Endovascular treatment of kissing aneurysms at the fenestrated basilar artery: Case report with literature review

doi:10.1016/S0090-3019(02)00748-6

Surgical Neurology

Volume 58, Issue 1, July 2002, Pages 54-58

https://doi.org/10.1016/S0090-3019(02)00748-6 Get rights and content

Abstract

BACKGROUND

Basilar artery fenestrations are most commonly located in the proximal basilar trunk close to the vertebrobasilar junction and may harbor saccular aneurysms. Surgical treatment of such aneurysms has been reported in several cases previously, despite the difficulty of the surgical approach. Endovascular treatment may provide a more convenient treatment alternative in such cases. This case is also interesting in that two discrete aneurysms arise from each limb of the fenestration.

CASE REPORT

A 20-year-old man presented with acute subarachnoid hemorrhage. He had two kissing aneurysms at the fenestrated proximal basilar artery as demonstrated by MRA and selective angiography. The two aneurysms were successfully treated with GDCs via the contralateral vertebral arteries. One-year control angiogram showed stable occlusion.

CONCLUSION

Aneurysms at the fenestrated basilar artery may be effectively treated with endovascular coil occlusion. The occurrence of multiplicity and the treatment alternatives are discussed, with relevant literature review.

Section snippets

Case report

A 20-year-old man was admitted to another hospital with sudden loss of consciousness. Noncontrast computed tomography (CT) obtained on the same day revealed diffuse subarachnoid hemorrhage. Magnetic resonance imaging (MRI) showed a lobulated aneurysm at the proximal basilar artery associated with fenestration at the aneurysm site (Figure 1). The patient was transferred to our hospital the following day. He was drowsy and his state of alertness was impaired. He was unable to obey commands and

Discussion

Fenestration of intracranial arteries is a rare anomaly and the true incidence is difficult to ascertain, with the data varying among series. In the large angiographic series of Sanders et al. [14] the incidence of fenestration was reported to be 0.72%, most of which were located at the basilar artery (0.31%), followed by the vertebral artery. They found the incidence of associated aneurysm at the fenestration site to be 3% in general and 7% at the basilar artery. In the series of Tasker and

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Cited by (39)

