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Gravino G, Abdelsalam N, Patel J, Aamir S, Babatola F, Chandran A. Benign versus sinister aetiologies underlying basal cistern subarachnoid haemorrhage: a case series. J Med Case Rep 2025; 19:166. [PMID: 40200309 PMCID: PMC11980157 DOI: 10.1186/s13256-024-04950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 11/13/2024] [Indexed: 04/10/2025] Open
Abstract
BACKGROUND Subarachnoid hemorrhage in the basal cisterns is usually identified on an unenhanced computed tomography scan of the head in patients presenting acutely with a characteristic sudden onset headache. CASE PRESENTATION Using imaging examples from our tertiary neurosciences center, we present six cases demonstrating a variety of causes for subarachnoid hemorrhage in the basal cisterns, ranging from benign to sinister causes. These include a venous perimesencephalic hemorrhage (35 years, female), pontine perforator aneurysm (54 years, male), vertebral artery dissection (69 years, male), cervical dural arteriovenous fistula (65 years, male), posterior fossa arteriovenous malformation (45 years, male), and vertebral artery aneurysm (78 years, female). Ethnically, all these patients were white. Specific imaging features are described and demonstrated. CONCLUSION A balance between avoiding excessive investigation and overlooking what may be a mimic of a venous perimesencephalic hemorrhage is important. To refine and establish more definitive indications on when to perform computed tomography angiogram, digital subtraction angiography, delayed angiography and magnetic resonance imaging in this context requires future research to focus on large-scale prospective multicenter studies with robust data.
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Affiliation(s)
- Gilbert Gravino
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK.
- School of Pharmacy and Bioengineering, Keele University, Stoke on Trent, UK.
| | - Nasr Abdelsalam
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Jay Patel
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Saad Aamir
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Feyi Babatola
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Arun Chandran
- Neuroradiology Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
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2
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Abdelsalam A, Oushy S, Lu A, Ramsay IA, Young J, Sanikommu S, Rinaldo L, Orscelik A, Shrigiri S, Savastano LE, Starke RM, Abla AA. Microsurgical clipping of ruptured basilar artery perforator aneurysms in the endovascular era: A single-center experience. Neurochirurgie 2025; 71:101669. [PMID: 40198935 DOI: 10.1016/j.neuchi.2025.101669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Revised: 03/13/2025] [Accepted: 03/25/2025] [Indexed: 04/10/2025]
Abstract
BACKGROUND Basilar artery perforator aneurysms (BAPAs) are a rare subset of intracranial aneurysms, accounting for <1% of cases. The natural history of BAPAs is unknown, and a standardized management approach is lacking. This report presents the largest cohort of surgically treated BAPAs to date, addressing gaps in the literature and guiding management strategies. METHODS A single-center retrospective analysis was conducted utilizing a prospectively maintained, IRB-approved database, which included a series of seven consecutive patients treated for BAPAs. The dataset included patient characteristics, surgical details, postoperative outcomes, complication rates, and imaging and clinical follow-up data. It also featured case illustrations. RESULTS A total of seven patients were included, all presenting with subarachnoid hemorrhage. The median age was 60 years (IQR: 56.5, 69), and 57% were female. The most common location of the perforators was mid-basilar (43%). Five cases (71.4%) had aneurysms that went undetected on the initial angiogram. All patients underwent microsurgical clipping as their treatment. Post-surgery, oculomotor nerve palsy was observed in four patients (57.1%), and three (42.8%) experienced hemiparesis, which improved during their hospital stay. Follow-up diagnostic angiograms revealed a complete aneurysm occlusion of all aneurysms with no residual filling. CONCLUSION Microsurgical clipping is an effective treatment option for BAPAs when observation and endovascular interventions are not feasible. Treatment decisions should be guided by presentation, aneurysm characteristics, and overall risk profile. A multicenter registry is needed to establish standardized management guidelines. A multidisciplinary, tailored approach is recommended to optimize individual patient outcomes.
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Affiliation(s)
- Ahmed Abdelsalam
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, United States
| | - Soliman Oushy
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, United States; Mayfield Clinic, Cincinnati, Ohio, United States
| | - Alex Lu
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, United States
| | - Ian A Ramsay
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, United States
| | - Jacob Young
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, United States
| | - Sai Sanikommu
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, United States
| | - Lorenzo Rinaldo
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Atakan Orscelik
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, United States
| | - Soumya Shrigiri
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, United States
| | - Luis E Savastano
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, United States
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, United States
| | - Adib A Abla
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, United States.
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Man IC, Pan TM, U KC. An unusual etiology of subarachnoid hemorrhage, basilar artery perforator aneurysms, in Macao: Three case reports and review of literature. World J Clin Cases 2024; 12:4337-4347. [PMID: 39015907 PMCID: PMC11235533 DOI: 10.12998/wjcc.v12.i20.4337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/14/2024] [Accepted: 05/27/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Subarachnoid hemorrhage is a severe neurological condition that requires prompt and appropriate treatment to prevent complications. Aneurysms are the most common cause of spontaneous subarachnoid hemorrhage. Conversely, basilar artery perforator aneurysms (BAPAs) are a rare etiology. There is no consensus on the optimal management of ruptured BAPAs in the acute setting. CASE SUMMARY We present a case series of 3 patients with ruptured BAPAs who were treated at our institution. Two patients had a modified Fisher grade of I, and one had a grade of IV on initial presentation. The aneurysms were detected by computed tomography angiography in two cases and conventional angiography in one case. The 3 patients underwent endovascular treatment with Guglielmi detachable coils. Post-treatment, the patients had good clinical outcomes, and follow-up brain computed tomography scans showed reduced subarachnoid hemorrhage without any new hemorrhage. However, one patient experienced a cerebral infarction 2 months later and eventually succumbed to the condition. The other 2 patients showed progressive recovery, and no aneurysm recurrence was observed at the 2-year follow-up. CONCLUSION Endovascular treatment may be a preferable approach for managing ruptured BAPAs compared with surgical intervention or conservative management. Early detection and prompt treatment is important to achieve favorable patient outcomes.
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Affiliation(s)
- Ieong-Chon Man
- Department of Radiology, Hospital Conde S. Januário, Macao SAR 999078, China
| | - Tam-Man Pan
- Department of Radiology, Hospital Conde S. Januário, Macao SAR 999078, China
| | - Kuok-Cheong U
- Department of Radiology, Hospital Conde S. Januário, Macao SAR 999078, China
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4
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Kaldas A, Zolnourian A, Ewbank F, Digpal R, Narata A, Ditchfield A, Macdonald J, Bulters D. Basilar artery perforator aneurysms: a comparison with non-perforator saccular aneurysms. Acta Neurochir (Wien) 2024; 166:141. [PMID: 38499881 DOI: 10.1007/s00701-024-06026-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Basilar artery perforator aneurysms (BAPAs) are rare. There is no systematic description of their presentation, imaging, natural history and outcomes and how these compare to conventional non-perforator aneurysms. Thus, the authors in this study aimed to compare BAPAs to non-perforator aneurysms. METHODS Cases were identified from a prospective neurovascular database, notes and imaging retrospectively reviewed and compared to a consecutive series of patients with non-perforator aneurysms. Blood volume on CT and vessel wall imaging (VWI) were compared to controls. RESULTS 9/739 patients with aneurysmal subarachnoid haemorrhage (aSAH) harboured BAPAs. Compared to 103 with aSAH from posterior circulation aneurysms, they were more likely to be male (6/9, p = 0.008), but of equal severity (4/9 poor grade, p = 0.736) and need of CSF drainage (5/9, p = 0.154). Blood volume was similar to controls (30.2 ml vs 26.7 ml, p = 0.716). 6/9 BAPAs were initially missed on CTA. VWI showed thick (2.9 mm ± 2.7) bright enhancement (stalk ratio 1.05 ± 0.12), similar to controls with ruptured aneurysms (0.95 ± 0.23, p = 0.551), and greater than unruptured aneurysms (0.43 ± 0.11, p < 0.001). All were initially managed conservatively. Six thrombosed spontaneously. Three grew and had difficult access with few good endovascular options and were treated through a subtemporal craniotomy without complication. None rebled. At 3 months, all presenting in poor grade were mRS 3-4 and those in good grade mRS 1-2. CONCLUSIONS Despite their small size, BAPAs present with similar volume SAH, WFNS grade and hydrocephalus to other aneurysms. They are difficult to identify on CTA but enhance strikingly on VWI. The majority thrombosed. Initial conservative management reserving treatment for growth was associated with no rebleeds or complications.
