Ruptured aneurysm arising from a basilar artery fenestration and associated with a persistent primitive hypoglossal artery

Imaging and blood flow characteristics of cerebrovascular fenestration malformation and its relationship with the occurrence of ischemic cerebrovascular disease

OBJECTIVE

To explore the imaging and transcranial Doppler cerebral blood flow characteristics of cerebrovascular fenestration malformation and its relationship with the occurrence of ischemic cerebrovascular disease.

METHODS

A retrospective analysis was conducted on the imaging data of 194 patients with cerebrovascular fenestration malformation who visited the Heyuan People's Hospital from July 2021 to July 2023. The location and morphology of the fenestration malformation blood vessels as well as the presence of other cerebrovascular diseases were analyzed. Transcranial Doppler cerebral blood flow detection data of patients with cerebral infarction and those with basilar artery fenestration malformation were also analyzed.

RESULTS

A total of 194 patients with cerebral vascular fenestration malformation were found. Among the artery fenestration malformation, basilar artery fenestration was the most common, accounting for 46.08% (94/194). 61 patients (31.44%) had other vascular malformations, 97 patients (50%) had cerebral infarction, of which 30 were cerebral infarction in the fenestrated artery supply area. 28 patients with cerebral infarction in the fenestrated artery supply area received standardized antiplatelet, lipid-lowering and plaque-stabilizing medication treatment. During the follow-up period, these patients did not experience any symptoms of cerebral infarction or transient ischemic attack again. There were no differences in peak systolic flow velocity and end diastolic flow velocity, pulsatility index and resistance index between the ischemic stroke group and the no ischemic stroke group in patients with basal artery fenestration malformation (P > 0.05).

CONCLUSION

Cerebrovascular fenestration malformation is most common in the basilar artery. Cerebrovascular fenestration malformation may also be associated with other cerebrovascular malformations. Standardized antiplatelet and statin lipid-lowering and plaque-stabilizing drugs are suitable for patients with cerebral infarction complicated with fenestration malformation. The relationship between cerebral blood flow changes in basilar artery fenestration malformation and the occurrence of ischemic stroke may not be significant.

Ruptured posterior inferior cerebellar artery aneurysm associated with persistent primitive hypoglossal artery: A case report

Until now, 9 cases of an association of a posterior inferior cerebellar artery (PICA) aneurysm with the persistent primitive hypoglossal artery (PPHA) have been reported. We reported a case of a ruptured PICA aneurysm associated with the PPHA, which was successfully treated by intravascular embolization using inflation of an endovascular occlusion balloon in the proximal artery to stabilize the microcatheter tip. A 19-year-old woman presenting headache and mild consciousness disturbance was admitted to our hospital. Head computed tomography (CT) showed a subarachnoid hemorrhage in the interpeduncular cistern. Right common carotid angiography revealed an aneurysm with a maximum diameter of 3.7 mm at the proximal PICA, which was fed from the common carotid artery (CCA) through the internal carotid artery (ICA) and the PPHA and the vertebral artery. During coil embolization, a pulsatile fluctuation of the microcatheter tip caused by the minimum curvature of the proximal arterial route from the aorta to the PPHA made the continuation of the coil embolization difficult. Then, we inflated an occlusion balloon in the PPHA to stabilize the microcatheter tip, and the coil embolization was performed under the blank roadmap fluoroscopy. The aneurysm disappeared completely with the preservation of the PICA on the postoperative angiogram. A case of ruptured PICA aneurysm with proximal PPHA, which was successfully embolized with the assist of a proximal occlusion balloon inflation. When the pulsative movement of a microcatheter tip made coil embolization difficult, this technique could be useful.

Management of basilar fenestration aneurysms: a systematic review with an illustrative case report

BACKGROUND

Basilar artery (BA) fenestration aneurysm (BAFA) is a rare phenomenon commonly accompanying other aneurysms. Treatment is challenging, and few cases have been reported. This review investigated the management outcomes of BAFAs.

