communicating artery, or middle cerebral artery. No reports have described an aneurysm along the transmastoid branches of the occipital artery. Case description A 70-year-old female presented with sudden-onset, excruciating headaches, associated with dizziness, nausea, and emesis. There was no history of trauma. Computed tomography (CT) head demonstrated a pure tentorial subdural hematoma. Vascular imaging revealed bilateral aneurysms along the transmastoid branches of the intracranial portion of both the occipital arteries. Consequently, these branches were embolized, with no residual filling of the aneurysms. After the procedure, the patient remained neurologically well. The patient was monitored appropriately for vasospasm, and was discharged home 10 days after presentation. Conclusion Rupture of aneurysms along intracranial branches of the occipital artery can lead to pure subdural hematoma along the tentorium.

Background: Aneurysms of the posterior cerebral artery (PCA) are rare and often associated with anterior circulation aneurysms. The lateral supraorbital approach allows for a very fast and safe approach to the ipsilateral lesions Circle of Willis. A technical note on the successful clip occlusion of two aneurysms in the anterior and posterior Circle of Willis via this less invasive approach has not been published before. The objective of this technical note is to describe the simultaneous microsurgical clip occlusion of an ipsilateral PCA-P1 and an internal carotid artery - posterior communicating artery (ICA-PCoA) aneurysm via the lateral supraorbital approach. Case Description: The authors present a technical report of successful clip occlusions of ipsilateral located PCA-P1 and ICA-PCoA aneurysms. A 59-year-old female patient was diagnosed with a PCA-P1 and an ipsilateral ICA-PCoA aneurysm by computed tomography angiography (CTA) after an ischemic stroke secondary to a contralateral ICA dissection. The patient underwent microsurgical clipping after a lateral supraorbital craniotomy. The intraoperative indocyanine green (ICG) videoangiography and the postoperative CTA showed a complete occlusion of both aneurysms; the parent vessels (ICA and PCA) were patent. The patient presents postoperative no new neurologic deficit. Conclusion: The lateral supraorbital approach is suitable for the simultaneous microsurgical treatment of proximal anterior circulation and ipsilateral proximal PCA aneurysms. Compared to endovascular treatment, direct visual control of brainstem perforators is possible.

Background True hemodynamic assessment of the posterior communicating artery (PComA) by preoperative angiography in terms of its perforators and configuration (adult vs. fetal vs. transitional) can be challenging in the surgical treatment of aneurysms involving the PComA, posterior cerebral artery, and basilar artery. Indocyanine green videoangiography (ICG-VA) is a widely accepted new technique in the surgical treatment of intracranial aneurysms to assess the patency of the parent artery, branches, and residual flow within the aneurysm after clipping. Case description Here we report two cases in which ICG-VA was utilized to assess either the direction of flow in the PComA or preservation of the PComA perforators with temporary clip application before dividing the PComA. Conclusions Our experience is that ICG-VA can be used to assess the main trunk, and perforating branches of the PComA providing real-time, dynamic intraoperative information of the surgical field. Therefore we suggest that ICG-VA may increase the safety of surgical treatment of aneurysm involving PComA.

Background: Arachnoid cysts are congenital lesions that contain fluid identical to cerebrospinal fluid (CSF). They usually do not communicate with CSF spaces. The vast majority of arachnoid cysts are congenital asymptomatic lesions that are discovered incidentally. Those lesions that do become symptomatic typically present in childhood with signs and symptoms of intracranial hypertension, seizures, and focal neurologic deficits specific to cyst location. Case Description: A rare case of a parasellar arachnoid cyst presenting with oculomotor palsy is presented. The patient is a 45-year-old male who presented with acute onset diplopia and frontal headache. Neurologic examination revealed right ptosis, pupillary dilation, and opthalmoparesis consistent with an oculomotor palsy. Computed tomography (CT) scan and lumbar puncture failed to reveal evidence of a subarachnoid hemorrhage. Magnetic resonance imaging (MRI) of the brain demonstrated a 1 cm right parasellar nonenhancing mass that was hyperintense on T2 flair and with a fluid-fluid level concerning for a thrombosed posterior communicating artery (PCommA) aneurysm. There was an additional finding of a left occipital pole intraparenchymal hemorrhage in the setting of multiple hereditary cavernomas. Formal cerebral angiography revealed normal intracranial and extracranial vasculature. The patient was taken to the operating room for a right frontotemporal craniotomy, which revealed compression of the right oculomotor nerve by an arachnoid cyst. The cyst was fenestrated and resected with decompression of the oculomotor nerve. Postoperatively, the third nerve palsy had completely resolved. Conclusions: The above case demonstrates that arachnoid cysts should be considered in the differential for patients presenting with nonpupil sparing third nerve palsy and require timely surgical intervention. As is the case for an expanding PCommA aneurysm, prompt decompression results in the best chance for recovery of oculomotor nerve function.

