title: Posterior circulation perforator aneurysms: a proposed management algorithm.
abstract: BACKGROUND
  Subarachnoid hemorrhage (SAH) from posterior circulation perforator aneurysms (PCPAs) is rare and its natural history is unknown. Diagnosis may be difficult, acute management is poorly defined, and long-term recurrent SAH rates and clinical outcome data are lacking.
  
  
  METHODS
  We searched our institution's records for cases of PCPA rupture and analyzed patient demographics, Hunt and Hess (HH) grades, diagnostic imaging, management, and clinical outcomes. We conducted telephone interviews to calculate modified Rankin Scale (mRS) scores.
  
  
  RESULTS
  We identified 9 patients (6 male, 3 female) with a ruptured PCPA who presented to the University of Virginia Health System (Charlottesville, VA, USA) between 2010 and 2016. Median and mean ages were 62 and 63 years, respectively. Median HH grade was 3. Seven of nine (78%) PCPAs were angiographically occult on initial imaging and median time to diagnosis was 5 days. Three conservatively managed patients had a mean mRS score of 0.67 (range 0-1) at mean follow-up of 35.3 months. Antifibrinolytic therapy was administered to all conservatively managed patients without thrombotic complication. Six patients receiving endovascular treatment had a mean mRS score of 2.67 (range 0-6) at mean follow-up of 49.2 months. No cases of recurrent SAH were seen in the study.
  
  
  CONCLUSIONS
  The rarity of PCPA has precluded long-term clinical follow-up until now. Our experience suggests low recurrent SAH rates. Until further studies are performed, conservative management, possibly combined with antifibrinolytic therapy, may be a viable treatment with acceptable long-term outcome.
authors.affiliation: Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Buell
authors.affiliation: Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Dale
authors.initials: D
authors.lastname: Ding
authors.affiliation: Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Daniel M S
authors.initials: DMS
authors.lastname: Raper
authors.affiliation: Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Ching-Jen
authors.initials: CJ
authors.lastname: Chen
authors.affiliation: Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Harry R
authors.initials: HR
authors.lastname: Hixson
authors.affiliation: Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA.
authors.forename: R Webster
authors.initials: RW
authors.lastname: Crowley
authors.affiliation: Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Avery J
authors.initials: AJ
authors.lastname: Evans
authors.affiliation: Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Jensen
authors.affiliation: Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.|Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Kenneth C
authors.initials: KC
authors.lastname: Liu
mesh_terms: D000368:Aged; D000465:Algorithms; D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging* / Q000628:therapy*; D002533:Cerebral Angiography / Q000379:methods; D019468:Disease Management; D004621:Embolization, Therapeutic / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Aneurysm; Angiography; Hemorrhage; Stroke; Subarachnoid