Endovascular strategies for treatment of posterior communicating artery aneurysm according to angiographic architecture: Preservation vs. sacrifice of posterior communication artery

We report ischemic complications related to obstruction of the posterior communicating artery (PcomA) and suggest treatment strategies according to the angiographic characteristics of the PcomA and the posterior cerebral artery (PCA). Twenty-one patients with PcomA aneurysm who had initially undergone endovascular treatment and had an identifiable PcomA occlusion on immediate or follow-up angiography were enrolled. We classified PcomA aneurysm according to the characteristics of the PcomA and PCA (P1) on baseline angiography, as follows: type I was defined as PcomA aneurysm with an absent PcomA and a normal-sized P1. Type II was defined as a hypoplastic PcomA and a normal-sized P1. Type III was defined as a normal-sized PcomA and an absent P1. Type IV was defined as a normal-sized PcomA and a hypoplastic P1. Type V was a normal-sized PcomA and a normal-sized P1. Among all cases of PcomA obstruction, 15 (71.4%) were type II PcomA aneurysms, four were type IV, one was type III, and one was type V. Ischemic events related to PcomA obstruction occurred in three cases (type II, III and VI), which included two tuberothalamic infarctions (type III and IV) and one cortical infarction in the territory of the PCA (type II). Follow-up angiographies showed flow change in the PcomA in 14 cases. It is relatively safe to sacrifice type II PcomA if necessary. However, physicians should pay attention to unexpected flow changes, such as recanalization or occlusion of the PcomA, which are possible after treatment.