History & examination\nA 31-year-old African-American female with no significant medical history presented with a sudden onset of severe headaches that were highly suggestive of subarachnoid hemorrhage (SAH). The patient was initially evaluated in the emergency department where a neurological examination revealed no deficits.\nPathological findings\nA computed tomography (CT) scan revealed a SAH filling the pre-pontine, crural, ambient, and quadrigeminal cisterns more prominently on the left side of the brain, with mild hydrocephalus (Figure ). A CT-angiography (CTA) showed an enlarged vessel within the left ambient cistern. Digital subtraction angiography (DSA) also revealed the large and irregular appearance of the left SCA in the ambient cistern. No immediate intervention was undertaken.\nThe patient was admitted to the neurosurgical intensive care unit (ICU) and treatment was initiated with regular neurological examinations and daily transcranial-doppler (TCD) studies. The patient remained intact, with TCD values showing only moderate vasospasm. The patient did not require any treatment for the mild radiographic hydrocephalus. On Day 14, the patient underwent a repeat DSA which showed a persistent vasospasm in the distal basilar and bilateral posterior cerebral arteries. Three-dimensional (3-D) reformatting also demonstrated a dissecting fusiform SCA aneurysm in the lateral ponto-mesencephalic segment (Figure ). Due to the persistent vasospasm, no intervention was undertaken at that time as definitive treatment measures were being discussed in a multidisciplinary board meeting.\nEndovascular intervention\nOn Day 21, the patient underwent a successful placement of a low-profile visualized intraluminal support (LVIS Jr.) device (MicroVention, Tustin, CA) covering the fusiform aneurysm, which measured 3-mm wide and 18-mm in length. After premedication with aspirin and clopidogrel, a 7-Fr sheath was inserted into the common femoral artery and a 6-Fr guide catheter was inserted into the left vertebral artery. The left SCA was catheterized using the microcatheter and microguidewire. The LVIS Jr. device was then deployed successfully along the fusiform segment of the SCA without evidence of contrast extravasation. The treatment goal was to preserve the intraluminal flow with flow diversion from the aneurysm for reduction and eventual obliteration.\nPostoperative course\nAt the three-month follow-up, the patient had no complaint and was neurologically intact on examination. A CTA performed at that time showed the SCA patency proximal and distal to the stent without evidence of persistent dilatation or an aneurysm (Figure ). A formal catheter angiogram was deferred by the patient. At the 10-month follow-up, a DSA demonstrated the interval healing of the aneurysm with preserved vessel patency as well as mild distortion caused by the stent in the SCA (Figure ). The patient remained neurologically intact on examination with no complaints.
A 60-year-old woman who developed intermittent diplopia underwent MRI scan revealing a tentorial meningioma as well as aneurysms of the posterior communication artery, right vertebral artery, and peripheral superior cerebellar artery. The tentorial meningioma tumor was located in the posterior aspect of the cerebellopontine angle and causing compression of the brainstem along the course of the 4th cranial nerve, and the complex, partially thrombosed dissecting aneurysm of the SCA was situated just proximal to the entry of the 4th nerve into the free edge of the tentorium. Angiography revealed a partially thrombosed wide-necked aneurysm not amenable to endovascular intervention. Microsurgical clipping and simultaneous tumor removal were recommended.\nA combined subtemporal, presigmoidal approach was performed. A wide bone removal of the middle cranial fossa was necessary to reach the tentorial incisura allowing exposure of the tumor. Due to the associated brainstem compression from the tumor, the meningioma was debulked first, and then the aneurysm was addressed. Interestingly, on reaching the SCA there was obvious hemosiderin staining of the arachnoid surrounding the aneurysm dome, indicating a previous rupture. During microsurgical dissection, it was confirmed that this aneurysm was thick-walled and partially thrombosed [Figure and ]. The aneurysm was reconstructed with a single clip placed well up on the aneurysm dome to avoid compromise of the parent artery. Intra-operative angiogram demonstrated complete obliteration of the aneurysm with normal flow through the SCA and distal branches. Post-operatively, apart from transient hyponatremia and hyperglycemia, the patient did well without complication.