Enlargement and rupture of distal basilar artery aneurysm after iatrogenic carotid occlusion

A case of angiographic enlargement and fatal rupture of a previously asymptomatic distal basilar aneurysm in a 12-year-old girl is reported. She had been treated by carotid sacrifice for a giant intracavernous carotid aneurysm. After superficial temporal-middle cerebral artery bypass, this patient underwent a trapping procedure and decompression of her symptomatic giant aneurysm. Despite postoperative patency of her bypass graft, the involved middle cerebral circulation was irrigated substantially by retrograde flow through her posterior communicating artery. An incidental distal basilar aneurysm involving the origin of her superior cerebellar arteries, posterior cerebral arteries, and multiple perforators was treated by a wrapping procedure. Eleven days after carotid ligation, she suffered a fatal subarachnoid hemorrhage from her basilar aneurysm. This catastrophe was undoubtedly produced by our failure to consider the additional hemodynamic stress placed upon the distal basilar artery by carotid sacrifice and may have been preventable by a more aggressive attack on this previously asymptomatic lesion.     

Intraaneurysmal embolization and parent artery trapping to treat a giant partial thrombosed vertebral artery aneurysm after surgical proximal clipping

We encountered a case with a giant partially-thrombosed vertebral artery aneurysm successfully treated by endovascular trapping following a surgical parent artery clipping two years previously. The patient complained only of headache on her admission. Initial CT showed no subarachnoid hemorrhage, and MRI of the left anterior aspect of the pons showed flow void and hematoma. The angiogram showed fusiform dilatation of the left vertebral artery just proximal to the vertebral union. At first, the patient was treated by surgical proximal clipping of the left vertebral artery, under a diagnosis of arterial dissection. Her symptom improved and the angiogram showed a slight retrograde aneurysmal filling after the operation. Two years later, she complained of dysphasia, right hemiparesis, and hemidysesthesia caused by the compression of the brain stem. On MRI study, a partially-thrombosed giant aneurysm was detected in the left anterior aspect of the brain stem. The retrograde filling did not change remarkably on the angiogram. We performed the GDC embolization of the left distal vertebral artery and non-thrombosed residual neck with an assisting balloon positioned through the right vertebral artery to the basilar artery. After the embolization, the patient's neurological deficits caused by the compression of the brain stem disappeared. MRI study showed the mass volume reducing gradually over a two-years follow-up period. Treatment for a partially-thrombosed giant vertebral artery aneurysm is difficult and controversial. It is necessary to shut off the blood flow into the aneurysm completely, so we consider that endovascular trapping with intraaneurysmal embolization is the most effective procedure.     

Balloon embolization of a large distal basilar artery aneurysm. Case report

Interventional neurovascular techniques have advanced to a level where treatment of intracranial aneurysms by intravascular detachable balloon embolization therapy is now possible. A patient is presented who had a spontaneous subarachnoid hemorrhage from a large aneurysm of the distal basilar artery. The aneurysm arose at the bifurcation of the posterior cerebral arteries and measured 15 X 9 X 9 mm. With the patient fully awake, a detachable silicone balloon was passed into the basilar artery by a transfemoral arterial approach. Stenosis (greater than 60%) of the mid-section of the basilar artery, secondary to arterial vasospasm from the recent hemorrhage, was present. The stenosis was treated by transluminal angioplasty, after which the balloon was passed into the aneurysm and detached. A follow-up angiogram 3 months later demonstrated complete occlusion of the aneurysm and a widely patent basilar artery at the angioplasty site.     

A ruptured aneurysm of the distal posterior inferior cerebellar artery associated with basilar artery occlusion: a case report]

We presented a case of a distal posterior inferior cerebellar artery (PICA) aneurysm associated with basilar artery occlusion. A 66-year-old female was found unconscious at home and transferred to our hospital in a deep coma on February 9, 1991. Emergency CT scan revealed subarachnoid hemorrhage in the posterior fossa. She was treated conservatively because of her poor neurological status. The angiograms performed on February 13 showed occlusion of the basilar artery and a saccular aneurysm at the cortical branch of the PICA. The contrast material remained in the aneurysm for a long time throughout the venous phase. The left vertebral artery was markedly hypoplastic. The patient improved remarkably after admission and became almost alert late in February, although she still presented tetraparesis, dysfunction of lower cranial nerves and other neurological signs linked with the brain stem. The unusual angiographical findings in this case prompted us to perform the examination again, expecting some angiographical changes. The angiograms taken on March 15 revealed spontaneous disappearance of the aneurysm, although the basilar artery occlusion remained unchanged. The authors discussed some problems involved in this case, including the relation between the aneurysm and the arterial occlusion, and the mechanism of spontaneous disappearance of the aneurysm.     

