Basilar Trunk Research Articles

Endovascular treatment of ruptured basilar artery trunk aneurysms: complications and long-term outcomes

ObjectTreatment of ruptured basilar artery trunk (BAT) aneurysms is challenging, and is associated with high complication and mortality rates. Herein, we analyzed the complications, long-term outcomes, and outcome predictors of endovascular treatment for ruptured BAT aneurysms. MethodsBetween January 2011 and July 2023, 36 patients with 36 ruptured BAT aneurysms underwent endovascular treatment at our institution. The postprocedural complications and clinical and angiographic outcomes were subsequently reviewed, and the risk factors for postprocedural complications were evaluated. ResultsAll 36 aneurysms in 36 patients were treated successfully. The median clinical follow-up time was 47.0 (IQR: 10.5, 84.5) months. Overall, complications occurred in 10 (27.8%) patients, including 3 (8.3%) deaths. Ischemic events occurred in seven (19.4%) patients, while three (8.3%) patients had shunt-dependent hydrocephalus, of whom one (2.8%) patient had both shunt-dependent hydrocephalus and ischemic events. The cumulative survival rates at 3 and 5 years were 94.1% and 87.8%, respectively. The cumulative 3- and 5-year complication-free survival rates were 75.0% and 70.0%, respectively. Multivariate Cox regression analysis revealed that diabetes mellitus (HR:8.76, 95%CI:2.35-32.69, p=0.001), and Glasgow coma scale score ≤ 12 before the procedure (HR:5.04, 95%CI:1.40-18.12, p=0.013) were associated with overall postprocedural complications. The complete aneurysm occlusion rate was 61.5% at a median angiography follow-up time of 6.0 (IQR: 5.0, 6.0) months. ConclusionsEndovascular treatment is a safe and feasible option for treating ruptured BAT aneurysms. The rate of favorable outcomes at the final follow-up was satisfactory. However, postprocedural complications, particularly ischemic events, should be carefully considered.

Endovascular Management of Basilar Artery Aneurysms: A Consecutive Series of 124 Patients

There is currently no established criterion for determining when interventional treatment is necessary and what strategy is appropriate for basilar artery (BA) aneurysms. Through this study, we aimed to propose an algorithm that can effectively determine the optimal endovascular treatment (EVT) option for BA aneurysms. We enrolled patients with BA aneurysms from June 2016 to December 2022 and performed procedures based on the algorithm. The analysis included demographic, clinical, and aneurysmal characteristics, procedural details, complications, angiographic outcomes, and clinical outcomes. This study included 124 patients (mean age 55.0 years) with a BA aneurysm who underwent EVT. Of these, 21 aneurysms were treated in the setting of subarachnoid hemorrhage (SAH). The majority of aneurysms were located at the basilar apex (74), followed by the basilar trunk (30) and vertebrobasilar junction (20). Coiling was used in 18.5% of cases, while stent-assisted coiling embolization was chosen for 58.9%. Overlapping stents were used in 12.9%, flow diverter (FD) implantation in 3.2%, Y/T stent techniques in 4.8%, and stent adjunctive coiling with unilateral vertebral artery (VA) occlusion in only 1.6%. Procedure-related complications occurred in 15 patients (12.1%). Patients had a modified Rankin Scale(mRS) score of 0.74±1.62; 98 (86.7%) had good prognosis with mRS scores ranging from 0 to 2 at the last follow-up. DSA was performed on 105 (84.7%) patients revealing that 101 (81.5%) achieved complete or near-complete occlusion. The endovascular treatment criteria for BA aneurysms depended on the multi-characteristics was safe and effective. However, further evidence is needed from large cohort studies.

Timing, type, and impact of thromboembolic events caused by flow diversion: a 10-year experience.

