Basilar Tip Research Articles

Alien sign as bad prognostic factor in basilar tip aneurysm

A 44-year-old pregnant women presented with sudden onset coma. Upon arrival, GCS was E2V2M4 with positive meningeal sign. CT showed massive subarachnoid haemorrhage around the basal cisterns and co...

Endovascular Treatment Outcome and CT Angiography Findings in Acute Basilar Artery Occlusion with and without Underlying Intracranial Atherosclerotic Stenosis

PurposeTo compare clinical characteristics and treatment outcomes of intra-arterial thrombectomy (IAT) in acute basilar artery occlusion (BAO) with and without underlying intracranial atherosclerotic stenosis (ICAS) and to investigate the usefulness of preprocedural CT angiography findings in the diagnosis of ICAS. Materials and MethodsTwenty patients who received IAT for acute BAO between September 2014 and March 2019 were included. Additional therapies such as angioplasty, stent placement, and tirofiban infusion were provided while treating ICAS. Clinical and angiographic results of treatment were recorded. Preprocedural CT angiography findings in ICAS and non-ICAS groups were compared to assess (i) basilar tip opacification, (ii) partial occlusion, (iii) presence of convex border, (iv) occlusion segment longer than two thirds of the basilar artery or 20 mm, (v) dense basilar artery, and (vi) wall calcification in the occluded segment. ResultsAmong the 20 patients (mean age, 71.3 y; mean stroke score, 24.8), optimal recanalization was achieved in 19 (95%). Three patients had good clinical outcomes. There were 6 patients with underlying ICAS. No difference was observed between ICAS and non-ICAS groups in terms of optimal angiographic recanalization and good outcome. On CT angiography, basilar tip occlusion (100% vs 29%), partial occlusion (100% vs 83%), and long occlusion length (100% vs 14%) significantly differed between the groups (P ≤ .01). ConclusionsIn acute BAO, underlying ICAS does not affect optimal recanalization rate or clinical outcome. Preprocedural CT angiography is a potentially useful tool to detect it.

A case of multiple Vertebrobasilar artery fenestration misdiagnosed as vertebral artery dissection

BackgroundFenestration of vertebra-basilar artery is an uncommon congenital vascular anomaly, which is identified by incidental findings on imaging in patients presented without related symptoms or in patients with intracerebral hemorrhage secondary to concomitant artery aneurysm or arteriovenous malformations. Yet, cases of fenestration being misdiagnosed as cerebral artery dissection have never been reported.Case presentationWe present a patient of 66-year-old female with acute onset of dizziness after chiropractic manipulation of the neck. Neck computed tomography angiography (CTA) showed ‘double lumen’ sign and ‘intimal flap’ of the V1 segment of the vertebral artery, which led to the initial diagnosis of vertebral artery dissection (VAD). However, vertebral artery fenestration at V1 segment was eventually identified by multi-directional digital subtraction angiography (DSA). Interestingly, concomitant vertebral fenestration at V3 segment, basilar fenestration and basilar artery tip aneurysm was also revealed by DSA.ConclusionThe triple fenestration at vertebrobasilar artery with basilar tip artery aneurysm is extremely rare, and the fenestration at the V1 segment of vertebral artery was easily misdiagnosed as VAD due to the similar imaging morphology.

Endovascular treatment of wide-necked intracranial aneurysms using the novel Contour Neurovascular System: a single-center safety and feasibility study

Background and purposeWide-necked bifurcation aneurysms pose a significant challenge to the treating clinician. The Contour Neurovascular System embolization device is a novel tool for the treatment of such intracranial aneurysms....

