Clipping of Anterior Circulation Aneurysms: Operative Instructions and Safety Rules for Young Cerebrovascular Surgeons.

INTRODUCTION: Due to the constant development of the technique, in the last 30 years, the endovascular treatment of the intracranial aneurysms (IAs) has gradually superseded the traditional surgery in the majority of centers. However, clipping still represents the best treatment for some anterior circulation IAs according to their angioarchitectural, topographical, and hemodynamic characteristics. Thus, the identification of residual indications for clipping and the maintenance of training programs in vascular neurosurgery appear nowadays more important than ever. MATERIALS AND METHODS: We reviewed our last 10-year institutional experience of ruptured and unruptured IAs clipping. We appraised in detail all technical refinements we adopted during this time span and analyzed the difficulties we met in teaching the aneurysm clipping technique to residents and fellows. Then, we described the algorithm of safety rules we used to teach young neurosurgeons how to surgical approach anterior circulation IAs and develop a procedural memory, which may intervene in all emergency situations. RESULTS: We identified seven pragmatic technical key points for clipping of the most frequent anterior circulation IAs and constructed a didactic approach to teach young cerebrovascular surgeons. In general, they concern craniotomy; cisternostomy; obtaining proximal control; cranial nerve, perforator, and vein preservation; necessity of specific corticectomy; aneurysm neck dissection; and clipping. CONCLUSION: In the setting of an IA clipping, particularly when ruptured, the young cerebrovascular surgeon needs to respect an algorithm of safety rules, which are essential not only to avoid major complications, but they may intervene during the difficulties helping to manage potentially life-tethering conditions.

Combined lie's type D and type A agenesis of the left internal carotid artery diagnosed by magnetic resonance angiography.

PURPOSE: To report an unusual case of combined Lie's types A and D of internal carotid artery (ICA) agenesis, diagnosed by magnetic resonance angiography (MRA). METHODS: A 60-year-old woman with dizziness underwent cranial magnetic resonance imaging (MRI) and MRA of the intracranial region for the evaluation of brain and vascular lesions. The magnetic resonance machine was a 3.0-T scanner. RESULTS: MRI showed no abnormalities, except for multiple small white matter lesions. MRA showed that the left ICA was absent, except for the supraclinoid segment, and an anastomotic vessel was present between the paraclinoid segments of the bilateral ICAs, indicating Lie's type D ICA agenesis. The left posterior communicating artery (PCoA) was also present. Thus, there were also features of type A ICA agenesis. The anastomotic vessels between the bilateral ICAs and ipsilateral PCoA were relatively small in caliber. CONCLUSION: Lie's type D ICA agenesis usually does not communicate with the anterior and posterior circulations. We encountered a case of combined type D and type A ICA agenesis. To our knowledge, no similar case has been reported in the English literature. This is the second case of type D ICA agenesis with patent ipsilateral PCoA. We speculate that in case of type A ICA agenesis, when the development of the PCoA is insufficient to support collateral blood flow, an anastomotic vessel between bilateral ICAs may develop.

How I do it? Preoperative Microsoft HoloLens 2 planning-assisted surgical clipping of a fetal posterior cerebral artery aneurysm.

BACKGROUND: The treatment of intracranial aneurysms has predominantly shifted towards endovascular strategies, but complex cases still necessitate microsurgery. Preoperative stimulation can be beneficial for inexperienced young neurosurgeons in preparing for safe microsurgery. METHOD: A 72-year-old female with a left irregular fetal posterior cerebral artery (PCA) aneurysm underwent clipping repair. Microsoft HoloLens 2, utilizing mixed reality technology, was employed for preoperative stimulation and anatomical study. During the operation, we successfully identified the planned relationship between the aneurysm and the fetal PCA. The patient was cured without any complications. CONCLUSION: We hope that this report will highlight the significance of Microsoft HoloLens 2 in microsurgical planning and education.

