Basilar Aneurysm Research Articles

One burr-hole craniotomy: Modified presigmoid approach in Helsinki Neurosurgery.

Background:In this video abstract, we present a one burr-hole craniotomy for a modified presigmoid approach developed in Helsinki Neurosurgery to access the space extended to both middle and posterior fossa. Thus, indications for this approach are lesions that extend to both middle and posterior fossa, petroclival tumors, basilar tip aneurysms located extremely low below the posterior clinoid process, trunk basilar aneurysms, and bypass procedures from the P2 segment of the posterior cerebral artery. The procedure is composed by three stages: a temporal and presigmoid craniotomy, a partial petromastoidectomy, and the dura opening with section of the superior petrosal sinus (SPS) and the tentorium. Even though some risks related to the opening of the mastoid cells or cut of the SPS may exist, benefits of this optimized craniotomy are higher compared with the complications.Case Description:The patient with a giant petroclival meningioma is placed in park bench position and spinal drainage is inserted. Skin incision starts in front of the ear curve going to 1 inch behind the mastoid line. Strong retraction with hooks keeps a clean space for the craniotomy. Hemostatic Raney clips are placed at the superior border of the skin flap. A burr-hole is made at the most cranial part of the temporal bone. After the detachment of the dura with long flexible blunt dissectors, the craniotomy is performed to expose the sigmoid sinus, the SPS and the dura of the inferior temporal lobe, and the floor of the middle fossa. Aiming to access the posterior fossa by a presigmoid route, a partial petromastoidectomy is performed preserving the semicircular canals. Few drill holes are made for tack-up sutures. Once we properly reach the dura of the middle and posterior fossa, dura of the temporal lobe and later, the presigmoid dura are opened joining at the level of the SPS. The SPS, which is running over the petrous bone between the posterior and the middle fossa, is coagulated, ligated, and cut. After SPS is sectioned, the tentorium is cut anterior to the drainage of vein of Labbé and posterior to the deep tentorial insertion of the fourth nerve. Finally, special care should be taken to seal the opened mastoid cells with muscle and glue, and for the hermetic dura closure using pericranium or temporal muscle aponeurosis.Conclusion:The described one burr-hole craniotomy may represent the more efficient approach for the management of the deep and hardly accessible lesions extended to both middle and posterior fossa.Videolink:http://surgicalneurologyint.com/videogallery/presigmoid-approach-craniotomy-lt

A Treatment Strategy for Basilar Bifurcation Aneurysm Associated with Moyamoya Disease: A Case Successfully Treated by Combined STA-MCA Anastomosis and Stent-assisted Coil Embolization

A Treatment Strategy for Basilar Bifurcation Aneurysm Associated with Moyamoya Disease: A Case Successfully Treated by Combined STA-MCA Anastomosis and Stent-assisted Coil Embolization

One burr-hole craniotomy: Subtemporal approach in helsinki neurosurgery.

Background:In this video-abstract, we present the Helsinki Neurosurgery one burr-hole craniotomy standard subtemporal approach to the floor of the middle fossa and the interpeduncular space. This procedure facilitates access to the multiple structures; the basilar artery bifurcation, the superior cerebellar artery, or the P1-P2 segments of the posterior cerebral artery, and lesions located around the posterior clinoid process/less than 10 mm above it. Even though the specific location and size of the lesion may vary, this approach accesses all mentioned structures with very minimal variation.Case Description:The patient with a basilar artery bifurcation aneurysm is placed in park bench position. A spinal drain is inserted to release 50–100 ml of cerebrospinal fluid. Next, the skin incision starts in front of the tragus above the earlobe, crossing the zygomatic line. Inferior retraction for the craniotomy is provided by hooks and hemostatic Raney clips placed at the superior border of the skin flap. The zygomatic line represents the anatomical landmark of the floor of the middle fossa. A burr-hole is made at the most cranial border of the bone flap. After the detachment of the dura with long flexible blunt dissectors, a craniotomy is performed to expose the dura of the inferior temporal lobe. A few drill holes are made for tacking-up sutures. The dural opening is then performed based on the zygomatic line. Cutting and opening of the tentorium runs posterior to the tentorial insertion of the fourth nerve.Conclusion:The described one burr-hole craniotomy offers a more efficient subtemporal approach.Videolink:http://surgicalneurologyint.com/videogallery/subtemporal-approach-unedited/

Fusiform aneurysms: A review from its pathogenesis to treatment options.

