Basilar Artery Trunk Aneurysm: Incidental Aneurysm of the Basilar Artery Trunk, Incorporating Cerebellar Arteries; Documented Growth, Implantation of Two Telescoping p64 Flow Diverter Stents Under Combined Dual Antiaggregation and Anticoagulation; Complete Aneurysm Occlusion; and Collateral Supply of the Cerebellar Arteries
- 87 Downloads
A 49-year-old female patient presented to hospital with recurrent severe headaches. Diagnostic work-up including DSA and MRI/MRA demonstrated a large aneurysm originating from the proximal trunk of the basilar artery just beyond the confluence of the vertebral arteries (maximum diameter 13 mm). Two efferent arteries, anatomically equivalent to anterior inferior cerebellar arteries (AICAs), originated from the aneurysm sac. The aneurysm was considered untreatable, and conservative management, including surveillance MRI/MRA examinations, was recommended. However, the patient only underwent a 1-year follow-up examination. Four years after the first MRI examination, another MRI/MRA examination was performed prior to paranasal sinus surgery. This demonstrated a significant size increase of the basilar trunk aneurysm (maximum diameter: 19 mm). At this stage, the patient underwent treatment with two p64 flow diverters implanted into her basilar artery covering the aneurysm neck. In addition to the standard dual antiplatelet treatment, with ASA and ticagrelor, oral anticoagulation with dabigatran was commenced in order to prevent rapid thrombus formation inside the aneurysm sac. A first follow-up DSA 2 months after treatment demonstrated partial thrombosis of the aneurysm sac with preserved patency of the efferent vessels. At this time the patient complained of diplopia, and a right abducens nerve palsy was found, which resolved during the following 6 weeks. A second follow-up DSA, performed 9 months after the procedure, demonstrated the complete exclusion of the aneurysm sac from the circulation. The efferent cerebellar arteries were occluded at their origins and collateralized via the pontine branches. MRI confirmed shrinkage of the aneurysm sac and no evidence of cerebellopontine ischemia. The patient was and remained, apart from the transient diplopia, neurologically asymptomatic. The treatment of basilar trunk aneurysms, with efferent arteries arising from the aneurysm sac, is the main topic of this chapter.
KeywordsBasilar artery Saccular aneurysm Conservative management Aneurysm growth p64 flow diversion Dual antiplatelet medication Anticoagulation
- Ali MJ, Bendok BR, Tella MN, Chandler JP, Getch CC, Batjer HH. Arterial reconstruction by direct surgical clipping of a basilar artery dissecting aneurysm after failed vertebral artery occlusion: technical case report and literature review. Neurosurgery. 2003;52(6): 1475–80;discussion 1480–1.
- Boet R, Poon WS, Yu SC, Chan MS. Endovascular GDC-mediated flow-reversal for complex posterior circulation saccular aneurysms. A report of two cases and critical appraisal. Minim Invasive Neurosurg. 2003;46(4):220–7. .
- Buckle C, Rabadi MH. Bilateral pontine infarction secondary to basilar trunk saccular aneurysm. Arch Neurol. 2006;63(10):1498–9. .
- Chung J, Park H, Lim YC, Hyun DK, Shin YS. Endovascular treatment of basilar artery trunk aneurysms. Acta Neurochir (Wien). 2011;153(11):2137–45. .
- Henkes H, Liebig T, Reinartz J, Miloslavski E, Kirsch M, Kühne D. Endovascular occlusion of the basilar artery for the treatment of dissecting and dysplastic fusiform aneurysms. Nervenarzt. 2006;77(2):192, 194–6, 198–200. .
- Higa T, Ujiie H, Kato K, Ono Y, Okada Y. Endovascular treatment of basilar trunk saccular aneurysms. Neuroradiol J. 2011;24(5):687–92. .
- Kulcsár Z, Houdart E, Bonafé A, Parker G, Millar J, Goddard AJ, Renowden S, Gál G, Turowski B, Mitchell K, Gray F, Rodriguez M, van den Berg R, Gruber A, Desal H, Wanke I, Rüfenacht DA. Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment. AJNR Am J Neuroradiol. 2011;32(1):20–5. .
- Limaye US, Baheti A, Saraf R, Shrivastava M, Siddhartha W. Endovascular management of giant intracranial aneurysms of the posterior circulation. Neurol India. 2012;60(6):597–603. .
- Saliou G, Sacho RH, Power S, Kostynskyy A, Willinsky RA, Tymianski M, terBrugge KG, Rawal S, Krings T. Natural history and management of basilar trunk artery aneurysms. Stroke. 2015;46(4):948–53. .
- Sheikh-Taha M. Idarucizumab for reversal of dabigatran: single-center real-world experience. Am J Cardiovasc Drugs. 2018. .
- Turowski B, Macht S, Kulcsár Z, Hänggi D, Stummer W. Early fatal haemorrhage after endovascular cerebral aneurysm treatment with a flow diverter (SILK-Stent): do we need to rethink our concepts? Neuroradiology. 2011;53(1):37–41. .
- Van Rooij WJ, Sluzewski M, Menovsky T, Wijnalda D. Coiling of saccular basilar trunk aneurysms. Neuroradiology. 2003;45(1):19–21. .
- Weisshaar S, Litschauer B, Gouya G, Mayer P, Smerda L, Kapiotis S, Kyrle PA, Eichinger S, Wolzt M. Antithrombotic triple therapy and coagulation activation at the site of thrombus formation: a randomized trial in healthy subjects. J Thromb Haemost. 2014;12(11): 1850–60. .