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Tarkiainen J, Pyysalo L, Hinkka T, Pienimäki JP, Ronkainen A, Frösen J. Stability of infundibular dilatations: a single center follow-up study and systematic review of the literature. Acta Neurochir (Wien) 2024; 166:48. [PMID: 38286939 PMCID: PMC10824818 DOI: 10.1007/s00701-024-05890-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/15/2023] [Indexed: 01/31/2024]
Abstract
PURPOSE Although infundibular dilatations (IDs) have been thought to be benign anatomical variants, case reports suggest that they can grow and rupture. The aim of this study was to determine whether IDs have a tendency to grow or rupture. METHODS The study population was collected from the Tampere University Hospital (TAUH) Aneurysm Database. The presence of IDs was screened from the medical records and imaging studies of 356 intracranial aneurysm patients left to follow-up from 2005 to 2020. The imaging studies were reviewed to confirm the IDs, and their clinical course. Finally, we performed a systematic review of published cases of ID leading to aneurysmatic rupture from PubMed. RESULTS We found 97 typical IDs in 83 patients and 9 preaneurysmal lesions resembling ID in 9 patients. Out of the typical cone-shaped IDs, none grew or ruptured in a total follow-up of 409 patient-years. One preaneurysmal lesion ruptured during a follow-up: this lesion had components of both infundibular dilatation and aneurysm at the beginning of follow-up. In the systematic literature search, we found 20 cases of aneurysmatic SAHs originating from an ID. Of those, only 7 had imaging available prerupture. All 7 IDs were typically cone-shaped, but a branching vessel originating from the apex of ID was only seen in 4/7. CONCLUSION Typical infundibular dilatations seem to be benign anatomical variants that are stable and, thus, do not need prophylactic treatment or imaging follow-up. Likely, the SAHs reported from IDs were actually caused by misdiagnosed preaneurysmal lesions.
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Affiliation(s)
- Jeremias Tarkiainen
- Department of Neurosurgery, Tampere University Hospital and University of Tampere, Tampere, Finland.
- Hemorrhagic Brain Pathology Research Group, Faculty of Medical Technology and Health Sciences, Tampere University, Tampere, Finland.
| | - Liisa Pyysalo
- Hemorrhagic Brain Pathology Research Group, Faculty of Medical Technology and Health Sciences, Tampere University, Tampere, Finland
- Department of Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Tero Hinkka
- Department of Radiology, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Juha-Pekka Pienimäki
- Department of Radiology, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Antti Ronkainen
- Department of Neurosurgery, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Juhana Frösen
- Department of Neurosurgery, Tampere University Hospital and University of Tampere, Tampere, Finland
- Hemorrhagic Brain Pathology Research Group, Faculty of Medical Technology and Health Sciences, Tampere University, Tampere, Finland
- Tays Research Services, Wellbeing Services County of Pirkanmaa, Tampere University Hospital, Tampere, Finland
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Matanov S, Sirakova K, Chupetlovksa K, Penkov M, Monov D, Krupev M, Minkin K, Ninov K, Karakostov V, Sirakov S. Flow Diversion for the Management of Ruptured Intracranial Arterial Infudibular Dilatation: Proof of Principle and Therapeutic Protocol. Front Neurol 2022; 13:913879. [PMID: 35685737 PMCID: PMC9170923 DOI: 10.3389/fneur.2022.913879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
Thought to be benign anatomical variants, cerebral infundibular dilatations (ID) are most commonly encountered at the junction of the internal carotid artery (ICA) and the posterior communicating artery (PcomA). The true nature of this entity remains controversial, as some literature reports suggest they should be considered preaneurysmal lesions and a potential source of devastating subarachnoid hemorrhage. This report describes cases of presumably ruptured IDs and their therapeutic endovascular management. We retrospectively reviewed and analyzed patients with isolated subarachnoid hemorrhage (SAH) where the only potential cause was ruptured cerebral IDs, treated or not, between January 2012 and June 2021. Morphological and radiological features, treatment and procedural considerations, clinical and angiographic outcomes were also reviewed. Natural history of the ID is poorly understood, and its relation to SAH remains controversial. Ruptured cerebral IDs can be the suspected cause of bleeding if no other vascular lesion is present during multimodal examinations. Endovascular flow diversion stenting is safe and effective for the proper treatment of ruptured IDs. Pending further validations with longitudinal data are needed to legitimate the natural course of these mysterious lesions.
