Hybrid Minimally Invasive Approach for Ruptured Proximal PICA Fusiform Aneurysms

Overview

This report details a single-stage hybrid surgical and endovascular technique for treating ruptured dissecting fusiform aneurysms of the proximal posterior inferior cerebellar artery (PICA). The approach combines microsurgical PICA–PICA bypass with endovascular coil embolization in a hybrid operating suite, enabling complete aneurysm obliteration while preserving PICA flow.

Background

Posterior inferior cerebellar artery aneurysms are rare, comprising less than 5% of aneurysmal subarachnoid hemorrhages. Proximal PICA aneurysms are located deep within the cerebellomedullary cistern, making surgical access challenging and associated with a high risk of lower cranial nerve deficits. Fusiform aneurysms complicate standard clipping or coiling due to the need to preserve PICA flow and brainstem perforators. Reconstruction via PICA–PICA bypass is often necessary to maintain flow during aneurysm obliteration.

Data Highlights

Imaging revealed a 5.5 × 4.1 mm dissecting fusiform aneurysm at the junction of the left vertebral artery and PICA. The PICA–PICA side-to-side bypass was performed with a total clamping time of 31 minutes. Intraoperative indocyanine green videoangiography and micro-Doppler confirmed bypass patency. Post-embolization angiography demonstrated complete aneurysm occlusion without retrograde filling and preserved bypass flow.

Key Findings

• Proximal PICA fusiform aneurysms pose significant surgical challenges due to deep location and involvement of critical perforators.
• A hybrid operating suite allows seamless transition between microsurgical bypass and endovascular coil embolization under a single anesthesia.
• Preemptive endovascular access via femoral artery sheath facilitates intraoperative angiography and subsequent embolization without patient repositioning.
• Microsurgical PICA–PICA side-to-side bypass using 10–0 nylon sutures successfully preserves distal PICA flow during aneurysm exclusion.
• Endovascular coil embolization achieves complete aneurysm obliteration including the proximal PICA segment, confirmed by digital subtraction angiography.
• Single-stage hybrid approach minimizes patient transfers and potentially reduces overall procedural risks and recovery time.

Clinical Implications

This hybrid technique offers a feasible and effective treatment option for complex proximal PICA fusiform aneurysms, combining the advantages of microsurgical bypass and endovascular embolization. Utilizing a hybrid operating suite enables single-stage management, reducing the risks associated with multiple procedures and improving surgical workflow. Preservation of PICA flow through bypass is critical to prevent infarction and maintain brainstem perfusion.

Conclusion

A single-stage hybrid minimally invasive approach integrating microsurgical PICA–PICA bypass and endovascular coil embolization is a safe and effective strategy for managing ruptured dissecting fusiform aneurysms of the proximal PICA. This technique facilitates complete aneurysm obliteration while preserving critical arterial flow.

References

1. Article Source 2024 -- A Hybrid Minimally Invasive Approach for Treating Ruptured Dissecting Fusiform Aneurysms of the Proximal Posterior Inferior Cerebellar Artery