AL Rhoton

B Lubicz

C Agostinis

C Cognard

C Haw

D Eckard

G Gacs

Guus N. Beute

H Cloft

HB Locksley

J Chaloupka

Jo P. P. Peluso

K Uda

L Pierot

LF Gonzalez

M Danet

M Sagoh

Menno Sluzewski

S Mabuchi

S Nagasawa

S Ushikoshi

T Kawase

TE Collins

TE Lempert

V Seifert

Willem Jan van Rooij

English

PubMed

Springer - Publisher Connector

INTERVENTIONAL NEURORADIOLOGY
Superior cerebellar artery aneurysms: incidence,
clinical presentation and midterm outcome
of endovascular treatment
Jo P. P. Peluso & Willem Jan van Rooij &
Menno Sluzewski & Guus N. Beute
Received: 6 February 2007 /Accepted: 3 May 2007 / Published online: 4 July 2007
# Springer-Verlag 2007
Abstract
Introduction The aim of this retrospective study was to
determine the incidence, clinical presentation and midterm
clinical and imaging outcome of endovascular treatment of
34 superior cerebellar artery (SCA) aneurysms in 33 patients.
Methods Between January 1995 and January 2007, 2,112
aneurysms were treated in our institution, and 36 aneu-
rysms in 35 patients were located on the SCA (incidence
1.7%). Two of three distal SCA aneurysms were excluded.
All the remaining 34 SCA aneurysms, of which 22 (65%)
were ruptured and 12 (35%) were unruptured, in 33 patients
were treated by endovascular techniques. There were 6 men
and 27 women ranging from 29–72 years. In 14 patients
(42%) multiple aneurysms were present.
Results Initial angiographic occlusion was (near) complete
in 32 aneurysms (94%) and incomplete in 2 aneurysms
(6%). Complications leading to permanent morbidity or
death occurred in two patients (6.1%, 95% CI 0.6 to
20.60%). Outcome at 6 months follow-up in 31 surviving
patients was GOS5 in 26 (84%), GOS4 in 4 (13%) and
GOS3 in 1 patient (3%). There were no episodes of (re)
bleeding during 118 patient-years of follow-up. The 6-
month angiographic follow up in 28 SCA aneurysms and
extended angiographic follow-up in 19 showed stable
occlusion in 27 aneurysms. No additional treatments were
performed.
Conclusion SCA aneurysms are rare with an incidence of
1.7% of treated aneurysms at our institution. They are
frequently associated with other aneurysms. Endovascular
treatment is effective and safe in excluding the aneurysms
from the circulation.
Keywords Superior cerebellar artery . Aneurysm .
Coiling . Outcome
Introduction
Aneurysms located on the superior cerebellar artery (SCA)
are uncommon and their presentation, natural history and
clinical management are poorly understood [1, 2]. Reports
about the endovascular or surgical management of SCA
aneurysms are rare and are usually incorporated in clinical
series of basilar artery or posterior circulation aneurysms
[3–18].
The aim of this retrospective study was to determine the
incidence, clinical presentation and midterm clinical and
imaging results of endovascular treatment of 35 patients
with 36 SCA aneurysms.
Methods
Patients
Between January 1995 and January 2007, 2,112 aneurysms
were treated in our institution. Of the 2,112 treated
aneurysms, 324 (15%) were located in the posterior
circulation and 1,788 (85%) in the anterior circulation.
Surgery was performed in 970 aneurysms and endovascular
treatment in 1,142 aneurysms. Of the 2,112 treated
Neuroradiology (2007) 49:747–751
DOI 10.1007/s00234-007-0251-z
J. P. P. Peluso :W. J. van Rooij (*) :M. Sluzewski
Department of Radiology, St. Elisabeth Ziekenhuis,
Hilvarenbeekseweg 60,
5022 GC Tilburg, The Netherlands
e-mail: radiol@knmg.nl
G. N. Beute
Department of Neurosurgery, St. Elisabeth Ziekenhuis,
Tilburg, The Netherlands
aneurysms, 36 aneurysms in 35 patients were located on the
SCA, resulting in an incidence of 1.7% of all treated intra-
cranial aneurysms and 11.1% of treated posterior circula-
tion aneurysms. We excluded one patient with a peripheral
SCA flow aneurysm associated with an arteriovenous
malformation and one peripheral partially thrombosed
SCA aneurysm presenting with trochlear nerve palsy. In
one patient with four aneurysms, one aneurysm was located
on the proximal right SCA and one aneurysm on the distal
left SCA. All 33 proximal SCA aneurysms were primarily
based on the basilar artery at the branching point of the
SCAwith or without incorporation of the SCA origin in the
base. All 34 SCA aneurysms in 33 patients were treated by
endovascular techniques. There were 6 men and 27 women
with a mean age of 50.7 years (median 49 years, range 29–
72 years). Of 34 aneurysms, 22 (65%) had ruptured, 7
(20%) were additional to another ruptured aneurysm, 4
(12%) presented with symptoms of a mass effect (trigem-
inal neuralgia 2, oculomotor palsy 2) and one (3%) was an
incidental finding (Fig. 1). The mean size of the 34 SCA
aneurysms was 7.3 mm (median 6 mm, range 2–27 mm).
The clinical condition of the 22 patients with a ruptured