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Affiliation(s)
| | | | | | - Marin Penkov
- University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | - Dimitar Monov
- University Hospital St. Ivan Rilski, Sofia, Bulgaria
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Lee W, Han HJ, Kim J, Choi JY, Park KY, Kim YB, Chung J. Ruptured Infundibular dilatation of the posterior communicating artery. Acta Neurochir (Wien) 2021; 163:797-803. [PMID: 33527210 DOI: 10.1007/s00701-021-04716-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/11/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE An infundibulum of the posterior communicating artery (PcomA) or infundibular dilatation (ID) is considered to be a benign anatomical variant. However, some evidence suggests that ID is a pre-aneurysmal state. This case series presents cases of ruptured IDs and aneurysms originating from the IDs. METHODS Between April 2002 and June 2020, 1337 patients were treated for aneurysmal subarachnoid hemorrhage (SAH). Among them, 7 patients with ruptured PcomA IDs were identified. Rupture IDs of the PcomA were categorized into 1) direct rupture of IDs, and 2) rupture of aneurysms originating from IDs. The clinical and radiographic factors were retrospectively reviewed. RESULTS Two patients experienced direct rupture of IDs, while the other 5 patients presented with ruptured aneurysms originating from IDs. The 2 patients with direct rupture of IDs at presentation were relatively younger (< 50 years), while the other 5 patients with ruptured aneurysms originating from IDs were over 70 and had a history of aneurysmal SAH due to other intracranial aneurysms. Ruptured IDs were treated with microsurgery or endovascular treatment. There were no complications related to the procedure for securing ruptured IDs. Five (71.4%) patients showed favorable outcomes. One patient with initial Hunt and Hess grade 4 died due to initial brain damage with cerebral vasospasm and medical complications. CONCLUSIONS ID of the PcomA rarely causes SAH with or without aneurysm formation. Thus, patients with IDs of the PcomA should be carefully followed up for a long period, especially those with a history of aneurysmal SAH.
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Affiliation(s)
- Woosung Lee
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyun Jin Han
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Young Choi
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Infundibular Dilations and Subarachnoid Hemorrhage: to Treat or Not to Treat? World Neurosurg 2018; 123:188-192. [PMID: 30576822 DOI: 10.1016/j.wneu.2018.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Infundibular dilations are funnel-shaped widenings at the origin of a cerebral artery, most commonly the posterior communicating artery. Controversy exists as to whether an infundibulum represents a normal anatomic variant or a lesion with the potential for rupture and subarachnoid hemorrhage (SAH). METHODS We reviewed all reported cases of infundibular dilations and SAH in the world literature and present an illustrative case. RESULTS Most infundibula in the context of SAH were associated with an aneurysm either on or near an infundibulum. However, there have been 7 reports in which the infundibulum could have been the primary site of rupture and no associated aneurysm was identified. Close review reveals significant limitations of those 7 reports. CONCLUSIONS The literature, and our own experience, do not support the treatment of infundibula, even in SAH patients. Treatment should be directed toward an associated aneurysm, not the infundibulum.
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Yang K, Park W, Koo HW, Suh DC. A tiny bleb at Junctional Dilatation of the Posterior Communicating Artery as a Predisposing Factor for Development of a De Novo Aneurysm. Neurointervention 2016; 11:59-63. [PMID: 26958416 PMCID: PMC4781921 DOI: 10.5469/neuroint.2016.11.1.59] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 02/24/2016] [Indexed: 11/24/2022] Open
Abstract
Formation of de novo aneurysm from a junctional dilatation at the origin site of the posterior communicating artery (PcomA) has been rarely reported. In this case report, three females in sixth decades of age developed a de novo aneurysm from the junctional dilatation of the PComA with a tiny bleb-like lesion over 5 years after initial presentation.
