Metastatic malignant struma ovarii to the pituitary presenting as a sellar mass and responding to total thyroidectomy with adjuvant radioactive iodine therapy.

Malignant struma ovarii (MSO) is a rare ovarian teratoma composed primarily of thyroid tissue. Common sites of metastasis include peritoneum, bone, liver, lung, gastrointestinal tract and omentum. We present a woman in her 50s with a history of remote oophorectomy presenting with hypopituitarism and a 2.7 cm sellar mass. Trans-sphenoidal surgery for presumed pituitary macroadenoma achieved near total resection and resultant pathology surprisingly showed ectopic thyroid tissue. The patient acquired her ovarian pathology report from Southeast Asia which showed struma ovarii of the left ovary. The pituitary mass was thus determined to be a metastatic lesion from MSO. She underwent total thyroidectomy and radioactive iodine ablation therapy with good initial response and no regrowth of the tissue or emergence of distant metastases after 5 years of annual follow-up. To our knowledge, this is the first reported case of MSO to the pituitary.

Emotional Lability as a Symptom of Extra-axial Posterior Fossa Tumors: a Case-Control Review of Neuroanatomy and Patient-Reported Quality of Life.

Introduction Emotional lability (EL), the uncontrollable and unmotivated expression of emotion, is a rare and distressing symptom of brainstem compression. In published case reports, EL from an extra-axial posterior fossa tumor was alleviated by tumor resection. The primary aim herein was to radiographically establish the degree of compression from mass lesions onto brainstem structures. Secondarily, we compared changes in patient-reported quality of life (QOL) pre- and postoperatively. Methods A retrospective review of posterior fossa tumors treated between 2002 and 2018 at Vancouver General Hospital revealed 11 patients with confirmed EL. Each case was matched to three controls. A lateral brainstem compression scale characterized mass effect at the level of the medulla, pons, and midbrain in preoperative axial T2-weighted fluid-attenuated inversion recovery magnetic resonance imaging (FLAIR MRI) scans. Compression and clinical variables were compared between patient groups. Short Form-36 version 1 health surveys were retrospectively obtained from patient charts to compare pre- versus postoperative changes in survey scores between EL and control patients. Results EL symptoms ceased postoperatively for all EL patients. EL tumors exert greater compression onto the pons ( p = 0.03) and EL patients more commonly have cerebellar findings preoperatively ( p = 0.003). Patients with EL-causing tumors experienced greater improvement postoperatively in "Health Change" ( p = 0.05), which was maintained over time. Conclusion Findings suggest that compression onto the pons inhibits control over involuntary, stereotyped expression of emotion. This adds to evidence that EL may be attributed to cerebellum deafferentation from cortical and limbic structures through the basis pontis, leading to impaired modulation of emotional response. QOL results augment benefits of offering patients EL-alleviating tumor resection surgery.

Vertebral Artery Mobilization During Transcondylar Extreme Far Lateral Approach for Excision of Large Foramen Magnum Meningioma: 2-Dimensional Operative Video.

Foramen magnum meningiomas are challenging lesions owing to their proximity to the lower brainstem, vertebrobasilar system, and lower cranial nerves.1,2 Tumor size, origin, morphology, relationship to neurovascular structures, and bony anatomy determine the optimal surgical approach.2,3 Classically, far lateral approaches have been the workhorse approach to the foramen magnum. Variations of the far lateral including transcondylar and extended transcondylar (paracondylar), with or without transposition of the vertebral artery, are sometimes used for a more lateral approach to the brainstem and clivus. Here, we present a 60-year-old male patient presenting with a large foramen magnum meningioma. Preoperative workup includes computed tomography and MRI with angiography to assess for posterior circulation dominance, anatomic variants including posterior inferior cerebellar artery origin, venous, and bony anatomy.1,4 An extreme far lateral provides access anterior to the vertebral artery to extend exposure beyond the standard far lateral approach. This comprised transcondylar drilling, bony mobilization of the V3 Vertebral artery from C1 foramen transversarium, and dural mobilization of vertebral artery with a dural cuff at its site of dural entry. The patient tolerated the procedure, gross total resection was achieved, and the patient was discharged home. This video demonstrates in detail the steps of exposure, condylar drilling, vertebral artery transposition, and dural opening. These maneuvers can be difficult to conceptualize yet are key to successful extended transcondylar exposure. The patient gave informed consent for surgery and video recording. Institutional Review Board approval was deemed unnecessary.