Dissecting aneurysm of basilar artery presenting with recurrent subarachnoid hemorrhage

Spontaneous basilar dissecting aneurysms secondary to subarachnoid hemorrhage are rare, usually presenting with ischemia rather than a subarachnoid hemorrhage (SAH). A 63-year-old man who had SAH repeatedly from a ruptured basilar dissecting aneurysm was treated with endovascular occlusion of the unilateral vertebral artery. Postoperative angiograms 1 month after the procedure showed complete obliteration of the aneurysm. The clinical follow-up at 20 months showed no evidence of recurrent hemorrhage. Received: 24 August 1998 / Accepted: 15 December 1998     

Distal aneurysms of basilar perforating and circumferential arteries. Report of three cases

Distal aneurysms of basilar perforating and circumferential arteries are exceedingly rare. The authors encountered one patient with a distal basilar perforating artery aneurysm and two with aneurysms arising from circumferential branches of the basilar artery (BA). The diagnostic features, microsurgical treatment, and outcomes in these three patients are described. The first patient, a 27-year-old man, presented with an angiogram-negative subarachnoid hemorrhage (SAH), and subsequent readmission for a new hemorrhage revealed a centrally thrombosed aneurysm arising from a basilar apex perforating artery. The second patient, a 68-year-old man, presented for follow-up evaluation 2 months after an angiogram-negative SAH, and an aneurysm was identified on a circumferential artery originating from the BA trunk. The third patient, a 2-year-old boy, presented with blunt head trauma and a pseudoaneurysm arising from a basilar apex circumferential artery. All three aneurysms were managed microsurgically with aneurysm trapping, via either an orbitozygomatic or an extended retrosigmoid approach. Occlusion of the distal perforating or circumferential artery was well tolerated in all cases, with no neurological sequelae resulting from surgery. Features common to all three aneurysms were dolichoectatic morphology, intraluminal thrombus, and SAH. These aneurysms may be difficult to diagnose given their small size and delayed filling on angiographic studies. Consequently, their presence in cases of angiogram-negative SAH may be underestimated. These aneurysms are not amenable to endovascular treatment, but excellent results can be obtained with microsurgical exposure and trapping.     

Internal trapping of a ruptured vertebral artery dissecting aneurysm followed by recanalization of the trapped vertebral artery without aneurysm recurrence: case report

A 61-year-old man presented with a ruptured vertebral artery dissecting aneurysm manifesting as severe headache, which was treated by internal trapping, and later resulted in recanalization of the affected vertebral artery without aneurysm recurrence. Computed tomography revealed subarachnoid hemorrhage caused by a dissecting right vertebral artery aneurysm located just distal to the origin of the posterior inferior cerebellar artery. The patient underwent uneventful internal trapping. However, recanalization of the affected vertebral artery with stenosis was found on the 22nd postoperative day, apparently caused by insufficient thrombosis related to the short trapping length. No aneurysm recurrence or ischemic events were detected, so the patient was observed carefully. After 4 months, right vertebral angiography revealed that the vertebral artery was normal with no stenosis or aneurysm. Restoration of the vertebral artery without complication probably occurred by complete thrombosis of the aneurysm followed by reconstruction of the injured arterial wall. We adopted a conservative approach in this case, but additional embolization and/or stenting should be considered if high risk of rebleeding is suggested by angiographic findings, although the management of recanalization remains controversial.     

Extracranial vertebral artery aneurysm ruptured into the thoracic cavity with neurofibromatosis type 1: case report

OBJECTIVE AND IMPORTANCE: We are sometimes involved in the care of patients with neurofibromatosis Type 1 because of the associated disorders of cervicocerebral vessels. However, extracranial vertebral artery aneurysm in neurofibromatosis Type 1 is very rare. We present the first reported case of a rupture of an extracranial vertebral artery aneurysm into the thoracic cavity in a patient with neurofibromatosis Type 1. CLINICAL PRESENTATION: A 52-year-old woman who presented with a decrease in left-sided grip and numbness of the left upper limb was admitted. During history taking, she developed shock. Radiological examination revealed that a left extracranial vertebral artery aneurysm had ruptured into the thoracic cavity. With consciousness decreasing gradually because of hemorrhagic shock, the patient became comatose. INTERVENTION: Balloon occlusion of the vertebral artery proximal to the aneurysm was performed and surgical ligation was attempted, but cardiac arrest occurred immediately after the beginning of surgery, and the patient died. The vertebral artery proximal to the aneurysm was removed for pathological examination. CONCLUSION: In this case, the changes noted were interpreted as changes showing fragility of the vascular wall secondary to neurofibromatosis Type 1. Patients with neurofibromatosis Type 1 exhibit disorders of cervicocerebral vessels, and in some cases progression may follow a violent course. Periodic follow-up of such patients and early diagnosis are important.     

