A vertebrobasilar junction aneurysm associated with fenestration treated by intra-aneurysmal embolization

Treatment of fenestrated vertebrobasilar junction-related aneurysms with endovascular techniques

Fenestrated vertebrobasilar junction-related aneurysms (fVBJ-AN) are uncommon and endovascular management strategies have become the first options for the treatment of these lesions. This clinical study aimed to report our experience in the endovascular management of these lesions and to review the literature. We retrospectively reviewed 10 consecutive patients harboring 12 fVBJ-AN between January 2007 and December 2014. The demographic, angiographic and clinical data were reviewed. Additionally, a literature review was performed. Endovascular management strategies were successfully applied in all 10 patients. Post-procedural angiograms indicated total occlusion in eight (66.7%) aneurysms, a residual neck in one (8.3%) aneurysm, and three residual aneurysms (25%). No procedure-related complications were observed. Follow-up angiograms were obtained in eight patients and revealed nine occluded aneurysms and one improved aneurysm; two patients were lost to angiographic follow-up. Clinical follow-ups were obtained in all patients (until July 2015), and the modified Rankin Scale scores at 69.5months (range 17-101months) of follow-up were 0 in eight patients and 1 in two patients. Endovascular management strategies provided a high occlusion rate and an acceptable complication rate and are thus efficacious in the treatment of fVBJ-AN. Further studies are necessary to validate the utility of these treatments due to the low incidence of fVBJ-AN.

Cerebral arterial fenestrations

Arterial fenestrations are an anatomic variant with indeterminate significance. Given the controversy surrounding fenestrations we sought their prevalence within our practice along with their association with other cerebrovascular anomalies. We retrospectively reviewed 10,927 patients undergoing digital subtraction angiography between 1992 and 2011. Dictated reports were searched for the terms "fenestration" or "fenestrated" with images reviewed for relevance, yielding 228 unique cases. A Medline database search from February 1964 to January 2013 generated 304 citations, 127 cases of which were selected for analysis. Cerebral arterial fenestrations were identified in 228 patients (2.1%). At least one aneurysm was noted in 60.5% of patients, with an aneurysm arising from the fenestration in 19.6% of patients. Aneurysmal subarachnoid hemorrhage or non-aneurysmal subarachnoid hemorrhage were present in 60.1% and 15.8%, respectively. For the subset of patients with an aneurysm arising directly from a fenestration relative to those patients with an aneurysm not immediately associated with a fenestration, the prevalence of aneurysmal subarachnoid hemorrhage was 66.7% vs. 58.6% (p = 0.58). Fenestrations were more often within the posterior circulation (73.2%) than the anterior circulation (24.6%), though there was no difference in the prevalence of aneurysms within these groups (61.1% vs. 60.7%, p = 1.0). Cerebral arterial fenestrations are an anatomic variant more often manifesting at the anterior communicating arterial complex and basilar artery and with no definite pathological relationship with aneurysms.

Treatment of ruptured saccular aneurysms of the fenestrated vertebrobasilar junction with balloon remodeling technique. A short case series and review of the literature

Fenestration of the intracranial arteries is a relatively common occurrence. This anatomic variation may predispose to aneurysm formation at certain sites. Treatment of such aneurysms is difficult as it may occlude one of the limbs of fenestration with resultant deficit. Thus, preservation of both the limbs with adequate exclusion of the aneurysm from the circulation should be the aim of any treatment. We describe a series of four cases of ruptured aneurysms arising from a fenestrated vertebrobasilar junction treated with endovascular balloon remodeling technique.

Fenestration and duplication of the vertebral artery: the anatomical and clinical points of view

The vertebral artery (VA) acts as a foundation for the posterior circulation of the head and neck. It presents a number of anomalies that can be easily visualized thanks to modern imaging techniques, such as MR and CT angiography or color Doppler ulrasonography. Determining the appropriate terminology for those anomalies can be sometimes more challenging than their recognition. One particular challenge concerns the differentiation between VA fenestration and duplication. Because of the different clinical prognoses associated with those anomalies, confusion should be avoided. Knowledge of the morphological anomalies associated with the VA is important for both radiologists and head and neck surgeons, because any injury to the VA can result in a threat to the vascular supply of the brain stem, the cerebral or cerebellar hemispheres, the thalamus, cervical nerve roots and particularly the lateral medulla (Wallenberg's syndrome). This article analyses world literature concerning the issue of VA fenestration and duplication to facilitate a differential diagnosis.

Fenestrated vertebrobasilar junction aneurysm: diagnostic and therapeutic considerations

Vertebrobasilar junction (VBJ) aneurysms are uncommon and are often found in association with basilar artery (BA) fenestration. The complex anatomical environment of the VBJ, and the complicated geometry of the fenestration make clipping of these aneurysms difficult. Therefore, endovascular treatment of these aneurysms is now widely accepted.

