Subarachnoid hemorrhage caused by posterior inferior cerebellar artery aneurysm with an anomalous course of the atlantoaxial segment of the vertebral artery

Case report and review of literature

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✓ Various anatomical courses of the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) have been described. The authors present a unique case of a subarachnoid hemorrhage resulting from an aneurysm in a patient with an anatomical variation of the extracranial portion of the VA and cervical origin of the PICA. The surgical implications of this variant are discussed, and the pertinent literature reviewed. Subarachnoid hemorrhage caused by rupture of a PICA aneurysm is reported for the first time in association with a rare variation of the course of the VA.

Article Information

Address reprint requests to: Michael R. Chicoine, M.D., Washington University School of Medicine, Campus Box 8057, 660 South Euclid, St. Louis, Missouri 63110. email: mchicoine@pol.net.

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative cerebral angiograms. In the later projection of the right VA (A), an approximately 6-mm lobulated PICA aneurysm is made visible. Because the bone anatomy is well demonstrated, one can appreciate the extracranial position of the PICA aneurysm and its relationship to the dens. Compare the course of the right VA (A) to the left VA in the anteroposterior projection (B). The VA traverses inferomedially after coursing through the foramen transversarium of C-2. Instead of taking a normal course through the foramen transversarium (arrow in A) of C-1, as seen on the left (B), it makes a hairpin turn and passes into the dura between C-1 and C-2. The aneurysm is not as easily seen on the lateral projections (C, right projection; D, left projection), but these projections highlight the abnormal anatomy of the right VA in relationship to the foramen transversarium of C-1 (arrow in C). Digital subtraction angiogram (inset, i), right VA injection, clearly demonstrating the multilobulated PICA aneurysm with its relatively narrow neck.

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    Artist's rendering of the anatomy encountered in the patient in the present case. One can see the inferomedial course of the right VA as it passes beneath the lamina of C-1 and not through its foramen transversarium. The VA then passes into the dura between C-1 and C-2. The left VA takes its normal course through the C-1 foramen transversarium. The PICA aneurysm is intradural but extracranial, located in the cervical region. The inset represents a view after partial C-1 and C-2 laminectomies were performed.

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    Intraoperative photograph illustrating the initial surgical exposure. Note the origin of the PICA and the aneurysm in the cervical spinal canal (arrow) and the distal course of the PICA (arrowhead) from right lateral to medial directions over the dorsum of the spinal cord. C = cerebellum; I = inferior; L = patient's left; R = patient's right; S = superior.

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    Intraoperative cerebral angiograms in the anteroposterior (A) and oblique (B) projections. The right VA—PICA aneurysm is obliterated by aneurysm clips, and the right PICA is preserved with normal blood flow. Note the position of the clips below the foramen magnum.

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