Microsurgical clipping of large MCA aneurysm in a 2-month-old child.

BACKGROUND: Cerebral aneurysms in children have a low incidence and accounts for less than 4% of all cerebral aneurysms. These aneurysms have been linked to various factors. Severe headache, seizures, and motor-sensory deficits are common presentations. CASE REPORT: We describe the case of a 2-month-old male patient who presented with generalized tonic-clonic seizures for 4 days. At the hospital, he was stabilized with ventilatory support, sedation, and antiepileptic drugs. A NCCT (Head) showed intraparenchymal hemorrhage in the left fronto-parieto-temporal lobe and subarachnoid hemorrhage. Subsequently a CT angiogram revealed an aneurysm of the left M3 segment of MCA. Successfully, the patient underwent microsurgical clipping of aneurysm and evacuation of hematoma. CONCLUSIONS: Pediatric cerebral aneurysms differ from their adult counterparts, mainly in their etiology and evolution. As per literature, aneurysmal clipping and neurological endovascular therapy have shown similar results.

Single Neuroform Atlas stent: a reliable approach for treating complex wide-neck bifurcated aneurysms.

Background: Treating wide-neck bifurcated cerebral aneurysms (WNBAs) using various techniques and new devices has shown favorable outcomes. However, endovascular coiling can be technically challenging when the aneurysm neck is incorporated into the parent vessel. Furthermore, although recent research has reported favorable outcomes of Neuroform Atlas stent (NAS)-assisted coiling, broad inclusion criteria have hampered precise evaluations of their effectiveness and safety for treating complex WNBAs. Therefore, this study evaluated whether the use of a single NAS is a safe and effective approach for treating complex WNBAs. Methods: We treated 76 complex WNBAs (unruptured, n = 49; ruptured, n = 27) using single NAS-assisted coil embolization and retrospectively analyzed the clinical and angiographic outcomes. Results: In a cohort of 68 patients (mean age, 58.3 ± 11.6 years; males n = 20, 29.4%; females, n = 48, 70.6%), 76 stents were successfully delivered to the target aneurysms, yielding a technical success rate of 98.6%. Complete occlusion was evident in 59 (77.6%) of 76 aneurysms, with neck remnants found in 16 (21.1%) and partial occlusion in 1 (1.3%). Treatment-related morbidities comprised one branch occlusion and one parenchymal hemorrhage. However, no new neurological symptoms of unruptured aneurysms were evident at discharge. The outcomes of 20 of the 27 ruptured aneurysms were favorable (Glasgow Outcome Scale scores of 4 or 5) at the final follow-up assessment (mean 12.2 [6-29] months), except for one initial subarachnoid hemorrhage. Post-treatment angiography revealed complete occlusion in 89.1%, neck remnants in 7.8%, and incomplete occlusion in 3.1% of the aneurysms. Approximately 88.2% of the patients were assessed at least once by follow-up diagnostic or magnetic resonance angiography (mean, 12.5 ± 4.3 [range, 6-29] months), with five (7.8%) minor and two (3.1%) major recurrences. Conclusion: A single NAS is safe and effective for treating WNBAs incorporated into parent vessels.

Microneurosurgery for Ruptured Aneurysm of Distal Intracranial Vertebral Artery: A Case Report.

The International Subarachnoid Aneurysm Trial led to a shift from clipping to endovascular coiling as the primary therapy for cerebral aneurysm particularly in the management of posterior circulation aneurysm. However, endovascular therapy is often unavailable in low-resource settings, emphasizing the importance of maintaining surgical skill sets in resource-poor countries. This article presents a detailed case report on the successful microneurosurgical management of a 65-year-old female with a history of headache and weakness with past history of hypertension and a right posterior cerebral artery territory infarct who was diagnosed with a ruptured aneurysm situated within the intracranial vertebral artery. Patient was operated with the far lateral approach and clipping of the aneurysm. This case report elucidates the intricate surgical techniques employed, and the challenges neurosurgeons encountered in treating posterior circulation intracranial aneurysms, particularly those with ruptured complications. The aneurysms' intricate anatomy and increased rupture risk necessitate a meticulous microneurosurgical approach. The severity of subarachnoid hemorrhage from ruptured aneurysms increases morbidity and mortality rates.