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Affiliation(s)
- Antony Kaldas
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ardalan Zolnourian
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Frederick Ewbank
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ronneil Digpal
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ana Narata
- Department of Interventional Neuroradiology, University Hospital Southampton, Southampton, UK
| | - Adam Ditchfield
- Department of Interventional Neuroradiology, University Hospital Southampton, Southampton, UK
| | - Jason Macdonald
- Department of Interventional Neuroradiology, University Hospital Southampton, Southampton, UK
| | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK.
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Orenday-Barraza JM, Jabre R, Venteicher AS. Orbitozygomatic Approach for a Ruptured P1 Perforator Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e284-e285. [PMID: 37527017 DOI: 10.1227/ons.0000000000000836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/19/2023] [Indexed: 08/03/2023] Open
Affiliation(s)
- José Manuel Orenday-Barraza
- Department of Neurosurgery, Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roland Jabre
- Département de Chirurgie, Service de Neurochirurgie, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Andrew S Venteicher
- Department of Neurosurgery, Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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KUMAGAWA T, OTANI N, KAKEI Y, NEGISHI H, SUMA T, YOSHINO A. Ruptured Basilar Artery Perforator Aneurysm Definitely Diagnosed with Intraoperative Microsurgical Findings: Case Report and Literature Review. NMC Case Rep J 2023; 10:1-7. [PMID: 36778213 PMCID: PMC9894615 DOI: 10.2176/jns-nmc.2022-0184] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/07/2022] [Indexed: 01/22/2023] Open
Abstract
Initial three-dimensional computed tomography and cerebral angiography fail to identify any aneurysm in 20% of cases of subarachnoid hemorrhage. Basilar artery (BA) perforator aneurysms are rare, and approximately 30%-60% were not identified by initial angiography. A 71-year-old male was transferred with a sudden onset of headache and loss of consciousness. Computed tomography demonstrated subarachnoid hemorrhage, but no ruptured aneurysm was detected. Repeat preoperative cerebral angiography indicated a bifurcation aneurysm of the circumflex branch of the superior cerebellar artery perforator, but microsurgical observation identified the BA perforator aneurysm. If the location of the BA perforator aneurysm cannot be clearly identified, as in this case, repeat angiography should be considered, and the treatment strategy should be decided based on a detailed consideration of the site of the aneurysm.
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Affiliation(s)
- Takahiro KUMAGAWA
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Naoki OTANI
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Yuzo KAKEI
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi NEGISHI
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi SUMA
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Atsuo YOSHINO
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
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Muacevic A, Adler JR, Laskay N, Hale AT, Fisher WS. Transpetrosal Approach to a Ruptured Distal Basilar Perforating Artery Aneurysm. Cureus 2023; 15:e34273. [PMID: 36860217 PMCID: PMC9969324 DOI: 10.7759/cureus.34273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
Basilar perforating artery aneurysms are rare and underreported vascular anomalies in the cerebrovascular literature. Various open and endovascular treatment approaches can be employed to treat these aneurysms based on several patient- and aneurysm-specific factors. Some authors have even advocated for conservative, nonoperative management. Here, we report a case of a ruptured distal basilar perforating artery aneurysm secured by an open transpetrosal approach. A 67-year-old male presented to our institution with a Hunt-Hess grade 2, modified Fisher grade 3 subarachnoid hemorrhage (SAH). Initial cerebral digital subtraction angiography (DSA) did not identify an intracranial aneurysm or other vascular lesions. However, the patient had a re-rupture event several days after presentation. DSA at this time revealed a posteriorly projecting distal basilar perforating artery aneurysm. Initial attempts with endovascular coil embolization were unsuccessful. Thus, an open transpetrosal approach was taken to gain access to the middle and distal basilar trunk to secure the aneurysm. This case underscores the unpredictability of basilar perforating artery aneurysms and the challenges encountered when considering active treatment. We demonstrate an open surgical approach with an intraoperative video for definitive management after failed attempted endovascular treatment.
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Affiliation(s)
- Alexander Muacevic
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - John R Adler
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
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Spontaneous subarachnoid hemorrhage caused by ruptured aneurysm of basilar trunk perforator: a case report and literature review. Chin Neurosurg J 2022; 8:14. [PMID: 35681227 PMCID: PMC9185891 DOI: 10.1186/s41016-022-00281-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Aneurysm of basilar perforator was rarely reported in the literature. It is difficult to treat due to its small size and deep-seated location. Excessive treatment may cause complications that resulted from ischemic events of parent perforators. Therefore, it is important to make clinical strategy for such patients to improve the prognosis. Case presentation One case, who presented as spontaneous subarachnoid hemorrhage, despite the negative result in computed tomography angiography firstly, was diagnosed angiographically as a ruptured aneurysm of the basilar perforator. A good clinical outcome of the case was achieved during the follow-up after conservative observation for 2 months, as well as the disappearance of previous lesion from angiography. Conclusions Aneurysm located at perforator of basilar trunk was rare and difficult to treat. Conservative observation for certain cases with periodic angiography follow-up was considered in order to prevent the patients from potential iatrogenic effects.
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Okamura K, Higuchi T, Izumo T, Takahira R, Sadakata E, Yoshida M, Yamaguchi S, Morofuji Y, Baba S, Hiu T, Matsuo T. Ruptured basilar artery perforator aneurysm: a novel mechanism of pure subarachnoid hemorrhage in moyamoya disease. Illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22238. [PMID: 36088605 PMCID: PMC9706322 DOI: 10.3171/case22238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/22/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Pure subarachnoid hemorrhage (SAH) in patients with moyamoya disease is a rare occurrence. Three underlying mechanisms have been described previously, except for ruptured aneurysm of the circle of Willis. Herein, the authors describe a novel mechanism: rupture of a perforator aneurysm in moyamoya disease. OBSERVATIONS A 51-year-old man experienced sudden onset of severe headache and vomiting. Computed tomography showed diffuse SAH. Digital subtraction angiography (DSA) showed unilateral moyamoya disease without remarkable etiology of SAH. The patient underwent conservative management with antihypertensive agents. The second DSA on day 17 revealed a slow-filling aneurysm emerging from the basilar top perforating artery. The diagnosis of SAH due to unknown origin was changed to ruptured basilar artery perforator aneurysm (BAPA). The third follow-up DSA on day 159 revealed the resolution of BAPA. LESSONS In the case of pure SAH, it is crucial to consider the possibility of perforator aneurysms due to hemodynamic stress caused by moyamoya disease. Repeated DSA is essential for detecting the lesion.
