J Cerebrovasc Endovasc Neurosurg.  2012 Mar;14(1):44-49. 10.7461/jcen.2012.14.1.44.

Coil Embolization of a Ruptured Basilar Tip Aneurysm Associated with Bilateral Cervical Internal Carotid Artery Occlusion: A Case Report and Literature Review

• Kim SS
• Park DH
• Lee NJ
• Kang SH
• Lim DJ
• Chung YG

• KMID: 1441684
• DOI: http://doi.org/10.7461/jcen.2012.14.1.44

Abstract

We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.

Keyword

Coil embolization; Bilateral proximal internal carotid artery occlusion; Basilar tip aneurysms; Ruptured; Subarachnoid hemorrhage; Collateral circulation

MeSH Terms

Acetazolamide
Aneurysm
Aneurysm, Ruptured
Angiography, Digital Subtraction
Basilar Artery
Carotid Artery, Internal
Collateral Circulation
Glycosaminoglycans
Meningeal Arteries
Middle Cerebral Artery
Moyamoya Disease
Perfusion
Posterior Cerebral Artery
Skull Base
Subarachnoid Hemorrhage
Acetazolamide
Glycosaminoglycans

Figure

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  Fig. 1 Brain computed tomography scans demonstrate a diffuse and thick subarachnoid hemorrhage in the bilateral sylvian fissures, the anterior interhemispheric fissure, the basal cistern and the posterior fossa, including the perimesencephalic region.

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  Fig. 2 Right (A) and left (B) carotid digital subtraction angiography scans show complete occlusion of both internal carotid arteries at the level of the carotid bulb without appreciable intracranial filling and small collaterals from both middle meningeal arteries to the anterior cranial fossa.

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  Fig. 3 A: A vertebral digital subtraction angiography (DSA) demonstrates that both hemispheres are filling in an antegrade fashion from the upper basilar artery and both posterior cerebral arteries through an extensive network of collateral vessels, which mimicked moyamoya vessels, to the internal carotid artery bifurcations. B: A 6 × 4 mm aneurysm is also observed at the basilar artery bifurcation. C: The postembolization DSA shows almost complete obliteration of the aneurysm and patency of the arteries surrounding it.

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  Fig. 4 Pre-acetazolamide (ACZ) perfusion computed tomography (CT) scans show no abnormalities of the cerebral blood flow (CBF) (A), the cerebral blood volume (CBV) (B) and the mean transit time (MTT) (C). Post-ACZ perfusion CT scans for the CBF (D), CBV (E) and MTT (F) show normal cerebrovascular reactivity to ACZ.

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