Arterial reconstruction by direct surgical clipping of a basilar artery dissecting aneurysm after failed vertebral artery occlusion: technical case report and literature review

OBJECTIVE AND IMPORTANCE: Dissecting aneurysms of the basilar artery are rare lesions with significant morbidity and mortality. Their management is controversial and often difficult. Although the rebleeding rate is high, clip reconstruction carries prohibitive risk because of the damage to the parent vessel induced by the dissection and the lack of tissue to gather. An enlarging pseudoaneurysm in the chronic phase, however, may have sufficient tissue for clip reconstruction. We present a case in which this strategy was used successfully. CLINICAL PRESENTATION: A 45-year-old woman presented 3 months after an initial presentation with a subarachnoid hemorrhage from a dissecting aneurysm of the basilar trunk at an outside institution. The aneurysm had grown compared with previous angiograms. INTERVENTION: The dominant vertebral artery was sacrificed. Despite this, the aneurysm continued to enlarge. Given the progressive enlargement of the aneurysm, the decision was made to proceed with arterial reconstruction by direct surgical clipping of the saccular component of the dissecting aneurysm. The patient made an excellent recovery with a durable result. CONCLUSION: Although clipping an intracranial pseudoaneurysm in the acute phase may carry a prohibitive risk, clipping such an aneurysm in the chronic phase may occasionally be warranted. To our knowledge, this is the first case reported in the literature in which direct surgical clipping was used as the primary mode of treatment for a basilar artery dissecting aneurysm that enlarged despite occlusion of the dominant vertebral artery. We review the literature on this rare pathological entity and discuss our management strategy.     

Enlargement of basilar artery aneurysms following balloon occlusion--"water-hammer effect". Report of two cases

Two patients with distal basilar aneurysms were treated with intra-aneurysmal balloon occlusion. After apparently successful therapy, follow-up angiograms demonstrated aneurysm enlargement with balloon migration distally in the sac. Geometric mismatch between the base of the balloons and the aneurysm neck together with transmitted pulsation through the 2-hydroxyl-ethylmethacrylate (HEMA)-filled balloon directly contributed to aneurysm enlargement. In this report, the authors discuss the problems of progressive aneurysm enlargement due to a "water-hammer effect" and the possibility of hemorrhage following subtotal occlusion.     

Successful Coil Embolization of a Ruptured Basilar Artery Aneurysm in a Child with Leukemia: A Case Report

Ruptured intracranial aneurysms are rare in the pediatric population compared to adults. This has incited considerable discussion on how to treat children with this condition. Here, we report a child with a ruptured saccular basilar artery aneurysm that was successfully treated with coil embolization. A 12-year-old boy with acute lymphoblastic leukemia and accompanying abdominal candidiasis after chemotherapy suddenly complained of a severe headache and suffered consciousness disturbance moments later. Computed tomography scans and cerebral angiography demonstrated acute hydrocephalus and subarachnoid hemorrhage caused by saccular basilar artery aneurysm rupture. External ventricular drainage was performed immediately. Because the patient was in severe condition and did not show remarkable signs of central nervous system infection in cerebrospinal fluid studies, we applied endovascular treatment for the ruptured saccular basilar artery aneurysm, which was successfully occluded with coils. The patient recovered without new neurological deficits after ventriculoperitoneal shunting. Recent reports indicate that both endovascular and microsurgical techniques can be used to effectively treat ruptured cerebral aneurysms in pediatric patients. A minimally invasive endovascular treatment was effective in the present case, but long-term follow-up will be necessary to confirm the efficiency of endovascular treatment for children with ruptured saccular basilar artery aneurysms.     

Ruptured anterior spinal artery aneurysm: a case report

BACKGROUND

Spinal artery aneurysms are rare, and are usually found in association with arteriovenous malformations or coarctation of the aorta.

