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

• Park WB
• Sung JH
• Huh J
• Cho CB
• Yang SH
• Kim IS
• Hong JT
• Lee SW

• KMID: 2069248
• DOI: http://doi.org/10.7461/jcen.2015.17.3.227

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).

Reference

1. Albanese E, Russo A, Ulm AJ. Fenestrated vertebrobasilar junction aneurysm: diagnostic and therapeutic considerations. J Neurosurg. 2009; 3. 110(3):525–529. PMID: 19012487.

2. Baskaya MK, Coscarella E, Jea A, Morcos JJ. Aneurysm of the anterior inferior cerebellar artery-posterior inferior cerebellar artery variant: case report with anatomical description in the cadaver. Neurosurgery. 2006; 2. 58(2):E388. discussion E388. PMID: 16462470.

3. Campos J, Fox AJ, Vinuela F, Lylyk P, Ferguson GG, Drake CG, et al. Saccular aneurysms in basilar artery fenestration. AJNR Am J Neuroradiol. 1987; Mar-Apr. 8(2):233–236. PMID: 3105281.

4. Cooke DL, Stout CE, Kim WT, Kansagra AP, Yu JP, Gu A, et al. Cerebral arterial fenestrations. Interv Neuroradiol. 2014; May-Jun. 20(3):261–274. PMID: 24976087.

5. Finlay HM, Canham PB. The layered fabric of cerebral artery fenestrations. Stroke. 1994; 9. 25(9):1799–1806. PMID: 8073460.

6. Giuffrè R, Sherkat S. The vertebral artery: developmental pathology. J Neurosurg Sci. 1999; 9. 43(3):175–189. PMID: 10817385.

7. Kai Y, Hamada J, Morioka M, Yano S, Fujioka S, Kuratsu J. Endovascular treatment of ruptured aneurysms associated with fenestrated basilar artery. Two case reports. Neurol Med Chir (Tokyo). 2006; 5. 46(5):244–247. PMID: 16723817.

8. Nordeen JD, Patel AV, Darracott RM, Johns GS, Taussky P, Tawk RG, et al. Clopidogrel Resistance by P2Y12 Platelet Function Testing in Patients Undergoing Neuroendovascular Procedures: Incidence of Ischemic and Hemorrhagic Complications. J Vasc Interv Neurol. 2013; 6. 6(1):26–34. PMID: 23826440.

9. Prabhakaran S, Wells KR, Lee VH, Flaherty CA, Lopes DK. Prevalence and risk factors for aspirin and clopidogrel resistance in cerebrovascular stenting. AJNR Am J Neuroradiol. 2008; 2. 29(2):281–285. PMID: 17989373.

10. Sogawa K, Kikuchi Y, O'Uchi T, Tanaka M, Inoue T. Fenestrations of the basilar artery demonstrated on magnetic resonance angiograms: an analysis of 212 cases. Interv Neuroradiol. 2013; 12. 19(4):461–465. PMID: 24355150.

11. Tanaka S, Tokimura H, Makiuchi T, Nagayama T, Takasaki K, Tomosugi T, et al. Clinical presentation and treatment of aneurysms associated with basilar artery fenestration. J Clin Neurosci. 2012; 3. 19(3):394–401. PMID: 22285479.

12. Trivelato FP, Abud DG, Nakiri GS, de Castro Afonso LH, Ulhoa AC, Manzato LB, et al. Basilar Artery Fenestration Aneurysms: Endovascular Treatment Strategies Based on 3D Morphology. Clin Neuroradiol. DOI: 10.1007/s00062-014-0336-0.

13. Yoon SM, Chun YI, Kwon Y, Kwun BD. Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with Guglielmi detachable coils. Surg Neurol. 2004; 3. 61(3):248–254. PMID: 14984996.