Basilar artery fenestration detected with CT angiography

Bihemispheric Right Anterior Cerebral Artery, Fenestrated Origin of the Left Pericallosal Artery, Fenestrated Basilar Artery, Double Right Posterior Cerebral Artery

Anatomical variations of the cerebral vasculature are frequently encountered. The archived magnetic resonance angiogram of a 62-year-old male patient was studied anatomically on planar slices and 3-dimensional volume renderings. Numerous anatomical variants were found in that single case. In the vertebrobasilar system were found: the proximal basilar artery fenestration, with a unilateral origin from that fenestration of an anterior inferior cerebellar artery, and the unilateral origin of the superior cerebellar artery from the P1 segment of the main posterior cerebral artery (PCA). There were also unilateral variants of the right internal carotid artery (ICA): a subvariant of an accessory PCA leaving the ICA as a hyperplastic anterior choroidal artery and united to the main PCA by a short communicating branch, distinctive of the posterior communicating artery in that side (unilateral double PCA); a right bihemispheric anterior cerebral artery (ACA) but with complete agenesis of the contralateral A1 ACA segment; from the right ACA continued an anatomically normal ipsilateral A2 segment and a short transverse contralateral A2 that, in turn, sent off long pericallosal and callosomarginal arteries; and fenestrated origin of the left pericallosal artery. Therefore, an arterial variant in one of the main cerebral circulations could not exclude anatomical variants in the other cerebral circulatory beds.

Retrospective analysis of image characteristics of 76 cases of cerebral vascular fenestrations

Objectives

This study aims to summarize the clinical and imaging features of cerebral vascular fenestration and to explore the association between cerebral vascular fenestration and cerebral infarction and aneurysm.

Materials and methods

The computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) imaging data of 76 cases of cerebral vascular fenestration from January 2021 and December 2021 in the Yantai Yuhuangding Hospital Affiliated to Qingdao University were analyzed. The general information was described. The location, morphology, and size of cerebral vascular fenestration were described. The association between cerebral vascular fenestration and infarction and aneurysm was analyzed.

Results

Among 76 patients, a total of 80 fenestrations were detected (two patients had three fenestrations), and basilar artery fenestration was the most common (28/80). The fenestration <5 mm was 43/80, 5-10 mm was 12/80, and ≥10 mm was 25/80. Moreover, 19 patients had other vascular diseases: 10 with aneurysms, 5 with moyamoya diseases, and 4 with cerebral artery dissections. Except for one aneurysm at the site of the fenestration, other aneurysms were separate from the fenestrations. In addition, 37 patients had cerebral infarctions, of which 16 had cerebral infarctions in the blood supply area of the arterial fenestration. Among these 16 patients, there was more cerebral infarction in posterior circulation than in anterior circulation. However, no statistically significant differences were detected in the risk factors between the fenestration-relevant cerebral infarctions group and the non-fenestration-relevant cerebral infarctions group.

Conclusion

In our study, cerebral vascular fenestration occurred most frequently in the basilar artery and may be combined with other vascular diseases. Fenestration in posterior circulation may be related to cerebrovascular diseases. Nonetheless, no clear clinical relevance was observed between fenestration and cerebral infarction. Also, we did not find a definite association between fenestration and aneurysm. For fenestration patients with cerebral infarctions, long-term antiplatelet and statin therapy may be safe and effective.

Acute cerebral infarction of posterior circulation in a patient with vertebral artery fenestration deformity: A case report

Introduction

Cerebrovascular fenestration malformation is a rare congenital vascular variation. Cerebrovascular fenestration malformation rarely directly leads to cerebral infarction, and the mechanism of cerebral infarction is not clear. Cases of young patients with vertebral artery fenestration malformation who suffered from acute cerebral infarction of posterior circulation are rare and have not been reported widely.

Patient concerns

A 36-year-old male patient, who had been in good health and without a family history of stroke, was admitted to our hospital with a 6-h history of dizziness and unstable walking.