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Mutlu U, Kortman H, Boukrab I. A giant basilar artery perforator aneurysm. Radiol Case Rep 2022; 17:911-913. [PMID: 35069959 PMCID: PMC8762371 DOI: 10.1016/j.radcr.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/17/2022] Open
Abstract
Basilar artery perforator aneurysms (BAPA's) are a rare entity. Their natural history and treatment are unclear. We describe the largest BAPA reported thus far in literature in a 64-year-old Caucasian woman. This patient did not present with subarachnoid hemorrhage, but with left hemiparesis due to pontine ischemia. The aneurysm was initially misdiagnosed as a tumoral mass in a referring center. Angiography confirmed the presence of a BAPA and a flow diverter was successfully placed. This case shows us that a BAPA can mimic a tumoral mass and can cause ischemia due to mass effect without having ruptured. Both conservative and flow diverter placement seems viable treatment options. Individual patient characteristics and preferences should be considered in decision-making for treatment.
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Affiliation(s)
- Unal Mutlu
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA, 3000 The Netherlands
- Corresponding author. U. Mutlu
| | - Hans Kortman
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA, 3000 The Netherlands
| | - Issam Boukrab
- Department of Radiology and Nuclear Medicine, Neurovascular Expertise Center, St. Elisabeth Hospital, Hilvarenbeekseweg 60, Tilburg, GC, 5022 The Netherlands
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11
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Flow Diverter Treatment of Ruptured Basilar Artery Perforator Aneurysms. Clin Neuroradiol 2022; 32:783-789. [PMID: 35059755 PMCID: PMC9424161 DOI: 10.1007/s00062-021-01133-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/18/2021] [Indexed: 11/27/2022]
Abstract
Purpose Ruptured basilar artery perforator aneurysms (BAPAs) represent a very rare cause of subarachnoid hemorrhage and an under-reported subtype of cerebral aneurysm. There is no consensus for the optimal treatment strategy (conservative vs. surgical vs. various endovascular approaches). We aim to present a multicenter experience of BAPA treatment using flow-diverter (FD) stents. Methods At five tertiary neurovascular centers, all cases of ruptured BAPAs treated by FD were retrospectively collected. Baseline imaging and clinical characteristics, complications, as well as early and long-term angiographic and clinical outcome (mRS) were analyzed. Results Eighteen patients (mean age, 57 years; SD, ±10.7 years) with acute SAH related to a BAPA were treated using 18 FD stents. Aneurysms were detected on initial imaging study in 28%; delayed diagnosis was triggered by clinical deterioration due to rebleeding in 15%. No rebleeding after FD was seen, 28% developed FD-related ischemic complications. At long term (n = 16), overall mortality was 13% (2/16), and favorable outcome (mRS 0–2) was 81% (13/16). All BAPAs (n = 13) were completely occluded at long-term angiographic follow-up. Conclusion In our multicenter experience, FD treatment of ruptured BAPAs appears to have comparable safety and efficacy outcomes to FD treatment of other ruptured posterior circulation aneurysms as well as to the conservative management of BAPAs. This treatment strategy for a ruptured BAPA achieved a high rate of angiographic occlusion and favorable clinical outcome; however, as the conservative management also seems to offer similar clinical outcomes an individualized treatment decision is warranted. Future prospective studies comparing both approaches are required. Supplementary Information The online version of this article (10.1007/s00062-021-01133-y) contains supplementary material, which is available to authorized users.
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Nakajima H, Tsuchiya T, Shimizu S, Suzuki H. Contrast extravasation from basilar artery without aneurysm formation on digital subtraction angiography in computed tomography angiogram-negative subarachnoid hemorrhage: A case report. Surg Neurol Int 2021; 12:498. [PMID: 34754548 PMCID: PMC8571361 DOI: 10.25259/sni_713_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The causes of angiogram-negative subarachnoid hemorrhage (SAH) on initial angiography, which accounts for 10–30% of spontaneous SAH, are heterogeneous and still unclear. We report a case of nonaneurysmal SAH, in which initial computed tomographic angiography (CTA) showed no source of bleeding, but the subsequent digital subtraction angiography (DSA) revealed contrast extravasation from the basilar artery without aneurysms. Case Description: A 67-year-old woman with a medical history of hypertension presented as SAH of World Federation of Neurological Surgeons Grade II. CTA on admission did not show any cause of bleeding and DSA was subsequently performed to show contrast extravasation from a perforator of the middle third of the basilar artery without aneurysms during the subsequent DSA, resulting in profound deterioration SAH and neurological status. The patient was conservatively treated. Follow-up DSAs on days 2 and 16 showed no source of bleeding as well. Conclusion: Although the precise cause of bleeding in this case is uncertain, SAH might be caused by local dissection of the basilar artery perforator, and the bleeding site might heal spontaneously without forming of a pseudoaneurysm.
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Affiliation(s)
| | | | | | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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13
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Iida Y, Mori K, Kawahara Y, Fukui I, Abe K, Takeda M, Nakano T, Yanagimoto K, Nomura M. Characteristics and Management of Ruptured Aneurysms Originating from the Penetrating Artery of the Distal Middle Cerebral Artery. NMC Case Rep J 2021; 8:7-12. [PMID: 34012742 PMCID: PMC8116915 DOI: 10.2176/nmccrj.cr.2020-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/09/2020] [Indexed: 11/20/2022] Open
Abstract
We report a rare case of an aneurysm originating from the penetrating artery of the distal middle cerebral artery (MCA). A 76-year-old man without a notable past history presented with sudden-onset severe headache, left hemiparesis, and a decreased level of consciousness. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) with intracerebral hemorrhage (ICH) in the right temporal lobe extending into the ventricle. Contrast-enhanced CT (CE-CT) demonstrated a focus of contrast enhancement (CE) adjacent to the hematoma in the right frontal lobe. An aneurysm fed by a penetrating artery branching off from the right distal MCA was found on angiography. The patient underwent emergency resection of the aneurysm and hematoma evacuation. Histological analysis revealed that arterial dissection may be an associated factor in the pathogenesis of this peripheral aneurysm formation. A focus of CE within or adjacent to the hematoma may be useful for diagnosing this peripheral aneurysm. ICH can result in a life-threatening situation. Therefore, microsurgery may be the first treatment choice for aneurysms in this location.