Thromboembolic (TE) events are among the most feared complications after flow diversion (FD) and have been reported to occur even with adequate dual antiplatelet therapy. Herein, the authors characterize thrombotic and embolic events that developed after FD, focusing on the morbidity of each of these events and the predisposing factors associated with their development. A retrospective analysis of aneurysms treated with FD at a single institution in the US between 2013 and 2023 was performed. The authors documented the emergence of intraprocedural and postoperative TE events. A survival analysis and a Cox regression model was conducted to identify predictors associated with these events. The authors included 651 procedures performed in 591 patients to treat 746 aneurysms. TE events occurred in 38 of the procedures performed (5.8%), causing permanent deficit in 20 patients and death in 4 patients. Eleven cases presented with acute stent thrombosis, 11 with large-vessel occlusion, and 9 with perforator strokes. At a median follow-up of 9.5 months, 73.0% of patients with an ischemic event had a modified Rankin Scale score ≤ 2. Three of the deaths were secondary to occlusion at the basilar trunk and vertebral artery. In patients with TE events in the anterior circulation, 7 of 11 patients with middle cerebral artery occlusion and 9 of 12 patients with internal carotid artery occlusion achieved independence. Time-to-event Cox regression analysis demonstrated that TE events were more frequent in patients exhibiting aspirin resistance (hazard ratio 2.66; 95% CI 1.10-6.70). TE events after FD result from multiple factors, including age, aneurysm characteristics, aneurysm location, antiplatelet resistance, and procedural factors. In our cohort, we found the highest morbidity for patients with TE events presenting with large-vessel occlusion at the middle cerebral artery, and vertebrobasilar system.

Thromboembolic Events in the Posterior Circulation After Flow Diversion—A Closer Look at Coverage of the Posterior Cerebral Artery

Flow diversion for bifurcation aneurysms requires excluding one of the branches from the parent artery, raising concern for ischemic events. We evaluated thromboembolic events and their relationship with covering the origin of the posterior cerebral artery (PCA). This retrospective analysis included patients with confirmed basilar and proximal PCA aneurysms treated with flow diversion between 2013 and 2023. Procedures were classified according to the coverage of the origin of the PCA. Thromboembolic events associated with the excluded PCA were evaluated. Of the total 28 aneurysms included, 7 were at the basilar tip, 16 in the basilar trunk, and 5 in the first segment of the PCA; 15 were treated by excluding one of the PCAs. Dual antiplatelet therapy included aspirin and ticagrelor (57.1%), aspirin and clopidogrel (35.7%), or aspirin and prasugrel (3.57%). Complete and near-complete aneurysm occlusion was achieved in 80.8% of the aneurysms treated at a median follow-up of 12.31 months. Thromboembolic complications occurred in 3 patients (2 with basilar perforator stroke and 1 with basilar in-stent thrombosis). However, the difference in these events was not statistically significant between patients with PCA coverage and those without (P= 0.46). Diminished flow and a lack of flow was seen in 8 and 7 of the covered vessels, respectively. A modified Rankin scale score of ≤2 was reported for 89.3% of patients at a median clinical follow-up of 5.5 months. The incidence of thromboembolic events is high in distal basilar and proximal PCA aneurysms; however, PCA coverage was not associated with their occurrence. There was no difference in postprocedural disability between patients whose aneurysms were treated by excluding one of the PCAs and those who were not.

Direct V3 Vertebral Artery Access for Embolization of Partially Thrombosed Fusiform Basilar Trunk Aneurysm: Technical Case Instruction.

Fusiform vertebrobasilar aneurysms carry significant morbidity. Endovascular strategies are preferred; however, unsafe or unfeasible access can call for innovative strategies. An octogenarian patient with an enlarging fusiform proximal basilar artery aneurysm causing a sixth nerve palsy was found to have multiple anatomic features that precluded a transradial or transfemoral endovascular approach. She was thus treated with direct microsurgical access of the V3 segment of the vertebral artery for subsequent coil embolization and flow diversion. This case introduces a novel combined microsurgical and endovascular strategy for treating a complex partially thrombosed fusiform basilar artery aneurysm. This approach should be reserved only for patients where conventional endovascular access is dangerous or unfeasible.