Correlation of Pituitary Descent and Diabetes Insipidus After Transsphenoidal Pituitary Macroadenoma Resection.

BACKGROUND: Endoscopic transsphenoidal surgery remains the technique of choice for resection of pituitary adenoma. Postoperative diabetes insipidus (DI) is most often transient and observed in 1.6% to 34% of patients, whereas permanent DI has been reported in 0% to 2.7% of patients. The proposed mechanism was the transduction of traction forces exerted by the surgeon on the descended diaphragma sellae and through the pituitary stalk. OBJECTIVE: To quantify and correlate the degree of pituitary gland descent with postoperative DI. METHODS: Of 374 patients who underwent transsphenoidal resection of a pituitary adenoma between 2010 and 2020 at our institution, we report a cohort of 30 patients (Group A) DI. We also report a matched cohort by tumor volume of 30 patients who did not develop DI (Group B). We quantified the tension on the pituitary stalk by calculating pituitary descent interval (PDI) by comparing preoperative and postoperative position of the pituitary gland and using Pythagoras' formula where , with craniocaudal (CC) and anterior-posterior (AP) representing measurements of pituitary translation in respective directions after resection. RESULTS: Patients who developed DI had significantly greater pituitary gland translations in the craniocaudal (23.0 vs 16.3 mm, P = .0015) and anteroposterior (2.4 vs 1.5 mm, P = .0168) directions. Furthermore, Group A had a statistically greater PDI, which was associated with development of DI (23.2 vs 16.6 mm, P = .0017). CONCLUSION: We were able to quantify pituitary descent and subsequent tension on the pituitary stalk, while also associating it with development of postoperative DI after pituitary adenoma resection.

Current Trends in Neurosurgical Management of Adult Diffuse Low-Grade Gliomas in Canada.

There is considerable variability in the management of diffuse low-grade gliomas (LGGs). To characterize treatment paradigms, a survey of Canadian neurosurgeons was performed with forty neurosurgeons responding. Their responses show that the management of patients with LGGs has evolved in the past decade and findings from the RTOG9802 trial have been integrated into the practice of Canadian neurosurgeons. Most respondents stated that the patient selection and treatment strategy advocated by the RTOG9802 trial needs further evaluation. Overall, there is a trend toward more aggressive surgical resections, and future investigations will have to more accurately stratify patient risk profiles.

The Unified Visual Function Scale Assessments Show Inter- and Intraobserver Agreement and Correlate with Patient Quality of Life in Skull Base Parasellar Tumors.

Introduction The authors have previously described the Unified Visual Function Scale (UVFS). Here, we assessed intra- and interobserver reliability of the scale, and investigated correlations with patient quality of life (QoL). Methods Eight healthcare practitioners independently applied the UVFS in 20 representative cases from our parasellar meningioma series. Scoring was compared with consensus grades assigned by lead authors. Inter- and intraobserver agreement was measured using intraclass correlation coefficient (ICC), Fleiss's κ, and Cohen's κ, respectively. Patient QoL was assessed Visual Function Questionnaire 25 (VFQ-25) or Activities of Daily Vision Scale (ADVS), and correlated with UVFS grades for each eye. Results The interobserver ICC was 0.734 (95% confidence interval [CI]: 0.652-0.811), with Fleiss's κ of 0.758, 0.691, and 0.899 for grades A, B, and C, respectively. The intraobserver ICC was 0.758 (95% CI: 0.638-0.872), and Fleiss's κ was 0.604, 0.268, and 0.910 for grades A, B, and C respectively. The Cohen's κ for agreement between UVFS category grades and consensus grades was 0.816 (95 CI: 0.698-0.934). Survey response rate was 51% (27/53). The UVFS demonstrated strong correlation with VFQ-25 subdivisions general vision ( r = 0.7712), near activities ( r = 0.7262), peripheral vision ( r = 0.6722), and driving ( r = 0.6608), and also demonstrated strong correlation with the overall ADVS score ( r = 0.5902). Conclusion This study shows that the UVFS is valid within a small subset of observers, and accurately reflects patient QoL. It is robust and practical, which make it suitable for broad implementation.

Survival and Recurrence Outcomes Following Adjuvant Radiotherapy for Grade 2 Intracranial Meningiomas: 13-Year Experience in a Tertiary-Care Center.