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Affiliation(s)
- Yu Iida
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Kentaro Mori
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Yosuke Kawahara
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Issei Fukui
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Katsuya Abe
- Department of Neurology, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Mutsuki Takeda
- Department of Neurology, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Tatsu Nakano
- Department of Neurology, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Kunio Yanagimoto
- Department of Pathology, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Motohiro Nomura
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
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Ma H, Zhao R, Fang Y, Li Q, Yang P, Huang Q, Xu Y, Hong B, Liu JM. Endovascular electrothrombosis: A promising alternative for basilar artery perforator aneurysm treatment. Interv Neuroradiol 2021; 27:511-515. [PMID: 33435781 DOI: 10.1177/1591019920987913] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Basilar artery perforator aneurysms (BAPAs) are rare. Traditional surgical clipping and endovascular coiling have proven to be challenging. We present three patients treated with endovascular electrothrombosis and describe the characteristics of this new approach. METHODS Three patients presented with subarachnoid hemorrhages (SAHs). Cerebral angiography identified BAPAs. Endovascular electrothrombosis was performed after obtaining informed consent. We placed the microwire into the sac of the aneurysms through the microcatheter and connected its proximal tip to the Solitaire stent detachment system. Electrothrombosis was conducted using 1.0 mA current. RESULTS Two aneurysms were successfully occluded without treatment-related complication. The third one failed and converted to endovascular coiling using a 1.3-F microcatheter. The patient suffered brainstem infarction and finally died of severe SAH. At follow-up, the two patients were neurologically intact and angiography showed total occlusion of both aneurysms. CONCLUSION Endovascular electrothrombosis might be a potential alternative to traditional treatment for BAPAs. Close follow-up with caution should be mandatory. More research is needed to confirm its safety and efficacy.
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Affiliation(s)
- Hongyu Ma
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Rui Zhao
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yibin Fang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jian-Min Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
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15
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Gardijan D, Herega T, Premužić V, Jovanović I, Ozretić D, Poljaković Z, Radoš M. Comparison between stenting and conservative management of posterior circulation perforator aneurysms: Systematic review and case series. Neuroradiology 2021; 63:639-651. [PMID: 33404790 DOI: 10.1007/s00234-020-02618-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/01/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Posterior circulation perforator aneurysms (PCPAs) are a rare type of intracranial aneurysms whose natural history and optimal clinical management are still largely unexplored. This study aims to report our experience with treating ruptured PCPAs and to provide a systematic review of the literature to compare the two most established treatment options, endovascular stenting, and conservative management including administration of antifibrinolytic drugs and watchful waiting. METHODS We performed a systematic review of the literature following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Major databases were searched for case reports and case report series written in the English language between 1995 and 2020. Additionally, we retrospectively reviewed our stroke center database for cases of ruptured PCPAs between January 2014 and July 2020. Endovascular stenting and conservative treatment were compared using endpoints, including favorable outcome rate (mRS 0-2), occlusion rate, mortality rate, periinterventional complication rate, and re-hemorrhage rate. RESULTS We identified 31 patients treated endovascularly using stents and 33 patients treated conservatively, with the administration of antifibrinolytic drugs in 3 of them. Our analysis showed no statistically significant difference between the groups, except for the occlusion rate. CONCLUSIONS The optimal management strategy of PCPAs is still unknown, but stenting can be considered as an effective occlusion method with an acceptable complication rate. Preventive ventricular drainage may be necessary due to the high hydrocephalus rate encountered in ruptured PCPAs.
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Affiliation(s)
- Danilo Gardijan
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Tomislav Herega
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia.
| | - Vedran Premužić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Ivan Jovanović
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - David Ozretić
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Zdravka Poljaković
- Department of Neurology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Marko Radoš
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
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16
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Lee JJ, Huang M, Guerrero J, Desai VR, Jenson A, Austerman R, Diaz O, Britz GW. Operative Treatment of a Superior Cerebellar Artery Perforator Dissecting Aneurysm. Oper Neurosurg (Hagerstown) 2020; 19:E203-E208. [PMID: 32123901 DOI: 10.1093/ons/opz407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Superior cerebellar artery (SCA) perforator aneurysms are extremely rare, with only one other case published in the literature. There is no conclusive management strategy for these aneurysms, although endovascular treatment, open surgical treatment with clipping, and antifibrinolytic administration with spontaneous thrombosis have all been discussed. CLINICAL PRESENTATION A 61-yr-old male presented with intraventricular hemorrhage (IVH) primarily in the posterior fossa. He was found to have a dissecting left SCA perforator aneurysm lying on the floor of the fourth ventricle. The aneurysm was not amenable to endovascular treatment, and antifibrinolytic therapy failed to spontaneously thrombose the aneurysm. We performed a suboccipital craniotomy and used a supracerebellar transvermian approach to resect the aneurysm. There was total obliteration of the aneurysm on postoperative cerebral angiogram. CONCLUSION SCA perforator aneurysms represent an extremely uncommon subset of intracranial aneurysms. The best therapeutic strategy has yet to be definitively proven. When pursuing surgical treatment, the supracerebellar transvermian navigated approach can be a useful and safe option, as described and illustrated in this video.
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Affiliation(s)
- Jonathan J Lee
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Meng Huang
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Jaime Guerrero
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Virendra R Desai
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Amanda Jenson
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Ryan Austerman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Orlando Diaz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Gavin W Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
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17
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Enomoto N, Shinno K, Tamura T, Shikata E, Shono K, Takase K. Ruptured Basilar Artery Perforator Aneurysm: A Case Report and Review of the Literature. NMC Case Rep J 2020; 7:93-100. [PMID: 32695555 PMCID: PMC7363639 DOI: 10.2176/nmccrj.cr.2019-0143] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/18/2019] [Indexed: 11/20/2022] Open
Abstract
Basilar artery perforator aneurysms (BAPAs) are a rare cause of subarachnoid hemorrhage (SAH), and the natural history is still unknown. Herein, we report a case of ruptured BAPA that appeared during the observation period and then spontaneously disappeared; we have also conducted a review of the literature and performed an analysis based on the type of management. This case of BAPA had a unique course, and our observations may help establish a treatment strategy. A 60-year-old man presented with acute diffuse SAH, World Federation of Neurosurgical Societies (WFNS) Grade II and Fisher Grade 3. Initial three-dimensional digital subtraction angiography (DSA) did not show the source of the hemorrhage. DSA performed on day 39 showed a BAPA with a diameter of 3 mm at the posterior surface of the upper third of the basilar artery. Conservative treatment was chosen. DSA performed on day 64 showed complete resolution of the aneurysm. BAPAs are likely pseudoaneurysms, and not saccular aneurysms, caused due to dissection of basilar perforator arteries. BAPAs are often not recognized on initial imaging, and hence, it is necessary to repeat the DSA examination. Considering the relatively high rate of spontaneous resolution, we chose conservative management. When BAPAs enlarge or do not disappear after conservative treatment, additional therapy such as multiple stents should be considered.
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Affiliation(s)
- Noriya Enomoto
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Kiyohito Shinno
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Tetsuya Tamura
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Eiji Shikata
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Kenji Shono
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Kensaku Takase
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
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18
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Da Ros V, Diana F, Sabuzi F, Malatesta E, Sanna A, Scaggiante J, Di Giuliano F, Gandini R, Floris R, Ruggiero M. Flow diverters for ruptured posterior circulation perforator aneurysms: multicenter experience and literature review. J Neurointerv Surg 2020; 12:688-694. [PMID: 32051323 DOI: 10.1136/neurintsurg-2019-015558] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/18/2020] [Accepted: 01/22/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND The management of ruptured posterior circulation perforator aneurysms (rPCPAs) remains unclear. We present our experience in treating rPCPAs with flow diverter stents (FDs) and evaluate their safety and efficacy at mid- to long-term follow-up. A diagnostic and therapeutic algorithm for rPCPAs is also proposed. METHODS We retrospectively analyzed data from all consecutive patients with rPCPAs treated with FDs at our institutions between January 2013 and July 2019. Clinical presentations, time of treatments, intra- and perioperative complications, and clinical and angiographic outcomes were recorded, with a mid- to long-term follow-up. A systematic review of the literature on rPCPAs treated with FDs was also performed. RESULTS Seven patients with seven rPCPAs were treated with FDs. All patients presented with an atypical subarachnoid hemorrhage distribution and a low to medium Hunt-Hess grade. In 29% of cases rPCPAs were identified on the initial angiogram. In 57% of cases, FDs were inserted within 2 days of the diagnosis. Immediate aneurysm occlusion was observed in 14% of the cases and in 71% at the first follow-up (mean 2.4 months). At mean follow-up of 33 months (range 3-72 months) one case of delayed ischemic complication occurred. Six patients had a modified Rankin Scale (mRS) score of 0 and one patient had an mRS score of 4 at the latest follow-up. CONCLUSIONS The best management for rPCPAs remains unclear, but FDs seem to have lower complication rates than other treatment options. Further studies with larger series are needed to confirm the role of FDs in rPCPA.