Endovascular treatment of unruptured aneurysm arising from duplicate origin of the middle cerebral artery - A case report and literature review.

Background: Duplicate origin of the middle cerebral artery (MCA) is a rare variation of MCA, often mislabeled as the fenestration of the M1 segment of MCA. Case Description: The authors treated an unruptured aneurysm, 8 mm in diameter, associated with a duplicate origin of MCA in a 42-year-old woman who underwent magnetic resonance imaging for transient vertigo. Clipping surgery was inapplicable due to the lack of space to insert clip blades between the neck and two origins of MCA. Under stent-assisted maneuver, the aneurysm sac was successfully obliterated using three coils, resulting in Raymond-Roy class 1 occlusion status. Digital subtraction angiography performed 3 months after the embolization showed complete obliteration of the aneurysm. So far, only 11 patients with aneurysms associated with duplicate origin of MCA have been reported. We performed a literature review of this very rare combination. The size of aneurysms ranged from 2 to 8 mm, with a mean of 5.2 mm. The neck of the aneurysm is mainly located at the corner between the inferior limb and the internal carotid artery. Ours is the youngest and has the largest aneurysm. Conclusion: Aneurysm can arise from duplicate origin of MCA, for which stent-assisted coiling may be an appropriate treatment modality.

"A national cohort with aneurysmal subarachnoid hemorrhage - patient characteristics, choice of treatment, clinical outcome, and factors of prognostic importance".

OBJECTIVE: To study associations of clinical characteristics and treatment choice with functional outcome, mortality, and time to death in a national sample of aneurysmal subarachnoidal hemorrhage (aSAH) patients. METHODS: Data were extracted from a prospective nationwide multicenter study performed in September 2014 to March 2018. Glasgow Outcome Scale Extended (GOSE) grade, 1-year mortality, and survival probability were assessed at one year after ictus. Logistic univariate, multivariate, and Cox regression analyses were used to study the variables' associations with the outcomes. RESULTS: Unfavorable dichotomized GOSE (dGOSE; grades 1-4) was observed in 35.4% of patients. Microsurgery was preferred for middle cerebral artery aneurysms and Fisher grade 4. Treatment modality was not associated with any outcome measure. Dichotomized World Federation of Neurosurgical Societies (dWFNS), age, and delayed ischemic neurological deficit (DIND) showed significant correlations with dGOSE and 1-year mortality in multivariate regression analyses. Pupil dilatation was associated with 1-year mortality outcome. Cox regression analysis showed lower survival probability for pupil dilatation (hazard ratio (HR) 3.546), poor dWFNS (HR 3.688), higher age (HR 1.051), and DIND occurrence (HR 2.214). CONCLUSIONS: The patient selection in Sweden after aSAH showed similar values for dGOSE, 1-year mortality, and survival probability between patients treated with microsurgery or endovascular technique. Poor dWFNS, higher age, and DIND were significantly associated with unfavorable dGOSE, mortality, and survival probability. Pupil dilatation was significantly associated with mortality and survival probability.

Direct carotid-cavernous fistula after functional endoscopic sinus surgery - A case report.

INTRODUCTION AND IMPORTANCE: Direct carotid-cavernous fistulas (CCF) are primarily caused by head trauma. Some cases have also been attributed to iatrogenic injuries during endovascular procedures. However, the reports of functional endoscopic sinus surgery (FESS) associated with direct CCFs are extremely rare. PRESENTATION OF CASE: A 52-year-old male worker, who suffered from chronic sinusitis and underwent functional endoscopic sinus surgery (FESS) performed by an otolaryngologist. Intra-operative finding indicated a left sphenoid sinus wall injury without internal carotid artery bleeding, which was repaired using mucosa and tissue glue. One month after discharge, he began experiencing tinnitus, headache and swelling in his left eye. Cerebral angiography revealed a direct carotid-cavernous fistula (CCF) on the left side. The patient underwent transarterial and transvenous stent-assisted coiling using detachable coils and Onyx, which alleviated his symptoms. CLINICAL DISCUSSION: A cavernous-carotid fistula following FESS is an exceedingly rare occurrence first reported by Karaman et al. in 2009. The incidence of internal carotid artery injury during FESS or endonasal endoscopic surgery (EES) is estimated to be between 0 and 0.1 %. Currently, there is no definitive explanation for the development of a carotid-cavernous fistula (CCF) post-FESS. Previous studies suggest that procedures like transsphenoidal surgery and EES can induce pseudoaneurysms in the internal carotid artery. If the cavernous pseudoaneurysm ruptures, it could lead to the formation of a CCF. CONCLUSION: A direct cavernous-carotid fistula following functional endoscopic sinus surgery is a very rare. Consequently, when encountering patients with a carotid-cavernous fistula, relevant procedure history should be considered.