Background: Olfactory hallucination, a symptom of medial temporal lobe epilepsy, is rarely associated with unruptured intracranial aneurysms. Case Description: We encountered this situation in a 70-year-old woman with an unruptured aneurysm at the bifurcation of the internal carotid and posterior communicating artery. We were able to achieve epileptic control by craniotomy clipping and medial temporal lesionectomy. Conclusion: According to our knowledge, previous reports are limited to cases of large middle cerebral artery aneurysms compressing the lateral orbitofrontal cortex, and this is apparently the first report of a case where olfactory hallucinations occurred from direct stimulation of the entorhinal cortex by an internal carotid and posterior communicating artery bifurcation aneurysm. We examined the pathophysiology underlying the development of olfactory hallucinations. We found craniotomy clipping and focal resection to be useful from the standpoint of seizure control. Whether seizure control can also be obtained with intracranial aneurysm coiling should be investigated in the future.

Background: The management of cerebral aneurysms requires a significant level of expertise, and large areas of the country have limited access to such advanced neurosurgical care. The objective of this study was to examine the impact of longer travel distance on aneurysm management. Methods: Adult patients treated for cerebral aneurysms from January 1, 2013 to January 1, 2016, were retrospectively identified. Demographic data, socioeconomic data, aneurysm characteristics, and postoperative outcomes were evaluated with univariate and multivariable analysis to determine factors that influenced treatment prior to or after rupture. Results: Two hundred fifty aneurysms (87 ruptured) were treated during the study period. Patients treated after rupture were more likely than those treated before rupture to live in areas with lower median household income (62% vs. 45%, P = 0.009), to live further from the treatment center (68% vs. 40%, P < 0.001), and to have aneurysms in the anterior communicating artery, anterior cerebral artery, or posterior communicating artery (P < 0.001). On multivariable analysis, longer travel distance (OR 3.288, 95% CI 1.562–6.922, P = 0.002), lower income (1.899, 95% CI 1.003–3.596, P = 0.049), and aneurysm location (P = 0.035) remained significantly associated with treatment after rupture. Conclusions: Patients who must travel further to receive advanced neurovascular care are more likely to receive treatment for their aneurysms only after they rupture. Further inquiry is needed to determine how to better provide neurosurgical treatment to patients living in underserved areas.

Background: The diencephalic leaf of the Liliequist’s membrane is a continuous structure that should be perforated in the endoscopic third ventriculostomy. Its lateral borders are penetrated by the third cranial nerve and the posterior communicating arteries. The most important complication of endoscopic third ventriculostomy is the vascular injury, such as the posterior communicating artery. The purpose of this study is to measure the distance between posterior communicating arteries located below the third ventricle floor and anterior of the mammillary bodies. Methods: In this observational prospective study 20 fresh brains from cadavers were utilized to measure the distance between the posterior communicating arteries in April 2008 at the Death Check Unit of our Institution. A digital photograph of the posterior communicating arteries was taken and the distance between the arteries was measured. The measurement was analyzed using descriptive statistics. Results: In the descriptive analysis of the 20 specimens, the posterior communicating arteries distance was 9 to 18.9 mm, a mean of 12.5 mm, median of 12.2 mm, standard deviation of 2.3 mm. Conclusion: The detailed knowledge of vascular structures involved in the endoscopic third ventriculostomy as to the posterior communicating arteries distance provides a safe lateral vascular border when performing such procedure.

