Subarachnoid Hemorrhage due to ruptured PICA aneurysm: Endovascular management and surgical intervention

Ganesh Veerabhadraiah1, Sumana B Palleger2, Vivek Chandra3, Manjunath Reddy4, Yashoda5

1HOD-Neurosurgery, Kauvery Hospital, Electronic City, Bangalore

2Senoir Consultant-Neurosurgery, Kauvery Hospital, Electronic City, Bangalore

3Neuro – Anesthetist, Kauvery Hospital, Electronic City, Bangalore

4Senior Registrar, Neurosurgery, , Kauvery Hospital, Electronic City, Bangalore

5Physician Assistant, Kauvery Hospital, Electronic City, Bangalore

Case Presentation

A 46-years aged female presented with a sudden onset of severe occipital headache, accompanied by seizure-like episodes (body stiffening, with tongue bite), drowsiness, vomiting, and neck pain.

There was no history of trauma or limb weakness.

Imaging confirmed a subarachnoid hemorrhage (SAH) due to a ruptured left posterior inferior cerebellar artery (PICA) aneurysm, with associated hydrocephalus. Digital Subtraction Angiography (DSA) revealed a 6x5mm multilobed aneurysm of the distal left PICA, necessitating urgent endovascular coiling with parent artery occlusion (PAO) for aneurysm securing.

Endovascular Procedure and Intraoperative Rupture Management

  • Right femoral artery access was obtained, and vertebral injection confirmed the PICA aneurysm.
  • A long sheath (Ballast) and intermediate catheter (Navien) were placed in the vertebral artery.
  • Prior to coiling, blood clots were observed emerging from the intermediate catheter, prompting administration of 2000 IU of heparin.
  • Repeat vertebral injection showed contrast extravasation, confirming intraoperative aneurysm rupture (IOR).
  • A microcatheter and guidewire were rapidly advanced near the aneurysm for hemorrhage control.
  • Cerebroprotection was initiated, and proximal and distal coils were deployed within the parent vessel, ensuring complete aneurysm occlusion.

Additional compaction coils were placed, and bradycardia during the procedure was managed with atropine. Final angiographic runs showed no further contrast leakage, with all intracranial vessels remaining patent.

Postoperative Course and Surgical Intervention

  • Immediate post-procedure CT scan revealed persistent hydrocephalus and perianeurysmal blood collection.
  • An external ventricular drain (EVD) was emergently placed via the right precoronal frontal bone for CSF diversion.
  • Despite initial stabilization, she developed progressive cerebellar infarction with mass effect, requiring urgent midline suboccipital craniectomy and posterior fossa decompression to relieve brainstem compression.
  • Post-surgery, her neurological status gradually improved, and she was mobilized with neurorehabilitation support.
  • She was discharged in stable condition with ongoing follow-up and rehabilitation.

Discussion: PICA Aneurysms and Challenges in Management

PICA aneurysms are rare (0.5%–3% of intracranial aneurysms) but have a high rupture risk, often leading to SAH, brainstem compression, and hydrocephalus. Intraoperative rupture (IOR) during endovascular coiling is a life-threatening event, especially in PICA aneurysms due to their deep location, small vessel caliber, and proximity to the brainstem.

Key challenges in IOR management include:

  • Immediate hemorrhage control while preventing thromboembolic complications.
  • Parent artery occlusion (PAO) as a lifesaving intervention, though it increases the risk of cerebellar infarction.
  • Maintaining hemodynamic stability and rapid cerebroprotection to prevent secondary ischemic injury.
  • Postoperative complications such as hydrocephalus and mass effect, requiring EVD placement and surgical decompression.

Conclusion

This case highlights the importance of rapid intraoperative decision-making, multidisciplinary expertise, and aggressive postoperative management in optimizing patient survival and recovery after ruptured PICA aneurysm treatment.

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