Posterior communicating artery infundibulum with oculomotor nerve palsy treated with microvascular decompression: a case report and 2-dimensional technical operative video.

Oculomotor nerve palsies are typically associated with posterior communicating artery (PcommA) aneurysms. We report a rare case of an oculomotor nerve palsy caused by a PcommA infundibular dilatation. Although there are cases of infundibular dilatations causing cranial nerve palsies, only reports of three involving the PcommA exists. We review these reported cases in the literature and discuss their treatments as well as other non-aneurysmal compressive etiologies that may cause oculomotor nerve palsies. We present the case of a 53-year-old female with transient oculomotor nerve palsy that was initially diagnosed with a PcommA aneurysm. She underwent a craniotomy with plans of microsurgical clipping; however, the dilatation was identified correctly as an infundibulum intraoperatively. The operation was completed as a microvascular decompression and her oculomotor nerve palsy has not returned at the 1-year follow-up. We provide a detailed microsurgical report and video detailing the operative technique and relevant anatomy for this operation. Although rare and not as life-threatening as aneurysms, infundibular dilatations as a cause of oculomotor nerve palsy should remain as a differential diagnosis. Given the difference in natural history and treatment of these two entities, it is important to diagnose and treat them appropriately. Multimodal imaging such as thin-sliced computed tomography angiogram (CTA) and 3-dimensional (3D) rotational angiography can aid in diagnosis.

Complete duplication of the posterior cerebral artery.

PURPOSE: Variations of the posterior cerebral artery (PCA) are rare, excluding aplasia or hypoplasia of the P1 segment. To the best of our knowledge, there are few reports of complete duplication of the PCA. METHODS: Herein, we report a case of complete duplication of the PCA diagnosed by 1.5 T magnetic resonance angiography. RESULTS: A 55-year-old woman visited our hospital for cerebrovascular disease screening. Magnetic resonance angiography revealed two right PCAs with similar diameters. One PCA originated as the P1 segment of the PCA branching from the basilar artery, and the other was the fetal-type posterior communicating artery (PCoA) branching from the internal carotid artery (ICA). Neither PCA supplied the right anterior choroidal artery (AChA) territory. Bilateral PCoAs branched from the same position as each ICA, respectively. The right AChA branched from the ICA distal to the PCoA branching position. CONCLUSION: Careful imaging assessment is important for identifying complete duplication of the PCA. In addition to the direct findings of AChA identification, the indirect findings of the PCoA branching position and that the PCAs did not supply the AChA territory were also useful for diagnosis in this case.

Extremely long posterior cerebral artery P1 segment.

PURPOSE: Excluding aplasia and hypoplasia of the P1 segment of the posterior cerebral artery (PCA), anatomical variations in the PCA are rare. To our best knowledge, there are few reports of an extremely long P1 segment of the PCA. METHODS: Herein, we report a rare case of an extremely long P1 segment of the PCA, which was diagnosed by 1.5-T magnetic resonance angiography (MRA). RESULTS: A 96-year-old woman was transferred by ambulance to our hospital with impaired consciousness. Her symptom improved, and magnetic resonance imaging showed no significant findings. MRA revealed an extremely long P1 segment of the left PCA. The length of the P1 segment of the left PCA was 27.3 mm. The left posterior communicating artery (PCoA) was 20.9 mm, which is not considered long. The left anterior choroidal artery branched from the internal carotid artery distal to the PCoA branching position. Basilar artery fenestration was also incidentally identified. CONCLUSION: Careful imaging assessment was important for identifying the extremely long P1 segment of the PCA in the present case. This rare anatomical variation can also be confirmed by 1.5-T MRA.

The Fetal Type of Posterior Cerebral Artery.