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Affiliation(s)
- Valerio Da Ros
- Department of Biomedicine, Fondazione PTV Policlinico Tor Vergata, Roma, Italy
| | - Francesco Diana
- Neuroradiology, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
| | - Federico Sabuzi
- Department of Biomedicine, Fondazione PTV Policlinico Tor Vergata, Roma, Italy
| | - Emanuele Malatesta
- Neuroradiology, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
| | - Antioco Sanna
- Neuroradiology, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
| | - Jacopo Scaggiante
- Department of Biomedicine, Fondazione PTV Policlinico Tor Vergata, Roma, Italy
| | | | - Roberto Gandini
- Diagnostic Imaging and Interventional Radiology, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Roberto Floris
- Department of Biomedicine, Fondazione PTV Policlinico Tor Vergata, Roma, Italy.,Diagnostic Imaging and Interventional Radiology, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Maria Ruggiero
- Neuroradiology, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
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19
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Endovascular management of basilar artery perforator aneurysm – Insights. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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20
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Granja MF, Monteiro A, Agnoletto GJ, Jamal S, Sauvageau E, Aghaebrahim A, Hanel R. A systematic review of non-trunk basilar perforator aneurysms: is it worth chasing the small fish? J Neurointerv Surg 2019; 12:412-416. [PMID: 31597686 DOI: 10.1136/neurintsurg-2019-015311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/18/2019] [Accepted: 09/22/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Non-trunk basilar artery perforator aneurysms (BAPAs) are rare intracranial vascular pathologies that have long been underdiagnosed, under-reported, and under-analyzed. We performed a systematic review of the efficacy and safety endpoints between conservative and active treatment approaches for non-trunk BAPAs. METHODS Major databases were analyzed for relevant publications between 1995 and 2019. Studies comparing the outcomes between conservative and active treatment approaches such as coiling, stenting, clipping, liquid embolization, and flow diversion were included. Mortality rate, rate of permanent neurological deficit as determined by the modified Rankin Score (mRS), rate of second treatment occurrence, and perioperative complication rate were also assessed. RESULTS A total of 24 studies, including 54 patients with 56 non-trunk BAPAs, were included. The mean maximum aneurysm diameter was 2.70 mm (range 1-10). A diagnosis was achieved with the initial DSA in 50.0% (27/54) of the patients. A conservative approach was used in 16 patients while active treatment was used in the other 38. Thirteen of 15 (86.7%) patients in the conservative group and 27/34 (79.4%) in the active treatment group had an mRS score 0-2. A non-significant higher odds of a positive outcome was observed in the conservative group (OR 1.51, 95% CI 0.50 to 4.54). The event-related mortality rate was 3.55% (3/54) with one procedure-related death in the active treatment group. CONCLUSIONS In patients with non-trunk BAPAs unamenable to active treatment, conservative approaches may result in acceptable functional outcomes and low morbidity. Small sample sizes and under-reporting of outcomes warrant further study.
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Affiliation(s)
- Manuel F Granja
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Andre Monteiro
- Stroke & Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Guilherme Jose Agnoletto
- Stroke & Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Sara Jamal
- Stroke & Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Neurological Institute, Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Ricardo Hanel
- Stroke & Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
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21
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Bhogal P, AlMatter M, Hellstern V, Pérez MA, Lehmberg J, Ganslandt O, Bäzner H, Henkes H. Basilar artery perforator aneurysms: Report of 9 cases and review of the literature. J Clin Neurosci 2019; 63:122-129. [PMID: 30732987 DOI: 10.1016/j.jocn.2019.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 12/18/2018] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
Basilar perforator artery aneurysms (BAPA's) are an under-recognised cause of sub-arachnoid haemorrhage (SAH). We present our single centre experience of BAPA's and review of the literature. We performed a retrospective review of our prospectively maintained database to identify all BAPA's that presented acute SAH between February 2009 and February 2018. We identified 9 patients (male = 7), each with a single aneurysm, and average age 55 ± 9.7 years. All aneurysms were small, 2.1 ± 0.5 mm (range 1-3 mm). Three aneurysms were not detected on initial angiography. Six aneurysms were treated with flow diversion, 3 were managed conservatively. No repeat haemorrhage occurred in the flow diverted patients. One patient treated conservatively suffered a repeat haemorrhage and died (mRS 6). Follow up imaging (n = 7), at average 5.6 months (range 3-12 months), showed complete occlusion in all the flow-diverted aneurysms and no change in one conservatively managed patient. There was no evidence of perforator infarction on the follow-up post treatment imaging. Clinical follow-up data was available in 8 patients, 6 of whom (75%) had a good outcome (mRS ≤ 2). A high index of suspicion is required to diagnose BAPA. Flow diversion can be used to treat BAPA's with acceptable risk of perforator infarction and low risk of repeat haemorrhage.
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Affiliation(s)
- P Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK.
| | - M AlMatter
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - V Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - J Lehmberg
- Klinik für Neurochirurgie, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - O Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - H Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - H Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany; Medical Faculty, University Duisburg-Essen, Germany
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22
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Chau Y, Sachet M, Sédat J. Should we treat aneurysms in perforator arteries from the basilar trunk? Review of 49 cases published in the literature and presentation of three personal cases. Interv Neuroradiol 2017; 24:22-28. [PMID: 29022843 DOI: 10.1177/1591019917734531] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Basilar trunk perforator artery aneurysms are rare. Their diagnosis and treatment are difficult, controversial, and challenging. Analysis of 52 cases (49 documented in the literature and three personal cases) clearly shows a re-bleeding rate of 15% in patients whose aneurysm has not been occluded and 0% in treated patients ( p < 0.05). The most effective treatment, and the one that presents the least complication, is double-stenting across the basilar trunk.
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Affiliation(s)
- Yves Chau
- Unité de Neuro-interverventionnelle, Hôpital Pasteur 2, CHU de Nice, France
| | - Marina Sachet
- Unité de Neuro-interverventionnelle, Hôpital Pasteur 2, CHU de Nice, France
| | - Jacques Sédat
- Unité de Neuro-interverventionnelle, Hôpital Pasteur 2, CHU de Nice, France
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23
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Buell TJ, Ding D, Raper DMS, Chen CJ, Hixson HR, Crowley RW, Evans AJ, Jensen ME, Liu KC. Posterior circulation perforator aneurysms: a proposed management algorithm. J Neurointerv Surg 2017; 10:55-59. [PMID: 28062803 DOI: 10.1136/neurintsurg-2016-012891] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 11/04/2022]
Abstract
INTRODUCTION 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.