Diagnosis

Brain MR examination showed multiple irregular high signal lesions in the left thalamus, left occipital lobe and left cerebellum. Brain MR enhancement examination confirmed multiple cerebral infarction in left thalamus, left occipital lobe and left cerebellum. CT angiography of head and neck showed fenestration deformity of V2–V3 segment of left vertebral artery.

Interventions

Considering that the patient was suffering from acute cerebral infarction of posterior circulation, he was treated with antiplatelet, lipid-lowering and plaque stabilization, etc.

Outcomes

After receiving our treatment, the patient's symptoms were relieved. At 3 and 6 months after discharge, there was no dizziness, unstable walking, no acute cerebral infarction, which meant that the patient recovered well.

Conclusion

In the absence of traditional risk factors and other evidence of cryptogenic stroke, the cerebral infarction in the blood supply area of fenestration malformation should be considered to be related to fenestration malformation, but its pathogenesis is not clear. Antiplatelet therapy, lipid-lowering and plaque stabilization, etc. are effective in prevention of new infarction for such patients.

The Incidence, Localization and Clinical Relevance of Arterial Fenestrations and Their Association to Brain Aneurysms: A Case-Control Study Based on the STROBE Guidelines

Background: Fenestrations are rare, but well-known, vascular variations of the cerebral arteries. They are mostly incidental, asymptomatic angiographic findings and might precipitate vascular lesions such as AVM, aneurysmal dilatation, or even ischemic symptoms. However, association between arterial fenestration and brain aneurysms has not been clearly established. Objective: To evaluate whether incidence of arterial fenestrations are associated with brain aneurysm development and investigate the prevalence and most-common localizations of arterial fenestrations of the human brain. Design: Case−control study. Setting: All patients examined by CT angiography in University Hospital No. 4 in Lublin from 2009 to 2019. Patients: Each patient showing at least one cerebral aneurysm was included in the case group and each patient without cerebral aneurysm on CT angiography was included in the control group. Measurements: CT angiography examinations were conducted using the standard protocol used in the 1st Department of Radiology, Medical University of Lublin, Poland. The database and statistical research were conducted by use of the Statistica software (ver. 13.3, Tibco Software Inc., Palo Alto, CA, USA). Results: A total of 6545 CTA examinations were included in the study. Most of the aneurysms were located on the MCA: 629 (38.59%), ICA: 466 (28.59%) and AComA: 192 (11.78%). Cerebral arterial fenestration showed a non-statistically significant elevated risk for brain aneurysms in the entire study population (OR: 1.157; 95% CI: 0.826−1.621; p = 0.39). Among 6545 cranial CTA examinations, cerebral vessel fenestration was found in 49 of them, which constituted 0.75%. The most common vascular fenestrations were those located in the ACA (30.61%), BA (30.61%) and AComA (22.45%), while other fenestrations occurred infrequently. There were no significant differences in the age of patients in the individuals with vascular fenestration (p > 0.05). VA fenestration was slightly more common in men (16.67%) than in women (5.41%). However, these differences were not statistically significant (p = 0.216). Limitations: Our study has several limitations, including selection bias regarding examined population. Second, we assume that the total number of fenestrations detected in our study was underestimated due to the limitations of the CT method in comparison to other radiologic modalities. Conclusions: Cerebral arterial fenestrations are rare vascular malformations. The ACA is the most common localization of fenestrations, followed by BA and AComA. Fenestrations of cerebral arteries insignificantly increase the risk of cerebral aneurysm formation. Further prospective studies are necessary to make this association more precise.

