A 67-year-old female with a medical history of hypertension and active smoking presented to the emergency department after experiencing a severe headache of sudden onset in the right side of her head. The patient had undergone elective screening colonoscopy the day prior. The morning following the colonoscopy procedure she woke up experiencing a right-sided headache associated with nausea, right-arm pain, right eye blurry vision, and slight fingertip numbness on her right side after which she decided to come to the hospital. She denied any recent trauma, fever, chills, or neck stiffness. On physical examination, she was neurologically intact.\nNoncontrast head CT demonstrated no acute intracranial pathology, specifically no evidence of subarachnoid hemorrhage. CT angiogram (CTA) demonstrated a 4.2 × 4.2 × 4.2 mm fusiform aneurysm arising off the superior cerebellar artery, approximately 1.5 cm distal to its origin off the basilar artery. The headache subsided the following day. Diagnostic cerebral angiogram was performed and redemonstrated the fusiform aneurysm, essentially unchanged in appearance when compared to the CTA []. The patient was started on dual antiplatelet agents consisting of clopidogrel 75 mg daily and aspirin 325 mg daily. One week later, the patient underwent successful Pipeline embolization of the aneurysm []. Briefly, a 6-Fr sheath was inserted into the right common femoral artery and a 6-Fr Benchmark guide catheter (penumbra) advanced over a diagnostic catheter and glide wire into the right vertebral artery. Through the guide catheter, a Phenom Plus distal access catheter was advanced over a Phenom microcatheter and Synchro-2 microwire into the proximal basilar artery. The microcatheter was then advanced over the microwire into the right superior cerebellar artery distal to the aneurysm. A 2.5 mm wide and 10 mm length Pipeline embolization device was then deployed along the fusiform aneurysm. Postdeployment angiogram demonstrated excellent apposition of the device to the parent vessel and evidence of some contrast stagnation within the aneurysm.\nThe patient was neurologically intact postoperatively and was discharged home on postoperative day 2. A cerebral angiogram performed 6 months later demonstrated resolution of the aneurysm with patency of the superior cerebellar artery []. The patient had no complaints and was neurologically intact.
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.