METHODS

Publication databases were searched to identify studies evaluating outcomes of endovascular treatment (EVT) and microsurgical treatment of BAFAs from inception through 2021. Outcomes (clinical, angiographic, postoperative complications, and retreatment rates) were collected and analyzed. The authors present their case of a patient treated for a BAFA.

RESULTS

Including the authors' case, 184 patients with 209 BAFAs were reported in 68 studies. Most patients (130/175; 74.3%) presented with ruptured aneurysms, most commonly involving the proximal segment of the BA. Most BAFAs were small (52/103, 50.5%) and saccular (119/143, 83.2%). Most patients underwent EVT (143/184, 77.7%); the rest underwent microsurgery. Postoperative complications after EVT occurred in 10 (8.3%) of 120 patients, with 4 of the 10 experiencing strokes. At clinical follow-up, most EVT patients (74/86, 86.0%) showed good outcomes; 3.9% (2/51) had died. Most aneurysms managed with EVT (56/73, 76.7%) showed complete occlusion at follow-up; 7.3% (8/109) were retreated. Postoperative complications occurred in 62.2% (23/37) of microsurgical patients; 5 (21.7%) of the 23 experienced strokes. All patients showed good clinical outcomes at follow-up. Most aneurysms (22/28, 78.6%) treated microsurgically showed complete occlusion at angiographic follow-up, with no retreatment required.

CONCLUSION

BAFAs are often symptomatic; thus, treatment is challenging. By the 2000s, treatment had moved from microsurgical to endovascular modalities, with good clinical and angiographic outcomes.

Association of cerebral infarction with vertebral arterial fenestration using non-Newtonian hemodynamic evaluation

PURPOSE

Cerebral artery fenestration is a rare vascular anomaly, but its existence has been increasingly documented. The association of cerebral infarction and fenestration is of great clinical interest, and the exact underlying mechanism remains unclear. This study aims to identify risk factors contributing to cerebral infarction by computational hemodynamics analysis.

METHODS

Eight patients with image findings of fenestration structure were recruited in this research, in which four suffered fenestration-related cerebral infarction (A series) while the other four (B series) were set as control matched by the fenestration size. Three-dimensional models were reconstructed from the MRA images and computational simulations with non-Newtonian flow model were performed to get interested hemodynamic characteristics.

RESULTS

The blood flow pattern was relatively separated along two channels of fenestration in series A compared with series B cases in Group 1-2, however, no significant difference was shown in Group 3-4. Quantitatively, planes were cut in the middle of fenestrations and the ratio of mass flow rate and area was calculated at systolic peak. Results showed that the side of the dominant blood supply was opposite between A and B series, and the dominant side was also opposite between small and large fenestrations. In infarction cases, the basilar top was distributed with larger areas of detrimental hemodynamic indicators and a larger concentrated high viscosity region.

CONCLUSION

The flow division condition throughout the fenestration structure has a key impact on further flow redistribution and flow pattern. The blood viscosity has the potential to be a useful tool in identifying the risk factors for cerebral infarction and more emphasis should be placed on the hemodynamic environment at superior cerebellar arteries.

Endovascular Therapy for an Aneurysm of a Distal Posterior Inferior Cerebellar Artery via the Ipsilateral Persistent Primitive Proatlantal Artery: A Case Report

Objective

We describe the rare case of a patient who was treated for a ruptured distal posterior inferior cerebellar artery (PICA) aneurysm via an ipsilateral persistent primitive proatlantal artery (PPPA).

Case Presentation

An 86-year-old female with a medical history of hypertension presented with headache and nausea. CT showed subarachnoid hemorrhage in the posterior cranial fossa, and CTA revealed an aneurysm at the left-side distal PICA. In the left-sided common carotid angiography, the artery with a branch of the occipital artery from the external carotid artery was described. This artery continued as the V3 segment and entered the dura via the foramen magnum. The artery perfused the territory of the left vertebral artery and PICA. We concluded that the artery, which entered the dura, was a PPPA. We decided to perform endovascular therapy that passed through the PPPA. The aneurysm was located in the cortical segments, beyond the cranial loop. We decided that parent artery occlusion (PAO) would be more effective than selective coil embolization to achieve safe and adequate hemostasis. The patient had a good outcome with PAO not assessing collateral circulation.