Multiple Ruptured Aneurysms Over Basilar Artery Fenestration: Endovascular Management

Basilar artery fenestrations (BAF) are rare vascular anomalies. Surgical intervention for aneurysms in this vascular segment is exceptionally arduous because of the complexity of the neurovascular structures in the vicinity of the brainstem. Endovascular therapy (ET) is the treatment of choice because of its safety and efficacy. Here, we report a 62-year-old female presenting with a two-day history of sudden onset severe headache, vomiting, and altered sensorium. A computed tomography (CT) and subsequent CT angiogram (CTA) revealed subarachnoid hemorrhage (SAH) and BAF with an aneurysm on each arm of the fenestration. Digital subtraction angiogram (DSA) with a three-dimensional rotational angiogram (3DRA) was employed before initiating ET. We used coiling and flow diversion to exclude the aneurysms from circulation. A six-month follow-up angiography reconfirmed the complete obliteration of the aneurysms. There was no focal neurological deficit.

Imaging markers of intracranial aneurysm development: A systematic review

BACKGROUND

Imaging markers of intracranial aneurysm (IA) development are not well established.

PURPOSE

To provide an overview of imaging markers of IA development.

METHODS

A systematic search of PubMed and Embase up to December 1st 2020 using predefined criteria. Thirty-six studies met our inclusion criteria. We performed a quantitative summary of the included studies.

RESULTS

We found converging evidence for A1 segment asymmetry as an anatomical marker of anterior communicating artery (Acom) aneurysm development, and moderate evidence for several other markers. No hemodynamic markers yielded converging or moderate evidence. There was large heterogeneity across studies, especially in the definitions of imaging markers and study outcomes used. Due to the poor methodological quality of many studies and unavailability of effect sizes or crude data to calculate effect sizes, a formal meta-analysis was not possible. Many studies had poor methodological quality and varied inmarkerdefinitions and outcome measuresused, which prevented us from performing a formal meta-analysis.

CONCLUSIONS

We only identified A1 segment asymmetry as an imaging marker of Acom aneurysm development with converging evidence. A meta-analysis was not possible due to the heterogeneity of marker definitions and outcomes used, and poor methodological quality of many studies. Future studies should use robust study designs and uniformly defined imaging markers and outcome measures.

Morphological Analysis of Cerebral Artery Fenestrations and Their Correlation with Intracranial Aneurysms

BACKGROUND

Fenestrations of cerebral arteries are congenital variants that develop when primitive vessels fuse incompletely. An association between the incidence of aneurysm and a fenestrated artery has been noted in the radiological literature. However, technical limitations of radiological studies may hamper visualization of small fenestrations and aneurysms. We sought to analyze a large, postmortem collection of human brains to assess the association between aneurysm formation and the presence of fenestrations.

METHODS

This study included 333 formalin-fixed brains. The arachnoid was dissected under a microscope, the cerebral arteries were completely exposed, and fenestrations and aneurysms were identified and measured. For each specimen, age, sex, and all vascular abnormalities and variations were recorded for analysis.

RESULTS

Fenestrations were present in 41% of the specimens, and 37% of these were multiple. Fenestrations were 3.1 ± 2.5 mm long and most commonly occurred in the anterior communicating artery (63%). Aneurysms were present in 8% of the specimens, usually in the anterior communicating artery or the middle cerebral artery. An aneurysm correlated with a fenestration was detected in 2% of all specimens (n = 4) and was not statistically significant (P = 0.18).

CONCLUSIONS

Fenestrations of the intracranial arteries are a common anatomical finding. They are present most often in the anterior communicating artery. Most aneurysms were detected in the anterior communicating artery and middle cerebral artery. We conclude that the existence of an aneurysm in a fenestrated artery is an incidental, rather than causal, relationship.

Reconstructive endovascular treatment of basilar artery fenestration aneurysms: A multi-centre experience and literature review

BACKGROUND

Data on outcome after endovascular treatment of basilar artery fenestration aneurysms (BAFAs) is limited. This study presents our multi-centre experience of BAFAs treated by different reconstructive techniques including coils, stent-assisted coiling (SAC), flow diversion and intra-saccular flow disruption with the Woven Endobridge (WEB).

