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Posterior communicating artery aneurysm diagnosis

Symptoms suggestive of Posterior communicating artery aneurysm vary, but most sources agree that the presence of oculomotor nerve palsy and severe SAH-like headache are the most common 1). 2).

Expert interpretation of modern noninvasive neuroimaging such as Computed tomography angiography (CTA) and magnetic resonance angiography (MRA), should detect nearly all aneurysms responsible for an isolated third nerve palsy 3) 4) 5) 6).

Whether a catheter angiogram should still be obtained in cases of isolated third nerve palsy with negative CTA or MRA remains a difficult decision 7) 8).

Although recent studies 9) have reported a risk of neurologic complications close to zero for diagnostic cerebral angiographies performed within a high volume neuro-interventional practice, the risk of neurologic complications following catheter cerebral angiography was once between 0.9 and 4% 10) and, therefore, algorithms trying to avoid routine catheter angiography, especially as a screening test, have been proposed in the past 11) 12) 13)

Recent publications have emphasized the importance of having presumed negative noninvasive vascular imaging studies reviewed by a skilled neuroradiologist before aneurysm is rejected as the cause of the third nerve palsy or before the patient undergoes catheter angiography 14).

Angiographic considerations

Vertebral artery (VA) injection is necessary to help evaluate the posterior communicating artery:

1. if the p-comm is patent: determine if there is a “fetal circulation” where the posterior circulation is fed only through the p-comm

2. determine if the aneurysm fills from VA injection

If additional views are needed t o better demonstrate aneurysm

Try paraorbital oblique 55° away from inject ion side, center beam 1 cm posterior to inferior portion of lateral rim of ipsilateral orbit, orient x-ray tube 12° cephalad

One cannot accurately predict blood supply dominance of the posterior cerebral artery with CTA. Knowledge of the blood flow dominance is essential when clipping a posterior communicating artery aneurysm to avoid compromise in posterior circulation 15).

Raps EC, Rogers JD, Galetta SL, et al. The clinical spectrum of unruptured intracranial aneurysms. Arch Neurol. 1993;50(3):265.
Friedman JA, Piepgras DG, Pichelmann MA, et al. Small cerebral aneurysms presenting with symptoms other than rupture. Neurology. 2001;57(7):1212.
3) , 8)
Trobe JD. Searching for brain aneurysm in third cranial nerve palsy. J Neuroophthalmol. 2009;29:171–173.
Kupersmith MJ, Heller G, Cox TA. Magnetic resonance angiography and clinical evaluation of third nerve palsies and posterior communicating artery aneurysms. J Neurosurg. 2006;105:228–234.
Mathew MR, Teasdale E, McFadzean RM. Multidetector computed tomographic angiography in isolated third nerve palsy. Ophthalmology. 2008;115:1411–1415.
Chaudhary N, Davagnanam I, Ansari SA, Pandey A, Thompson BG, Gemmete JJ. Imaging of intracranial aneurysms causing isolated third cranial nerve palsy. J Neuroophthalmol. 2009;29:238–244.
Lee AGBP. Clinical evaluation for aneurysm in patients with third cranial nerve palsy. Expert Rev Ophthalmol. 2009;4:547–552.
Thiex R, Norbash AM, Frerichs KU. The safety of dedicated-team catheter-based diagnostic cerebral angiography in the era of advanced nonivasive imaging. AJNR. 2010;31:230–234.
Kaufmann TJ, Huston J, 3rd, Mandrekar JN, Schleck CD, Thielen KR, Kallmes DF. Complications of diagnostic cerebral angiography: evaluation of 19,826 consecutive patients. Radiology. 2007;243:812–819.
Trobe JD. Isolated pupil-sparing third nerve palsy. Ophthalmology. 1985;92:58–61.
Trobe JD. Third nerve palsy and the pupil. Footnotes to the rule. Arch Ophthalmol. 1988;106:601–602.
Bruce BB, Biousse V, Newman NJ. Third nerve palsies. Semin Neurol. 2007;27:257–268.
Elmalem VI, Hudgins PA, Bruce BB, Newman NJ, Biousse V. Underdiagnosis of posterior communicating artery aneurysm in noninvasive brain vascular studies. J Neuroophthalmol. 2011 Jun;31(2):103-9. doi: 10.1097/WNO.0b013e3181f8d985. PubMed PMID: 21150642; PubMed Central PMCID: PMC3682504.
Ahmed O, Kalakoti P, Menger R, Brown B, Zhang S, Guthikonda B, Cuellar H. Accuracy of CT angiography in detection of blood supply dominance of posterior cerebral artery in patients with posterior communicating artery aneurysm. Neuroradiol J. 2015 Dec;28(6):598-603. doi: 10.1177/1971400915615082. Epub 2015 Oct 29. PubMed PMID: 26515748.
posterior_communicating_artery_aneurysm_diagnosis.txt · Last modified: 2019/12/18 08:55 by administrador