Coil Embolization Is Not Justified for Treating Patients with Veno-Occlusive Dysfunction: Case Series and Narrative Literature Review.

Introduction: Herein, we explore whether coil embolization (CE) is effective in treating veno-occlusive dysfunction (VOD). We present five cases with seven CE episodes and a narrative literature review. Methods: From 2013 to 2018, refractory impotence prompted five men to seek penile vascular stripping (PVS), although seven CE episodes were included. All received dual cavernosography in which erection-related veins and VOD were documented. PVS entailed the venous stripping of one deep dorsal vein and two cavernosal veins. The abridged five-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS) were used, and yearly postoperative follow-ups were conducted via the Internet. Using Pub Med, a narrative literature review was performed on CE treatment for VOD or varicocele. Results: Inserted coils were scattered along the erection-related veins, including the deep dorsal veins (n = 4), periprostatic plexus (n = 5), iliac vein (n = 5), right pulmonary artery (n = 2), left pulmonary artery (n = 2), and right ventricle (n = 1). PVS resulted in some improvements in the IIEF-5 score and EHS scale. Six articles highly recommend CE treatment for VOD. All claimed it is a minimally invasive effective treatment for varicocele. Conclusions: CE is not justified as a VOD treatment, regardless of its viability in the treatment of varicocele.

Endovascular treatment of an iatrogenic right subclavian artery pseudoaneurysm associated with an arteriovenous fistula.

This report describes the case of a frail 36-year-old patient who underwent an endovascular treatment of a right subclavian artery pseudoaneurysm (SAP) associated with an arteriovenous fistula secondary to a traumatic central venous catheter insertion. The deployment of a covered stent from the innominate to the right common carotid artery combined with coiling of the SAP and the internal mammary artery was performed. Two additional covered stents were deployed from the vertebral artery to the distal subclavian artery to preserve right upper extremity circulation. This case highlights the feasibility of an endovascular treatment of a complex SAP in a candidate unsuitable for open surgery.

A High-grade Aneurysmal Subarachnoid Hemorrhage in the Peripartum Period.

Aneurysmal subarachnoid hemorrhage (aSAH) is a rare but devastating complication with increased morbidity and mortality. It is still unclear whether the incidence is increased during pregnancy and in the peripartum period. However, the incidence of cerebral aneurysmal rupture is higher during the third trimester than in the first trimester. The risk of aneurysmal rupture and subarachnoid hemorrhage (SAH) during general anesthesia or spinal anesthesia is unclear. We report a case of left supraclinoid aneurysm rupture after spinal anesthesia for Low Segment Caesarean Section (LSCS) in the immediate postpartum period causing high-grade aSAH.

Endovascular Treatment of Basilar Apex Aneurysms: An Updated Systematic Review and Meta-Analysis in the Era of Flow Diversion.

