J Cerebrovasc Endovasc Neurosurg.  2015 Sep;17(3):227-233. 10.7461/jcen.2015.17.3.227.

Double Stent Assist Coiling of Ruptured Large Saccular Aneurysm in Proximal Basilar Artery Fenestration

Affiliations
  • 1Department of Neurosurgery, Hallym University College of Medicine, Seoul, Korea.
  • 2Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea. jaehoonsung@gmail.com

Abstract

Basilar artery fenestration is infrequent and even rarer in association with a large aneurysm. With proximity to brain stem and vital perforators, endovascular coiling can be considered first. If the large ruptured aneurysm with a wide neck originated from fenestra of the proximal basilar artery and the fenestration loop has branches of posterior circulation, therapeutic consideration should be thorough and fractionized. We report endovascular therapeutic details for a case of a ruptured large saccular aneurysm in proximal basilar artery fenestration.

Keyword

Intracranial aneurysm; Fenestration; Endovascular coil; Stents

MeSH Terms

Aneurysm*
Aneurysm, Ruptured
Basilar Artery*
Brain Stem
Intracranial Aneurysm
Neck
Stents*

Figure

  • Fig. 1 (A) Initial non-enhanced brain CT shows diffuse subarachnoid hemorrhage. (B) At low median pons level, thin round hemorrhagic high density is definite.

  • Fig. 2 (A) Initial CT angiography confirms "teardrop" shaped large saccular aneurysm penetrate and fill the fenestration loop at low basilar artery, just distal to vertebrobasilar junction. (B) Lateral view shows daughter sac at the anterior-upper side of aneurysm, which elicited subarachnoid hemorrhage rather than intracerebral hemorrhage into pons.

  • Fig. 3 The anterior-posterior (A) and lateral (B) view of 3-dimensional (3D) angiography confirms large ruptured aneurysm at fenestration loop of distal basilar artery (13.4 × 14 × 18.6 mm). The both AICA-PICA common trunks are originated from each fenestration.

  • Fig. 4 (A) The roadmap view during endovascular procedure shows successful launching of Prowler select plus microcatheters into upper basilar artery by way of each fenestration loop (right side, arrows & left side, arrow heads). (B) The right VA angiography shows successful deploy of Enterprise stent from basilar artery, by way of right fenestration loop, to vertebral artery (arrows). (C) The left VA angiography shows tips of Enterprise stents (right side, arrows & left side, arrow heads).

  • Fig. 5 The 2D right (A) and 3D left (B) VA angiography shows complete coil embolization of aneurysm with excellent patency of posterior circulation including both AICA-PICA common trunks.

  • Fig. 6 The diffusion weighted image of MRI, checked 4 days after procedure, shows small high signals at left cerebellar hemisphere and splenium of corpus callosum, suggesting embolic infarction (arrows).


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