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Affiliation(s)
- Kuhyun Yang
- Department of Radiology, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Radiology, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
- Department of Neurosurgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - Hae-Won Koo
- Department of Radiology, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - Dae Chul Suh
- Department of Radiology, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
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Chen CJ, Moosa S, Ding D, Raper DM, Burke RM, Lee CC, Chivukula S, Wang TR, Starke RM, Crowley RW, Liu KC. Infundibular dilations of the posterior communicating arteries: pathogenesis, anatomical variants, aneurysm formation, and subarachnoid hemorrhage. J Neurointerv Surg 2015; 8:791-5. [DOI: 10.1136/neurintsurg-2015-011827] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 06/08/2015] [Indexed: 11/04/2022]
Abstract
BackgroundCerebrovascular infundibular dilations (IDs) are triangular-shaped widenings less than 3 mm in diameter, which are most commonly found at the posterior communicating artery (PCoA). The aims of this systematic review are to elucidate the natural histories of IDs, determine their risk of progression to significant pathology, and discuss potential management options.MethodsA comprehensive literature search of PubMed was used to find all case reports and series relating to cerebral IDs. IDs were classified into three types: type I IDs do not exhibit morphological change over a long follow-up period, type II IDs evolve into saccular aneurysms, while type III IDs are those that result in subarachnoid hemorrhage without prior aneurysmal progression. Data were extracted from studies that demonstrated type II or III IDs.ResultsWe reviewed 16 cases of type II and seven cases of type III IDs. For type II IDs, 81.3% of patients were female with a median age at diagnosis of 38. All type II IDs were located at the PCoA without a clear predilection for sidedness. Median time to aneurysm progression was 7.5 years. For type III IDs there was no clear gender preponderance and the median age at diagnosis was 51. The PCoA was involved in 85.7% of cases, with 57.1% of IDs occurring on the left. Most patients were treated with clipping. Risk factors for aneurysm formation appear to be female gender, young age, left-sided localization, coexisting aneurysms, and hypertension.ConclusionsIDs can rarely progress to aneurysms or rupture. Young patients with type II or III IDs with coexisting aneurysms or hypertension may benefit from long-term imaging surveillance.
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Karekezi C, Boutarbouch M, Djoubairou BO, Melhaoui A, Arkha Y, El Ouahabi A. Are infundibular dilatations at risk of further transformation? Ten-year progression of a prior documented infundibulum into a saccular aneurysm and rupture: Case report and a review of the literature. Neurochirurgie 2014; 60:307-11. [PMID: 25239381 DOI: 10.1016/j.neuchi.2014.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 03/25/2014] [Accepted: 04/29/2014] [Indexed: 10/24/2022]
Abstract
Infundibular dilatations (IFDs) are conical, triangular, or funnel-shaped enlargements at the origin of cerebral arteries, and they are primarily located (7-25%) on the posterior communicating artery (PComA). Progression over time into a saccular aneurysm with a risk of rupture of a previously demonstrated IFD has rarely been reported. We report the case of a 60-year-old female who presented 10 years earlier with a subarachnoid hemorrhage caused by a left internal carotid artery aneurysm rupture. At that time, the carotid angiography showed the left internal carotid artery aneurysm and a right posterior communicating artery infundibular dilatation. Neck clipping for the left internal carotid artery aneurysm was performed and the patient was discharged with no neurological deficit. Ten years later, the patient suffered a second fatal subarachnoid hemorrhage; carotid angiography revealed a right posterior communicating artery aneurysm developed from the previously documented infundibular dilatation with a de novo right anterior choroidal artery aneurysm. This case is another proof of the small but growing number of examples of infundibular transformation over time, as well as their risk of progression into saccular aneurysms and subsequent rupture.
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Affiliation(s)
- C Karekezi
- Department of Neurosurgery, Mohamed Vth, University, School of Medicine, Hôpital des Spécialités, ONO CHU Ibn Sina, Rabat 10100, Morocco.
| | - M Boutarbouch
- Department of Neurosurgery, Mohamed Vth, University, School of Medicine, Hôpital des Spécialités, ONO CHU Ibn Sina, Rabat 10100, Morocco
| | - B O Djoubairou
- Department of Neurosurgery, Mohamed Vth, University, School of Medicine, Hôpital des Spécialités, ONO CHU Ibn Sina, Rabat 10100, Morocco
| | - A Melhaoui
- Department of Neurosurgery, Mohamed Vth, University, School of Medicine, Hôpital des Spécialités, ONO CHU Ibn Sina, Rabat 10100, Morocco
| | - Y Arkha
- Department of Neurosurgery, Mohamed Vth, University, School of Medicine, Hôpital des Spécialités, ONO CHU Ibn Sina, Rabat 10100, Morocco
| | - A El Ouahabi
- Department of Neurosurgery, Mohamed Vth, University, School of Medicine, Hôpital des Spécialités, ONO CHU Ibn Sina, Rabat 10100, Morocco
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First demonstration of resolution of an infundibulum by direct treatment of the arterial wall with Pipeline flow-diverting stent. Neuroradiology 2013; 56:35-9. [PMID: 24221534 DOI: 10.1007/s00234-013-1295-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 10/17/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Infundibula are symmetrical funnel-shaped widening, measuring more than 3 mm at its base with the branch artery arising from its apex. The pathological significance of this entity remains controversial. Although a relatively common appearance in otherwise normal angiograms, they have occasionally been described to progress into saccular aneurysms or directly rupture. METHODS/RESULTS We describe the first case of a disappearing infundibulum after a flow diverting stent was deployed across the infundibulum during the treatment of an adjacent aneurysm. CONCLUSIONS We concur in the view that infundibula are at least pre-pathological lesions that may in certain circumstances require consideration for treatment. Our case for the first time offers a potential treatment option for such situations.
