Ruptured brainstem arteriovenous malformation associated with a thalamoperforating artery aneurysm arising from the P1 segment of the right posterior cerebral artery: illustrative case.

Abstract

Cerebral aneurysms of perforating arteries are rare and can be difficult to detect on computed tomography angiography (CTA) and digital subtraction angiography. Treatment is challenging and associated with a significant risk of morbidity. Endovascular treatment of a thalamoperforating artery (TPA) aneurysm within the midbrain has not previously been reported. A 13-year-old girl with no previous medical history presented with unconsciousness and anisocoria. Head computed tomography showed a right midbrain hemorrhage. CTA showed a midbrain arteriovenous malformation fed by a TPA aneurysm arising from the P1 segment of the right posterior cerebral artery. The feeder had a small distal aneurysm, which increased in size over time. Endovascular embolization was then performed. Cerebral aneurysms of perforating arteries are rare and can be difficult to treat. This is the first report of the endovascular treatment of a TPA aneurysm within the midbrain. Understanding the individual patient's brainstem perforator anatomy and the associated blood flow is essential before occluding a TPA aneurysm to avoid causing ischemia or infarction. Arteriovenous malformation embolization within the brainstem should be avoided because of interperforator anastomoses.