J Korean Neurosurg Soc.  2013 Apr;53(4):235-240. 10.3340/jkns.2013.53.4.235.

Fusiform Aneurysm on the Basilar Artery Trunk Treated with Intra-Aneurysmal Embolization with Parent Vessel Occlusion after Complete Preoperative Occlusion Test

• Jung YJ
• Kim MS
• Choi BY
• Chang CH

• KMID: 1426210
• DOI: http://doi.org/10.3340/jkns.2013.53.4.235

Abstract

Fusiform aneurysms on the basilar artery (BA) trunk are rare. The microsurgical management of these aneurysms is difficult because of their deep location, dense collection of vital cranial nerves, and perforating arteries to the brain stem. Endovascular treatment is relatively easier and safer compared with microsurgical treatment. Selective occlusion of the aneurysmal sac with preservation of the parent artery is the endovascular treatment of choice. But, some cases, particularly giant or fusiform aneurysms, are unsuitable for selective sac occlusion. Therefore, endovascular coiling of the aneurysm with parent vessel occlusion is an alternative treatment option. In this situation, it is important to determine whether a patient can tolerate parent vessel occlusion without developing neurological deficits. We report a rare case of fusiform aneurysms in the BA trunk. An 18-year-old female suffered a headache for 2 weeks. Computed tomography and magnetic resonance image revealed a fusiform aneurysm of the lower basilar artery trunk. Digital subtraction angiography revealed a 7.1x11.0 mm-sized fusiform aneurysm located between vertebrovasilar junction and the anterior inferior cerebellar arteries. We had good clinical result using endovascular coiling of unruptured fusiform aneurysm on the lower BA trunk with parent vessel occlusion after confirming the tolerance of the patient by balloon test occlusion with induced hypotension and accompanied by neurophysiologic monitoring, transcranial Doppler and single photon emission computed tomography. In this study, we discuss the importance of preoperative meticulous studies for avoidance of delayed neurological deficit in the patient with fusiform aneurysm on lower basilar trunk.

Keyword

Cerebral aneurysm; Fusiform aneurysm; Balloon test occlusion; Provocative test; Embolization

MeSH Terms

Aneurysm
Angiography, Digital Subtraction
Arteries
Basilar Artery
Brain Stem
Cranial Nerves
Female
Glycosaminoglycans
Headache
Humans
Hypotension
Intracranial Aneurysm
Magnetic Resonance Spectroscopy
Parents
Tomography, Emission-Computed, Single-Photon
Glycosaminoglycans

Figure

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  Fig. 1 A and B : Preoperative vertebral angiogram revealing fusiform aneurysm on the basialar artery trunk, located between the vertebrobasilar juction and anterior inferior cerebellar artery (arrow). C : Three dimensional angiogram reveals a 7.1×11.0 mm-sized fusiform aneurysm. D and E : Both internal carotid angiograms showed that both posterior communicating arteries were patent and the diameters exceeded 1 mm (arrowhead).

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  Fig. 2 A : The patient-customized transcranial Doppler headset was mounted and continuous electroencephalography monitoring was done throughout the procedure. B : Over-the-wire microballoons were used for balloon test occlusion and inflated in the both vertebral arteries just around the C2 vertebra foramen (arrow). C : Views of left side internal carotid angiograms. The basilar artery (black arrowhead) and both anterior inferior cerebellar arteries (white arrowhead) through the posterior communicating arteries are visualized by an angiographic injection in the left internal carotid artery.

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  Fig. 3 A : Baseline mean blood flow velocity (MBFV) of middle cerebral artery (MCA) was 74 cm/s. B : The reduction in right MBFV of MCA (48 cm/s) and P1 reversal upon inflation of the balloon in both vertebral arteries. C : It immediately recovered at the baseline value (72 cm/s) without additional treatment. And it maintained during the balloon test occlusion. D : After induced hypotension the MBFV of the MCA slightly dropped (65 cm/s); the patient tolerated the drop during the test. E : Lastly, after deflation of the balloon it recovered to the baseline value (72 cm/s). The reduction of MBFV was 2.7% in the normotensive state and 12.2% in the induced hypotensive state.

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  Fig. 4 A : Baseline single photon emission computed tomography (SPECT) images do not show focal perfusion reduction. B : SPECT images obtained during balloon test occlusion also do not show any hypoperfusion lesion of the cerebral hemisphere and cerebellum compare to the baseline SPECT.

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  Fig. 5 A and B : After coil embolization, left side internal carotid artery angiogram reveals good filling of the basilar artery (arrow) and both anterior inferior cerebellar arteries (arrowhead) through the posterior communicating arteries. C : On right side vertebral artery angiogram shows complete obliteration of the aneurysm and no filling of the basilar artery though the vertebral artery.

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