Background and Objectives: Anatomical variations of the arterial circle of Willis (cW) are common. A posterior cerebral artery (PCA) fed mostly or exclusively from the internal carotid artery is a fetal PCA (FPCA), partial (p-FPCA), or full/complete (f-FPCA), respectively. Because FPCA occurs in different anatomical configurations of the cW sides, we aimed to document in detail these morphological possibilities of FPCA within the cW. Materials and Methods: FPCAs were documented on a retrospective set of 139 computed tomography angiograms. Results: FPCAs were found in thirteen cases, nine males and four females. In 7/13 cases there were two modified sides of the cW. In 5/13 cases there were three altered sides of the cW. Another case with FPCA showed four altered sides of the cW. In 10/13 cases, FPCA was unilateral and in the other three cases it was bilateral. Compared to the overall group, unilateral p-FPCAs were found in 1.43%, while unilateral f-FPCAs were found in 5.75%. A bilateral p-FPCA-f-FPCA combination was found in 0.71% and a bilateral f-FPCA-f-FPCA combination occurred in 1.43%. An anatomically isolated ICA was found in just one case with bilateral f-FPCA (0.71%). In 7/13 FPCA cases there were arterial variants exclusively in the posterior cW. In the other 6/13 FPCA cases, there were variants in both anterior and posterior circulation. There were no statistically significant associations of FPCA with sex or age. The higher prevalence of right-sided FPCA was not statistically significant. Conclusions: Anatomical assessments of cW should be performed on a case-by-case basis, as they may correspond to different cW morphologies.

Cerebral ischemia after treatment of posterior communicating artery aneurysms: clipping versus coiling.

OBJECTION: This study aimed to compare the incidence of cerebral ischemia and outcomes between surgical clipping and endovascular coiling in patients with posterior communicating artery (PCoA) aneurysms. METHODS: Clinical and imaging data of patients with at least one PCoA aneurysm who underwent surgical clipping or endovascular coiling in our institution from January 2017 to December 2019 were analyzed. RESULTS: Three hundred sixty-three aneurysms in 353 patients were included for analysis, 257 in the clipping group, and 106 in the coiling group. The groups did not differ in terms of baseline characteristics. The incidence of postoperative cerebral ischemia (23.35% vs. 11.32%, p = 0.029) was higher in the clipping group. The proportion of patients with a modified Rankin Scale score ≥ 2 was significantly higher in the clipping group at discharge (35.80% vs. 15.09%; p < 0.05) but not six months after discharge (15.56% vs. 8.49%; p > 0.05). In the clipping group, the mean age was significantly higher in patients who developed cerebral ischemia than in those who did not. In the coiling group, modified Fisher grade and incidence of fetal PCoA were significantly higher in patients who developed ischemia. CONCLUSION: The incidence of postoperative cerebral ischemia was higher after PCoA aneurysm clipping than after coiling. The causes and characteristics of postoperative cerebral ischemia after PCoA clipping and coiling are different; therefore, treatment should be selected accordingly.

Effects of endovascular treatment and prognostic factors for recovery of oculomotor nerve palsy caused by posterior communicating artery aneurysms: a multi-center retrospective analysis.

BACKGROUND: Oculomotor nerve palsy (ONP) may result from posterior communicating artery (PcomA) aneurysms. We aimed to evaluate the resolution of ONP after endovascular treatment with the intention of clarifying predictors of nerve recovery in a relatively large series. METHODS: A total of 211 patients with ONP caused by PcomA aneurysms underwent endovascular coiling between May 2010 and December 2020 in four tertiary hospitals. We evaluated the demographics, clinical characteristics, aneurysm morphology parameters and ONP resolution to analyze the predictors of ONP recovery using univariate and multivariate analyses. RESULTS: At the last available clinical follow-up, ONP resolution was complete in 126 (59.7%) patients, partial in 73 (34.6%) patients, and no recovery in 12 (5.7%) patients. The median resolution time after endovascular treatment was 55 days (interquartile range: 40-90 days). In multivariate analysis, degree of ONP (incomplete palsy) on admission (OR 5.396; 95% CI 2.836-10.266; P < 0.001), duration of ONP (≤ 14 days) before treatment (OR 5.940; 95% CI 2.724-12.954; P < 0.001) were statistically significant predictors of complete recovery of ONP. In the subgroup analysis of patients with unruptured aneurysms, aspirin showed a higher complete recovery rate in univariate analysis (OR 2.652; 95% CI 1.057-6.656; P = 0.038). CONCLUSION: Initial incomplete ONP and early management might predict better recovery of ONP after endovascular treatment.