BACKGROUND: Endovascular options for the treatment of basilar apex aneurysms (BAAs) are heterogeneous, and evidence is limited to retrospective cohorts and case series. We seek to evaluate the efficacy and complications associated with various endovascular treatment methods of BAAs. METHODS: Systematic review of PubMed, Embase, and Web of Science adhering to the PRISMA guidelines. Retrospective and prospective studies evaluating endovascular treatment of BAAs between January 2010 and July 2024 were included. Relevant information including occlusion rates, aneurysm recurrence, retreatment rates, and complications were subjected to meta-analysis. RESULTS: Fifteen studies with 1,049 BAAs were included. The median aneurysm diameter was 8.5 mm (range 4.6-19.75), with a median follow-up of 33.7 months (range 6.0-117.6). Residual aneurysm filling occurred in 24% after primary coiling (95% CI=0.16-0.32), 25% after single stent-assisted coiling (s-SAC; 95% CI=0.04-0.46), 25% after Y-stenting (95% CI=0.12-0.37), and 23% after flow diverter stenting (FDS; 95% CI=0.11-0.35). Recurrence rates were high for primary coiling (27%, 95% CI=0.18-0.36) and s-SAC (19%, 95% CI=0.13-0.26), but significantly lower for Y-stenting (9%, 95% CI=0.03-0.15) and FDS (4%, 95% CI=-0.04-0.11). Retreatment rates were 19% for primary coiling (95% CI=0.12-0.26), 17% for s-SAC (95% CI=0.07-0.27), 5% for Y-stenting (95% CI=-0.03-0.12), and 13% for FDS (95% CI=-0.01-0.27). Meta-regression indicated larger aneurysms had higher complication rates (p=0.02). Thromboembolic events were most frequent with FDS and Y-stenting (12%). CONCLUSION: Occlusion rates were similar across treatments, but recurrence rates were significantly lower after Y-stenting and FDS treatments compared to primary coiling, although they carried a higher number of thromboembolic complications.

Simultaneous resolution of arachnoid cyst and chronic subdural hematoma after middle meningeal artery embolization: illustrative case.

BACKGROUND: Arachnoid cysts are cerebrospinal fluid-filled spaces that are typically congenital and treated conservatively or with fenestration when symptomatic. Chronic subdural hematomas (cSDHs) can arise in the presence of arachnoid cysts due to fragile leptomeningeal vessels or veins within the cyst wall or cyst lumen, leading to bleeding and subsequent hematoma formation. Middle meningeal artery (MMA) embolization is regularly used for the treatment of cSDH as an alternative to craniotomy and evacuation. OBSERVATIONS: Here, the authors present the first known report of the simultaneous resolution of an arachnoid cyst and cSDH following MMA embolization in an adult. A 24-year-old male presented to the emergency department with 1 month of worsening headaches. Imaging revealed the presence of a cSDH and ipsilateral arachnoid cyst. The cSDH was treated with MMA embolization using coils exclusively. Follow-up imaging 4 months after embolization demonstrated simultaneous resolution of both the hematoma and the arachnoid cyst. LESSONS: MMA embolization has been used for the treatment of cSDH. In cases in which the hematoma is related to an arachnoid cyst, MMA embolization can also lead to the concurrent resolution of both pathologies. https://thejns.org/doi/10.3171/CASE24192.

Microsurgical clipping versus endovascular therapy for treating patients with middle cerebral artery aneurysms presenting with neurological ischemic symptoms.

Studies comparing different treatment methods in patients with middle cerebral artery (MCA) aneurysms in different subgroups of onset symptoms are lacking. It is necessary to explore the safety and efficacy of open surgical treatment and endovascular therapy in patients with MCA aneurysms in a specific population. This study aimed to compare microsurgical clipping versus endovascular therapy regarding complication rates and outcomes in patients with MCA aneurysms presenting with neurological ischemic symptoms. This was a retrospective cohort study in which 9656 patients with intracranial aneurysms were screened between January 2014 and July 2022. Further, 130 eligible patients were enrolled. The primary outcome was the incidence of serious adverse events (SAEs) within 30 days of treatment, whereas secondary outcomes included postprocedural target vessel-related stroke, disabling stroke or death, mortality, and aneurysm occlusion rate. Among the 130 included patients, 45 were treated with endovascular therapy and 85 with microsurgical clipping. The primary outcome of the incidence of SAEs within 30 days of treatment was significantly higher in the clipping group [clipping: 23.5%(20/85) vs endovascular: 8.9%(4/45), adjusted OR:4.05, 95% CI:1.20-13.70; P = 0.024]. The incidence of any neurological complications related to the treatment was significantly higher in the clipping group [clipping:32.9%(28/85) vs endovascular:15.6%(7/45); adjusted OR:3.49, 95%CI:1.18-10.26; P = 0.023]. Postprocedural target vessel-related stroke, disabling stroke or death, mortality rate, and complete occlusion rate did not differ significantly between the two groups. Endovascular therapy seemed to be safer in treating patients with MCA aneurysms presenting with neurological ischemic symptoms compared with microsurgical clipping, with a significantly lower incidence of SAEs within 30 days of treatment and any neurological complications related to the treatment during follow-up.