LVIS Blue as a Stand-alone “Flow Diverter”

Flow diversion fundamentally changes the treatment approach towards intracranial aneurysms. Most currently available devices established efficacy and safety data in the proximal anterior circulation; the distal and posterior circulations remain areas of active research. LVIS Blue is a stent with 28% metal coverage approved for use as a coil adjuvant. Some studies indicate potential “flow diverter” properties. We sought to evaluate the LVIS Blue as a stand-alone “flow diverter” for the treatment of intracranial aneurysms. We performed an observational single-center study to evaluate initial occlusion and occlusion at six months follow-up for patients with distal or posterior circulation aneurysms treated with the LVIS Blue as a “flow diverter” at our institution. Ten aneurysms were treated over the course of two years with six-month angiographic follow-up. Seven lesions were in the distal anterior circulation and were unruptured (five anterior communicating artery, one M2 middle cerebral artery, one pericallosal). Three were posterior circulation (two basilar tip aneurysms, one P2 posterior cerebral artery aneurysm). Follow up demonstrated treatment effect in nine of ten aneurysms (four complete aneurysm occlusions, five lesions with decreased size and flow). One lesion showed no treatment response. No ischemic or hemorrhagic complications were noted during placement or clinical follow-up. LVIS Blue can function safely as a “flow diverter” in the distal and posterior circulations. Further data regarding long-term efficacy is needed.

Basilar aneurysm and coarctation of the aorta

A 31-year-old male presented with subarachnoid haemorrhage due to a basilar tip aneurysm associated with an incidental coarctation of the aorta (CoA). The aneurysm was treated with endovascular coiling. Patients with CoA frequently harbour intracranial aneurysms at a young age. The occurrence of basilar tip aneurysm associated with CoA is extremely rare. The relevant literature on the subject is discussed.

Utility of platelet function testing in stent-assisted coiling of cerebral aneurysms.

Thromboembolic complications are the primary risks of stent-coiling of cerebral aneurysms. The utility of platelet function testing in stent-assisted aneurysm coiling remains controversial. This study aimed to assess a pharmacy-mediated antiplatelet management protocol for stent-assisted coiling. Stent-coiled aneurysms at an academic institution in the United States between 2015 and 2018 were retrospectively reviewed. All patients were managed using a pharmacy-mediated antiplatelet protocol, which required repeated platelet function testing and subsequent dose adjustments. Medication dosage, number of adjustments, aspirin reaction units (ARU) and P2Y12 reaction units (PRU), as well as complication rates, angiographic and functional outcome were analyzed. A total of 56 aneurysms (median size 5 mm, range 2.6-14.0 mm) in 54 patients (median age 58.5 years) were treated with stent-assisted coil embolization. Most aneurysms were located at the basilar tip (28.6%). Median pre-procedure ARU and PRU were 442.5 (range 363-594) and 123.5 (range 1-252), respectively. Approximately two-thirds of all procedures required at least one aspirin dose adjustment and 88.5% of procedures required at least one clopidogrel dose adjustment. There were two (3.6%) thromboembolic complications. One of the thromboembolic complications occurred in a patient where the pharmacy-mediated protocol was violated. There were no hemorrhagic complications. Last imaging follow-up demonstrated complete aneurysm occlusion in 83.9%. In patients where the pharmacy-mediated antiplatelet protocol was followed, the thromboembolic complication rate was 1.8%. This complication rate compares favorably to those reported in large contemporary series. Nevertheless, the pharmacy-mediated protocol places a significant burden on both the patient and healthcare system.

A dermoid cyst mimicking a large thrombosed basilar tip aneurysm

A dermoid cyst mimicking a large thrombosed basilar tip aneurysm

Anterior temporal approach and clipping of a high-riding basilar tip aneurysm: Case report and review of the surgical technique

Basilar apex aneurysms constitute 5%–8% of all intracranial aneurysms. Microsurgical clipping of basilar tip aneurysms is still advocated for as it is safe, especially for unruptured basilar tip aneurysms which have a low risk of postoperative mortality or morbidity. Careful patient preparation is needed preoperatively because the risk of intraoperative rupture is significant. Good surgical techniques should be applied. The skill will need to be preserved as endovascular surgery becomes more popular. This is a case of basilar tip aneurysm managed by clipping through the anterior temporal approach, followed by a review of the literature.

