Korean Journal of Cerebrovascular Surgery 2009;11(4):150-153.
Published online December 1, 2009.
A Occluded Posterior Communicating Artery Mimicking a Cerebral Aneurysm: A Case Report.
Jun, Jae Kyun , Hyun, Dong Keun , Park, Hyeon Seon , Kim, Eunyoung , Yoon, Seung Hwan , Park, Chong Oon
Department of Neurosurgery, College of medicine, Inha university hospital, Incheon, Korea. dkhyun@inha.ac.kr
Abstract
A 47-year-old man was admitted to the emergency department due to a sudden onset of headache during exercise. Brain computed tomography (CT) and CT angiography showed a subarachnoid hemorrhage (SAH) with a small sac in the left posterior communicating (pcom) artery and total obstruction in the proximal portion of the right middle cerebral artery (MCA). Catheter angiography revealed a protruding lesion in the left p-com artery and a total obstruction in the right MCA. It was difficult to differentiate the aneurysm from the occlusion of the pcom artery. We planned to confirm whether or not the protruded lesion was an aneurysm. Intraoperatively, the aneurysmal opacification seen on the preoperative catheter angiography proved it to be the occluded p-com artery filled with thrombus. The possibility of a vascular stump should be considered when diagnosing a protruding vascular lesion at the p-com artery.
Key Words: Posterior communicating artery, Occlusion, Aneurysm

Introduction

As a resulting to the diagnosis of intracranial aneurysm technique developed, also increased false positive aneurysm. Their differentiation is crucial to establishing the appropriate treatment. Our institution had experience of posterior communicating (p-com) artery occlusion that mimicking the p-com aneurysm with subarachnoid hemorrhage (SAH). We reported our case with literature review and discussions.

 

Case

A 47-year-old man was admitted to emergency department due to sudden onset of headache during exercise. There was no neurological deficit on admission. Brain CT showed a SAH which were localizing in basal cistern, especially perimesencephalic cistern. 3 dimensional CT angiography showed a small sac in left p-com artery which seemed like a aneurysm and a total obstruction in proximal portion of right middle cerebral artery (MCA) (Fig.1). Brain perfusion magnetic resonance images (MRI) with enhancement showed the increased mean transient time and decreased cerebral blood volume in right MCA territories (Fig. 2). Catheter angiography revealed a lesion protruded to inferolateral direction in left p-com artery, narrow right distal ICA, and total obstruction in proximal portion of right MCA with multiple collateral vessel such as both anterior cerebral arteries and right posterior cerebral artery, which was correlated with moyamoya disease probable (Fig. 3). Catheter angiography can not rule out whether ruptured aneurysm or junctional dilatation. We confused origin of SAH because of small p-com aneurysm with good contour and perimesencephalic located SAH. And we were not sure that cause of SAH was whether venous origin or moyamoya disease. After 2 weeks later, repeated catheter angiography was performed. But the finding was same with previous catheter angiography (Fig. 4). So we planned to confirm whether the lesion at the p-com artery was an aneurysm or not. Intraoperatively, the aneurysm was proved to be the proximal stumps of the occluded middle portion of the p-com artery. And the proximal portion of p-com artery was filled with thrombus (Fig. 5). We performed wrapping of the protruded lesion.

 

Discussion

A Stump of occluded vessels may be misinterpreted as an aneurysm on cerebral angiogram.3-6) Occlusion of the p-com artery can mimick a cerebral aneurysm.4) In diagnosing protruding vascular lesions at the bifurcation between the internal carotid artery (ICA) and the p-com artery, infundibular dilatation and occlusion of the p-com artery should be considered.1)2)

Thrombosis of a stump of occluded vessel may be noticed. Kalia et al.3) reported a patient whom a partially thrombosed basilar artery was misinterpreted an aneurysm of the vertebrobasilar junction on preoperative angiography. Intraoperatively, partial thrombosis of one limb of the fenestrated basilar artery was noticed and no aneurysm was detected. The nodular appearance of the residual lumen of the vessel corresponded to the angiographic finding.

The arterial stump of an occluded intracranial vertebral artery may mimic an aneurysm at the vertebrobasilar junction. The differentiation is crucial because their natural history and treatment are totally different. Komiyama et al.5) recommended that magnetic resonance images with three-dimensional constructive interference in steady state sequences can be a useful adjunct for establishing the differential diagnosis and avoiding unnecessary exploratory surgery.

In this case, the angiographic finding of the residual lumen was seemed to the rectangular appearance. It was difficult to distinguish junctional dilatation and aneurysm sac on angiogram. First of all, if vascular lesion was suspicious due to the high risk of morbidity and mortality associated with aneurysmal SAH, surgical exploration had to be considered. We could not rule out a cerebral aneurysm. We performed surgical exploration and confirmed that the protruded sac was occluded p-com artery filled with thrombus. We made a reason of SAH as a venous origin of perimesencephalic, not cerebral aneurysm nor moyamoya disease. The cause of occluded p-com artery filled with thrombus probably resulted from the progression of moyamoya disease. Retrospectively considering the angiographic finding in this case, the rectangular appearance of the residual lumen could help to differentiate a stump from funnel shaped junctional dilatation and saccular shaped aneurysmal dilatation.

 

Conclusion

An aneurysmal protrusion at the p-com artery does not always indicate an aneurysm. If protruding vascular lesion is rectangular shape in angiographic finding, the possibility of a vascular stump should be considered.

 

 

References

 

1)              Endo S, Furuichi S, Takaba M, Hirashimo Y, Nishijima M, Takaku A : Clinical study of enlarged infundibular dilation of the origin of the posterior communicating artery. J Neurosurg 83 : 421-5, 1995

 

2)              Furuichi S, Endo S, Nisijima M, Takaku A : Dilated lesion at internal carotid artery posterior communicating artery junction. No Shinkei Geka 21 : 605-9, 1993

 

3)              Kalia KK, Pollack IF, Yonas H : A partially thrombosed fenestrated basilar artery mimicking an aneurysm of the vertebrobasilar junction. Case report. Neurosurgery 30 : 276-8, 1992

 

4)              Kawanishi M, Sakaguchi I, Miyake H : Occlusion of the posterior communicating artery mimicking cerebral aneurysm. Case report. Neurol Res 25 : 543-5, 2003

 

5)              Komiyama M, Ishiguro T, Morikawa T, Nishikawa M, Yasui T : Distal stump of an occluded intracranial vertebral artery at the vertebrobasilar junction mimicking a basilar artery aneurysm. Acta Neurochir (Wien) 143 : 1013-7, 2001

 

6)              Nakano S, Yokogami K, Ohta H, Wakisaka S : A stump of occluded posterior cerebral artery mimicking a ruptured aneurysm. Case report. Int J Angiol 9 : 51-2, 200


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