Background: Technical advancements have significantly improved surgical and endovascular treatment of cerebral aneurysms. In this paper, we review the literature with regard to treatment of one of the most common intra-cranial aneurysms encountered by neurosurgeons and interventional radiologists. Conclusions: Anterior clinoidectomy, temporary clipping, adenosine-induced cardiac arrest, and intraoperative angiography are useful adjuncts during surgical clipping of these aneurysms. Coil embolization is also an effective treatment alternative particularly in the elderly population. However, coiled posterior communicating artery aneurysms have a particularly high risk of recurrence and must be followed closely. Posterior communicating artery aneurysms with an elongated fundus, true posterior communicating artery aneurysms, and aneurysms associated with a fetal posterior communicating artery may have better outcome with surgical clipping in terms of completeness of occlusion and preservation of the posterior communicating artery. However, as endovascular technology improves, endovascular treatment of posterior communicating artery aneurysms may become equivalent or preferable in the near future. One in five patients with a posterior communicating artery aneurysm present with occulomotor nerve palsy with or without subarachnoid hemorrhage. Factors associated with a higher likelihood of recovery include time to treatment, partial third nerve deficit, and presence of subarachnoid hemorrhage. Both surgical and endovascular therapy offer a reasonable chance of recovery. Based on level 2 evidence, clipping appears to offer a higher chance of occulomotor nerve palsy recovery; however, coiling will remain as an option particularly in elderly patients or patients with significant comorbidity.

Background: The authors provide a review of true aneurysms of the posterior communicating artery (PCoA). Three cases admitted in our hospital are presented and discussed as follows. Case Descriptions: First patient is a 51-year-old female presenting with a Fisher II, Hunt-Hess III (headache and confusion) subarachnoid hemorrhage (SAH) from a ruptured true aneurysm of the right PCoA. She underwent a successful ipsilateral pterional craniotomy for aneurysm clipping and was discharged on postoperative day 4 without neurological deficit. Second patient is a 53-year-old female with a Fisher I, Hunt-Hess III (headache, mild hemiparesis) SAH and multiple aneurisms, one from left ophthalmic carotid artery and one (true) from right PCoA. These lesions were approached and successfully treated by a single pterional craniotomy on the left side. The patient was discharged 4 days after surgery, with complete recovery of muscle strength during follow-up. Third patient is a 69-year-old male with a Fisher III, Hunt-Hess III (headache and confusion) SAH, from a true PCoA on the right. He had a left subclavian artery occlusion with flow theft from the right vertebral artery to the left vertebral artery. The patient underwent endovascular treatment with angioplasty and stent placement on the left subclavian artery that resulted in aneurysm occlusion. Conclusion: In conclusion, despite their seldom occurrence, true PCoA aneurysms can be successfully treated with different strategies.

Background Aneurysms arising from the posterior communicating artery (PCoA) itself are rare in which aneurysms usually located in the proximal portion of the PCoA. The authors report a case of the true PCoA ruptured aneurysm in the distal portion of the PCoA. Case description The patient was an 83-year-old man who suffered subarachnoid hemorrhage. Cerebral angiography revealed a saccular aneurysm arising on the fetal type right PCoA itself in the distal portion of the PCoA. 2 days after the onset of symptoms, the patient underwent right interfascial pterional craniotomy, with anterior temporal approach. The aneurysm was successfully clipped with the preservation of both the PCoA and the thalamoperforating artery. Conclusion We speculated that blood flow into the PCoA gradually increased after occlusion of the left vertebral artery, which induced tortuosity of the PCoA. As a result, hemodynamic stress might increase near the curvature and cause aneurysm formation.

Background Posterior communicating artery (PCoA) aneurysms are most commonly located at the junction of the internal carotid artery and the PCoA. "True" PCoA aneurysms, which originate from the PCoA itself, are rarely encountered. Most previously reported cases were treated surgically mainly before the endovascular option became available. Case description A 53-year-old male presented with sudden onset of right hemiparesis and aphasia. Left middle cerebral artery stroke was diagnosed. Further studies revealed a 3 mm left PCoA aneurysm arising from the PCoA itself, attached to neither the internal carotid artery nor the posterior cerebral artery. Endovascular treatment was performed and the aneurysm was coiled completely. Conclusion Technical advances in endovascular interventional technology have permitted an additional approach to these lesions. The possible endovascular significance of the treatment of true PCoA aneurysms is discussed.