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Savic D, De Angelis M, Grujicic D. The Clinic of Neurosurgery at the Clinical Center of Serbia in Belgrade--building on the past. World Neurosurg 2013; 82:e15-20. [PMID: 23994133 DOI: 10.1016/j.wneu.2013.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 08/15/2013] [Indexed: 11/27/2022]
Abstract
Neurosurgery as an independent discipline in Serbia has a distinguished history, beginning in 1938 when Dr. Milivoje Kostic, Professor and Chairman of Surgery, opened the Department of Neurosurgery within the Clinic of Surgery in Belgrade. Since then, thanks to the founding fathers' efforts and their successors' work, the Clinic for Neurosurgery in Belgrade has become a highly specialized health, scientific, and educational institution that is part of the University of Belgrade and is a referral center for all neurosurgical clinics in Serbia. Currently, the Clinic for Neurosurgery, with 160 patient beds, is one of the largest European institutions of its kind. Neurosurgery at the Clinical Center of Serbia (CCS) involves a wide range of patients and resources, with an average daily inpatient census of 15 to 20 patients. Each year, there are more than 3000 admissions at the neurosurgical service. Approximately 3500 operations per year are performed in the main campus neurosurgical operating rooms of CCS, while approximately 15,000 patients alone are evaluated in emergency room or inpatient consultations. Despite economic restraints, the department continues to grow in strength, and we remain optimistic of exciting times ahead for neurosurgery at the CCS.
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Affiliation(s)
- Dragan Savic
- Clinic of Neurosurgery, Department of Neurooncology, Clinical Center of Serbia, Belgrade, Serbia
| | - Michelangelo De Angelis
- Division of Neurosurgery, Department of Neurosciences, Reproduction and Odontostomatological Sciences, Faculty of Medicine and Surgery, Federico II University, Naples, Italy.
| | - Danica Grujicic
- Clinic of Neurosurgery, Department of Neurooncology, Clinical Center of Serbia, Belgrade, Serbia
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González-Darder J, Verdú-López y F, Quilis-Quesada V. Manejo y tratamiento microquirúrgico de las dilataciones infundibulares de la arteria comunicante posterior. Serie de nueve casos y revisión de la literatura. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70026-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fischer S, Hopf N, Henkes H. Evolution from an infundibulum of the posterior communicating artery to a saccular aneurysm. Clin Neuroradiol 2010; 21:87-90. [PMID: 21140127 DOI: 10.1007/s00062-010-0038-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 09/29/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION An infrequent case of a de novo aneurysm formation originating from an infundibulum at the origin of the posterior communicating artery (PcomA) is presented. The aneurysm developed within 7 years in a patient who initially presented with subarachnoid hemorrhage (SAH) from a saccular aneurysm of the vertebral artery. CASE SUMMARY A 43-year-old female patient was admitted to our hospital on 16th June 2000 after an acute onset of massive occipital headache. A computed tomography (CT) scan showed a subarachnoid hemorrhage (SAH) around the brainstem and 4-vessel angiography revealed an aneurysm originating from the V4 segment of the right vertebral artery (VA) as the cause of the SAH. A small aneurysm at the basilar artery (BA)/superior cerebellar artery (SCA) bifurcation was also found. Injection of the left internal carotid artery (ICA) showed a diffuse enlargement at the origin of the left PcomA, which at this time was considered to be a so-called infundibulum. The VA aneurysm was treated by coil occlusion. Follow-up digital subtraction angiography (DSA) in 2005 showed a de novo aneurysm formation at the VA junction, again treated by coil occlusion. The PcomA infundibulum at the left ICA was not examined. Follow-up angiography performed in 2007 revealed a saccular de novo aneurysm of the left ICA arising from the origin of the left PcomA with a maximum diameter of 12 mm. Coil occlusion of the PcomA aneurysm was subsequently carried out. CONCLUSION Infundibular widening of cerebral arteries can develop into true aneurysms. Mid-term and long-term follow-up MRI (e.g., in yearly intervals) is advised for infundibula with a diameter of 3 mm or more. In patients with other aneurysm(s), with a documented de novo aneurysm formation or with a familial occurrence of aneurysms, the risk of evolution of an infundibulum to a saccular aneurysm may be increased and follow-up should be even more stringent.
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