Transcirculation Approach for Endovascular Embolization of Intracranial Aneurysms, Arteriovenous Malformations, and Dural Fistulas: A Multicenter Study

Unfavorable anatomy can preclude traditional anterograde endovascular interventions. Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, can provide alternative pathways for successful treatment of these patients. We aimed to assess the safety, efficacy, and outcomes of endovascular embolization through transcirculation approaches. Nine centers provided retrospective data on patients who underwent transcirculation procedures for embolization of intracranial aneurysms (IAs), dural arteriovenous fistulas (dAVFs), and arteriovenous malformations (AVMs). Raymond-Roy Occlusion Classification (RROC) grades and degree of obliteration were used to evaluate treatment success. Minor/major complications and clinical/angiographic outcomes were also assessed. A review of the literature reporting patients who underwent transcirculation embolizations was also performed. Forty patients were included in the study (34 IAs, 3 AVMs, and 3 dAVFs). Most IAs (22/34, 64.7%) were treated electively. Three AVMs and 2 dAVFs presented ruptured. RROC grade I-II was achieved in 97% of IAs. All AVMs and dAVFs were completely obliterated. One patient developed a transient arterial thrombus that was successfully treated with intravenous tirofiban. The most common indications for a transcirculation approach were difficult access angle of the target lesion (42.5%) and occlusion of the parent artery (27.5%). The review of the literature pooled 152 IAs treated via transcirculation approaches. Most common locations were the basilar tip (27%), posterior inferior cerebellar artery (25%), and internal carotid artery (15.1%). The posterior communicating artery was crossed in 60 (39.5%), anterior communicating artery in 48 (31.6%), and vertebral artery in 37 (24.3%) patients. Primary coiling alone was performed in 22 (14.5%), stent-assisted coiling in 67 (44.1%), balloon-assisted coiling in 36 (23.7%), stent-assisted coiling+ balloon-assisted coiling in 20 (13.2%) and flow diversion in 7 (4.6%) patients. After intervention, 142 (93.4%) IAs achieved successful RROC grades I-II. Two major complications (1.3%) leading to death were reported, both of which were intraprocedural aneurysmal ruptures with massive subarachnoid hemorrhage and herniation. After a mean angiographic follow-up of 11.3 months, only 6/108 (5.6%) IAs showed intrasaccular filling/recurrence. Transcirculation approaches seem to be safe and effective in the treatment of IAs, dAVFs, and AVMs. The most common indication for a transcirculation approach is the presence of a difficult angle to access the target lesion and occlusion of the parent artery.

How reliable is CT angiography in the etiologic workup of intracranial hemorrhage? A single surgeon's experience

ObjectivesCT angiography (CTA) is gradually replacing digital subtraction angiography (DSA) in the etiologic workup of intracranial hemorrhage, though debate persists regarding its diagnostic accuracy. To better define the role of CTA in a pragmatic, real-world setting, we reviewed the experience of a single dual vascular-endovascular neurosurgeon. Patients and methodsNontraumatic intracranial hemorrhage cases managed by the senior author over a 15-month period were retrieved from a prospectively maintained database. Cases where a hypertensive etiology was presumed were excluded. Demographics, intracranial hemorrhage pattern, CTA and DSA findings were recorded. ResultsThe study cohort consists of 59 cases where both CTA and DSA were obtained, including 32 women and 27 men with mean age 50 years (18–83). Intracranial hemorrhage pattern was: aneurysmal subarachnoid hemorrhage (SAH) in 37, perimesencephalic SAH (PMSAH) in 8, intraparenchymal in 11, intraventricular in 2, subdural in 1. The overall yield of vascular imaging was 62.7 % (37/59): 29 saccular aneurysms, 4 dissecting aneurysms, 4 microarteriovenous malformations (microAVMs). The specificity and positive predictive value of CTA were 100 %. Its sensitivity and negative predictive value were only 89.2 % and 84.6 %, respectively. CTA missed 4 lesions: 2 dissecting aneurysms, 1 microAVM, 1 small saccular aneurysm. Of 8 patients with PMSAH, 3 (37.5 %) had a vascular lesion: 1 vertebrobasilar dissection, 1 cerebellar microAVM, 1 basilar tip aneurysm. Of those, 2 were missed by CTA. ConclusionsDSA may identify a lesion in up to 15 % of intracranial hemorrhage cases with negative CTA. Excessive reliance on CTA can be potentially hazardous, especially in the setting of PMSAH.

Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial.