The authors describe the case of a 43-year-old woman with sickle cell anemia. She presented with subarachnoid hemorrhage. Digital subtraction angiography was performed and depicted multiple intracranial aneurysms. The patient had a left superior hypophysial artery aneurysm, a right superior cerebellar artery–posterior cerebral artery aneurysm, and a VBJ aneurysm associated with a fenestration of the BA. The VBJ aneurysm was not identified on the initial angiogram and was only revealed after 3D rotational angiography was performed. The 3D reconstruction was critical to the understanding of the complex geometry associated with the fenestrated BA. The VBJ was reconstructed using a combination endovascular technique. The dominant limb of the fenestration was stented and balloon-assisted coiling was performed, followed by sacrifice of the nondominant vertebral artery using coils and the embolic agent Onyx. Postoperative angiography demonstrated successful occlusion of the aneurysm with reconstruction of the VBJ.

To the authors' knowledge, this is the first report of a fenestrated VBJ aneurysm treated with the combination of stenting, balloon remodeling, coiling, and vessel sacrifice. Three-dimensional angiography was critical in making the correct diagnosis of the source of the subarachnoid hemorrhage and with operative planning.

Aneurysms of the vertebrobasilar junction: incidence, clinical presentation, and outcome of endovascular treatment

BACKGROUND AND PURPOSE

The aim of this retrospective study was to report the incidence, clinical presentation, and midterm clinical and imaging results of endovascular treatment of 10 aneurysms of the vertebrobasilar junction.

MATERIALS AND METHODS

Between January 1995 and January 2007, 2112 aneurysms were treated in our institution. Ten aneurysms in 10 patients were located on the vertebrobasilar junction and 7 aneurysms (70%) were associated with proximal basilar fenestration. There were 5 men and 5 women, ranging from 29 to 75 years of age. Nine aneurysms presented with subarachnoid hemorrhage, and one was a giant partially thrombosed aneurysm with mass effect on the brain stem.

RESULTS

Nine ruptured aneurysms were treated by primary coil occlusion. One giant unruptured aneurysm was initially treated with bilateral vertebral artery occlusion, 2 months later followed by selective coil occlusion of the remaining aneurysm lumen via the posterior communicating artery. At imaging follow-up of 6-30 months in 7 patients, all aneurysms were adequately occluded. In 2 patients, the vertebrobasilar junction and distal vertebral arteries (including the aneurysm) thrombosed completely on follow-up without clinical sequelae.

CONCLUSION

Vertebrobasilar junction aneurysms are rare, with an incidence of 0.5% of treated aneurysms at our institution. Vertebrobasilar junction aneurysms are frequently associated with proximal basilar fenestration. Most patients present with subarachnoid hemorrhage. Endovascular treatment is effective and safe in excluding the aneurysms from the circulation.

Basilar trunk aneurysms with associated fenestration treated by using Guglielmi detachable coils: two cases reports

Basilar trunk saccular aneurysms associated with fenestration are infrequent. Surgical treatment of a basilar trunk aneurysm is difficult because of its anatomic environment and complicated surgical exposure. We experienced two cases of basilar fenestration aneurysm, and the patients were treated using Guglielmi detachable coils. The usefulness of 3-dimensional digital subtraction angiography and efficacy of endovascular treatment for basilar trunk aneurysms with associated fenestration is discussed in this article, and the relevant literature is reviewed.

Treatment of a giant vertebrobasilar artery aneurysm using stent grafts

✓This 65-year-old man presented to the authors' institution reporting neck swelling. Stage IIIA Hodgkin disease was diagnosed, and a computed tomography scan of the neck revealed a vertebrobasilar artery aneurysm. His medical history was significant for subarachnoid hemorrhage and coma 2 years earlier. Subsequent digital subtraction angiography demonstrated a giant fusiform vertebrobasilar junction aneurysm with associated basilar artery (BA) fenestration. Endovascular treatment of the giant aneurysm was performed by left vertebral artery (VA) occlusion and placement of two Jo-stent coronary stent grafts from the right VA to the BA. The postprocedure course was uneventful. Follow-up angiography performed 1 week postoperatively demonstrated complete exclusion of the aneurysm. This unique case is described and a review of the relevant literature is presented.

Neuroradiological Analysis of 23 Cases of Basilar Artery Fenestration Based on 2280 Cases of MR Angiographies

SUMMARY

Basilar artery (BA) fenestrations are the most frequently observed variant of the cerebral arteries. We examined the magnetic resonance (MR) angiographic incidence, location, characteristic configuration of BA fenestration and associated vascular disease. From April 2004 to September 2004, a total of 2280 cranial MR angiographies were performed at our institution. Twenty-three BA fenestrations (1.0%) were detected on MRA. There were 13 males and ten females in this group and mean age was 57.6 years old. Three cases of these fenestration group are suffered with atherothrombic infarction in the territory of vertebro-basilar system. Seven of 23 cases (30%) were associated with intracranial aneurysm. Of those four cases, aneurysms were located at anterior circulation. Of those three cases, the aneurysms were associated with BA fenestration. Since saccular aneurysms are reported to arise frequently at BA fenestration, knowledge and recognition of fenestration are useful and important in the interpretation of cerebral MR angiography.