OBJECTIVE: We sought to evaluate overall survival (OS) and local recurrence (LR) in patients with grade 2 meningiomas treated with adjuvant radiotherapy compared to surgery alone at time of diagnosis. METHODS: All patients at the authors' institution between 2007 and 2020 were retrospectively reviewed. OS, LR, and treatment toxicities were assessed. Sensitivity analyses were performed for patients with initial gross total resection (GTR) and subtotal resection (STR). Kaplan-Meier analyses and log-rank test for significance were used to compare surgery alone and adjuvant radiotherapy groups. RESULTS: We included 189 patients with mean age 57.4 ± 14.6 years. Patients were 64% female, and median follow-up was 64 (interquartile range: 20-96) months. At initial treatment, 21 patients received adjuvant radiotherapy and 168 received surgery alone. There was no significant difference for OS (hazard ratio = 1.3 [95% confidence interval 0.4-4.5], P = 0.92) overall or when limited to GTR (P = 0.38) or STR (P = 0.85). There was no significant difference in LR overall (P = 0.75) or when restricted to GTR (P = 0.77) or STR (P = 0.20). No patient had radiotherapy stopped or altered because of side effects; however, 71.4% reported tolerable side effects during the treatment period and 14.3% reported chronic side effects persisting longer than 12 months post treatment. CONCLUSIONS: In a large retrospective cohort, we found no survival or local recurrence benefit to adjuvant radiotherapy in treatment of grade 2 meningiomas. Sensitivity analysis limited to initial GTR and STR also failed to demonstrate any OS or LR benefit with adjuvant radiotherapy. In our experience, there is limited utility to upfront adjuvant radiotherapy following initial surgical resection in the treatment of grade 2 meningiomas.

The impact of brain invasion criteria on the incidence and distribution of WHO grade 1, 2, and 3 meningiomas.

BACKGROUND: In 2016 brain invasion was added as a standalone diagnostic criterion for Grade 2 meningiomas in the WHO Classification of Brain Tumors. The aim of this study was to compare the incidence and distribution of meningiomas, and agreement, between the 2007 and 2016 WHO criteria. METHODS: All cases of intracranial meningiomas diagnosed between 2007 and 2020 at a tertiary care academic hospital were identified. The incidence of each meningioma grade in the WHO 2007 and WHO 2016 cohorts were compared. Additionally, each case in the 2007 cohort was re-graded according to the WHO 2016 criteria to determine the intra-class correlation (ICC) between criteria. RESULTS: Of 814 cases, 532 (65.4%) were in the 2007 WHO cohort and 282 (34.6%) were in the 2016 WHO cohort. There were no differences in the distribution of meningioma grades between cohorts (P = .11). Incidence rates were: 75.0% vs. 75.2% for Grade 1, 22.7% vs. 24.5% for Grade 2, and 2.3% vs. 0.4% for Grade 3, for the 2007 and 2016 cohorts, respectively. Upon re-grading, 21 cases (3.9%) were changed. ICC between original and revised grade was 0.92 (95% CI: 0.91-0.93). Amongst Grade 2 meningiomas with brain invasion, 75.8% had three or more atypical histologic features or an elevated mitotic index. CONCLUSIONS: Including brain invasion as a standalone diagnostic criterion for Grade 2 meningiomas had minimal impact on the incidence of specific meningioma grade tumors. There is strong agreement between the 2007 and 2016 WHO criteria, likely due to cosegregation of grade elevating features.

Delayed coil migration into oropharynx following endovascular coiling of a traumatic carotid cavernous fistula: management considerations.

Carotid-cavernous fistulas (CCFs) are abnormal vascular shunts between the carotid artery and the cavernous sinus. A 37-year-old male presented with a traumatic CCF and basal skull fracture extending through the medial wall of the cavernous sinus and sphenoid sinus. The CCF was treated with endovascular coiling. Three months after this procedure, he was found to have coil migration through the traumatic sphenoid defect into the pharynx. He underwent urgent endonasal endoscopic surgery to disconnect and remove the extruded coil. Post-operative coil migration is a rare but serious complication following endovascular treatment of traumatic CCF.

Quantitative Optical Coherence Tomography Angiography in Patients with Moyamoya Vasculopathy: A Pilot Study.

Moyamoya (MM) disease is a chronic cerebrovascular disease that can lead to progressive stenosis of the terminal portions of the internal carotid arteries and their proximal branches. We sought to investigate and quantify retinal vascular changes in patients with MM vasculopathy (MMV) using optical coherence tomography angiography (OCTA) compared to healthy controls. Our findings reveal retinal microvascular changes in patients with MMV and highlights the potential of OCTA imaging for the detection of subclinical retinal pathology.