λ stenting: a novel technique for posterior communicating artery aneurysms with fetal-type posterior communicating artery originating from the aneurysm dome.

PURPOSE: Endovascular treatment of posterior communicating artery aneurysms with fetal-type posterior communicating artery originating from the aneurysm dome is often challenging because, with conventional techniques, dense packing of aneurysms for posterior communicating artery preservation is difficult; moreover, flow-diversion devices are reportedly less effective. Herein, we describe a novel method called the λ stenting technique that involves deploying stents into the internal carotid artery and posterior communicating artery. METHODS: Between January 2018 and September 2020, the λ stenting technique was performed to treat eight consecutive cases of aneurysms. All target aneurysms had a wide neck (dome/neck ratio < 2), a fetal-type posterior communicating artery with hypoplastic P1, and a posterior communicating artery originating from the aneurysm dome. The origin of the posterior communicating artery from the aneurysm, relative to the internal carotid artery, was steep (< 90°: V shape). RESULTS: The maximum aneurysm size was 8.0 ± 1.9 mm (6-12 mm). The average packing density (excluding one regrowth case) was 32.7 ± 4.2% (26.8-39.1%). Initial occlusion was complete occlusion in 6 (75.0%) patients and neck remnants in 2 (25.0%) patients. Follow-up angiography was performed at 18.4 ± 11.6 months (3-38 months). There were no perioperative complications or reinterventions required during the study period. CONCLUSION: The λ stenting technique enabled dense coil packing and preservation of the posterior communicating artery. This technique enabled safe and stable coil embolization. Thus, it could become an alternative treatment option for this sub-type of intracranial aneurysms.

Premammillary artery infarction after microsurgical clipping of unruptured posterior communicating artery aneurysm: risk factors and surgical and anatomical considerations.

Posterior communicating artery (PCoA) aneurysm is common and sometimes requires microsurgery; however, as data on premammillary artery (PMA) infarction after clipping is scarce, we retrospectively reviewed cases of post-clipping PMA infarction to analyze incidence, independent risk factors of infarction, and anatomical considerations. Data from 569 consecutive patients who underwent microsurgical clipping for unruptured PCoA aneurysm between January 2008 and December 2020 were included. Patients were categorized into the normal or the PMA infarction group. Statistical analyses and comparisons between the two groups were used to determine the influence of various factors. The normal group included 515 patients while the PMA infarction group had 31. The mean length of hospital stay was significantly longer in the PMA infarction group (10.3 ± 9.1 days) than in the normal group (6.5 ± 6.4 days; p < 0.0001). The distribution of Glasgow Outcome Scale at discharge was significantly different between the two groups (p ≤ 0.0001) but was not so at 6 months after discharge (p = 0.0568). Multivariate logistic regression analysis identified aneurysm size (odds ratio [OR], 1.194; 95% confidence interval [CI], 1.08-1.32; p = 0.0005) and medial direction of aneurysm (OR, 4.615; 95% CI, 1.224-17.406; p = 0.0239) as independent risk factors of post-clipping PMA infarction. Surgeons must beware of PMA infarction after clipping of large aneurysms that are medial in direction. Intraoperative verification of the patency of the PCoA and the PMA from various angles using various intraoperative methods can reduce morbidity due to PMA infarction.

Super-selective balloon test occlusion with electrophysiological monitoring to occlude angiographically invisible posterior communicating artery perforators with unruptured aneurysm.

