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

Basilar artery fenestration in migraine patient

Basilar artery fenestration should be considered in migraine patients, especially with a cerebrovascular family history, necessitating annual magnetic resonance imaging/angiography (MRI/MRA) monitoring and careful assessment of birth control regimens to mitigate risks.

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.

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.