Background:This study aims to present the most important considerations when it comes to patients features, clinical presentation, localization, and morphology of the aneurysm and the treatments outcomes of the fusiform aneurysms.Methods:We performed a literature review using PubMed. The search was limited to the studies published in English, from 2003 to 2017.Results:The studies analyzed that showed data about the patient features, clinical presentation, the aneurysm localization, morphology, and pathogenesis didn't present much divergence. The surgical and the endovascular approach showed similar treatments outcomes. The reconstructive techniques seem to be safer than the deconstructive. The flow diversion is a technique that showed great results.Conclusion:Most of the patients are men, younger than 50 years old, pediatric patients are the most affected. Surgical procedures still have an important place in this field. Reconstructive and deconstructive techniques are both effective; the reconstructive techniques are possibly safer than deconstructive techniques. The most important feature of an aneurysm to predict a bad prognose is to determine if the aneurysm is ruptured. The reconstructive EVT accompanied by dual antiplatelet after and before the procedure showed the best results to treat the basilar fusiform aneurysms. Deconstructive treatment including posterior inferior cerebellar artery occlusion should be considered.

Endovascular treatment of a complex broad neck bifurcation aneurysm at peripheral center by pconus stent: A new neck bridging device

Endovascular treatment of wide-necked aneurysms is a challenge in itself, especially, if branches are incorporated in the neck or base of the aneurysm. The problem is greater if the availability of technical resources and expertise is limited. Difficult endovascular treatment options in such cases include the use of double balloon remodeling and bilateral intracranial stents with associated higher complication rates. However, with availability of a new neck bridging device, treatment of such aneurysms is becoming relatively easy. We present a case of the ruptured basilar top aneurysm with incorporated bilateral posterior cerebral artery origins treated with pCONus stent-assisted coiling. We intend to draw the attention of neurointerventionists to newly available neck bridging device which has lower thrombogenicity than stents, require a shorter learning curve, are compatible with routine delivery catheters, can be deployed quickly and can be performed even on a single plane digital subtraction angiography equipment with minimal expertise.

Spinal Cord Infarction after Successful Coil Embolization of Recurrent Basilar Bifurcation Aneurysm: A Case Report

Spinal Cord Infarction after Successful Coil Embolization of Recurrent Basilar Bifurcation Aneurysm: A Case Report

A new endovascular treatment of a recurrent giant proximal basilar aneurysm after coiling

BackgroundTreatment of giant basilar aneurysms is extremely challenging, especially recurrences after previous coiling.Case presentationA 20-year-old male was referred for a recurrent giant proximal basilar aneurysm 3 months after coiling, with headache, blurred vision, and brainstem compression symptoms. Angiography showed that the previously placed coils were compacted within the caudal portion of the 43 mm × 31 mm aneurysm, with spontaneous occlusion of the right vertebral artery and absence of the posterior communicating arteries. The diameter of the aneurismal neck, the afferent and efferent arteries was 6 mm, 3.5 mm and 4.1 mm, respectively. A balloon-expandable covered-stent of 3.5 mm × 10 mm was selected, matching the above 3 measurements; and deployed precisely across the aneurismal neck, immediately creating the “sub-complete reconstruction with intentional endoleak distal to aneurismal neck”. Subsequently, 2 self-expanding 4.5 mm × 37 mm stents were telescopically implanted within the covered-stent to adjust the angulation of the proximal basilar artery. After the procedure, the patient’s symptoms gradually disappeared. Catheter angiography at 18 days, 3 months and 15 months demonstrated complete aneurismal exclusion from the patent vertebrobasilar artery, with dramatic elimination of aneurismal volume and reconfiguration of the compacted coils. The patient was asymptomatic at 15-month follow-up.ConclusionsSub-complete reconstruction with intentional endoleak distal to aneurismal neck can be safely achieved after implantation of a covered-stent and conventional stents in the case of a recurrent post-coiling proximal giant basilar aneurysm, with complete vascular reconstruction subsequently.

Flanking the fenestration: circumferential limb-to-limb stent-assisted coiling of a basilar artery fenestration aneurysm

A man aged 61 years with a history of a ruptured basilar fenestration aneurysm underwent unassisted coiling in 1997 and repeat intervention for a recurrence at the aneurysm mouth in...

Flanking the fenestration: circumferential limb-to-limb stent-assisted coiling of a basilar artery fenestration aneurysm

A man aged 61 years with a history of a ruptured basilar fenestration aneurysm underwent unassisted coiling in 1997 and repeat intervention for a recurrence at the aneurysm mouth in...