Balloon test occlusion (BTO) can predict the ischemic complication risk associated with arterial occlusion. We present a case of an unruptured, broad-necked internal carotid artery-posterior communicating artery (PcomA) aneurysm that was successfully embolized after super-selective BTO of fetal PcomA with electrophysiological monitoring. The proximal portion of the PcomA was internally occluded without causing major neurological deficits, although we observed a small new infarction in the ipsilateral anterior thalamus postoperatively. We recognized small perforators arising from the proximal PcomA during a previous clipping surgery. Super-selective BTO with electrophysiological monitoring could be useful for functional preservation after infarction from angiographically invisible perforators.

Posterior Communicating Artery Hypoplasia: A Risk Factor for Vertebral Artery Dissection Causing Subarachnoid Hemorrhage.

OBJECTIVE: Subarachnoid hemorrhage due to vertebral artery dissection is often fatal; however, its anatomical predictors remain unclear. We conducted a retrospective hospital-based case-control study to evaluate whether variations in the posterior communicating artery are associated with the risk of vertebral artery dissection with subarachnoid hemorrhage. MATERIALS AND METHODS: We obtained data from patients who underwent computed tomography angiography at our hospital between April 2010 and March 2020. Based on the connection between the anterior and posterior circulation of the arterial circle of Willis, the patients were categorized into a separated group (posterior communicating artery hypoplasia) and a connected group (all others). We evaluated the association between the development of posterior communicating artery and subarachnoid hemorrhage due to vertebral artery dissection using multivariate logistic regression analysis. RESULTS: Thirty-eight patients had subarachnoid hemorrhage due to vertebral artery dissection and 76 were identified as age- and sex-matched controls. In conditional multivariate logistic regression analysis, the separated group showed a significant association with subarachnoid hemorrhage due to vertebral artery dissection, with an adjusted odds ratio of 2.8 (95% confidence interval, 1.2-6.5; P = 0.021). CONCLUSIONS: The present study demonstrates that posterior communicating artery hypoplasia may be associated with subarachnoid hemorrhage due to vertebral artery dissection. Our results highlight the importance of anatomical variations in the cerebral artery and provide evidence to help develop preventive measures against strokes.

An extremely short posterior communicating artery diagnosed by magnetic resonance angiography.

PURPOSE: To describe a case of an extremely short posterior communicating artery (PCoA) incidentally diagnosed by magnetic resonance (MR) angiography. CASE REPORT: A 48-year-old woman with Parkinson's disease underwent cranial MR imaging and MR angiography. MR imaging revealed no abnormality. After creating partial maximum-intensity-projection (MIP) images, MR angiography showed an extremely short right PCoA, only 4 mm long. The P1 segment of the right posterior cerebral artery (PCA) took an anterior course, and at the junction with the PCoA, the PCA made a hairpin turn and ran posteriorly. The length of the P1 segment was approximately 20 mm, which was relatively long. DISCUSSION: According to an anatomical study using 170 cadaveric brains, the length of the PCoA ranged 5 to 26 mm (mean: 15 mm). Another 2 anatomical studies reported that the shortest PCoA was 7 mm. The present case had an extremely short right PCoA connecting with a hairpin turn at the P1-P2 junction, a unique configuration. CONCLUSION: To identify this variation by MR angiography, creation of partial MIP images was useful.

Ischemic chiasmal syndrome associated with posterior communicating artery (PCoA) and tuberothalamic artery (TA) infarction: a case report.

Lesions affecting the body of the optic chiasm typically produce bitemporal hemianopia. The blood supply comes from the anterior communicating artery, anterior cerebral, posterior communicating, posterior cerebral, and basilar arteries. We herein report a young patient admitted to the emergency department with acute confusion, left-sided hemiparesis, hemihypoesthesia, and dysarthria. Bitemporal hemianopia was detected after resolution of confusion. On cranial magnetic resonance imaging (MRI), infarction in the right anterolateral thalamus in the territory of tuberothalamic artery (TA) and in posterior chiasma in the territory of the posterior communicating artery (PCoA) was revealed. Cerebral MR angiography showed luminal irregularity of the PCoA. The patient was presented to draw attention to the rare entity ischemic chiasmal syndrome.