CASE REPORT

A 42-year-old man with a ruptured anterior spinal artery aneurysm is presented here. He experienced subarachnoid hemorrhage, which was confirmed by computed tomography. Magnetic resonance imaging revealed an aneurysm in front of the upper part of the medulla. Angiography demonstrated bilateral vertebral artery occlusion. Distal vertebral arteries and the basilar artery were perfused via the dilated anterior spinal artery, which originates in the right subclavian artery. The aneurysm was located at the distal part of the anterior spinal artery, and was successfully clipped through a lateral suboccipital craniotomy 2 months after bleeding from the aneurysm. After rehabilitation, the patient was able to walk with no apparent neurologic deficit.

CONCLUSIONS

This case suggests that the anterior spinal artery as a collateral route after bilateral vertebral arery occlusion is under hemodynamic stress, resulting in aneurysm formation and rupture.     

Enlarging thrombosed aneurysm of the distal basilar artery

The case of a 65-year-old man who had partial left third nerve palsy is reported. Radiographic examination disclosed a completely thrombosed giant suprasellar aneurysm. Although an angiogram appeared to indicate that his aneurysm arose from the distal basilar artery, he was also noted to have an unusual and ectatic distal internal carotid artery on the left side, and this was also felt to be a potential source of the aneurysm. Operative exploration was performed and confirmed the basilar artery as the sight of origin, and definitive therapy was deferred. The patient's progress was monitored, and for 3 years his neurological course was stable and there was no change in his radiographic abnormalities. During the 6 months following this period, the patient developed signs and symptoms of progressing hydrocephalus and was found to have significant enlargement of his still completely thrombosed giant aneurysm. This complicated case highlights the controversy regarding the management of this difficult condition, particularly with regard to endovascular therapies, and also provides insight into the evolution of this dynamic disease process.     

Dissecting vertebral aneurysm with subarachnoid hemorrhage after ischemic onset on the same day: a case report

We report a case of a dissecting vertebral aneurysm with subarachnoid hemorrhage (SAH) after ischemic onset on the same day. A 48-year-old man had abrupt vertigo and nausea. CT & MRI on admission showed no abnormality, but he complained of left hemiparesis after admission. Twelve hours after the ischemic onset he suddenly complained of severe headache and his consciousness deteriorated. The follow-up CT showed diffuse SAH. Cerebral angiography showed occlusion of the right vertebral artery at the origin of the posterior inferior cerebellar artery (PICA) and segmental stenosis of the left vertebral artery at the portion distal to the vertebral PICA junction. We treated the patient conservatively. Four days later, he suddenly fell into a coma, but CT showed no bleeding. Because of this we suspected brain stem ischemia due to deterioration of vertebral dissection. The patient died 8 hours after the ischemic reattack. We report difficulty of treatment of a dissecting vertebral aneurysm with simultaneous ischemia and subarachnoid hemorrhage.     

Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with Guglielmi detachable coils

BACKGROUND: Fenestration of vertebrobasilar junction is a rare congenital anomaly and often associated with aneurysm formation. We describe five cases of vertebrobasilar junction aneurysms in four patients associated with fenestration, which were treated with endovascular coil occlusion using Guglielmi detachable coils (GDCs). The importance of preoperative computed tomography (CT) angiography to understand the complex anatomy of fenestration and aneurysm is emphasized. CASE REPORTS: Three patients presented with subarachnoid hemorrhage and one patient presented with headache only. Among 3 patients with subarachnoid hemorrhage, 1 patient was referred for endovascular coil occlusion after clipping of ruptured distal ACA aneurysm. A six-French guiding catheter was placed in the left vertebral artery via right femoral artery, except for 1 patient who had two vertebrobasilar junction aneurysms with complex anatomic relationship, accessed bilaterally. Five vertebrobasilar junction aneurysms with fenestration were treated with endovascular coil occlusion using GDCs. Postoperative angiography demonstrated successful occlusion of aneurysmal sac with preservation of basilar artery. CONCLUSIONS: Vertebrobasilar junction aneurysms are frequently associated with fenestrations. In addition to vertebral angiography on both sides, CT angiography may be a valuable tool for better understanding of complex anatomy of aneurysms associated with fenestration. The surgically difficult aneurysms such as vertebrobasilar junction aneurysm with fenestration can be successfully treated with GDCs.     