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Affiliation(s)
- Thomas J Buell
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Daniel M S Raper
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Harry R Hixson
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - R Webster Crowley
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Avery J Evans
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mary E Jensen
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.,Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
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24
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Finitsis S, Derelle AL, Tonnelet R, Anxionnat R, Bracard S. Basilar Perforator Aneurysms: Presentation of 4 Cases and Review of the Literature. World Neurosurg 2016; 97:366-373. [PMID: 27751930 DOI: 10.1016/j.wneu.2016.10.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Basilar perforator aneurysms (BPAs) are rare lesions that present a therapeutic challenge. We present 4 cases of ruptured BPAs treated either conservatively or by flow diverter deployment and review the literature. METHODS Patients (age 78, 59, 53, and 62 years) presented with World Federation of Neurological Societies grade I-IV and Fisher grade 3-4 subarachnoid hemorrhage. Initial angiography results were normal in 3 patients and necessitated a second angiography. BPA diameter was 0.5-3 mm; BPAs were located in the mid-third of the basilar artery in 2 patients and the upper third in 2 patients. RESULTS All patients were managed conservatively. One patient experienced rebleeding 10 days after initial ictus, which required the deployment of a flow diverter in the basilar artery. One patient developed a severe spontaneous pontine ischemic stroke with severe quadriparesis and refused further imaging. He was clinically stable at 1-year clinical follow-up. The other 3 patients showed complete resolution of BPAs on control follow-up imaging. CONCLUSIONS Ruptured BPAs are rare lesions that may heal spontaneously or be associated with spontaneous ischemic brainstem stroke or rerupture. These lesions can be managed conservatively initially with flow diverter deployment the most suitable therapeutic alternative in selected cases. Larger studies are needed to fully understand the natural history and refine the therapeutic strategy for these lesions.
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Affiliation(s)
- Stephanos Finitsis
- Neuroradiology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Anne-Laure Derelle
- Service de Neuroradiologie Diagnostique et Therapeutique, CHU Nancy, Nancy, France; The Neurointerventional Department, University of Nancy, Nancy, France
| | - Romain Tonnelet
- Service de Neuroradiologie Diagnostique et Therapeutique, CHU Nancy, Nancy, France; The Neurointerventional Department, University of Nancy, Nancy, France
| | - René Anxionnat
- Service de Neuroradiologie Diagnostique et Therapeutique, CHU Nancy, Nancy, France; The Neurointerventional Department, University of Nancy, Nancy, France
| | - Serge Bracard
- Service de Neuroradiologie Diagnostique et Therapeutique, CHU Nancy, Nancy, France; The Neurointerventional Department, University of Nancy, Nancy, France
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25
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Satti SR, Vance AZ, Fowler D, Farmah AV, Sivapatham T. Basilar artery perforator aneurysms (BAPAs): review of the literature and classification. J Neurointerv Surg 2016; 9:669-673. [PMID: 27302158 DOI: 10.1136/neurintsurg-2016-012407] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/23/2016] [Indexed: 11/04/2022]
Abstract
Basilar artery perforator aneurysms (BAPAs) are an uncommon subtype of perforating artery aneurysms, with only 18 published cases since their initial description in 1996 by Ghogawala et al To date, there are only seven published cases of ruptured BAPAs treated using endovascular techniques. Given the rarity of these aneurysms, the natural history and ideal approach to treatment has not been established. We describe a new endovascular approach to treating these aneurysms using staged telescoping stents, summarize all published cases of BAPAs, and present a unique classification system to enable future papers to standardize descriptions.
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Affiliation(s)
- Sudhakar R Satti
- Department of Neurointerventional Surgery, Christiana Care Health System, Newark, Delaware, USA
| | - Ansar Z Vance
- Department of Neurointerventional Radiology, Christiana Care Health System, Newark, Delaware, USA
| | - Dawn Fowler
- Neurocritical Care, Christiana Care Health System, Newark, Delaware, USA
| | - Anthony V Farmah
- Neurocritical Care, University of Delaware, Newark, Delaware, USA
| | - Thinesh Sivapatham
- Department of Neurointerventional Surgery, Christiana Care Health System, Newark, Delaware, USA
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Hafez A, Numminen J, Rahul R, Järveläinen J, Niemelä M. Perimesencephalic subarachnoid hemorrhage with a positive angiographic finding: case report and review of the literature. Acta Neurochir (Wien) 2016; 158:1045-9. [PMID: 27106848 DOI: 10.1007/s00701-016-2801-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 04/04/2016] [Indexed: 11/29/2022]
Abstract
The vast majority of perimesencephalic subarachnoid hemorrhage cases are reported as negative-finding etiologies. Recently, high-resolution images allowed us to overcome the previous difficulty of finding the source of bleeding, which underlies the concept of a "negative finding". We discovered a venous etiology, hidden behind the tip of the basilar artery; namely, the lateral pontine vein. Here, we review the literature on perimesencephalic subarachnoid hemorrhage and on venous aneurysm. We highlight this type of aneurysm as a candidate source of perimesencephalic hemorrhage. This case may change our way of dealing with what we have termed a negative finding of subarachnoid hemorrhage.
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Affiliation(s)
- Ahmad Hafez
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland.
| | - Jussi Numminen
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Raj Rahul
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Juha Järveläinen
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
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Forbrig R, Eckert B, Ertl L, Patzig M, Brem C, Vollmar C, Röther J, Thon N, Brückmann H, Fesl G. Ruptured basilar artery perforator aneurysms--treatment regimen and long-term follow-up in eight cases. Neuroradiology 2015; 58:285-91. [PMID: 26700826 DOI: 10.1007/s00234-015-1634-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/16/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Basilar artery (BA) perforator aneurysms may lead to severe subarachnoid hemorrhage (SAH). The acute management is uncertain. The anatomic approach is challenging both for coiling and clipping, and flow diverter stenting may be dangerous due to the required antiplatelet therapy. We report on our experiences in eight patients. METHODS We retrospectively analyzed eight patients with ruptured BA perforator aneurysm, including clinical characteristics, imaging data, treatment regimen, clinical course, and long-term outcome. RESULTS Patients presented with major SAH and World Federation of Neurosurgical Societies (WFNS) scores of I in three, II in two, and V in three cases. In four patients, the aneurysm was detected in the initial angiography, in four only in follow-up angiography. Five patients were treated conservatively and three patients had endovascular therapy. In the conservative group, the aneurysm spontaneously thrombosed in three cases. One patient suffered from a re-SAH and stayed permanently dependent due to an associated perforator stroke (modified Rankin Scale (mRS) 5). The remaining four patients recovered well (mRS 0 and 1 in two cases, each) including three patients also exhibiting perforator strokes. Regarding the endovascular group, one parent vessel was an angioma feeder and embolized with Onyx. The second aneurysm spontaneously thrombosed periinterventionally. The third patient underwent coiling. Two parent vessels were occluded postinterventionally, resulting in perforator strokes. Final mRS scores were 0, 2, and 2, respectively. CONCLUSION Conservative management of ruptured BA aneurysms might be a first-line treatment option with common spontaneous aneurysm occlusion, low rate of re-SAH, and promising clinical outcome.