Ruptured Infundibular dilatation of the posterior communicating artery.

OBJECTIVE: An infundibulum of the posterior communicating artery (PcomA) or infundibular dilatation (ID) is considered to be a benign anatomical variant. However, some evidence suggests that ID is a pre-aneurysmal state. This case series presents cases of ruptured IDs and aneurysms originating from the IDs. METHODS: Between April 2002 and June 2020, 1337 patients were treated for aneurysmal subarachnoid hemorrhage (SAH). Among them, 7 patients with ruptured PcomA IDs were identified. Rupture IDs of the PcomA were categorized into 1) direct rupture of IDs, and 2) rupture of aneurysms originating from IDs. The clinical and radiographic factors were retrospectively reviewed. RESULTS: Two patients experienced direct rupture of IDs, while the other 5 patients presented with ruptured aneurysms originating from IDs. The 2 patients with direct rupture of IDs at presentation were relatively younger (< 50 years), while the other 5 patients with ruptured aneurysms originating from IDs were over 70 and had a history of aneurysmal SAH due to other intracranial aneurysms. Ruptured IDs were treated with microsurgery or endovascular treatment. There were no complications related to the procedure for securing ruptured IDs. Five (71.4%) patients showed favorable outcomes. One patient with initial Hunt and Hess grade 4 died due to initial brain damage with cerebral vasospasm and medical complications. CONCLUSIONS: ID of the PcomA rarely causes SAH with or without aneurysm formation. Thus, patients with IDs of the PcomA should be carefully followed up for a long period, especially those with a history of aneurysmal SAH.

Higher oscillatory shear index is related to aneurysm recanalization after coil embolization in posterior communicating artery aneurysms.

BACKGROUND: The recurrence rate of posterior communicating artery (Pcom) aneurysms after endovascular treatment (EVT) is higher than that for aneurysms located in other sites. However, it is still unclear what mechanisms are responsible for the recanalization of cerebral aneurysms. In this investigation, we compared hemodynamic factors related with recanalization of Pcom aneurysms treated by endoluminal coiling using computational fluid dynamics (CFD) with high-resolution three-dimensional digital subtraction angiography images. METHODS: Twenty patients were enrolled. A double-sinogram acquisition was performed with and without contrast injection after coil embolization to get true blood vessel lumen by relatively complementing the first sinogram with the second. Adaptive Cartesian meshing was performed to produce vascular wall objects for CFD simulation. The boundary condition for inlet (ICA) was set for dynamic velocity according to the cardiac cycle (0.8 s). Hemodynamic parameters were recorded at two specific points (branching point of Pcom and residual sac). The peak pressure, peak WSS, and oscillatory shear index (OSI) were recorded and analyzed. RESULTS: The median age was 61.0 years, and 18 patients (90%) were female. During a median follow-up of 12 months, seven (35%) treated aneurysms showed recanalization. The median aneurysm volume was significantly higher, and aneurysm height and neck sizes were significantly longer in the recanalization group than those in the stable group. At the branching point of the Pcom, the peak pressure, peak WSS, or OSI did not significantly differ between the two groups. The only statistically significant hemodynamic parameter related with recanalization was the OSI at the aneurysm point. Multivariate logistic regression showed that with an increase of 0.01 OSI at the aneurysm point, the odds ratio for the aneurysm recanalization was 1.19. CONCLUSIONS: A higher OSI is related with recanalization after coil embolization for a Pcom aneurysm.

Recurrence and risk factors of posterior communicating artery aneurysms after endovascular treatment.