Fatal Basilar Aneurysm Rupture 6 Months Following Pipeline Flow Diversion Treatment

Abstract Background Very delayed aneurysmal rupture represents a rare, poorly understood, catastrophic complication of intracranial aneurysm flow diversion (FD) treatment. Case Description A 48-year-old woman presented to the neurosurgical clinic for an elective admission 6-month post-FD treatment with a single pipeline embolization device (PED) treatment of a fusiform, large, midbasilar artery aneurysm. During her admission, the patient suffered a tonic-clonic seizure and collapsed. She was intubated and transferred for an urgent computed tomographic scan of the brain, which revealed subarachnoid hemorrhage and hydrocephalus. She was subsequently transferred to the operating room where an external ventricular drain was placed. Urgent diagnostic cerebral angiography revealed rupture of the previously treated aneurysm which was managed with deployment of a second PED and coil embolization of the right vertebral artery. Unfortunately, the patient succumbed to the disease 15 days later. Conclusion The pathophysiologic mechanism responsible for delayed aneurysmal rupture post-FD treatment remains to be defined and may involve an acute rise in intra-aneurysmal pressures in a partially thrombosed aneurysm, continued hemodynamic stress on the aneurysmal wall due to persistent blood inflow, and thrombus-induced inflammation-mediated degradation the aneurysmal wall. Further clinical and anatomical studies are necessary to define the mechanisms responsible for delayed aneurysm ruptures and identify appropriate preventive measures.

Case Series on Perforator Aneurysm: Endovascular Stenting—A Safe Strategy

AbstractPerforator aneurysms are rare vascular lesions that are infrequently reported in literature, and because of difficult anatomic approach, their treatment and management pose challenges. Given the rarity of these aneurysms, the natural history and ideal approach to treatment has not been established. The authors retrospectively analyzed six patients, age ranging from 16 to 75 years with ruptured perforator aneurysm, four of posterior circulation and two of anterior circulation including clinical characteristics, imaging data, treatment regimen, and outcome. All but two patients presented with the World Federation of Neurosurgical Societies grades I to III and Fisher grade 2 or 3 subarachnoid hemorrhage, and the other two presented with intracerebral bleed in the right gangliocapsular region. Four patients were managed conservatively whereas two basilar perforator aneurysms were treated with endovascular stent. At the last follow-up, the endovascularly treated group of patients demonstrated complete thrombosis of aneurysm with preservation of perforators, and the conservatively managed group showed spontaneous occlusion in one patient, whereas three were lost to follow-up and ultimate outcome remains unknown. The authors report single-center hospital-based experience in six patients, which adds to the scarce published literature that addresses the limited understanding of the natural course and consolidating safe endovascular management of this entity.

Super-selective coil embolization of a basilar perforator artery aneurysm previously treated by the stent-in-stent technique, using an extremely soft bare coil delivered through a one-marker microcatheter

Background Aneurysms of the perforating arteries arising from the basilar artery trunk are rare and represent a therapeutic challenge. Methods A basilar perforator aneurysm was initially treated by the stent-in-stent technique. Enlargement of the aneurysm was seen on follow up and the sac was secondarily coiled using two extremely soft bare coils, delivered through a one-marker microcatheter. Results At 6 months, the patient had a modified Rankin Scale score of 0 and cerebral arteriography demonstrated complete occlusion of the lesion. Conclusions We describe, as far as we are aware, the first case of basilar perforator aneurysm occlusion using extremely soft bare coils, inserted through the mesh of two stents previously placed in the basilar trunk.

Surgical treatment of unruptured distal basilar artery aneurysm: durability and risk factors for neurological worsening.

Distal basilar artery aneurysms (DBAs) consist of basilar apex and basilar artery-superior cerebellar artery bifurcation (BA-SCA) aneurysms. The authors aimed to investigate clinical and radiological differences between two locations and to evaluate the 12-month surgical outcome in unruptured DBAs. Fifty-six consecutive patients who underwent surgical treatment (37 basilar apex and 19 BA-SCA aneurysms) between April 2012 and February 2016 were retrospectively evaluated. In patients with a preoperative modified Rankin Scale score (mRS) of more than 1, neurological worsening (NW) was defined as an increase in one or more mRS. In patients without symptoms, NW was defined as mRS ≥2. The mean age of the patient population was 64±9.6years, and 48 (86%) were female. Mean follow-up period was 2.6 ± 0.94years. An excellent (mRS 0 to 1) outcome was archived in 31 (55%), 45 (82%), and 48 (87%) patients at 30 days, 6 months, and 12 months, respectively. Clinical and radiological characteristics showed no differences between two locations. One early death (1.8%) and one severe morbidity (1.8%) due to rupture were observed. The postoperative annual rupture rate was 1.4% overall (145 patient-years). After adjustment for age and location, large or giant DBA was related to 30-day and 12-month NW [n=22 (39%) and n=6 (11%); p=0.009 and 0.002, respectively], aneurysm localization in the interpeduncular cistern (LIC) and perforator territory infarction were related to 30-day NW (p=0.002 and 0.002), and DBA that needed bypass surgery and previously treated recurrent DBA were related to NW at 12 months (p=0.017 and 0.001). Multivariate analysis showed that LIC was significantly related to perforator territory infarction (p=0.003). Clinical and radiological characteristics were not different between basilar apex and BA-SCA aneurysms; therefore, they should not be discussed separately. To avoid neurological worsening, results of surgical treatment for unruptured DBAs should be improved.