Conclusion

The emergency endovascular treatment with rare vascular variations requires accurate anatomical knowledge for treatment.

Endovascular treatment of a ruptured aneurysm arising from the proximal end of a partial vertebrobasilar duplication with a contralateral prominent persistent primitive hypoglossal artery: illustrative case

BACKGROUND

Ruptured aneurysms associated with a partial vertebrobasilar duplication or a persistent primitive hypoglossal artery (PPHA) have been reported. Only rarely has endovascular treatment of ruptured aneurysms in association with both vascular variations been reported.

OBSERVATIONS

A 66-year-old woman experienced the sudden onset of a severe headache caused by a subarachnoid hemorrhage. Cerebral angiograms demonstrated a prominent PPHA originating from the left internal carotid artery at the C2 vertebral level and a partial vertebrobasilar duplication between the hypoplastic right vertebral artery and proximal basilar artery with a small aneurysm at the proximal end of the duplication from where the anterior spinal artery originated. The left vertebral artery was aplastic. A microcatheter was introduced into the aneurysm via the PPHA under the control of high blood flow, using a balloon-assisted technique. The aneurysm was completely obliterated with a coil. Although small cerebellar and cerebral infarcts developed during the procedure, the patient was discharged without neurological symptoms.

LESSONS

To avoid serious neurological complications, precise analysis of the complex vascular anatomy, including the anterior spinal artery and hemodynamics, is clinically important for endovascular therapy of cerebral aneurysms in patients with an association between a partial vertebrobasilar duplication and a PPHA.

Unusual case of persistent primitive hypoglossal artery with anterior choroidal artery aneurysm in Chiari type I malformation

Persistent primitive hypoglossal artery (PPHA) is a rare form of persistent embryonic carotid-basilar anastomosis. We present an unusual case of PPHA and an anterior choroidal artery (AChoA) aneurysm associated with Chiari type I malformation. A 45-year-old woman presented with transient dizziness. Magnetic resonance imaging revealed Chiari type I malformation and a left AChoA aneurysm. Digital subtraction angiography incidentally revealed a left PPHA. To the best of our knowledge, this is the first reported case of Chiari malformation in conjunction with PPHA and aneurysms. In this case, the perfusion of the posterior circulation is completely dependent on PPHA. It is very important to identify such variant vessels and complex angioarchitecture before planning neuroendovascular or surgical intervention to prevent possible risks.

Persistent Primitive Hypoglossal Artery Associated With Multiple Cerebral Aneurysms

Persistent primitive hypoglossal artery is a rare anastomosis between the carotid and basilar arteries, and sometimes associated with cerebral aneurysms. However, association of persistent primitive hypoglossal artery with aneurysms located on arteries other than persistent primitive hypoglossal artery itself or posterior circulation is very rare. An 80-year-old woman suffered from subarachnoid hemorrhage, whose angiography demonstrated aneurysms on the left middle cerebral artery and anterior communicating artery, and the left persistent primitive hypoglossal artery. The middle cerebral artery aneurysm was the origin of hemorrhage. Although repeated craniotomy was necessary for the left middle cerebral artery aneurysm, both aneurysms were successfully clipped. In our case, neither aneurysm was located on an artery related to the persistent primitive hypoglossal artery. There is a possibility that cases of persistent primitive hypoglossal artery are accompanied by cerebral aneurysms on arteries other than the persistent primitive hypoglossal artery or in the posterior circulation.

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.

Persistence of a hypoglossal artery: case report

The authors present a case of persistent hypoglossal artery. Persistent hypoglossal artery is the second most common carotid-basilar anastomosis with a frequency of 0.02% to 0.09% and it can be associated with cerebrovascular disease. Diagnosis is by imaging methods and angiotomography is the method most often employed.