Ruptured wide-neck aneurysms (WNAs) are difficult to treat and few publications have compared clipping to coiling. To determine, using Barrow Ruptured Aneurysm Trial (BRAT) data: (1) How many aneurysms had a wide neck? (2) Did wide-neck status influence treatment? (3) How did clipping compare to coiling for WNAs? A post hoc analysis was conducted of saccular WNAs in the BRAT. A WNA was defined as maximum neck width≥4 mm or maximum aneurysm dome-diameter-to-neck-width ratio<2. Both intent-to-treat and as-treated analyses were performed. Of the 327 patients analyzed, 177 (54.1%) had a WNA. WNAs were more likely to occur in older patients (P=.03) with worse presenting clinical grade (P=.02), were more likely to arise from the middle cerebral artery, basilar tip, or internal carotid artery other than the junction with the posterior communicating artery (P=.001) and were associated with worse clinical outcomes at all time points (P≤.01). WNAs were equally distributed in assigned treatment groups (clip 56.6% vs coil 51.8%; P=.38), but were overrepresented in the actual clipping group (clip 62.4% vs coil 37.6%, P<.001). Most patients (76.7%) in the coil-to-clip crossover group had a WNA. Comparing clipping to coiling, there was no difference in clinical outcomes at any time point in either analysis (P≥.33). The aneurysm obliteration rate was lower (P<.001) and the retreatment rate higher (P<.001) in the actual coiling group. Wide-neck status significantly impacted treatment strategy in the BRAT, favoring clipping. Clipping and coiling of ruptured WNAs resulted in statistically similar long-term clinical outcomes. 10.1093/neuros/nyy439 Video Abstract 10.1093.neuros.nyy439 5850292551001.

Y stent technique for treatment of wide-based neck cerebral aneurysm

BackgroundWide-based neck bifurcation aneurysms can be treated with stent-assisted coiling using 2 stents making Y-shape to protect both branches. Endovascular progression resulted in safe and efficacy management of these procedures. In this study we evaluate the clinical outcomes and feasibility of Y-stenting using Lvis Jr stents for treatment of cerebral wide-neck bifurcation aneurysms. MethodsIn this study patients in whom Y-stenting was attempted using LVIS Jr were entered. Clinical outcomes, interventional success rate, and morbidity were assessed. ResultsY-stenting with coiling was attempted for 23 patients. Mean age was 60±8.2 years and 14 patients were male. 13 patients (56%) were presented with SAH. 12 patients with A.com aneurysms , 7 with basilar tip artery and 4 with MCA aneurysms were included. Coiling was performed by microcatheter passing through both stents without jailing. All procedures were successful. In one procedure, both stents were closed by thrombosis, that is completely resolved by 24 hours of IV Integrilin and doubling Plavix doses. Patient did not experience any deficit. All 23 patients had good outcomes. MRS score was 0 in 20 patients and mRS score 1 in 3 patients in 12 months follow-up. ConclusionsY-stenting by LVIS Jr stents and coiling for wide-based neck aneurysms seems to be feasible and safe with low rates of complications. It can use in ruptured aneurysms with safety.

Predicting Factors of Angiographic Aneurysm Occlusion after Treatment with the Woven EndoBridge Device: A Single-Center Experience with Midterm Follow-Up.

Flow disruption with the Woven EndoBridge is increasingly used for the treatment of intracranial aneurysms. We examined factors leading to aneurysm occlusion and Woven EndoBridge shape change during a midterm follow-up. Patients with a minimum 12-month angiographic follow-up were included. Through a univariate and multivariate analysis, independent predictors of adequate occlusion (Raymond-Roy 1/Raymond-Roy 2) and Woven EndoBridge shape change (decrease of the height of the device) were assessed. Eighty-six patients/aneurysms were included. The aneurysm mean size was 5.5 mm (range, 3-11.5 mm). The most common locations were the MCA (43/86 = 50%), basilar tip (13/86 = 15.1%), and anterior communicating artery (12/86 = 14%). Twenty-one patients (21/86 = 24%) had acute SAH. Immediate and long-term Raymond-Roy 1/Raymond-Roy 2 occlusion rates were 49% (42/86) and 80% (68/86), respectively. Woven EndoBridge shape change was detected among 22% (19/86) of cases. At binary logistic regression, wide ostium (≥4 mm) (OR = 0.2; 95% CI, 0.01-1; P = .04) and regular aneurysm morphology (OR = 5.9; 95% CI, 1.4-24; P = .01) were independent factors of incomplete and adequate aneurysm occlusion, respectively. In addition, irregular morphology (OR = 5.4; 95%CI, 1.4-19; P = .01) and a wide ostium (OR = 9.8; 95% CI, 1.6-60; P = .03) significantly increased the probability of the Woven EndoBridge shape change. Decrease of the Woven EndoBridge height was more common among incompletely occluded aneurysms (6/12 = 50% versus 13/74 = 17.5%), but it was not an independent prognosticator of occlusion at the multivariate model. The likelihood of good occlusion was 5 times lower in the presence of a wide ostium, whereas aneurysms with regular morphology were 6 times more likely to be occluded. Woven EndoBridge shape modification was strongly influenced by the aneurysm shape and ostium size, and it was not independently associated with the angiographic occlusion.