SCA aneurysm at the time of treatment was HH I–II in 16,
HH III in 3 and HH IV–V in 3. Seven SCA aneurysms in
six patients were additional to another ruptured aneurysm
Fig. 1 Incidentally found SCA aneurysm in a 39-year-old man with
vertebrobasilar embolic infarcts. a T1-weighted MR image shows a
hyperintense lesion adjacent to the brainstem. b 3-D vertebral angio-
gram reveals a small SCA aneurysm
Fig. 2 Pre- and posttreatment
images of two patients with
multiple posterior circulation
aneurysms. a A 44-year-old man
with a ruptured middle cerebral
artery aneurysm and four addi-
tional aneurysms. 3-D vertebral
angiogram reveals right SCA
aneurysm (short single arrow),
left distal SCA aneurysm (long
single arrow) and basilar tip
aneurysm (pair of arrows).
b Complete occlusion after
coiling. c A 61-year-old woman
with a ruptured middle cerebral
artery aneurysm and additional
aneurysms on the left SCA and
basilar tip. d Adequate occlu-
sion of basilar tip and SCA
aneurysms
748 Neuroradiology (2007) 49:747–751
and were coiled in the same session as the ruptured
aneurysm. The clinical condition of these six patients was
HH I–II in five and HH IV–V in one.
Of the 33 patients, 14 (42%) had multiple aneurysms
(Fig. 2) for a total of 72 aneurysms: 5 patients had 2 aneu-
rysms, 3 patients had 3 aneurysms, 3 patients had 4 aneu-
rysms, 1 patient had 5 aneurysms, 1 patient had 7 aneurysms
and 1 patient had 8 aneurysms. Of the 72 aneurysms in 35
patients, 53 were coiled, 13 were clipped, and 6 were small
(<2 mm) and left untreated.
Coiling procedure
Coiling of aneurysms was performed on a biplane angio-
graphic unit (Integris BN 3000 Neuro, Philips Medical
Systems, Best, The Netherlands) with the patient under
general anaesthesia and systemic heparinization. Heparin
was continued intravenously or subcutaneously for 48 h
after the procedure, followed by low-dose aspirin for 3 months
orally. Coiling was performed with Guglielmi detachable
coils (GDC, Boston Scientific, Fremont, Calif.) or TruFill
DCS coils (Cordis, Miami, Fl.). The aim of coiling was to
pack the aneurysm as densely as possible, until not a single
additional coil could be placed. Four wide-necked aneu-
rysms (12%) were coiled with the aid of a supporting
balloon in the basilar artery. One aneurysm was located
distal on the SCA and was selectively occluded with coils
sparing the parent SCA. Complications of coiling were
recorded.
Initial angiographic results of coiling were classified as
complete occlusion (100%), near complete occlusion (90–
100%) and incomplete occlusion (<90%).
Clinical and angiographic follow-up
Patients who survived the hospital admission period were
scheduled for a follow-up visit in the outpatient clinic
6 weeks after treatment and for follow-up angiography
Fig. 3 Ischemic complication
of coiling in a 71-year-old
woman with a ruptured SCA
aneurysm. a Vertebral angio-
gram demonstrates a wide-
necked right SCA aneurysm
with the SCA arising from the
sac. b, c Balloon-assisted coiling
with adequate occlusion and
preserved flow in the SCA. The
patient did not awake from
general anaesthesia. Immediate
control angiography revealed
that the SCA had become oc-
cluded (not shown). d MRI
several days later showing
brainstem and cerebellum
infarctions in the SCA territory
Neuroradiology (2007) 49:747–751 749
after 6 and 18 months. Neurological status according to
the Glasgow Outcome Scale (GOS) was evaluated at
every outpatient clinic visit and at every admission for
follow-up angiography. The results of follow-up angi-
ography were classified in the same way as for initial
angiographic results.
Results
Initial angiographic results and complications
Initial angiographic occlusion was complete or near com-
plete (90–100% occlusion) in 32 aneurysms and incomplete
in 2 aneurysms (both 80% occlusion). Complications
leading to permanent morbidity or death occurred in two
patients. The first patient was a 42-year-old woman who
presented with a ruptured 2-mm wide-necked SCA aneu-
rysm in HH I. During insertion of a coil with the aid of
a supporting balloon, a rupture occurred and the patient
died 12 h later (mortality 1 of 33, 3.0%, 95% CI 0.01–
16.65%). The second patient was a 71-year-old woman
admitted with a ruptured 10-mm wide-necked SCA
aneurysm (Fig. 3). The SCA itself originated from the
sac. The aneurysm was coiled with the aid of a supporting
balloon with adequate occlusion and preserved flow in the
SCA. However, the patient did not awake from general
anaesthesia. Immediate control angiography revealed that
the SCA had become occluded. MRI several days later
showed infarctions in the vascular territory of the SCA in
the brainstem and cerebellum. The patient gradually
recovered but remained dependent. At the time of this