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Affiliation(s)
- Robert Forbrig
- Department of Neuroradiology, Institute of Clinical Radiology, Grosshadern Campus, Marchioninistr 15, D-81377, Munich, Germany.
| | - Bernd Eckert
- Department of Neuroradiology, Asklepios Klinik Altona, Hamburg, Germany
| | - Lorenz Ertl
- Department of Neuroradiology, Institute of Clinical Radiology, Grosshadern Campus, Marchioninistr 15, D-81377, Munich, Germany
| | - Maximilian Patzig
- Department of Neuroradiology, Institute of Clinical Radiology, Grosshadern Campus, Marchioninistr 15, D-81377, Munich, Germany
| | - Christian Brem
- Department of Neuroradiology, Institute of Clinical Radiology, Grosshadern Campus, Marchioninistr 15, D-81377, Munich, Germany
| | - Christian Vollmar
- Department of Neurology, Grosshadern Campus, University of Munich, Munich, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Niklas Thon
- Department of Neurosurgery, Grosshadern Campus, University of Munich, Munich, Germany
| | - Hartmut Brückmann
- Department of Neuroradiology, Institute of Clinical Radiology, Grosshadern Campus, Marchioninistr 15, D-81377, Munich, Germany
| | - Gunther Fesl
- Department of Neuroradiology, Institute of Clinical Radiology, Grosshadern Campus, Marchioninistr 15, D-81377, Munich, Germany
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Chavent A, Lefevre PH, Thouant P, Cao C, Kazemi A, Mourier K, Ricolfi F. Spontaneous resolution of perforator aneurysms of the posterior circulation. J Neurosurg 2014; 121:1107-11. [PMID: 25148013 DOI: 10.3171/2014.7.jns132411] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present the cases of 3 patients with ruptured perforator aneurysms of the posterior circulation. Patients were 39, 55, and 59 years old. None of the patients had relevant past medical or family history. All presented with World Federation of Neurosurgical Societies Grade I and Fisher Grade 2 or 3 subarachnoid hemorrhage. Initial angiography results were normal. A second cerebral angiogram in each case revealed a small (< 3 mm) aneurysm of perforator arteries of the posterior circulation. Patients were successfully managed conservatively. None of the patients developed symptomatic vasospasm, rebleeding, or hydrocephaly. Control angiograms at 3 months showed spontaneous resolution of the aneurysm in all cases. Rupture of perforator aneurysms of the posterior circulation is a rare condition and it may be underdiagnosed because of limitations of imaging techniques. Treatments can lead to complications in highly functional territories and should be considered wisely, especially due to the fact that the causes and natural history of such aneurysms are unknown and spontaneous healing remains a possibility.
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29
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Basilar trunk perforator artery aneurysms. Case report and literature review. Neurosurg Rev 2012; 36:163-8; discussion 168. [PMID: 22940823 DOI: 10.1007/s10143-012-0422-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 07/12/2012] [Accepted: 07/29/2012] [Indexed: 10/27/2022]
Abstract
Perforator artery aneurysms of the basilar trunk are rarely described in the literature. In addition to presenting our own case, we performed a PubMed search to comprehensively illustrate demographics, hemorrhage patterns, and treatment outcomes for these lesions. We found 12 patients with basilar perforator artery aneurysms. Mean patient age was 47.3, and there was a 3:1 male to female predominance. All patients had ruptured aneurysms, though all were clinically low or medium grade (I-III). Six patients had diffuse subarachnoid hemorrhage (SAH), and six had prepontine and/or perimesencephalic hemorrhage patterns. All aneurysms arose off middle or rostral basilar perforator arteries; mean aneurysm size was 4.5 mm. All except one was partially thrombosed, and 4 out of 12 patients did not have their aneurysms detected on initial angiography (33%). Seven were treated surgically, two were coiled, and three were observed. At last follow-up, all were occluded, and 8 out of 12 patients were neurologically intact (67%). Of seven patients that were not treated with early intervention, one suffered a rebleed over a combined total of 37.3 months of observation. Two aneurysms amenable to coiling were occluded without complication. Three of seven patients treated surgically had transient complications, though five were neurologically intact at follow-up. Basilar perforator artery aneurysms may be sources of hemorrhage in diffuse or perimesencephalic/prepontine SAH. While endovascular coiling is an excellent option if parent vessel anatomy allows for catheterization, many are unamenable to endovascular treatment. Surgical obliteration via proximal occlusion or trapping is a safe and effective means of treating these aneurysms.
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30
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Apok V, Tarnaris A, Brydon HL. An unusual aneurysm of a basilar perforating artery presenting with a subarachnoid haemorrhage. Br J Neurosurg 2012; 27:105-7. [PMID: 22931354 DOI: 10.3109/02688697.2012.717977] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 65-year-old man had a perimesencephalic subarachnoid haemorrhage with normal angiography initially. After a rebleed 5 days later, a repeat angiogram revealed a pea-like aneurysm a short distance behind and below the basilar bifurcation. It was not amenable to endovascular treatment and the feeding vessel was coagulated and divided at open surgery via a sub temporal approach. He developed a right hemiparesis and dysphasia, from which he slowly recovered. Basilar perforating artery aneurysms are extremely rare, with only 4 previous cases reported.
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Affiliation(s)
- Vino Apok
- Department of Neurosurgery, University Hospital of North Staffordshire, North Staffordshire Royal Infirmary, Stoke-on-Trent, UK
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31
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Nyberg EM, Chaudry MI, Turk AS, Spiotta AM, Fiorella D, Turner RD. Report of two cases of a rare cause of subarachnoid hemorrhage including unusual presentation and an emerging and effective treatment option. J Neurointerv Surg 2012; 5:e30. [PMID: 22842211 DOI: 10.1136/neurintsurg-2012-010387] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To report two cases of a rare cause of subarachnoid hemorrhage (SAH), including unusual presentation and an emerging and effective treatment option. CASE REPORTS Ruptured basilar perforator artery aneurysm is a rare cause of SAH. Catheter angiography in the immediate post hemorrhage period may be unrevealing. We report two cases of ruptured basilar pontine perforator aneurysms. In one of these cases the perforator aneurysm was not apparent on the initial or the 1 week follow-up angiograms. Both patients returned for follow-up angiography 2 months later by which time aneurysmal filling and conspicuity had increased. Both patients were treated solely with two overlapping Neuroform stents. Follow-up angiograms demonstrated complete resolution of the aneurysms in both patients. CONCLUSIONS Rupture of aneurysms arising from basilar artery perforators is a rare cause of SAH and attention to this area should be part of an interventionist's search pattern. Aneurysms in this area may not be apparent in the immediate post rupture setting and delayed post hemorrhage angiography has a role in detecting this entity. Stent monotherapy may be effective in treating these lesions.