METHODS

Retrospective analysis of 38 BAFAs treated endovascularly between 2003 and 2020. The primary endpoint was complete aneurysm obliteration defined as Raymond-Roy occlusion classification (RROC) I on immediate and follow-up (FU) angiography. The secondary endpoints were procedure-related complications, rate of re-treatment, and clinical outcome.

RESULTS

Endovascular treatment was feasible in 36/38 aneurysms (95%). The most frequent strategy was coiling (21/36, 58%), followed by SAC (7/36, 19%), WEB embolization (6/36, 17%) and flow diversion (2/36, 6%). A successful aneurysm occlusion (defined as RROC 1 and 2) on the final angiogram was achieved in 30/36 (83%) aneurysms including all patients presenting with baseline subarachnoid haemorrhage and 25/36 (69%) were occluded completely. Complete occlusion (RROC 1) was more frequently achieved in ruptured BAFAs (15/25, 60% v. 2/11, 18%; p = 0.031). Procedure-related complications occurred in 3/36 (8%) aneurysms. Re-treatment was executed in 12/36 (33%) aneurysms. After a median angiography FU of 38 months, 30/31 (97%) BAFAs were occluded successfully and 25/31 (81%) showed complete occlusion.

CONCLUSION

Reconstructive endovascular treatment of BAFAs is technically feasible with a good safety profile. Although in some cases re-treatment was necessary, a high rate of final aneurysm occlusion was achieved.

Endovascular treatment modalities for basilar artery fenestration aneurysms: experience of two centers and literature review

Background/aim

The aim of this study is to present our experience on various endovascular treatment modalities of basilar fenestration aneurysms and reviewing our findings together with literature data.

Materials and methods

A total of 26 basilar artery fenestration (BAF) aneurysms in 24 patients were endovascularly treated in two different neurointerventional radiology clinics. All patients had been evaluated with computed tomography (CT), CT angiography, and digital subtraction angiography before the procedure.

Results

Aneurysms of all patients were successfully occluded (technical success rate 100%). Procedure-related complications were seen in two patients. Our comprehensive literature research revealed that studies related with the topic are composed mostly of case reports. In the literature, a total of 113 BAF aneurysms of 101 patients had been treated endovascularly in 46 studies between 1993 and 2019. Success rate of the treatment was reported as 97%, clinical success rate as 91%, and complication rate as 8.8%, while these rates are 100%, 92%, and 7.6% in our study, respectively.

Conclusion

Although the number of cases is low in our study, to our knowledge, it is the widest series in the literature until today. Our results demonstrate that BAF aneurysms can be treated successfully and safely with different endovascular techniques, with more stent use in recent years.

Endovascular Treatment of Fenestration-related Aneurysms : Morphological Features, Operative Techniques and Therapeutic Outcomes

PURPOSE

Endovascular treatment of fenestration-related aneurysms (FAs) is prone to technical challenges, given the inherent complexities. Herein, we have analyzed FAs in terms of angioarchitectural characteristics and outcomes achieved through endovascular intervention.

METHODS

Data accrued prospectively between January 2002 and July 2020 were productive of 105 FAs in 103 patients, each classifiable by the nature of incorporated vasculature as proximal portion, fenestrated limb, or distal end. Our investigation focused on clinical and morphological outcomes, with emphasis on technical aspects of treatment.

RESULTS

The FAs selected for study originated primarily in anterior communicating artery (AcomA: 88/105, 83.8%), followed by basilar (7/105, 6.7%), anterior cerebral (4/105, 3.8%), and internal carotid (3/105, 2.8%) arteries. In nearly all locations, proximally situated aneurysms (43/105, 41%) were more frequent than aneurysms arising at distal ends (3/105, 2.8%), but the majority of AcomA lesions involved fenestrated segments (58/88, 65.9%); and most fenestrated channels (90/105, 85.7%) were asymmetric in size. Orifices of smaller fenestrated limbs were intentionally compromised during coil embolization in 23 aneurysms (21.9%), achieving complete (n = 19) or incomplete (n = 4) compromise, without resultant symptomatic ischemia. Saccular occlusion proved satisfactory in 77 lesions (73.3%). In follow-up monitoring of 100 patients for a mean period of 35.3 ± 26.5 months, 17 instances of recanalization (17.0%) occurred (minor, 9; major, 8). There was no recanalization of aneurysms with compromised limbs.