BACKGROUND: Endovascular treatment (EVT) of posterior communicating artery aneurysms (PcomA) is challenging because of posterior communicating artery (Pcom) architecture. Additionally, these aneurysms have a high risk of recanalization compared with those located elsewhere. METHODS: The radiographic findings of 171 patients treated with EVT at two institutions were retrospectively reviewed. Univariate and multivariate analyses were performed, and subgroup analyses were performed based on Pcom characteristics. RESULTS: Recanalization of PcomAs occurred in 53 patients (30.9%). Seven patients (4.0%) were retreated (six endovascularly and one with microsurgical clipping). The mean follow-up duration was 27.7 months (range: 3.5-78.6). The maximum diameter (odds ratio [OR] 1.23, P = .006, 95% CI 1.07-1.44), a Raymond-Roy classification of grade II or III (OR 2.26, P = .03, 95% CI 1.08-4.82), and the presence of reinforcement (balloon or/and stent, OR 0.44, P = .03, 95% CI 0.20-0.91) were associated with recanalization using multivariate logistic regression. Significant differences were found in maximum aneurysm diameter (P = .03) between normal- and fetal-type Pcoms on analysis of variance. CONCLUSIONS: The recanalization rate of PcomAs after EVT was 30.9%; the retreatment rate was 4.0%. Maximum diameter, Raymond-Roy classification, and presence of reinforcement were significantly associated with recanalization but not associated with fetal-type Pcom. Aneurysm size was larger in patients with a fetal-type Pcom than in those with a normal Pcom. Pcom size was not related to recanalization rate.

Unilateral oculomotor nerve palsy caused by arterial compression accompanying subarachnoid hemorrhage: a case report.

Unilateral oculomotor nerve palsy, often caused by aneurysmal compression, is one of the decisive findings for confirming the site of a ruptured aneurysm. However, arterial compression can also cause unilateral oculomotor nerve palsy. Here, we present the case of a 59-year-old woman with a ruptured right internal carotid-posterior communicating artery aneurysm accompanied by contralateral oculomotor nerve palsy. The nerve was found to be compressed by the posterior cerebral artery and was isolated from the ruptured aneurysm. When confirming a ruptured aneurysm based on the evidence of unilateral oculomotor palsy, the arteries surrounding the nerve must be thoroughly assessed.

Radiological outcomes for endovascular treatment of posterior communicating artery aneurysms: a retrospective multicenter study of the occlusion rate.

Although several innovations in techniques and implantable devices were reported over the last decades, a consensus on the best endovascular treatment for intracranial aneurysms originating from the posterior communicating artery is still missing. This work investigates radiological outcomes of different endovascular techniques for posterior communicating artery aneurysms treatment in a retrospective multi-centric cohort. We included patients endovascularly treated for posterior communicating artery aneurysms from 2015 through 2020 in six tertiary referral hospitals. We evaluated the relationship between patients and aneurysms characteristics, baseline neurological status, radiological outcomes, and the different endovascular techniques. Overall, 250 patients were included in this study. Simple coiling was the most frequent treatment in 171 patients (68%), followed by flow-diverter stenting in 32 cases (13%). Complete occlusion was reported in 163 patients (65%), near-complete occlusion in 43 (17%), and incomplete occlusion in 44 (18%). Radiological follow-up was available for 247 (98%) patients. The occlusion rate was stable in 149 (60%), improved in 49 (19%), and worsened in 51 (21%). No significant difference in exclusion rate was seen between ruptured and unruptured aneurysms at the last follow-up (p = 0.4). Posterior communicating artery thrombosis was reported in 25 patients (9%), transient ischemic attack in 6 (2%), and in 38 patients (15%), subsequent procedures were needed due to incomplete occlusion or reperfusion. Endovascular strategies for posterior communicating artery aneurysms represent effective and relatively safe treatments. Simple coiling provides a higher immediate occlusion rate, although recanalization has been frequently reported, conversely, flow-diversion devices provide good long-term radiological outcomes.