Surgical treatment of a posterior inferior cerebellar artery aneurysm via transcranial neuroendoscopic approach: A case report

RATIONALE: Posterior inferior cerebellar artery (PICA) aneurysms are rare and heterogeneous in both location and morphology, and the management of proximal PICA aneurysms is challenging. In 2011, Joaquim reported a successfully treated VA-PICA ruptured aneurysm using a pure endoscopic endonasal transclival approach for the first time. However, the patient suffered CSF rhinorrhea and underwent an additional operation to repair the CSF leak. In this case report, we describe the treatment of proximal PICA aneurysm by transcranial neuroendoscopic approach. PATIENT CONCERNS: A 68-year-old woman presented with a sudden onset of severe headache followed by loss of consciousness and computed tomography of the head showed a mild SAH, located predominantly in the posterior fossa. Clinical signs and symptoms included headache and a positive meningeal irritation sign; no other neurological symptoms were found. DIAGNOSIS: A 3-dimensional CT angiography revealed the diagnosis as left VA-PICA junction aneurysm. INTERVENTIONS: After a medical treatment, the patient regained consciousness and the aneurysm was treated by pure neuroendoscopy via a modified far-lateral surgical approach. OUTCOMES: The patient recovered well after the procedure, and the post-operation image view shows a proper placement of the clip, obliteration of the aneurysm, and the parental artery was unobstructed. LESSONS: To our best knowledge, this is the first reported case of treating aneurysm by neuroendoscopic transcranial approach and the second reported case treated by endoscopy. In the present report, we propose that ruptured VA-PICA junction aneurysms could be treated by a pure transcranial neuroendoscopic approach. The advantages of this approach included no risk of CSF rhinorrhea compared with the endoscopic endonasal transclival approach.