Fenestration of the Basilar Artery Associated with Aneurysm Treated by the Support of a Temporary Bridging Device—Comaneci: A Case Report
2018, World Neurosurgery
Fenestration of the basilar artery is a segmental duplication of the vessel due to nonfusion of the embryonal arteries and is the second most common vascular disjunction. Here, we present a single case example demonstrating the utility of the temporary bridging device Comaneci as a new option in the endovascular treatment of ruptured basilar artery aneurysms associated with fenestrations.
A 57-year-old female patient presented to our hospital with a 3-month history of frequent multiple sentinel severe headaches. At the time of hospitalization, the patient was neurologically intact with a Glasgow Coma Scale score of 15. There was no evidence of focal neurologic deficits or cranial nerve lesions, but there was discrete neck stiffness and a diagnosed saccular aneurysm associated with a fenestration of the basilar artery. After multidisciplinary discussion involving neurosurgeons and interventional neuroradiologists and taking into consideration the patient’s clinical presentation and previous history of subarachnoid hemorrhage, as well as the morphology of the posterior circulation aneurysm, endovascular treatment of the basilar fenestration aneurysm was deemed appropriate or simply use was chosen.
Our case results are similar to previously published good results of endovascular coiling and add information regarding the relatively new Comaneci device, which helped to achieve considerable packing density of the aneurysmal sac. Using this device lowers the risk of peri- and postoperative complications. We believe that this technique is safer and better than the balloon-assisted and stent-assisted coiling in ruptured case scenarios of wide-neck aneurysms in the posterior circulation.
Treatment of fenestrated vertebrobasilar junction-related aneurysms with endovascular techniques
2016, Journal of Clinical Neuroscience
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 69.5 months (range 17–101 months) 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.
Arterial fenestrations and their association with cerebral aneurysms
2014, Journal of Clinical Neuroscience
Fenestrations of intracranial arteries and associated aneurysms are rare. The significance of these fenestrations in relation to aneurysms remains unclear. We present four patients with fenestration-associated aneurysms and a comprehensive review of associations with aneurysms and other vascular lesions. A PubMed search of the literature was conducted from 1970–2012 reporting cases of intracranial aneurysms associated with arterial fenestration or duplications. Data were collected on patient presentation, sex, age, aneurysm and fenestration location, aneurysm treatment, and presence of other vascular lesions. We performed a retrospective review of four patients with intracranial fenestrations associated with aneurysms at our institution from 2012–2013. There were 59 cases of fenestrations and associated aneurysms in the literature. Aneurysms were reported as either arising from (n = 50) or adjacent to but distinct from (n = 13) fenestrations. The most common single fenestration location was at the basilar artery (n = 23, 36.5%); however the majority of fenestrations were in the carotid circulation (n = 34, 54.0%). The majority of patients with aneurysms and fenestrations at all locations except those at the anterior communicating artery (70.5%) presented with subarachnoid hemorrhage. Patients with aneurysms arising from a fenestration or adjacent to a fenestration presented with an additional intracranial vascular lesion in 38% and 31% of cases, respectively. The majority of all aneurysms were treated with microsurgical clipping. Aneurysms associated with cerebral arterial fenestrations are most commonly discovered after subarachnoid hemorrhage and are most often located in the carotid circulation. A high index of suspicion must be maintained for an associated vascular lesion if an intracranial fenestration is discovered.
Human basilar artery abnormalities in the prenatal and postnatal period
2013, World Neurosurgery
Citation Excerpt :
The simultaneous presence of the basilar fenestration and persistent trigeminal artery (22) or unnamed carotid-basilar anastomosis (50) also was reported. The presence of one fenestration in the proximal (36, 41) or in mid-portion (1) of the BA and two associated aneurysms also were described. The association of double fenestrations and an aneurysm was reported by Chen et al. (9).
Although complex and varied, adult cerebral angioarchitecture has its origins in embryologic development, where normal components, variations, and abnormalities evolve from modifications of primitive vessels. Therefore, the aim of this report was the study of the morphologic features of the basilar fenestrations in prenatal and postnatal period and associated variants and/or pathologies.
We studied the brain vessels of 120 fetuses microscopically (i.e., with an operative microscope) and 112 adult cadavers macroscopically.
We described 10 cases of basilar abnormalities, five fetal and four adult fenestrations, as well as one adult case with a basilar aneurysm. The location of the vertebrobasilar junction on a caudal myelencephalon and a prolongation of the basilar trunk followed both fetal and adult forms of fenestrations. The same caliber values of the basilar and internal carotid arteries, a variation in the number and origin of some of the basilar side branches, and a tendency of fenestrations to be multiple in number, as particular fetal features, were mostly present in adults.
The fact that basilar fenestrations in adult specimens shared similar features with fetal ones and without aneurysms, as well as the fact that a basilar aneurysm was without fenestration in its base, lead us to hypothesis that the basilar fenestration is a vascular developmental variant related to the maintenance of vascular symmetry in the midline of the human brain base.
Clinical presentation and treatment of aneurysms associated with basilar artery fenestration
2012, Journal of Clinical Neuroscience
Citation Excerpt :
Aneurysms (AN) associated with a fenestrated basilar artery (fBA–AN) are uncommon; their incidence is reported to be 0.33% of all intracranial aneurysms.1 Since 1980, only 73 patients have been reported in the literature.1–23 The angiographically confirmed incidence of BA fenestration is 0.31% to 0.6%24,25; and based on magnetic resonance (MR) angiography, its incidence is 2%.26
Aneurysms associated with a fenestrated basilar artery are rare, and treatment strategies have yet to be established. A direct surgical approach to the basilar artery is challenging because the surrounding anatomy is complex. We retrospectively compared the clinical features and treatment outcomes of eight patients (seven female, one male) with aneurysms associated with a fenestrated basilar artery after clipping or coil embolisation and reviewed the literature. Of the eight aneurysms, four were ruptured; seven aneurysms were located at the proximal part of the basilar artery and one aneurysm was located at the middle of the basilar artery. Six aneurysms were surgically treated. Four aneurysms were embolised with Guglielmi detachable coils, two aneurysms were clipped via the transcondylar or temporopolar approach, and two aneurysms were not treated. All six surgically treated patients had good outcomes. We found that both coil embolisation and direct clipping to treat aneurysms associated with a fenestrated basilar artery have advantages and disadvantages. To obtain favourable outcomes, the selected treatment modality must consider the patient’s age and clinical condition, the aneurysm size and shape, the direction of the dome, the relationship with perforators, and the neurosurgeon’s expertise.
Kissing aneurysms of the distal anterior cerebral artery
2011, Journal of Clinical Neuroscience
Citation Excerpt :
Fortunately, the two aneurysms were clipped separately without premature rupture in our patient. Endovascular approaches have been also applied to treat kissing aneurysms, especially those in the posterior circulation.9,13,18 Imai recommended endovascular treatment because of the potential risk of premature rupture during surgery.5
Kissing aneurysms, a particular type of multiple aneurysm are rare. A kissing aneurysms was identified at the distal anterior cerebral artery (ACA) in a 59-year-old male patient diagnosed with subarachnoid hemorrhage (SAH). The use of three-dimensional intracranial CT angiograms revealed that kissing aneurysms (that is, an aneurysm with a bilateral symmetrical mirror image) were located at the distal ACA and diffuse SAH in basal, sylvian, and interhemispheric cisterns. Both conventional carotid angiograms showed that both distal ACA aneurysms were seen separately on both internal carotid angiograms. Two aneurysms were observed simultaneously on carotid compression of either side. Some particular cautions required in diagnosing and treating kissing aneurysms are discussed, together with a literature review.

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Case reportEndovascular treatment of kissing aneurysms at the fenestrated basilar artery: Case report with literature review

Abstract

Section snippets

Case report

Discussion

Surg Neurol

Surg Neurol

Variant aneurysms of the fenestrated basilar artery

Neurosurgery

Saccular aneurysm associated with segmental duplication of the basilar artery. A morphological study

J Neurosurg

Saccular aneurysms in basilar artery fenestration

AJNR

Ruptured vertebrobasilar junction aneurysm associated with basilar artery fenestration

Acta Neurochir (Wien)

Vertebrobasilar junction aneurysms associated with fenestrationtreatment with Guglielmi detachable coils

AJNR

Fenestrated basilar artery with associated saccular aneurysm

J Neurosurg

Endovascular treatment of basilar trunk aneurysm treated with fenestration of the basilar artery

Neurosurg Rev

Case report
Endovascular treatment of kissing aneurysms at the fenestrated basilar artery: Case report with literature review