CONCLUSION

Coil embolization of FAs is safe and effective, enabling tailored procedures that accommodate aberrant angioanatomic configurations. Compromise of a single limb during coiling also appears safe, conferring long-term protection from recanalization.

Complex basilar artery fenestration aneurysm successfully treated with single flow diverter using novel "crossing flow diverter technique" - A rare case report and review of literature

Basilar artery fenestration aneurysms are very rare and endovascular management of large and complex aneurysms is extremely challenging. Most of these type of cases are managed with stent assisted coiling, dual flow diverters (FD) and single FD with additional coiling of aneurysm and occlusion of one of the vertebral artery. Here, we report a case of large complex basilar artery fenestration aneurysm successfully treated with single FD using novel technique called "crossing flow diverter technique" without any additional coiling of aneurysm or occlusion of vertebral artery. Using this technique cost of procedure and procedural complexity inherent with other above mentioned techniques can be significantly reduced.

Characteristics of Clinical Symptoms, Cerebral Images and Stroke Etiology in Vertebro-Basilar Artery Fenestration-Related Infarction

Cerebral artery fenestration is a rare variant of the vascular architecture, but its existence is well documented. The common site of fenestration is the vertebra-basilar artery and it may be found incidentally with subarachnoid hemorrhage. However, fenestration-related cerebral infarction is rare. We analyzed the clinical characteristics, stroke etiology, and image findings of fenestration-related cerebral infarction of the vertebrobasilar artery. We reviewed our hospital records and previously published reports to find cases of fenestration-related cerebral infarction. We excluded those with unknown clinical features or radiological findings. We retrieved 4 cases of fenestration-related infarction from our hospital, in which vascular change, headache, vertigo/dizziness, and dissection in stroke etiology were detected. In eight previously reported cases of fenestration-related infarction, similar vascular changes were noted, but they were mainly diagnosed as embolic stroke of undetermined source. However, based on the criteria for dissection in this study, dissection as the stroke etiology was suspected in the previously reported cases. Many hypotheses have been proposed for the development of dissection, thrombus, and aneurysms in fenestration. Although an embryological and morphological study is needed, clinicians must consider basilar artery fenestration-related infarction as a differential diagnosis and intensive non-invasive image study is recommended.

Basilar artery fenestration and ischemic stroke: An unclear causal relationship

Basilar artery fenestration is the second most commonly observed fenestration of the cerebral arteries. In addition to our case, we reviewed the clinical, imaging findings, treatment, and prognosis of 9 other reported cases. Patients' mean age was 45.1 years. Half of them had cardiovascular risk factors. Mean time to diagnosis was 9.4 days. The main symptoms were right hemiparesis and dysarthria. Basilar artery fenestration was found in all patients, as well as ours, in addition to a thrombus, found in 2 cases. One patient was treated by IV thrombolysis and thrombectomy. In other cases, antiplatelet drugs or anticoagulants were used. A favorable outcome was observed in most cases with one reported death.

A case of multiple Vertebrobasilar artery fenestration misdiagnosed as vertebral artery dissection

Background

Fenestration of vertebra-basilar artery is an uncommon congenital vascular anomaly, which is identified by incidental findings on imaging in patients presented without related symptoms or in patients with intracerebral hemorrhage secondary to concomitant artery aneurysm or arteriovenous malformations. Yet, cases of fenestration being misdiagnosed as cerebral artery dissection have never been reported.