The Interlenticulostriate Approach to Very High-Riding Distal Basilar Trunk Aneurysms.

Most high-riding distal basilar trunk aneurysms can be surgically approached via the transsylvian route and its orbitozygomatic variant. However, on rare occasions, the basilar bifurcation may be unusually high and an approach above the carotid terminus may be required. In this cadaveric study, we sought to determine the feasibility and exposure limits of the interlenticulostriate approach (ILSA). A standard transsylvian approach was performed in 10 cerebral hemispheres of 5 formalin-fixed, silicone-injected cadaver heads. The interpeduncular cistern was exposed via the opticocarotid window, carotid-oculomotor window, and supracarotid ILSA window. The latter was measured and an aneurysm clip or ventriculostomy stylet was placed as high as possible through each corridor. Using noncontrast 3-D rotational angiography, clip/stylet positions were measured relative to the dorsum sellae. ILSA provided a 9.4 × 4.6 mm mean surgical corridor, just enough room for a standard clip applier. This space was limited by the carotid bifurcation inferiorly, the lenticulostriate arteries medially and laterally, and the optic tract superiorly. There was no difference between opticocarotid and carotid-oculomotor windows, in terms of clip position (+8.9 vs +8.6 mm, respectively; P = .78). In contrast, ILSA provided significantly improved superior exposure, compared with either approaches (mean stylet position: +14.3 mm; P = .005). The exposure benefit afforded by ILSA was consistent across all 10 hemispheres, ranging from +2.5 to +8 mm. For high-riding distal basilar trunk aneurysms that cannot be reached via the frontotemporal orbitozygomatic approach, ILSA can provide a viable route of access. Vascular neurosurgeons should be familiarized with this approach.

Large Basilar Apex Aneurysms Treated with Flow-Diverter Stents.

The treatment of wide-neck, large basilar apex aneurysms is challenging with either an endovascular or a surgical approach. The aim of the present study was to report our experience treating basilar apex aneurysms with flow-diverter stents and to evaluate their efficacy and safety profile in this specific anatomic condition. We retrospectively analyzed data from all consecutive patients treated with flow-diverter stents at our institution between January 2011 and January 2015. Patients with large basilar apex aneurysms treated with a flow-diverter stent were included in the study. Clinical presentations, technical details, intra- and perioperative complications, and clinical and angiographic outcomes were recorded, with a midterm follow-up. Of the 175 aneurysms treated with flow-diverter stents at our institution, 5 patients (2 women and 3 men; age range, 44-58 years) received flow-diverter stent for basilar apex aneurysms. The mean follow-up after stent deployment was 21 months (range, 15-24 months). One patient died on day 31 from an early postprocedural midbrain hemorrhage. One patient had a right cerebellar hemispheric ischemic lesion with a transient cerebellar syndrome resolved within 24 hours without neurologic sequelae at the latest follow-up. The mRS was 0 in 4 patients and 6 in 1 patient at last follow-up. Flow diversion is a feasible technique with an efficacy demonstrated at a midterm follow-up, especially in the case of basilar apex aneurysm recurrences after previous endovascular treatments. Concern about its safety profile still exists.

Outcome of the Treatment of Basilar Apex Aneurysms Using Advanced Transcavernous Microsurgical Clipping155

Outcome of the Treatment of Basilar Apex Aneurysms Using Advanced Transcavernous Microsurgical Clipping155

Quantitative Anterior and Posterior Clinoidectomy Analysis and Mobilization of the Oculomotor Nerve during Surgical Exposure of the Basilar Apex Using Frameless Stereotaxis.