The Safety and Efficacy of Leo Stents with Coiling or Alone for Anterior Cerebral Artery Aneurysms.

INTRODUCTION: Treatment of anterior cerebral artery (ACA) aneurysms is still not well established. The Leo stent with blood flow direction is a retrievable stent for intracranial aneurysms, whereas it needs to be studied clearly in patients with ACA aneurysms. METHODS: Consecutive patients with ACA aneurysms were retrospectively enrolled in three neurosurgical centers between January 2016 and October 2021. The data on demographics, aneurysm characteristics, symptom resolution, and postoperative course were collected and analyzed. The aneurysm occlusion status was appraised by Raymond-Ray Occlusion Class (RROC). RESULTS: A total of 57 patients with ACA aneurysms were included in our study. Immediate postprocedural angiograms showed that 20 aneurysms (35.1%) were in complete occlusion (RROC 1), 26 aneurysms (45.6%) were in near-complete occlusion (RROC 2), 11 aneurysms (19.3%) were in incomplete occlusion (RROC 3). The angiographic follow-up found that the rate of complete occlusion increased to 57.9%, and near-completion and incomplete occlusion dropped to 29.8% and 12.3%, respectively. The angiographic result of the last follow-up improved significantly (Z=- 2.805, P=0.005). Univariate analysis indicated that distal location of aneurysms (Z=4.538, P=0.033) and ruptured aneurysms (χ2=.6120, P=0.032) were potential risk factors for intra-parent artery narrowing. Furthermore, multivariate logistic regression analysis found that A3 aneurysms (95% CI 1.427~32.744, P=0.016) are the key risk factor for intra-parent artery narrowing. CONCLUSIONS: The Leo stent is safe and effective for aneurysms located in ACA circulations. The overall occlusion degree improved during follow-up. A distal, small artery was the risk factor for intra-parent artery narrowing.

Rare simultaneous fetal posterior cerebral artery and conventional posterior cerebral artery duplication in a patient with a ruptured posterior communicating artery aneurysm: illustrative case.

BACKGROUND: The fetal-type posterior cerebral artery (PCA) is defined as a variant anatomy in which the posterior communicating artery (PCOM) is larger than the hypoplastic or aplastic P1 segment of the PCA. The authors present the novel case of a patient with a duplicated right PCA in parallel with fetal-type and conventional PCAs supplying adjacent components of the PCA cerebral territory. OBSERVATIONS: A 59-year-old woman presented with a modified Fisher Scale score 4 subarachnoid hemorrhage. A right irregular PCOM aneurysm that measured 9.5 mm × 4.5 mm × 4.5 mm arose from the base of a variant branch supplying a portion of the PCA, rather than a conventional PCOM, and was found on digital subtraction angiography. Following endovascular coil embolization, the patient was discharged home. LESSONS: The fetal-type variant has implications for thromboembolic events. If an embolism occludes the anterior circulation in a patient with a fetal-type PCA, it may result in an infarct in the PCA territory. Awareness of cerebral arterial anatomy, including an atypical collateral supply, informs a treating team's latitude in tolerance of which sites must be preserved and which can be safely sacrificed. https://thejns.org/doi/10.3171/CASE23735.

Complex intracranial aneurysms: a DELPHI study to define associated characteristics.

PURPOSE: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA. METHODS: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability. RESULTS: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac. CONCLUSIONS: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach.

Multiple Intracranial Aneurysms Associated With Brain Arteriovenous Malformation: A Case Report and Treatment Strategies.

In the field of cerebrovascular neurosurgery, intracranial aneurysms (IAs) have been occasionally associated with brain arteriovenous malformations (BAVMs), indicating a more aggressive clinical course, and increased rates of hemorrhage and rehemorrhage. Treatment of flow-related IAs in BAVMs remains debatable, with considerations for preventive intervention versus concurrent BAVM treatment. Managing such situations might be challenging, especially in determining which of the IAs or BAVMs should be treated first, and which treatment strategy would be most appropriate for each situation. A precise identification of the rupture site is required, whether it is the AVM nidus or the IA, for choosing the best treatment plans. We present a case of a 29-year-old male patient diagnosed with several intracranial vascular conditions: a ruptured anterior communicating artery (ACoA) aneurysm and an unruptured ophthalmic artery aneurysm, associated with a frontal BAVM. Moreover, we discussed the possible scenarios regarding the association of these conditions, highlighting their manifestations and the most suitable therapeutic approach for each. Thus, our exploration of the challenges and considerations involved in treating these intricate neurovascular conditions underscores the need for a customized approach for each patient's situation.