Giant Intracranial Aneurysms in Infants: Case Report and Review of the Literature

Intracranial aneurysms are extremely rare in infants and differ from those in adults in their mode of presentation, location, size, and long-term outcome. Their treatment is very complex. Our case is a 24-month-old infant who featured a giant aneurysm of the basilar trunk diagnosed at the age of 04 months by an alternate syndrome of sudden onset, with a follow-up for 2 years. Therapeutic management is much discussed between surgical treatment, endovascular treatment, and therapeutic abstention which depends on the age, location, size, and mode of installation of these aneurysms.

A vertebrobasilar junction aneurysm successfully treated with a combination of surgical clipping and flow diverter placement based on the results of computational fluid dynamics analysis: illustrative case.

The treatment of vertebrobasilar junction (VBJ) aneurysms is challenging. Although flow diverters (FDs) are a possible treatment option, geometrical conditions hinder intervention. VBJ aneurysms possess dual inflow vessels from the bilateral vertebral arteries (VAs), one of which is ideally occluded prior to FD treatment. However, it remains unclear which VA should be occluded. A 75-year-old male with a growing VBJ complex aneurysm exhibiting invagination toward the brainstem and causing perifocal edema required intervention. Preoperative computational fluid dynamics (CFD) analysis demonstrated that left VA occlusion would result in more stagnant flow and less impingement of flow than right VA occlusion. According to the simulated strategy, surgical clipping of the left VA just proximal to the aneurysm was performed, followed by FD placement from the basilar artery trunk to the right VA. The patient demonstrated tolerance of the VA occlusion, and follow-up computed tomography angiography at 18 months after FD treatment confirmed the disappearance of the aneurysm. Preoperative flow dynamics simulations using CFD analysis can reveal an optimal treatment strategy involving a hybrid surgery that combines FD placement and direct surgical occlusion for a VBJ complex aneurysm.

Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series.

Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms. We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale. Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant. Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.

Endothelin Receptor Blockade Improves Cerebral Blood Flow-Mediated Dilation in a Mouse Model of Alzheimer’s Disease

Introduction: Cerebral blood flow (CBF) is reduced in patients with Alzheimer’s disease (AD). Flow-mediated dilation (FMD), which plays a key role in the regulation of blood flow, is attenuated by endothelin-1. We hypothesized that endothelin receptor blockade may improve CBF in AD. Methods: We investigated cerebrovascular reactivity in a mouse model of AD (APP-PS1; 5-6-month-old male subjects). We assessed the in vivo response to normoxic hypercapnia and in vitro FMD in isolated cerebral and mesenteric resistance arteries before and after endothelin receptor blockade (bosentan). Results: Normoxic hypercapnia increased basilar trunk blood flow velocity (+12.3 ± 2.4%; p = 0.006, n = 6) in wild-type (WT) mice but reduced blood flow in APP-PS1 mice (−11.4 ± 1.2%; p < 0.0001, n = 8). Bosentan (50 mg/kg, acute intraperitoneal injection) restored cerebrovascular reactivity in APP-PS1 mice (+10.2 ± 2.2%; p < 0.0001, n = 8) but had no effect in WT. FMD was reduced in the posterior cerebral artery of APP-PS1 compared to WT and was normalized by bosentan (1 μmol/L, 30 min, or 50 mg/kg/day for 28 days). FMD was similar in the mesenteric artery of APPS-PS1 and WT. Conclusion: APP-PS1 mice exhibited cerebrovascular endothelial dysfunction. Acute and chronic blockade of endothelin receptors restored endothelial vasomotor function, suggesting a promising therapeutic approach to restoring cerebral vasoreactivity in AD.