Endovascular treatment of intracranial aneurysms using the Woven EndoBridge (WEB) device: retrospective analysis of a single center experience

IntroductionWoven EndoBridge (WEB) is an innovative device for the treatment of intracranial aneurysms especially wide-necked bifurcation aneurysms. Here we present our experience with the WEB device. Material and methodsPatients treated using only the WEB device between September 2014 and November 2018 were included in the study. Follow up imaging studies and medical records of the patients were retrospectively reviewed. ResultsForty-two aneurysm of 42 patients (27 female, 15 male; median age: 56, range: 32–76) were treated using the WEB device. The mean diameter of the aneurysms was 6.6 mm (range: 3–12 mm). The neck diameter was ≥4 mm in 57% of the aneurysms. The locations of the aneurysms were the middle cerebral artery bifurcation in 29 (69%), basilar tip in 5 (12%), anterior communicating artery in 5 (12%), internal carotid artery tip in 2 (5%), and M1 segment of the middle cerebral artery in 1 (2%) of the patients. Five patients had subarachnoid hemorrhage due to aneurysm rupture. The device could be successfully deployed in all of the cases. There were control imaging studies available for 36 patients who were followed up for a median of 7 months (range: 1–33 months). Adequate occlusion was observed in 35 of these 36 patients (97%). There was no treatment related morbidity or mortality. ConclusionAlthough long term follow-up data are not available, WEB intrasaccular flow disruptor seems to be effective and safe for intracranial bifurcation aneurysm treatment in the mid-term follow up.

Multi-modality cerebral aneurysm haemodynamic analysis: in vivo 4D flow MRI, in vitro volumetric particle velocimetry and in silico computational fluid dynamics.

Typical approaches to patient-specific haemodynamic studies of cerebral aneurysms use image-based computational fluid dynamics (CFD) and seek to statistically correlate parameters such as wall shear stress (WSS) and oscillatory shear index (OSI) to risk of growth and rupture. However, such studies have reported contradictory results, emphasizing the need for in-depth multi-modality haemodynamic metric evaluation. In this work, we used in vivo 4D flow MRI data to inform in vitro particle velocimetry and CFD modalities in two patient-specific cerebral aneurysm models (basilar tip and internal carotid artery). Pulsatile volumetric particle velocimetry experiments were conducted, and the particle images were processed using Shake-the-Box, a particle tracking method. Distributions of normalized WSS and relative residence time were shown to be highly yet inconsistently affected by minor flow field and spatial resolution variations across modalities, and specific relationships among these should be explored in future work. Conversely, OSI, a non-dimensional parameter, was shown to be more robust to the varying assumptions, limitations and spatial resolutions of each subject and modality. These results suggest a need for further multi-modality analysis as well as development of non-dimensional haemodynamic parameters and correlation of such metrics to aneurysm risk of growth and rupture.

