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.
A 70-year-old woman with hypertension, hyperlipidemia, and a history of smoking presented with a peripheral fusiform SCA aneurysm found incidentally during a routine MRI investigation due to “black out” symptoms. The aneurysm was located 2 cm from the SCA origin, and measured 7 mm in maximal diameter [Figure and ]. After a thorough discussion of treatment options, the patient elected to undergo a combined subtemporal, presigmoidal approach. On the lateral aspect of the brainstem, the aneurysm was exposed along with the parent artery and two major efferent branches. One of these branches, the largest one, was superiorly directed and a double, smaller branch, presented inferiorly around the aneurysm fundus. It was necessary during microsurgical dissection to detach the aneurysm dome from the tentorial undersurface as well as from the 4th cranial nerve. Multiple clips were used to reconstruct the aneurysm without intra-operative complication. Intra-operative angiogram confirmed reconstruction of the fusiform aneurysm with preservation of distal flow [Figure –]. The patient tolerated the procedure well and was extubated and returned to the intensive care unit in stable condition. She was discharged home on the fourth post-operative day without new deficit.