Abstract 286: Endovascular Management of Pediatric Vertebro‐Vertebral Arterio‐Venous Fistula: Case report

Introduction Vertebro‐vertebral arteriovenous fistula (VV‐AVF) is a rare vascular malformation with abnormal high flow shunt between extracranial vertebral artery and an adjacent vertebral vein plexus without intervening capillaries.1 While seen in both adult and pediatric populations, the majority of the VV‐AVFs seen in childhood are largely congenital, seen in the setting of connective tissue diseases such as Ehler‐Danlos Syndrome, Neurofibromatosis type 1, and Marfan’s syndrome, with abnormal involution of the proatlantal system also thought to be implicated.2,3,4 Approximately 70% of the presenting population are symptomatic at presentation, with a pulsatile mass over the side of the neck or pulsatile tinnitus. Additionally, symptoms of vertebrobasilar insufficiency including gait abnormalities, limb weakness, vertigo, recurrent vomiting, diplopia, and in severe cases, cardiac decompensation can also be seen.5 Methods This is a case report of a 2‐year‐old boy presented to our pediatric neurovascular center of excellence with a progressively enlarging pulsatile left neck mass appreciated a year ago. Further evaluation with neck MRA followed by catheter cerebral angiogram revealed an upper cervical AVF with primary arterial feeders from V3 segment of the left vertebral artery, enlarged left occipital artery, and retrograde filling via the right vertebral artery into the left V4 with a direct shunt into a large venous pouch which drained into the vertebral venous plexus. Results Given the progressive enlargement of the mass, location of AVF, and concern for detrimental subsequent venous congestion, decision was made to pursue elective endovascular embolization of the VV‐AVF. The goal was set to obtain complete occlusion of the venous pouch to obliterate all arterial inflow contribution and prevent further recruitment. Occipital artery catheterization was attempted however given the redundant anatomical loops; optimum microcatheter navigation was not feasible. Given the non‐dominant configuration of the left VA, along with the presence of left AICA‐PICA system off the basilar trunk, coil embolization of the venous pouch followed by sacrifice of the V3 segment left VA was achieved satisfactorily leading to obliteration of the AVF along with all the arterial contributions from bilateral vertebral arteries and left occipital artery (Figure‐1). Given the potential vertebrobasilar inadvertent embolization, the procedure was performed under continuous neurophysiological monitoring and post‐periprocedural therapeutic anticoagulation. The patient tolerated the procedure well without any intraoperative issues. He was monitored in the pediatric ICU for 24 hours after the procedure, and subsequently discharged home. Conclusion We report a successful endovascular coil embolization of a VV‐AVF. To our knowledge, this is the youngest reported case where endovascular technique was successfully utilized to achieve cure of such high flow VV‐AVF in this 2‐year‐old patient. Systematic and methodical angiographic analyses with close post‐procedural monitoring are pivotal in ensuring successful outcomes.

Abstract 089: A Case of Complicated Dissection: Vertebral Artery Sacrifice for Recurrent Stroke Prevention