Fenestrations of the basilar artery demonstrated on magnetic resonance angiograms: an analysis of 212 cases

Fenestration of the basilar artery (BA) is a rare variant of the intracranial artery, well demonstrated in autopsy and angiographic studies. Some angiographic series show a high incidence of associated aneurysms at the basilar fenestration site. The purpose of this study is to report the incidence of BA fenestration, its configurations, associated aneurysms, and arterial anomalies in a large series of intracranial MR angiograms (MRAs). A total of 16,416 MRAs were retrospectively reviewed to identify the location, size and associated intracranial arterial anomalies of BA fenestrations. All images were obtained with the time-of-flight (TOF) technique. Of the 16,416 MRAs, 215 fenestrations were found in 212 cases (1.29%). Most fenestrations were located in the proximal BA. The average length of the fenestration was 4.6 mm; the largest was 15.6 mm. No aneurysm was found at the site of the fenestration. Thirteen aneurysms were found in nine cases at locations other than the BA: seven in the middle cerebral artery (MCA), one in the anterior cerebral artery (ACA), one in the anterior communicating artery (Acom), one in the vertebral artery (VA), one at the carotid siphon, and two at the internal carotid-posterior communicating artery (IC-PC). Arterial anomalies in other locations were found in 26 cases. BA fenestrations were found in 1.29% of the 16,416 cases studied. There were no aneurysms at the BA fenestration site. Aneurysms at the BA fenestration site may be an exceedingly rare phenomenon.

Endovascular treatment of a large aneurysm arising from a basilar trunk fenestration using the waffle-cone technique

OBJECTIVE

Endovascular treatment of large intracranial aneurysms arising from a fenestrated parent vessel may prove particularly difficult. We present a case of a large, broad-based aneurysm arising from a proximal basilar artery (BA) fenestration treated with the waffle-cone technique. Technical nuances and indications for this treatment option are reviewed.

CLINICAL PRESENTATION

A 38-year-old man presented with headache, blurred vision, and dizziness. Angiography demonstrated an 11 x 14-mm BA aneurysm associated with the proximal portion of a BA fenestration.

TECHNIQUE

A 28 x 4.5-mm Enterprise stent was placed from the right vertebral artery directly into the aneurysm. The stent tines were allowed to flare out in the aneurysm neck creating the "waffle cone." The aneurysm was then coiled with a series of Presidio coils.

CONCLUSION

Use of the waffle-cone technique for stent placement resulted in nearly complete embolization of the aneurysm, retention of the entire coil mass in the dome, and preservation of flow through both vertebral arteries and both limbs of the fenestration.

A case of aneurysm on a persistent hypoglossal artery treated by endovascular coiling

SUMMARY

We describe a 22-year-old woman admitted to hospital in emergency with nuchal headache and vomiting. CT scan disclosed subarachnoid hemorrhage. Digital subtraction angiography with three-dimensional rotational acquisitions showed a ruptured aneurysm of a right persistent primitive hypoglossal artery as the cause of symptoms and hemorrhage. The patient was successfully treated with endovascular coiling of the aneurysm. This is the second literature report describing endovascular treatment in this unusual condition.

Cavernous carotid aneurysms: to treat or not to treat?

Most cavernous carotid aneurysms (CCAs) are considered benign lesions, most often asymptomatic, and to have a natural history with a low risk of life-threatening complications. However, several conditions may exist in which treatment of these aneurysms should be considered. Several options are currently available regarding the management of CCAs with resultant good outcomes, namely expectant management, luminal preservation strategies with or without addressing the aneurysm directly, and Hunterian strategies with or without revascularization procedures. In this article, we discuss the sometimes difficult decision regarding whether to treat CCAs. We consider the natural history of several types of CCAs, the clinical presentation, the current modalities of CCA management and their outcomes to aid in the management of this heterogeneous group of cerebral aneurysms.

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.