Background Anterior and posterior clinoidectomies have been proposed to augment exposure of the basilar apex. A sequential quantitative benefit analysis offered by these maneuvers has not been reported. Methods Fourteen datasets from eight cadaveric specimens were analyzed. A modified orbitozygomatic frontotemporal craniotomy was performed. The extent of proximal control of the basilar artery was determined through the exposed opticocarotid and carotidoculomotor triangles before and after clinoidectomies and mobilization of the third nerve at the porous oculomotarius. Results Removal of the anterior and posterior clinoids significantly improved proximal basilar artery access ( p < 0.012) and increased the opticocarotid triangle and carotidoculomotor triangle areas ( p < 0.017). Surgical freedom increased inferosuperiorally in the opticocarotid triangle following anterior clinoidectomy ( p < 0.047) and in carotidoculomotor triangle following posterior clinoidectomy ( p < 0.047). Mobilization of the third nerve increased surgical freedom in the mediolateral projection of the carotidoculomotor triangle ( p < 0.047). Conclusion Anterior and posterior clinoidectomies significantly improved the area of exposure of the opticocarotid triangle, carotidoculomotor triangle, and the exposed length of the basilar artery available for proximal control. This improvement is extremely important for large or giant aneurysms of the upper basilar artery or aneurysms hidden by the posterior clinoid.

Surgical Management of Ruptured Posterior Circulation Aneurysms – A Single Center Experience

Objective The treatment of ruptured aneurysms of the posterior circulation is a controversy in neurosurgery. The aim of this work is to describe the experience and results of the early surgical treatment of this pathology at Centro Hospitalar do Porto. Method We retrospectively analyzed the medical records of all patients aged over 18 who, in the period between 1999–2013, were admitted to our center with the diagnosis of ruptured saccular posterior circulation aneurysm. The patients were clinically staged at admission using the Hunt &amp; Hess (H&amp;H) scale. The modified Glasgow Outcome Scale (mGOS) was used to assess the outcome at discharge and after 6 months. Results Between 1999–2013, 59 patients underwent surgery for ruptured posterior circulation aneurysms. Eighty percent of the patients were female, and their average age was 58.7 years. Posterior-inferior cerebellar artery aneurysms accounted for 49.2% of surgeries, while basilar aneurysms accounted for 28.8%. Upon admission, 86.4% of patients were classified as H&amp;H1–3, and 13.6% as H&amp;H4–5. The outcomes at discharge and at 6 months were as follows: at discharge, mGOS1 in 5.1%, mGOS2–3 in 18.6%, and mGOS4–5 in 76.3%; at 6 months, mGOS1 in 10.2%, mGOS2–3 in 10.2%, and mGOS4–5 in 79.6%. There was a statistically significant correlation between basilar aneurysms and worse outcomes (p = 0.011). No correlation was found between the values of the H&amp;H scale upon admission and outcome. Conclusions The functional outcome of our group of patients is mainly in line with what is described in other series from the literature. However, there is a trend toward lower mortality but higher morbidity rates.

Surgical Clipping of a Basilar Tip Aneurysm: Case Report and Literature Review

Basilar tip aneurysms account for 5% - 8% of all intracranial aneurysms. They are known to rupture more frequently than aneurysms in other locations. Surgical clipping of basilar apex aneurysms however challenging; remains the treatment of choice in Ivory Coast due in part, to multiple technical barriers. A 60-year-old right-handed patient presented to our Neurosurgical Unit in February 2nd 2013 after a sudden onset of altered consciousness. Neurological examination revealed both an upper motor neuron and meningeal syndromes with a Glasgow Coma Scale of 12. Brain NECT scan and a subsequent brain CT angiography showed a subarachnoid haemorrhage and a 3.8 mm (height) × 5.2 mm (width) basilar tip aneurysm respectively. Surgical clipping of the aneurysm was indicated but due to multiple technical barriers, surgery was delayed and the patient underwent surgery after the critical vasospasm period. The patient developed a hospital acquired pneumonia after surgery and was successfully treated with antibiotics. Since her discharge, she has been asymptomatic. We sought to report this case of a basilar apex aneurysm successfully occluded with non-ferromagnetic SUGITA clips and to share our experience of clipping these lesions through the frontotemporal approach. The patient was informed that non identifying information from the case would be submitted for publication, and she provided consent.

Impact of bifurcation angle and inflow coefficient on rupture risk of bifurcation type basilar artery top aneurysms

Impact of bifurcation angle and inflow coefficient on rupture risk of bifurcation type basilar artery top aneurysms