Anterior Temporal Approach for Clipping of Upper Basilar Artery Aneurysms: Surgical Techniques and Treatment Outcomes

Upper basilar artery (BA) aneurysms, which consist of basilar tip and BA-superior cerebellar artery aneurysms, are challenging to treat with microsurgical clipping. The anterior temporal approach is one surgical approach used to treat aneurysms in this region. Most previous reports on this approach have consisted of unruptured cases. Assessing mostly ruptured cases in this study, we describe the surgical technique, patient characteristics, and surgical outcomes. Twenty-three patients with aneurysms arising from the upper BA who received aneurysm clipping via an anterior temporal approach between December 2015 and January 2019 were retrospectively evaluated. The location of the aneurysms was the basilar tip in 15 patients (65.2%) and the BA-superior cerebellar artery junction in 8 patients (34.8%). Twenty-one patients (91.3%) presented with subarachnoid hemorrhage. Good outcomes (modified Rankin Scale score 0-2) at 3 months were achieved in 55.6% of all patients and in 80% of good-grade patients (World Federation of Neurosurgical Societies grades I-III) and patients with unruptured aneurysms. For patients with subarachnoid hemorrhage, a good outcome was achieved in 75% of good-grade patients. Postoperative transient oculomotor nerve palsy and thalamic infarctions were detected in 7 patients (30.4%) and 2 patients (8.7%), respectively. With appropriate case selection, the anterior temporal approach was effective and safe for clipping of upper BA aneurysms, especially under subarachnoid hemorrhage conditions.

Transradial Access for Newly Food and Drug Administration–Approved Devices for Endovascular Treatment of Cerebral Aneurysms: A Technical Note

Despite the recent increase of transradial access among neurointerventionalists, there is still a paucity of evidence in the neurosurgical literature. There are 3 newly Food and Drug Administration-approved devices-Woven EndoBridge (WEB), Surpass, and PulseRider-that significantly expand the options available for endovascular treatment of cerebral aneurysms. Our work reports the safety and feasibility of radial artery catheterization for the deployment of these new devices. We performed a review of the first 10 patients with an unruptured cerebral aneurysm treated via a transradial cerebral angiogram. Seven patients underwent embolization with the WEB device, 1 patient underwent embolization with the PulseRider, and 2 patients underwent embolization with the Surpass device. We describe in detail our workflow and the devices used for transradial access. The aneurysms treated include internal carotid artery bifurcation, middle cerebral artery, anterior communicating artery, basilar tip, and posterior communicating artery. All patients underwent radial artery catheterization, and none of them had to be converted to femoral artery access. Of the 10 patients, 9 required a single attempt for accurate device deployment. One patient had unsuccessful placement of the WEB device and required coiling of the aneurysm because of device herniation into the parent vessel. None of the patients had any postoperative complications and were discharged the following day with the same modified Rankin scale score as preoperatively. Our experience with 10 patients revealed no limitations during catheterization and deployment of these devices. One patient had to be converted to coil embolization, which was feasible through the same vascular access. None of the patients had vascular complications postoperatively with minimal wrist discomfort.

Clinical outcomes and cost-effectiveness analysis for the treatment of basilar tip aneurysms

BackgroundEndovascular treatment of basilar tip aneurysms is less invasive than microsurgical clipping, but requires closer follow-up.ObjectiveTo characterize the additional costs associated with endovascular treatment of basilar tip aneurysms rather than...

Transient Cortical Blindness: a Rare Complication After Cerebral Digital Subtraction Angiography

Transient cortical blindness (TCB) is a rare complication after cerebral or coronary angiography. In this article, we elaborate the condition and present a case which occurred in our hospital. With increasing numbers of diagnostic angiographies and endovascular interventions, we want to raise awareness of TCB and its clinical course. We report about a 57-year-old woman with TCB after a diagnostic digital subtraction angiography (DSA) and endovascular treatment of a ruptured aneurysm of the basilar tip. Symptoms disappeared spontaneously after 36 h with no residual deficits. Multimodal imaging including non-contrast enhanced cerebral CT-scan (NECT), cerebral magnetic resonance imaging (cMRI), and cerebral DSA are presented. Despite the seemingly grave event, the prognosis of this condition can be considered as excellent. The exact pathophysiology remains speculative, but might be related to contrast agent neurotoxicity with transient disruption of blood brain barrier integrity. Immediate computed tomographic angiogram (CTA) and CT-scan or magnetic resonance angiography (MRA) and cMRI should be performed after an occurrence of a suspected TCB to rule out embolic occlusions or hemorrhage. The administration of steroids can be considered.