Ultrasound findings of bilateral hypoplasia of the vertebral arteries associated with a persistent carotid-hypoglossal artery

We present a 31-year-old female who was admitted to our neurology department for vertigo, partial left-sided hemihypesthesia and nuchal headache of subacute onset. Colour-duplex ultrasound disclosed bilateral low flow with a high resistance flow pattern in both vertebral arteries in the V2 segments, while the basilar artery had normal flow. CT angiography and MRI ruled out any ischaemic cerebral infarct and disclosed a persistent hypoglossal artery (PHA) originating from the left internal carotid artery (ICA). The patient was eventually treated for cervicobrachialgia. Persistent carotid-basilar anastomosis such as PHA may account for an atypical stroke pattern in carotid disease, aneurysms and arterovenous malformations. In retrospect, PHA is amendable to colour-Duplex investigation due to an abnormal ICA flow and a discrepancy between the vertebral and basilar flow patterns. Ultrasound investigation of the vertebrobasilar system remains a challenge as variants appear frequently; hypoplasia of the vertebral arteries should thus be confirmed using CT or MR angiography.

Endovascular management of multiple cerebral aneurysms in acute subarachnoid hemorrhage associated with fenestrated basilar artery. A case report and literature review

Aneurysms arising from the fenestration of the basilar artery are rare. We describe a patient with two aneurysms originating from the fenestration of the basilar artery and the middle cerebral artery. Endovascular treatment with detachable platinum coils was performed, and two aneurysms were cured at the same time. Endovascular treatment of aneurysms associated with fenestrated basilar artery appears to offer advantages over traditional open surgical techniques.

Persistent Hypoglossal Artery Associated with a Ruptured Ipsilateral Posterior Inferior Cerebellar Artery Aneurysm

A rare case of persistent hypoglossal artery in conjuction with a ruptured aneurysm at the left proximal posterior inferior cerebellar artery (PICA) is presented. A ruptured PICA aneurysm was successfully treated by endovascular occlusion of the aneurym with coiling.

Ruptured aneurysm of a persistent primitive hypoglossal artery treated by endovascular approach—case report and literature review

BACKGROUND

A persistent PHA is the second most common of the embryonic carotid-basilar anastomoses that fail to regress in the embryo. The fact that PHA often is functionally a single artery providing blood to the posterior circulation poses challenging therapeutic problems in case of an aneurysm located on the PHA.

CASE DESCRIPTION

A 46-year-old woman presented with SAH due to a large ruptured aneurysm of the left PHA. Identification of such an artery by CT angiogram is the proposed cold standard. The aneurysm was obliterated by coil embolization. To our knowledge, this is the first reported case of aneurysm located on a primitive persistent hypoglossal artery that was endovascularly treated.

CONCLUSION

Aneurysms located on a persistent PHA can be treated safely and effectively via an endovascular approach.

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.

Intracranial aneurysms associated with other lesions, disorders or anatomic variations

Intracranial aneurysms (IAs) can be related to or associated with some vascular anatomic variations, lesions, diseases, or systemic disorders in which a causative or predisposing factor(s) in aneurysm formation can be identified. This article includes flow-related, infectious, traumatic iatrogenic, and neoplastic aneurysms and aneurysms related to systemic disorders and drug abuse. In some conditions, IAs associated with other disorders are true aneurysms. Most of them, however, are false aneurysms. Characteristics and management of these unusual aneurysms are discussed.

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.

Endovascular Treatment of Ruptured Aneurysms Associated With Fenestrated Basilar Artery-Two Case Reports-

Two patients with ruptured aneurysm associated with fenestrated basilar artery (BA) were treated using the endovascular approach. Angiography showed these patients had different types of BA bifurcation. One type had two points of bifurcation and a bridging artery in the BA fenestration, with the aneurysm at the bifurcation of the right loop of the fenestration. The aneurysm had different appearances on right and left vertebral angiograms. The other type had only one point of bifurcation, and the appearance of this aneurysm was similar on both angiograms. To ensure successful embolization, bilateral vertebral angiography should be performed for complete assessment of the morphological characteristics of aneurysm associated with fenestrated BA.