Three-dimensional CT angiography for the surgical management of the vertebral artery-posterior inferior cerebellar artery aneurysms

Background. Surgery of vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms is not easy because there is a close anatomical relationship between aneurysms and the surrounding neurovascular structures, and bony structures in the lateral foramen magnum. The preoperative evaluation for a circumstantial comprehension of anatomical relationships is very important for the surgical treatment of the VA-PICA aneurysms. Our experience in using three-dimensional CT angiography (3D-CTA) for the surgical management of VA-PICA aneurysms is herein reported. Methods and findings. We successfully performed neck clipping in 5 cases of VA-PICA aneurysm using 3D-CTA. On 3D reconstructed images, we could see the characteristics of the aneurysms such as their relationships to the jugular tubercle and hypoglossal canal, the projecting direction of the dome, and the configuration of the neck in each case. 3D-CTA also provided a clear surgical view as well as the relationships of the aneurysms to the VA and origin of the PICA. Based on such information, we selected the most appropriate surgical approach among the transcondylar fossa approach, the transcondylar approach, or the far lateral approach with a C1 laminectomy. Conclusions. Since 3D-CTA demonstrates the surgical anatomy of VA-PICA aneurysms in detail, it is very useful for helping surgeons to select the optimal approach.