Quality of life scores in patients with unruptured cerebral aneurysm: Prospective cohort study.

BACKGROUND: Living with the diagnosis of an unruptured cerebral aneurysm can understandably cause distress to a patient. The goal of preventive treatment is to increase the number of years with good quality of life (QoL). OBJECTIVE: This study aimed to measure the effect of unruptured intracranial aneurysm treatment on change in QoL scores measured by the SF36 and EQ-5D-5L. METHODS: We prospectively collected SF36 and EQ-5D-5L survey data for patients with unruptured intracranial aneurysms at two time-points over 1 year between 2 treatment groups: observation and intervention (microsurgical and endovascular). Multivariable linear regression was used to examine treatment group differences in the mean change in scores from baseline to 1 year when adjusted for covariates. RESULTS: 92 patients were included in the observation group and 68 patients were included in the intervention group, for a total of 160 patients. The intervention group had lower SF36 total scores at baseline (p = 0.001). With multivariate linear regression models, the effect of treatment on mean change in SF36 total score from baseline to 1 year was not statistically significant (p = 0.4); similarly, there was no difference in mean change in EQ-5D-5L. CONCLUSION: In this large prospective study, preventive aneurysm treatment was not associated with a significant change in QoL score at 1 year compared to observation as measured by the SF36 and EQ-5D-5L. Further studies are needed to explore the lower QoL scores in patients seeking treatment and its impact on management decision making.

Brain Hypoxia Is Associated With Neuroglial Injury in Humans Post-Cardiac Arrest.

[Figure: see text].

Intraparenchymal Neuromonitoring of Cerebral Fat Embolism Syndrome.

OBJECTIVES: We aimed to characterize the cerebrovascular physiology of cerebral fat embolism using invasive multimodal neuromonitoring. DATA SOURCES: ICU, Vancouver General Hospital, Vancouver, BC, Canada. STUDY SELECTION: Case report. DATA EXTRACTION: Patient monitoring software (ICM+, Cambridge, United Kingdom), clinical records, and surgical records. DATA SYNTHESIS: None. CONCLUSIONS: Our integrated assessment of the cerebrovascular physiology of fat embolism syndrome provides a physiologic basis to investigate the importance of augmenting mean arterial pressure to optimize cerebral oxygen delivery for the mitigation of long-term neurologic ischemic sequelae of cerebral fat embolism.

Cost-effectiveness analysis in patients with an unruptured cerebral aneurysm treated with observation or surgery.

OBJECTIVE: The main goal of preventive treatment of unruptured intracranial aneurysms (UIAs) is to avoid the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage. A comparison between the conservative approach and the surgical approach combining endovascular treatment and microsurgical clipping is currently lacking. This study aimed to conduct an updated evaluation of cost-effectiveness comparing the two approaches in patients with UIA. METHODS: A decision tree with a Markov model was developed. Quality-adjusted life-years (QALYs) associated with living with UIA before and after treatment were prospectively collected from a cohort of patients with UIA at a tertiary center. Other inputs were obtained from published literature. Using Monte Carlo simulation for patients aged 55, 65, and 75 years, the authors modeled the conservative management in comparison with preventive treatment. Different proportions of endovascular and microsurgical treatment were modeled to reflect existing practice variations between treatment centers. Outcomes were assessed in terms of QALYs. Sensitivity analyses to assess the model's robustness and completed threshold analyses to examine the influence of input parameters were performed. RESULTS: Preventive treatment of UIAs consistently led to higher utility. Models using a higher proportion of endovascular therapy were more cost-effective. Models with older cohorts were less cost-effective than those with younger cohorts. Treatment was cost-effective (willingness to pay < 100,000 USD/QALY) if the annual rupture risk exceeded a threshold between 0.8% and 1.9% in various models based on the proportion of endovascular treatment and cohort age. A higher proportion of endovascular treatments and younger age lowered this threshold, making the treatment of aneurysms with a lower risk of rupture more cost-effective. CONCLUSIONS: Preventive treatment of aneurysms led to higher utility compared with conservative management. Models with a higher proportion of endovascular treatment and younger patient age were most cost-effective.

