Technical considerations and challenges in treatment of a ruptured PICA aneurysm in a morbidly obese patient

Morbid obesity presents unique challenges in the treatment of many neurosurgical conditions. In ruptured posterior circulation aneurysms, endovascular treatment has emerged as the safest and most efficacious treatment modality in the majority of cases. We present a technical report of a patient with extensive subarachnoid hemorrhage from a ruptured distal PICA aneurysm. The patient was taken to the hybrid OR with biplane fluoroscopy, utilizing a unique operative set-up to enable safe endovascular treatment. The PICA aneurysm was treated via a transradial approach with distal PICA occlusion using Onyx liquid embolysate. The patient remained neurologically intact and was discharged home after 14 days. This case illustrates a number of technical adjustments that may be made in the safe treatment of patients in whom obesity otherwise limits treatment options.