Anatomical variations of the extracranial internal carotid artery: prevalence, risk factors, and imaging insights from CT-angiography.

PURPOSE: To determine the prevalence of different extracranial internal carotid artery (EICA) variations in CT angiography (CTA) of the neck and its predisposing factors. METHODS: In this retrospective study from 2021 to 2023 conducted in the radiology department of Shafa Hospital, Kerman, Iran, all patients who had undergone neck CTA were included. Expert radiologists blindly examined each CTA image for the following: EICA variations-coiling, kinking, straight morphology, and tortuosity-and the distance between the internal carotid artery and the apex of the epiglottis and the C2 lower margin. RESULTS: Of the 106 patients, the mean age was 55.9 ± 16.9 years. 64.2% were men, and 35.8% were women. Considering each patient's bilateral anatomy, the reported 70.28% (149/212) frequency of EICA variations of all arteries. Tortuosity, kinking, and coiling variation were found in 61.8%, 4.2%, and 4.2% of arteries, respectively. Also, 54.72%, 1.89%, and 0.94% of the participants had bilateral tortuosity, kinking, and coiling, respectively. There was a significant relationship between the prevalence of EICA variations and female sex, age, and hypertension. CONCLUSION: The frequency of EICA variations in arteries and patients was 70.28% and 73.58%, respectively. Tortuosity was the most common variation. Female sex, old age, and hypertension were significant risk factors for EICA variations.

Endothelial Progenitor Cells: A Review of Molecular Mechanisms in the Pathogenesis and Endovascular Treatment of Intracranial Aneurysms.

This comprehensive review explores the multifaceted role of endothelial progenitor cells (EPCs) in vascular diseases, focusing on their involvement in the pathogenesis and their contributions to enhancing the efficacy of endovascular treatments for intracranial aneurysms (IAs). Initially discovered as CD34+ bone marrow-derived cells implicated in angiogenesis, EPCs have been linked to vascular repair, vasculogenesis, and angiogenic microenvironments. The origin and differentiation of EPCs have been subject to debate, challenging the conventional notion of bone marrow origin. Quantification methods, including CD34+ , CD133+ , and various assays, reveal the influence of factors, like age, gender, and comorbidities on EPC levels. Cellular mechanisms highlight the interplay between bone marrow and angiogenic microenvironments, involving growth factors, matrix metalloproteinases, and signaling pathways, such as phosphatidylinositol-3-kinase (PI3K) and mitogen-activated protein kinase (MAPK). In the context of the pathogenesis of IAs, EPCs play a role in maintaining vascular integrity by replacing injured and dysfunctional endothelial cells. Recent research has also suggested the therapeutic potential of EPCs after coil embolization and flow diversion, and this has led the development of device surface modifications aimed to enhance endothelialization. The comprehensive insights underscore the importance of further research on EPCs as both therapeutic targets and biomarkers in IAs.

Posterior Inferior Cerebellar Artery Aneurysm Presenting With Severe Vertigo and Altered Sensorium.

Posterior inferior cerebellar artery (PICA) aneurysms are relatively uncommon among intracranial aneurysms and present unique challenges due to their complex anatomical origins. PICA aneurysms arise from the vertebral artery (VA), basilar artery, or anterior inferior cerebellar artery and can have complex anatomical sites and structures. A 31-year-old female known case of trigeminal neuralgia, currently asymptomatic for the same, experienced acute vertigo, headache, and altered sensorium. On the basis of the magnetic resonance imaging of the brain with angiography, she was diagnosed with a PICA aneurysm, necessitating immediate intervention. The patient subsequently underwent endovascular coiling of the aneurysm. The successful management of this unusual case emphasizes the significance of prompt diagnosis and early intervention in managing posterior inferior cerebellar artery aneurysms, leading to a favourable outcome. The patient is on regular follow-ups and has satisfactory progress.