Goal-Directed Care Using Invasive Neuromonitoring Versus Standard of Care After Cardiac Arrest: A Matched Cohort Study.

PURPOSE: Following return of spontaneous circulation after cardiac arrest, hypoxic ischemic brain injury is the primary cause of mortality and disability. Goal-directed care using invasive multimodal neuromonitoring has emerged as a possible resuscitation strategy. We evaluated whether goal-directed care was associated with improved neurologic outcome in hypoxic ischemic brain injury patients after cardiac arrest. DESIGN: Retrospective, single-center, matched observational cohort study. SETTING: Quaternary academic medical center. PATIENTS: Adult patients admitted to the ICU following return of spontaneous circulation postcardiac arrest with clinical evidence of hypoxic ischemic brain injury defined as greater than or equal to 10 minutes of cardiac arrest with an unconfounded postresuscitation Glasgow Coma Scale of less than or equal to 8. INTERVENTIONS: We compared patients who underwent goal-directed care using invasive neuromonitoring with those treated with standard of care (using both total and matched groups). MEASUREMENTS AND MAIN RESULTS: Goal-directed care patients were matched 1:1 to standard of care patients using propensity scores and exact matching. The primary outcome was a 6-month favorable neurologic outcome (Cerebral Performance Category of 1 or 2). We included 65 patients, of whom 21 received goal-directed care and 44 patients received standard of care. The median age was 50 (interquartile range, 35-61), 48 (74%) were male, and seven (11%) had shockable rhythms. Favorable neurologic outcome at 6 months was significantly greater in the goal-directed care group (n = 9/21 [43%]) compared with the matched (n = 2/21 [10%], p = 0.016) and total (n = 8/44 [18%], p = 0.034) standard of care groups. Goal-directed care group patients had higher mean arterial pressure (p < 0.001 vs total; p = 0.0060 vs matched) and lower temperature (p = 0.007 vs total; p = 0.041 vs matched). CONCLUSIONS: In this preliminary study of patients with hypoxic ischemic brain injury postcardiac arrest, goal-directed care guided by invasive neuromonitoring was associated with a 6-month favorable neurologic outcome (Cerebral Performance Category 1 or 2) versus standard of care. Significant work is required to confirm this finding in a prospectively designed study.

Lack of agreement between optimal mean arterial pressure determination using pressure reactivity index versus cerebral oximetry index in hypoxic ischemic brain injury after cardiac arrest.

INTRODUCTION: Invasive monitoring of cerebral autoregulation using the pressure reactivity index (PRx) allows for the determination of optimal mean arterial pressure (MAPOPT) in hypoxic ischemic brain injury (HIBI) patients following cardiac arrest. However, the utility of non-invasive surrogates to determine MAPOPT has not been addressed. We aimed to determine the agreement between PRx-derived MAPOPT versus MAPOPT determined by the near-infrared spectroscopy (NIRS) based cerebral oximetry index (COx). METHODS: Ten HIBI patients were enrolled. PRx-derived MAPOPT, lower (LLA) and upper limits of autoregulation (ULA) were compared against COx-derived MAPOPT, LLA and ULA. Multimodal neuromonitoring included mean arterial pressure, intracranial pressure, brain tissue oxygenation, jugular venous oxygen saturation, and NIRS-derived regional cerebral oxygen saturation. RESULTS: Repeated measures Bland-Altman plots demonstrated limited agreement between MAPOPT derived from COx and PRx (mean bias: 1.4 mmHg; upper limit of agreement: 25.9 mmHg; lower limit of agreement: -23.0 mmHg). Similarly, there was limited agreement between the absolute values of PRx and COx. Mean bias was 0.26 and the upper and lower limits of agreement were 1.05 and -0.53, respectively. Systematic bias was apparent, whereby at low PRx values COx overestimated PRx and at high PRx values, COx underestimated PRx. COx was limited in its ability to determine impaired autoregulation defined by PRx (receiver operator characteristic area under the curve was 0.488). CONCLUSION: Collectively, we demonstrate that COx-based determination of MAPOPT lacks agreement with MAPOPT derived from PRx. Further research must be done to evaluate the physiologic and clinical efficacy of PRx derived MAPOPT in HIBI.

Basilar Apex Aneurysm: Case Series, Systematic Review, and Meta-analysis.