report almost 4 years later she was still in a nursing home
(procedural morbidity 1 of 33, 3.0%, 95% CI 0.01–
16.65%).
Clinical follow-up
Clinical follow-up was available for all 33 patients. One
patient died of a procedural rupture and another patient died
of diffuse vasospasm after subarachnoid haemorrhage
(SAH). The remaining 31 patients had clinical follow-up
of mean 45 months (median 44.5 months, range 4–
103 months, 118 patient-years). Outcome at 6 months
follow up of these 31 patients was GOS 5 in 26 (84%),
GOS 4 in 4 (13%) and GOS 3 in 1 patient (3%). Symptoms
of mass effect on cranial nerves in four patients were cured
in all. During extended follow up, two patients died of
unrelated disease 3 and 6 years after coiling of a SCA
aneurysm: pulmonary embolism in one patient and dissem-
inated bronchial carcinoma in the other patient. There were
no episodes of (re)bleeding during the 118 patient-years of
follow-up.
Angiographic follow-up
Of the 31 surviving patients, 4 refused follow-up angiog-
raphy. The remaining 27 patients (with 28 SCA aneurysms)
all had 6 months follow-up angiography and 19 had
extended angiographic follow-up of a mean of 31 months
(median 22 months, range 18–84 months). Stable complete
or near-complete occlusion was apparent in 25 of 28
aneurysms. In one patient, a 66-year-old man with a
27-mm partially thrombosed SCA aneurysm presenting
with trigeminal neuralgia, the coils had migrated into the
intraluminal thrombus at the 6-month follow-up angiog-
raphy. However, the trigeminal neuralgia was cured and the
aneurysm was not retreated. The patient died 6 years later
of disseminated bronchial carcinoma. Two aneurysms in
two patients that were initially incompletely occluded (both
80% occlusion) remained so at extended angiographic
follow-up. Additional treatment was judged impossible in
both patients.
Discussion
In this study, we found that SCA aneurysms are rare with
an incidence of 1.7% of all treated intracranial aneurysms
and 11.1% of treated posterior circulation aneurysms at our
institution. The majority of patients presented with SAH
and 42% of patients also had aneurysms at other locations.
This frequent association with multiple aneurysms has not
been established before. Endovascular occlusion with
detachable coils is feasible with good angiographic and
clinical results and with low morbidity [3].
The proximal SCA has an intimate relation with cranial
nerves III, IV and V [19]. Aneurysms on the SCA may
therefore present with palsies of these nerves, as was the
case in four of our patients [10, 11]. After coiling,
symptoms of nerve compression regressed in all four
patients.
One of 34 SCA aneurysms was located distally on the
artery. It was possible to occlude this aneurysm with
sparing of the parent SCA. When selective occlusion of
such an aneurysm is not possible, simultaneous occlusion
of the aneurysm together with the parent artery can be
performed. Collateral blood flow may limit ischemic
infarctions and outcome is usually good [4, 12–15].
Although surgical treatment of SCA aneurysms in
experienced hands is associated with good results, access
may be challenging needing destructive approaches [20–
22]. The presence of important perforating arteries and
adjacent cranial nerves makes clipping of SCA aneurysms
difficult and complications may occur. Because SCA
aneurysms are rare, not many surgeons will gain experience
in the treatment of these aneurysms. In addition, many
750 Neuroradiology (2007) 49:747–751
patients are in bad clinical condition and are not good
surgical candidates in the acute phase.
While surgery for SCA aneurysms is often difficult,
limited to good-grade patients and associated with substan-
tial morbidity, coiling is technically easy and can also be
performed in the acute phase of haemorrhage in bad-grade
patients. This makes coiling the method of choice to treat
SCA aneurysms.
Conclusion
SCA aneurysms are rare with an incidence of 1.7% of
treated aneurysms at our institution. There is a frequent
association with aneurysms at other locations. Most patients
present with SAH. Since the SCA is closely related to
cranial nerves III, IV and V, some aneurysms present with
palsies of these nerves. Endovascular occlusion with
detachable coils is feasible with good angiographic and
clinical results.
Conflict of interest statement We declare that we have no conflict
of interest.
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Superior cerebellar artery aneurysms: incidence, clinical presentation and midterm outcome of endovascular treatment

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Superior cerebellar artery aneurysms: incidence, clinical presentation and midterm outcome of endovascular treatment

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