Endovaskulärer Verschluss der A. basilaris zur Behandlung dissektionsbedingter und dysplastischer fusiformer Aneurysmen

Massive Dissecting Aneurysm in the Basilar Tip Artery Treated with Intra-aneurysm and Basilar Artery Coiling

Introduction:

Deconstructive versus reconstructive technique remains controversial on the management of acute basilar tip artery dissection.

Aim:

We introduced a case report of massive dissecting aneurysm in the basilar tip artery treated with intra-aneurysm and basilar artery coiling.

Results:

A 30-year-old male presented with sudden headache and severe vomiting. Radiographic study showed a large unruptured dissecting aneurysm in the basilar tip artery involving bilateral P1 segment. This aneurysm was treated with intra-aneurysm and basilar artery coiling. Patient was discharge after 7 days without any neurological deficits. Post-operatively, the patient received 75 mg aspirin and 75 mg clopidogrel PO per day for 3 months - then 75 mg aspirin per day for up to 1 year. Angiographic follow-up at 3 months showed a complete occlusion of aneurysmal sac and basilar tip artery without any deficits (mRS 0). Cerebral arteriography at 6 months follow-up confirmed a stable occlusion of aneurysmal sac with a minor recurrence of aneurysm in left P1 segment.

Conclusion:

Intra-aneurysm and basilar artery coiling is valuable alternative technique to treat complex basilar tip dissecting aneurysm in case of infeasible reconstructive technique. Clinical presentation, aneurysm characteristics and collateral circulation have to be investigated on each case to adopt this technique.

Results of endovascular management for mid-basilar artery aneurysms

We evaluated the results of endovascular management of patients with mid-basilar artery aneurysm (mBAA). During a seven year period, 14 patients (mean age 39.6 years, male/female ratio 1:1) with mBAA were treated with endovascular techniques at our institute. Pretreatment clinical grades were determined using the Hunt-Hess scale. Outcome was evaluated using the Glasgow Outcome Scale scores (GOS) during a mean follow-up period of 15.6 months (range, three to 70 months). Fourteen patients with 15 mBAAs were treated endovascularly. Four (28.6%) patients died of rebleeding within one day after embolization. In ten mBAAs, immediate postprocedural angiograms showed that complete occlusion was achieved, subtotal occlusion in one, and incomplete occlusion in four. Follow-up angiographic results in ten patients confirmed complete occlusion of 11 aneurysms. Long-term outcome was good (GOS Score 4 or 5) in ten patients (71.4%) and fatal (GOS Score 1) in four (28.6%). Favorable overall long-term outcome can be achieved in 78.6% patients with mBAAs. Endovascular management of mBAAs is an effective treatment in the long-term. In our experience, the natural history of mBAAs is dismal.

Clinical outcomes of basilar artery aneurysms

To evaluate the effects of endovascular treatments, we retrospectively analyzed a consecutive series of patients with basilar artery aneurysms (BAAs) treated endovascularly. During a seven year period, 43 patients (mean age 42.2 years, male/female ratio 21:22) with BAAs were treated mainly with endovascular techniques at Beijing Tiantan Hospital. Pretreatment clinical grades were determined using the Hunt-Hess scale. Outcome was evaluated using the Glasgow Outcome Scale scores (GOS) during a mean follow-up period of 21.1 months (range, 1 to 72 months). Forty-three patients had 44 BAAs, one MCA aneurysm and one P1 aneurysm. Endovascular treatment was technically feasible in 40 patients. One aneurysm thrombosed spontaneously after initial angiography. Four (9.3%) patients died periprocedurally. Immediate postprocedural angiograms in 44 BAAs showed that complete occlusion was achieved in 33 BAAs, subtotal occlusion in one and incomplete occlusion in seven. Follow-up angiographic results in 30 patients confirmed complete occlusion of 27 aneurysms, subtotal occlusion in one, and incomplete occlusion in two. Two patients with vertebrobasilar atheromatous fusiform aneurysms were treated with antiplatelet medications. Long-term outcome was good (GOS Score 4 or 5) in 39 patients (90.7%) and fatal (GOS Score 1) in four (9.3%). Favorable overall long-term outcome can be achieved in patients with BA apex aneurysms, and in 78.6% of those with BA trunk aneurysms when using endovascular techniques. Endovascular coil embolization of BAAs is an effective treatment in the long-term. Patients with vertebrobasilar atheromatous fusiform aneurysms can be treated with antiplatelet medications.

Endovascular treatment of huge dissecting aneurysms involving the basilar artery. Experience and lessons from two cases

SUMMARY

Dissecting aneurysms involving the basilar artery (BA) are lesions with significant morbidity and mortality. Their management is controversial and often difficult. There is no generally approved strategy. Two cases of huge dissections involving the BA presented with subarachnoid hemorrhage in one case and mass effect in both cases. The dissection of case 1 involved the upper two thirds of the BA distal to the anterior inferior cerebellar arteries (AICA). Another dissection of case 2 involved the bilateral vertebral arteries (VA) distal to bilateral PICA and extended to upper third of the BA. After making a basket with coils inside the pseudoaneursym, proximal dissection was totally occluded in case 1. Dissection on the bilateral VA distal to the bilateral PICA and proximal BA was occluded in case 2 with a small residual dissection on the left VA. Case 1 had an excellent recovery with a durable image and clinical result. But recanalization and regrowth occurred in case 2, which might have originated from the residual dissection on the left VA, induced acute mass effect and sudden coma six weeks after the initial treatment. The residual and regrown dissection had to be occluded in a second intervention. The patient died two days later. BA occlusion is safe and efficient for dissections involving the BA as in our case and the literature. Proximal occlusion might be enough for huge and long lesions like ours. It seems that completely dense packing of proximal dissection is the key point to prevent recanalization.