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Affiliation(s)
- Eric MacKenzie Nyberg
- Department of Neurosciences and Radiology, Medical University of South Carolina, Charleston, SC 29466, USA
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32
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An endovascular approach to ruptured aneurysms of the circumferential branch of the basilar artery. J Clin Neurosci 2012; 19:527-31. [PMID: 22321361 DOI: 10.1016/j.jocn.2011.04.049] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 04/21/2011] [Accepted: 04/30/2011] [Indexed: 11/23/2022]
Abstract
Aneurysms of the basilar perforating arteries are uncommon and those of the circumferential artery are particularly rare. Microsurgical clipping or trapping is the preferred treatment as these aneurysms are usually not accessible for endovascular treatment. We report two patients with ruptured aneurysms arising from the basilar circumferential artery. The first patient, a 66-year-old male, presented with a prepontine hematoma and a delayed filling aneurysm of the basilar circumferential artery. The second patient, a 28-year-old female, presented with a narrow-neck aneurysm of the basilar circumferential artery, associated with an arteriovenous malformation in the left cerebellum. Both patients were treated successfully with endovascular coiling, flow was preserved in the perforating parent vessels and the patients had excellent outcomes. This is the first report of this type of aneurysm being successfully treated by endovascular coiling. The treatment challenges regarding microsurgical and endovascular approaches are discussed.
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33
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Mathieson CS, Barlow P, Jenkins S, Hanzely Z. An unusual case of spontaneous subarachnoid haemorrhage - a ruptured aneurysm of a basilar perforator artery. Br J Neurosurg 2011; 24:291-3. [PMID: 20233029 DOI: 10.3109/02688690903572095] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 51-year-old gentleman with no significant past medical history presented with a WFNS grade 1 subarachnoid haemorrhage. Initial angiographic investigations revealed no cause, but repeat tests showed a small basilar perforator aneurysm. Following a failed attempt at endovascular treatment, a craniotomy and excision of the aneurysm was performed. Post-operatively the patient made a good recovery. This case highlights the importance of delayed repeat catheter angiography in selected patients with suspicious initial CT head results.
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Affiliation(s)
- Calan S Mathieson
- Department of Neurosurgery, Institute of neurological sciences, Southern General Hospital, Glasgow, UK.
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34
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Deshaies EM, Jacobsen W, Krishnamurthy S. Enterprise stent-within-stent embolization of a basilar artery perforator aneurysm. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/wjns.2011.13007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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35
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Kurita M, Endo M, Kitahara T, Fujii K. Subarachnoid haemorrhage due to a lateral spinal artery aneurysm misdiagnosed as a posterior inferior cerebellar artery aneurysm: case report and literature review. Acta Neurochir (Wien) 2009; 151:165-9. [PMID: 19209383 DOI: 10.1007/s00701-009-0183-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Accepted: 10/14/2008] [Indexed: 11/24/2022]
Abstract
CLINICAL DESCRIPTION A 61 year old man presenting with subarachnoid haemorrhage had a distal posterior inferior cerebellar artery (PICA) aneurysm diagnosed on the initial cerebral angiogram. However, a PICA aneurysm was not found during surgery. A follow-up, super-selective vertebral artery (VA) performed demonstrated a saccular aneurysm located on the lateral spinal artery (LSA). A right sub-occipital craniotomy was performed and the aneurysm arising was identified and obliterated with a small titanium clip. CONCLUSION We describe the first example of an LSA aneurysm without occlusion or severe stenosis of the VA and PICA. This extremely rare lesion illustrates how knowledge of the angiographic features and super-selective cerebral angiography aids the precise diagnosis and the prevention of surgical complications.
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Affiliation(s)
- Mari Kurita
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan.
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36
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Peltier J, Fichten A, Page C, Havet E, Foulon P, Mertl P, Le Gars D, Laude M. [Endoscopic anatomy of the terminal portion of the basilar artery and its distal perforating branches]. Morphologie 2008; 92:31-36. [PMID: 18424150 DOI: 10.1016/j.morpho.2008.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The aim of this study was to describe and highlight the endoscopic anatomy of the tip of the basilar artery and its perforating branches. Knowledges of the anatomy are crucial for neurosurgeons to avoid pitfalls during endoscopic third ventriculostomy.
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Affiliation(s)
- J Peltier
- Laboratoire d'Anatomie et d'Organogenèse, Faculté de Médecine, Université de Picardie-Jules-Verne, Amiens, France.
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37
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Sanchez-Mejia RO, Lawton MT. Distal aneurysms of basilar perforating and circumferential arteries. Report of three cases. J Neurosurg 2007; 107:654-9. [PMID: 17886568 DOI: 10.3171/jns-07/09/0654] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Rene O Sanchez-Mejia
- Department of Neurological Surgery, University of California, San Francisco, California 94143, USA
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38
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Hamel W, Grzyska U, Westphal M, Kehler U. Surgical treatment of a basilar perforator aneurysm not accessible to endovascular treatment. Acta Neurochir (Wien) 2005; 147:1283-6. [PMID: 16133771 DOI: 10.1007/s00701-005-0615-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Accepted: 07/14/2005] [Indexed: 11/30/2022]
Abstract
Aneurysms originating from perforatoring branches of the midbasilar artery are extremely rare. Rupture of such an aneurysm resulted in a subarachnoid hemorrhage with a prepontine clot in a 44 year old male who presented with an acute confusional state. After coil embolization had failed, the partially thrombosed aneurysm was wrapped and coagulated via a combined supra-/infratentorial subtemporal presigmoid approach in prone position. The postoperative course was complicated by a tension pneumatocephalus and liquorrhea. Additional aneurysms of the anterior communicating artery and right middle cerebral artery were clipped several months later. The patient recovered well, and except for slight gait ataxia no other deficit remained.
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Affiliation(s)
- W Hamel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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39
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Ahn JY, Han IB, Joo JY. Aneurysm in the penetrating artery of the distal middle cerebral artery presenting as intracerebral haemorrhage. Acta Neurochir (Wien) 2005; 147:1287-90; discussion 1290. [PMID: 16133768 DOI: 10.1007/s00701-005-0622-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Accepted: 07/14/2005] [Indexed: 12/01/2022]
Abstract
We are recording the first reported case of a 20-year-old man with an intracerebral haemorrhage due to a ruptured aneurysm, which arose from a penetrating artery of the distal middle cerebral artery (MCA; M4 segment). Excision of the aneurysm was successfully achieved via a right pterional approach. The follow-up angiogram demonstrated filling of the parent vessel and no residual aneurysm. This report illustrates the angiographical finding of a penetrating artery aneurysm of the distal MCA and summarizes the previous reports to discuss their pathological and clinical characteristics.
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Affiliation(s)
- J Y Ahn
- Department of Neurosurgery, College of Medicine, Pochon CHA University, Sungnam, South Korea.
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40
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Yanaka K, Meguro K, Narushima K, Takano S, Doi M, Nose T. Basal perforating artery aneurysm within the cavum septi pellucidi. Case report. J Neurosurg 1998; 88:601-4. [PMID: 9488321 DOI: 10.3171/jns.1998.88.3.0601] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The authors describe the case of a 16-year-old boy presenting with clinical onset of subarachnoid hemorrhage. The patient was found to have a small aneurysm arising from the distal portion of a basal perforating branch of the anterior cerebral artery (ACA), lying within a cavum septi pellucidi. Neuroimaging demonstrated a hematoma within the cavum septi pellucidi and the aneurysm was resected via a transcallosal approach guided by an intraoperative portable digital subtraction angiography (DSA) system. The origin of the aneurysm was presumed to be idiopathic. This report is the first to describe an aneurysm of a basal perforating artery arising from the ACA that resulted in an intracaval hematoma. When approaching small vascular lesions during surgery, intraoperative DSA is the method of choice to identify the precise trajectory and distance to the lesions.
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Affiliation(s)
- K Yanaka
- Department of Neurosurgery, Tsukuba Medical Center, Ibaraki, Japan
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