Case presentation

We present a patient of 66-year-old female with acute onset of dizziness after chiropractic manipulation of the neck. Neck computed tomography angiography (CTA) showed ‘double lumen’ sign and ‘intimal flap’ of the V1 segment of the vertebral artery, which led to the initial diagnosis of vertebral artery dissection (VAD). However, vertebral artery fenestration at V1 segment was eventually identified by multi-directional digital subtraction angiography (DSA). Interestingly, concomitant vertebral fenestration at V3 segment, basilar fenestration and basilar artery tip aneurysm was also revealed by DSA.

Conclusion

The triple fenestration at vertebrobasilar artery with basilar tip artery aneurysm is extremely rare, and the fenestration at the V1 segment of vertebral artery was easily misdiagnosed as VAD due to the similar imaging morphology.

Fenestration deformity of the basilar artery trunk with an aneurysm: A case report

RATIONALE

Fenestration of the basilar artery is most common in the proximal portion near the vertebrobasilar artery junction. Conversely, fenestration of the middle and distal portions of the basilar artery is not common, and fenestration of the basilar artery with an aneurysm is even less common.

PATIENT CONCERNS

This study reports the case of a 37-year-old woman with basilar artery fenestration malformation and an aneurysm at the mid-distal junction; her symptoms included sudden headaches with nausea and vomiting.

DIAGNOSES

Head digital subtraction angiography showed fenestration at the junction of the middle and upper portions of the basilar artery associated with an aneurysm, and spontaneous pseudoaneurysm formation could not be excluded.

INTERVENTIONS

The patient underwent stent-assisted fenestration and channel occlusion.

OUTCOMES

Five months later, no abnormalities were found by head magnetic resonance imaging. The stents were well positioned, and no occluded branches or aneurysms were present.

LESSONS

For mid-distal basilar artery fenestration malformation with an aneurysm, occlusion of the lesion channel is relatively safe when there are no perforating vessels in the fenestration channel and the lesion channel is a nondominant channel. Overall, more attention should be paid to the possibility of pseudoaneurysm formation in the diagnosis and treatment of this type of aneurysm.

Posterior circulation ischaemic stroke-a review part I: anatomy, aetiology and clinical presentations

Posterior circulation ischaemia is a clinicopathological condition with complex symptomatology associated with an infarction within the vertebrobasilar arterial system. Posterior circulation strokes account for about 20-25% of all ischemic strokes and remain a significant cause of patient disability and mortality. Diagnosis can be challenging because presenting symptoms are often non-focal and because there is a substantial overlap in symptoms and signs of ischaemia in the anterior circulation. Despite better imaging techniques, diagnosis and treatment of life-threatening conditions, such as basilar artery occlusions, are often delayed. Therefore, early detection of symptoms and causes of posterior circulation ischaemia is essential for choosing the most appropriate therapy. In this review, we summarise the anatomy, aetiology, typical presentations and characteristic findings of common strokes resulting from disease in the vertebrobasilar arterial system.

Plaque Distribution of Basilar Artery Fenestration by 3D High-Resolution MR Vessel Wall Imaging

The association between fenestrations and neurovascular pathology is not well defined. The morphology of vessel wall plays an important role in the development of neurovascular pathology. We sought to explore the plaque distribution around basilar artery fenestration (BAF) by three-dimensional high-resolution MR vessel wall imaging (3D HRMRI). Patients with BAF on 3D HRMRI images were enrolled. All cross-sectional slices of basilar arteries were assessed and categorized based on the location of fenestration as proximal segment, in-bifurcation segment, and distal segment. Furthermore, plaques in the in-bifurcation segment were classified according to their orientation being centered on the lateral, interior, dorsal, or ventral wall of the vessel. In all, 12 cases with BAF involving 661 cross-sectional image slices in entire basilar arteries were included. Plaques were found in 190 image slices, with the distribution of 41 slices in the proximal segment, 144 slices in the in-bifurcation segment and 67 slices in the distal segment. Plaques were found more frequently in the proximal and in-bifurcation segments than in the distal segment (P < 0.001), but there was no statistical difference between the proximal and in-bifurcation segment (P = 0.11). In the in-bifurcation segment, plaques were more frequently located at the lateral (50.0%) than other interior (16.0%), dorsal (21.0%), and ventral (13.0%) wall (P < 0.001).Plaques of BAF tend to locate in the proximal and in-bifurcation segments, especially at the lateral wall of the in-bifurcation segment.