Antegrade recanalization of parent artery in internal trapping of vertebral artery dissecting aneurysm: a case report

BACKGROUND: We describe a case involving technical success with internal trapping using controllable detachable coils yet antegrade recanalization of the occluded vertebral artery, in the vertebral artery dissecting aneurysm. Possible explanations for the antegrade recanalization of the occluded vertebral artery and lessons from the case are also discussed. CASE DESCRIPTION: A 42-year-old woman with a history of stupor (Hunt and Hess grade III) and right vertebral artery dissecting aneurysm, was admitted to our hospital. Endovascular treatment was performed. The dissecting aneurysm and affected right vertebral artery were both completely occluded, whereas the right PICA was preserved. Nine months after the embolization, follow-up angiography was performed, which revealed recanalization of the occluded right vertebral artery with a normal arterial configuration and antegrade flow into the basilar artery. The recanalized vertebral artery was located just superior and lateral to the deployed coil meshes. It was decided that no further intervention was needed. At the last clinical follow-up 15 months after the initial treatment, the patient was fully recovered. CONCLUSION: Even in the case of technical angiographic success in the endovascular management of a dissecting aneurysm, a prompt follow-up angiography is still crucial. Plus, if the false lumen cannot be separated from the true lumen, treatment with just a stent may not be adequate.     

Rapid revascularization after therapeutic parent artery occlusion for a large intracavernous carotid artery aneurysm

A 21-year-old woman presented with an unruptured large intracavernous aneurysm, which was spontaneously revascularized via unusual collateral pathways a short time after extracranial-intracranial bypass and surgical ligation of the proximal internal carotid artery. The patient had been treated for a large basilar trunk aneurysm with intraaneurysmal embolization using Guglielmi detachable coils, and an intracavernous carotid artery aneurysm treated conservatively. Two years later, the patient presented with right abducens nerve palsy, and was referred to our hospital. She had small nevi in the right forehead and eyelid. Cerebral angiography revealed enlargement of the intracavernous aneurysm. Superficial temporal artery-middle cerebral artery bypass followed by surgical carotid artery ligation were performed, and good patency of bypass and disappearance of the aneurysm were confirmed by intraoperative angiography. However, follow-up magnetic resonance angiography and cerebral angiography on the 20th postoperative day revealed revascularization of the internal carotid artery and the intracavernous carotid artery aneurysm via unusual collateral pathways. Subsequently, the recurrent aneurysm and the recanalized internal carotid artery were occluded by endovascular procedures. Histological examination of the nevus showed lack of properly organized vascular structures, and the diagnosis was angiodysplasia. The early development of unusual collateral pathway, and aneurysm formation at a young age might be related to the angiodysplasia. Revascularization is possible within a short time even in cases of intracavernous carotid artery aneurysm successfully treated with surgical ligation of the parent artery.     

NBCA embolization of a ruptured intraventricular distal anterior choroidal artery aneurysm in a patient with moyamoya disease

Occasionally an aneurysm is the cause of hemorrhage in patients with moyamoya disease (MMD). We present a case of a ruptured intraventricular distal anterior choroidal artery (AChA) aneurysm treated with n-butyl cyanoacrylic acid (nBCA) (Trufill nBCA Liquid Embolic, Codman Neurovascular, Raynham, Massachusetts, USA) embolization in a patient with MMD. There were no procedural complications and at 6 month follow-up she remained neurologically normal. Six month follow-up cerebral angiography showed no residual aneurysm. The endovascular route is an attractive option for many aneurysms associated with MMD as the lesions can be treated without disturbing the moyamoya collaterals. nBCA, delivered through a flow-guided microcatheter, is a good embolic agent choice when the lesion is distal on a small vessel and when distal parent artery occlusion can be tolerated. Intraventricular AChA aneurysms are well suited for this treatment strategy.     

A case of a persistent primitive proatlantal intersegmental artery with a ruptured basilar bifurcation aneurysm

A case of persistent primitive proatlantal intersegmental artery (PPPIA) associated with a ruptured basilar bifurcation aneurysm was reported. A 44-year-old male with sudden headache was admitted to our hospital. CT scan revealed subarachnoid hemorrhage. Cerebral angiography revealed anomalous anastomosis between the internal carotid artery and the vertebral artery at the proatlantal region. This anastomosis branched off from the left internal carotid artery at the C4 level and joined the horizontal portion of the left vertebral artery. It was thought to be PPPIA. Angiography also revealed an aneurysm of the basilar bifurcation which was responsible for the patient's subarachnoid hemorrhage. The aneurysm was successfully treated by endovascular embolization with Guglielmi detachable coils in an acute stage, and resulted in good outcome. PPPIA with basilar bifurcation aneurysm has not been presented or reported in the literature to date. To our knowledge, this is the first report of such an association of vascular anomalies. The frequency of PPPIA combined with the intracranial aneurysm is relatively high, whereas the occurrence of PPPIA is extremely rare. Therefore, it was suggested that some congenital and/or hemodynamic factors changed by PPPIA may affect the pathogenesis of intracranial aneurysms.