BACKGROUND: A lower rate of aneurysmal recanalization in stent assisted coiling versus coiling alone has been observed in aneurysms overall. This study aims to primarily stratify and compare degree of occlusion per treatment modality in basilar apex aneurysms. Secondary outcomes were retreatment, posttreatment hemorrhage, and procedure-related complications. METHODS: Medical literature including MEDLINE and EMBASE database was searched. We performed metaregressions, bias analysis, and fail-safe N. We controlled for the quality of the studies. RESULTS: Data from eligible studies (N = 12) and study center patients (n = 117) were pooled for a total of 396 nonduplicated patients. Stent-assisted coiling had a lower rate of retreatment (17% vs. 24%) and higher rate of posttreatment hemorrhage (5% vs. 3%) compared with coiling. Stent-assisted coiling had a higher rate of complete occlusion (55% vs. 45%) and a lower rate of residual aneurysm (15% vs. 23%) compared with coiling. Comparative analyses were performed. Microsurgical technique remained the most morbid treatment modality with the best rate of complete occlusion (93%) and lowest rates of rehemorrhage (2%) and retreatment (5%). CONCLUSIONS: This is the first and largest meta-analysis focused on patients treated for basilar apex aneurysm. We report higher rehemorrhage rates with stent-assisted coiling. This study provides benchmark data to guide clinicians in future treatment decision making and encourages future research to stratify outcomes.

Cannabis use and outcomes after aneurysmal subarachnoid hemorrhage: A nationwide retrospective cohort study.

BACKGROUND: Cannabis is the most consumed recreational drug in the world. It is possible that cannabis has an association with an increased risk of vasospasm-related strokes and delayed cerebral ischemia (DCI), which are major causes of morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH). Hence, this study aimed to explore the independent relationship between cannabis use and outcomes after aSAH using the 2016 United States Nationwide Inpatient Sample. METHODS: This study was conducted using the 2016 National Inpatient Sample with ICD-10 codes. Multivariate logistic regression was used to examine the association between cannabis use, the primary (inpatient mortality) and secondary outcomes. RESULTS: There were 42,394 patients identified with aSAH, of whom 925 were identified as cannabis users. Cannabis users and non-users were similar in terms of severity of aSAH. Although the unadjusted mortality rate was lower among cannabis users (16%) than non-users (22%), (p = 0.04), both the age-adjusted odds ratio (OR) (0.83, 95% confidence interval (CI): 0.56; 1.24) and the multivariate-adjusted OR (0.87, 95% CI: 0.54; 1.42) did not reach statistical significance. Secondary outcomes did not reach statistical significance. CONCLUSION: In this nationwide cohort, cannabis users with aSAH had similar outcomes compared to nonusers. However, these results are likely limited by underreporting of cannabis use. Future prospective studies are needed to elucidate the pathophysiology and association between cannabis and outcomes following aSAH.

Functional Outcomes After Treatment of Posterior Inferior Cerebellar Artery Aneurysms.

Objective Aneurysms of the posterior inferior cerebellar artery (PICA) are a rare cause of subarachnoid hemorrhage. Treatment for this type of aneurysm may be microsurgical clipping or endovascular. This decision is based on patient characteristics, aneurysm location and dimensions, along with surgeon and institutional experience. In this study we aim to assess the outcomes of surgical and endovascular treatment of PICA aneurysms. Methods We retrospectively reviewed the charts of 52 patients who were admitted to Vancouver General Hospital for ruptured or symptomatic PICA aneurysms between 2005 and 2015. Modified Rankin scores were assigned at the time of discharge and at two subsequent follow-up time points. The mean short-term follow-up period post-operatively was 11.1 months and the mean long-term follow-up period was 19.3 months. Clinical and radiological characteristics were collected for all patients. Results Of the 52 patients, two died prior to obtaining treatment. Of the 50 patients who were treated for their PICA aneurysm, 39 presented with subarachnoid hemorrhage while 11 had symptomatic unruptured PICA aneurysms. Overall, 11 patients had endovascular treatment (coil embolization) while 39 patients underwent microsurgical clipping/trapping of the aneurysm. At the time of hospital discharge, patients in the microsurgical group trended towards a better the modified Rankin Scale score (2.3) compared to the endovascular group, though this did not reach significance (3.0) (p=0.20). The long-term score in the endovascular group (1.6) was also comparable to the microsurgical group (1.9) (p=0.55). Conclusion While the early outcomes in patients treated endovascularly appear better, there is no statistically significant difference in outcomes between the microsurgical and endovascular treatment groups at short- and long-term follow-up.