Dear Mike, Chris, Fred, and Bob,
Please accept the above named for coiling/surgery.
Basilar tip, Fetal Rt PCA, relatively wide neck extending into the Lt PCA. In the absence of obvious views of the Rt PCA relative to the basialr bifurcation, this aneurysm could also possibly be an SCA aneurysm (had some like that)- but this is mainly academic, and less likely here...
For Coiling - in my (lay) endovascular opinion - not great for GDC alone because of the neck and configuration re-Lt PCA. Would use either balloon assisted- or Neuroform stent assisted- coiling. For the latter, would have to pre-medicate with Plavix. GDC alone less likely to completely obliterate aneurysm, or run the risk of losing the Lt PCA. One caveat is the "Murphy's teat"-like structure visible posteriorly on the aneurysm (top right 3D angio) - is this a part of the Rt PCA that's getting washed out (likely), or is it the site of the rupture? Would pay attention to that if we repeat the angio. If it is the latter, would pay great attention to obliterating the neck of the aneurysm.
For Surgery - Good one- it is anteriorly pointing. Consideration is that the Lt PCA may contain the thalamoperforators for both sides, as these often arise unilaterally when one PCA is higher than the other. In fact, I think that both PCA's are at the same level, but the Rt PCA is washed out by the carotid circulation on the Vert injection.... Would approach the aneurym from the Left, because 1. Aneurysm is more on that side, 2. Can afford to take down the p-com if needed (Wallace hates that, but he's getting on in years...), 3. Contralateral P1 less important if taken prox to p-com - but watch out for the key perforators.
What I would do - Give endovascular a try... at age 67, sparing her open surgery would be more convenient. If not a candidate, or if coiling fails, or the "non-lay" endovascular boys reject- I'd operate.
Mike has summarized angiographic issues nicely.
I would think that it will be coilable either with or without stent assistance but if not, it is favourable surgically.
I agree with Mike. Suitable for coiling. We may need to use either balloon remodelling or the neuroform. In that location, I favour the neuroform since the stent may allow better packing and therefore better long term results.