Background: Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging. Case Description: The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery. Conclusions: M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators.

Background: Recent studies have hypothesized that hemodynamic changes in parent vessels are responsible for the formation and regression of cerebral aneurysms. One author has described regression of a “flow-related” 4-mm posterior communicating artery (PCoA) aneurysm following ipsilateral carotid endarterectomy (CEA), resulting in reversal of blood flow in the PCoA. Case Description: We report a 68-year-old woman with a coincidental intracranial aneurysm (ICA) and contralateral internal carotid artery stenosis. The aneurysm spontaneously regressed subsequent to contralateral ICA endarterectomy as documented by repeat computed tomographic angiography. This report also demonstrates the first known case of an ICA in the anterior cerebral artery territory to undergo spontaneous regression. Conclusions: We conclude that the regression and potentially the formation of this aneurysm correlated with hemodynamic factors associated with stenosis of the contralateral ICA.

Background: We describe an unusual presentation of a ruptured aneurysm of the posterior communicating artery with an acute subdural hematoma (SDH) located in the posterior fossa. We also reviewed the literature, focusing on the location of this intracranial hematoma. Case Description: An 83-year-old woman was admitted to our institution with recent sudden headache and dizziness. Magnetic resonance imaging showed a thin collection of blood in the subdural space adjacent to the clivus, along the wall of the posterior fossa, and at the cervical spine level. A right posterior communicating artery aneurysm was diagnosed using computed tomography angiography and digital subtraction angiography. The aneurysm had two lobes, one of which was attached to the right dorsum sellae. The aneurysm was occluded by stent-assisted coil embolization. The patient was discharged 3 weeks after admission with absence of neurological deficit. Conclusion: A ruptured aneurysm of the posterior communicating artery may cause an acute SDH.

Background: Cerebral aneurysm rupture can lead to devastating neurological complications and present a complex problem to treat. We report a unique case of a ruptured posterior communicating artery (PCoA) aneurysm presenting with sudden and complete vision loss. Case Description: A 39-year-old man presented with the acute onset of severe headache and complete bilateral vision loss. The patient described headaches for several months prior to presentation. However, prior to the day of presentation, he had no visual disturbance. A CT angiogram (CTA) and magnetic resonance imaging (MRI) of the brain revealed a 1.6-cm, non-contrast enhancing suprasellar mass, eccentric to the left side, consistent with hemorrhagic mass. There was no obvious aneurysm or vascular malformation. The sella tursica was normal in appearance. The patient was taken for an immediate endoscopic endonasal transtuberculum approach for optic nerve decompression. Hematoma without an associated tumor was encountered and partially evacuated before aborting with resultant partial improvement in vision. A subsequent cerebral angiogram revealed an irregularly shaped, postero-laterally pointing, 2.5-mm left PCoA aneurysm. The patient was then taken for open clipping of the ruptured aneurysm. A large, fibrinous capsule was found over the superolateral aspect of the aneurysm. The ruptured aneurysm was secured with clips and the surrounding hematoma was evacuated. Conclusion: In the immediate postoperative period, the patient regained vision in the nasal field of his right eye. This case illustrates a unique presentation of a ruptured PCoA aneurysm, and thus must be considered in the differential diagnosis of a suprasellar hemorrhage resulting in visual loss in absence of a recognizable associated tumor.

Coon et al. have performed an interesting study on aneurysm referral patterns to the Johns Hopkins Hospital utilizing the prospective neurovascular database which has been maintained by Dr. Rafael Tamargo and his team. Using this database, the authors have retrospectively analyzed and compared 200 consecutively treated intracranial aneurysms between the years of 1999-2000 to 200 consecutively treated intracranial aneurysms in 2009 and 2010 at their tertiary medical center. A key difference in practice patterns in these two eras has been the proliferation of neurointerventional surgery services at community hospitals. The authors hypothesized that this proliferation would have an impact on the types of aneurysms treated at their center. During the 10 year span of this review, the percentage of unruptured ophthalmic and middle cerebral artery aneurysms among aneurysms that were treated at their center increased from 10% to 25% (P < 0.05) and 12% to 21% (P