A Ruptured Tri-Lobulated ICA-PCom Aneurysm Presenting with Preserved Neurological Function - Case Report and Clinical–Anatomical Analysis

Sep 30, 2026

Although rupture of internal carotid–posterior communicating artery (ICA–PCom) junction aneurysms represents a small fraction of intracranial ruptures, it carries high clinical relevance due to proximity to perforator-rich cisterns, optic–carotid–oculomotor pathways, and flow-diverting zones, with frequent early neurologic instability. In tri-lobulated forms, wall shear stress variability, inflammatory remodeling, and rupture propensity at smaller sizes increase. This case enables correlation between minimal early symptoms, tri-lobulation, and confined cisternal hemorrhage to clarify rupture behavior, surgical decisions in a challenging anatomy, and postoperative recovery.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages13

Reading Time33 min

AccessFree to download

Abstract

Background and Clinical Significance

Case Presentation

Conclusions

1. Introduction

Case Report A Ruptured Tri-Lobulated ICA–PCom Aneurysm Presenting with Preserved Neurological Function: Case Report and Clinical–Anatomical Analysis Stefan Oprea 1,2, Cosmin Pantu 1,2, *, Alexandru Breazu 1,2,*, Octavian Munteanu 1,2, Adrian Vasile Dumitru 1,3, Mugurel Petrinel Radoi 1,4, Daniel Costea 1,5 and Andra Ioana Baloiu 1,2,6,7 Academic Editor: Hung-Chieh Chen Received: 26 November 2025 Revised: 22 December 2025 Accepted: 23 December 2025 Published: 25 December 2025 Copyright: © 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license. 1 Faculty of General Medicine,“Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania 2 Department of Anatomy,“Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania 3 Department of Pathology, Faculty of Medicine,“Carol Davila” University of Medicine and Pharmacy, 030167 Bucharest, Romania 4 Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania 5 Department of Neurosurgery,“Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania 6 Doctoral School,“Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania 7 Puls Med Association, 051885 Bucharest, Romania * Correspondence: [cosmin.pantu@umfcd.ro](cosmin.pantu@umfcd.ro) (C.P.); [alexandru-valeriu.breazu@umfcd.ro](alexandru-valeriu.breazu@umfcd.ro) (A.B.) Abstract Background and Clinical Significance: Although rupture of aneurysms at the internal carotid-posterior communicating artery (ICA-PCom) junction accounts for a small percentage of all ruptured intracranial aneurysms, they are clinically relevant due to their proximity to perforator-rich cisterns, the optic-carotid-oculomotor pathways and flowdiverting zones, as well as their high likelihood for causing early neurological instability. Additionally, ruptured ICA-PCom aneurysms that have multiple lobulations are associated with increased variability in wall shear stress, local inflammatory remodeling and higher propensity for rupture at smaller sizes compared to other types of aneurysms. Due to the rapidity of early physiological destabilization in most patients with ruptured ICA-PCom aneurysms, clinical–anatomical correlations in these cases are often obscured by neurological deterioration; therefore, the presentation of this patient provides a unique opportunity to correlate the minimal early symptoms, tri-lobulation of the aneurysm and confined cisternal hemorrhage, to better understand rupture behavior, surgical decision-making in an anatomically challenging area, and postoperative recovery. Case Presentation: A 48-year-old hypertensive female experienced an acute “thunderclap” headache accompanied by intense photophobia and focal meningeal irritation, but, unexpectedly, retained a normal neurologic examination. She did exhibit some minor ocular motor micro-latencies, early cortical attentional strain and lateralized pain sensation that suggested localized cisternal involvement despite lack of generalized neurologic impairment. Digital subtraction angiography and three-dimensional CT angiography revealed a ruptured, tri-lobulated aneurysm originating from the communicating portion of the left internal carotid artery proximal to its origin from the posterior communicating artery, oriented toward the perimesencephalic cisterns. The aneurysm was surgically clipped using a standard left pterionalcraniotomy with direct visualization, after careful dissection through the carotid and optic windows to preserve the anterior choroidal artery, oculomotor nerve, and surrounding perforators. The neck of the aneurysm was reconstructed with a single straight clip, without compromise to the parent vessel lumen. The patient had an uneventful postoperative course without va

FAQs

Why are ruptured ICA–PCom aneurysms clinically important despite being uncommon?

They are near perforator-rich cisterns and key pathways, and they have a high likelihood of causing early neurologic instability, which can obscure clinical–anatomical correlations soon after rupture.

What was distinctive about the patient’s presentation in this case?

A 48-year-old hypertensive woman had an acute thunderclap headache with intense photophobia and focal meningeal irritation, yet she retained a normal neurologic examination with only minor ocular motor micro-latencies and lateralized pain sensation.

How was the aneurysm treated and what were the outcomes during follow-up?

The aneurysm was surgically clipped via a standard left pterional craniotomy with careful dissection and a single straight clip for neck reconstruction. Postoperatively, she had an uneventful course, no vasospasm or deficits, and imaging at 3 and 9 months showed continued aneurysm exclusion and preserved anatomy without delayed ischemic injury or hydrocephalus.

Sep 30, 2026

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