Intracranial Arterial Fenestration and Risk of Aneurysm: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies have been inconsistent regarding risk for intracranial aneurysm related to intracranial arterial fenestration. We conducted a meta-analysis to examine the association between intracranial arterial fenestration and risk of aneurysm.

METHODS

We performed a systematic review of PubMed and Embase through August 2017 for potentially relevant articles. Summary odds ratios with 95% confidence intervals were pooled using a random-effects model.

RESULTS

Of 446 articles found, 7 were selected for meta-analysis. Pooled odds ratios revealed an increased risk of aneurysm owing to fenestration of 1.50 (95% confidence interval, 0.61-3.71; P = 0.38). Subgroup analyses based on the population presenting with various indications suggested that pooled odds ratios indicated a significant increase in risk for aneurysm of 2.43 (95% confidence interval, 1.04-5.69; P = 0.04).

CONCLUSIONS

Our findings indicate that intracranial arterial fenestration may be associated with increased risk for aneurysm formation.

Basilar artery fenestration: an unusual possible cause of ischaemic stroke?

Basilar artery fenestration is an uncommon congenital dysplasia and may be associated with ischaemic stroke. We present a case of a previously healthy 36-year-old man who presented with vertigo and vomiting. MRI showed posterior circulation territory infarction. High-resolution magnetic resonance angiography revealed a slit-like fenestration in the basilar artery. This patient had no traditional vascular risk factors or aetiology of cryptogenic stroke. The patient recovered from his neurological deficit after antiplatelet therapy and was given prophylactic aspirin therapy. There was no recurrence of symptoms after 12 months of follow-up.

Fenestra Obscura: Flow Diverter Reconstruction of a Complex Vertebrobasilar Aneurysm Through an Obscured Fenestration Limb: Technical Case Report

BACKGROUND AND IMPORTANCE

Basilar fenestration aneurysms are rare, challenging intracranial vascular lesions with atypical anatomy. The posterior circulation represents a difficult therapeutic dilemma because of the close proximity of crucial life-sustaining brainstem structures. The use of flow diverter technology has been very limited in posterior circulation vessels.

CLINICAL PRESENTATION

We present the case of a 49-year-old female patient, who was diagnosed with a symptomatic large vertebrobasilar junction aneurysm, which was initially thought to be a proximal basilar dilatation. The aneurysm was later verified to arise from the proximal end of a basilar fenestration, distended by the aneurysm fundus. The small-caliber fenestration limbs were the only connection to the distal basilar artery, but were stretched laterally and concealed by the aneurysm fundus. This complex lesion was successfully treated by flow diverter deployment through one of the fenestration limbs, followed by coiling of the aneurysm fundus, and sacrificing the contralateral vertebral artery. A 6-month follow-up angiogram showed remodeling of the basilar artery and complete occlusion of the aneurysm with good clinical outcome. Careful diagnostic workup, multidisciplinary discussions, and the innovative use of versatile endovascular technology were crucial to achieve an optimal result in this case.

CONCLUSION

This is the first report of a successful basilar artery reconstruction for the treatment of a large atypical vertebrobasilar junction fenestration aneurysm by deployment of a flow diverter device directly in a small, obscured fenestration limb.

Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management

Posterior circulation strokes represent approximately 20% of all ischemic strokes (1, 2). In contrast to the anterior circulation, several differences in presenting symptoms, clinical evaluation, diagnostic testing, and management strategy exist presenting a challenge to the treating physician. This review will discuss the anatomical, etiological, and clinical classification of PC strokes, identify diagnostic pitfalls, and overview current therapeutic regimens.