Introduction Posterior circulation strokes account for 20% of ischemic strokes (1). Optimal management for posterior circulation strokes has been studied less than for anterior circulation strokes (2). Endovascular parent vessel sacrifice is an established technique used to treat vascular pathologies. There is limited evidence for parent artery sacrifice for recurrent strokes and there is no current guideline for standard of care. Methods '‐ Results 51‐year‐old gentleman with history of tobacco use presented with left homonymous hemianopsia, onset 1.5 hours prior to arrival. CT brain showed no bleed and patient received IV tissue‐plasminogen activator (tPA). CT angiography (CTA) demonstrated occlusion of the right posterior cerebral artery (PCA) and dissection of the left vertebral artery (V2 segment) with distal reconstitution. He underwent emergent thrombectomy for right P2 thrombus with complete reperfusion TICI 3 (Thrombolysis in Cerebral Infarction Score). Less than 24 hours later, he developed a right homonymous hemianopsia, and was found to have a new occlusion of the left P1 segment of the left PCA. Emergent thrombectomy was performed with complete reperfusion (TICI3). MRI brain demonstrated bilateral PCA territory infarcts. Within 12 hours of the second thrombectomy, his neurological exam deteriorated, and interval imaging revealed a basilar trunk thrombus, for which he underwent a successful endovascular thrombectomy complete reperfusion (TICI3). His antiplatelet regimen was optimized with Aspirin. Heparin was considered as treatment but was not provided because of the hemorrhagic conversion of his ischemic strokes. Given the persistent recurrence of thromboemboli in the posterior circulation despite being on optimal medical management, and evidence of hemorrhagic conversion, a decision was made to perform endovascular coil embolization of the left vertebral artery V2 segment at the site of dissection. Angiographic imaging demonstrated antegrade blood flow through the dissection as the source of recurrent embolic strokes. Six Stryker Target coils were deployed spanning the region of dissection within the left V2 segment via a right radial access with the guide catheter in the right vertebral artery. Post coil embolization angiographic runs demonstrated complete occlusion of the left vertebral V2 segment at the region of dissection which was confirmed via a left vertebral injection from a left femoral arterial access. There was preservation of ascending cervical collaterals beyond the dissection with patency of the contralateral vertebral artery supplying the intracranial circulation. Following embolization, repeat imaging showed no new infarcts and no new or worsening hemorrhage. He was continued on Aspirin monotherapy. It is notable that though his neurological exam deteriorated during each recurrent thromboembolic event, his neurologic exam at the time of discharge significantly improved with NIHSS of 3. He is currently being followed at our neuroscience institute. Conclusion Cervical arterial dissections pose increased risk for ischemic strokes (3). Vertebral artery dissection accounts for approximately 2%, of which, 10‐25% occur in middle‐aged and younger patients (4). This is a case of a young patient that exemplifies a successful role for vertebral artery sacrifice with coil embolization to prevent recurrent thromboembolic posterior circulation strokes. However controlled studies are needed for safety and efficacy of these interventions.

Failure of Reconstructive Technique to Repair a Giant Intracranial Fusiform Aneurysm of the Basilar Artery: Case Report and Literature Review in the Pediatric Population

AbstractTreatment of giant basilar aneurysm presents a major treatment challenge, especially in the pediatric population. Morbidity and mortality approach 80 and 30%, respectively. Both reconstructive and deconstructive techniques are associated with high rates of complete occlusion and good neurological outcomes. We report a 14-year-old male with a giant basilar trunk aneurysm treated with an endovascular approach. Clinical symptoms began following an ischemic stroke 2 weeks prior to admission. Endovascular treatment was performed through a reconstructive technique by single flow diverter device (FDD) in the basilar artery; however, this technique failed. At 1-year follow-up, without additional endovascular treatment, the mid-basilar artery and aneurysm were occluded, with vertebrobasilar flow maintained through collaterals from the right posterior communicating artery. We present a challenging management of giant basilar aneurysm in a pediatric patient experiencing a failure of FDD deployment; however, we highlight the importance of collateral flow development in progressive occlusions.

Energy device injury. Common basilar arterial trunk injury with harmonic scalpel.

Energy device injury. Common basilar arterial trunk injury with harmonic scalpel.

Primary suture repair. Right common basilar trunk of pulmonary artery primary suture during S6 segmentectomy.

Primary suture repair. Right common basilar trunk of pulmonary artery primary suture during S6 segmentectomy.

Complications after endovascular treatment of large basilar trunk aneurysms.

Large basilar trunk aneurysms (BTAs) have a poor natural history if left untreated and always pose a significant challenge to endovascular treatment. The present study aimed to analyze the complications after endovascular treatment of large BTAs. This was a retrospective, observational, cohort study. Between January 2015 and September 2022, 9116 patients with intracranial aneurysms came to our institution for management, of which 34 patients with 34 large (≥10 mm) BTAs were treated with endovascular treatment. Postprocedural complications, clinical, and angiographic outcomes were evaluated. All 34 patients (34 aneurysms) were successfully treated, of which 13 aneurysms were treated with flow diversion (FD), and 21 aneurysms were treated with stent-assisted coiling. Neurological complications occurred in 12 (35.3%) patients, with 7 (20.6%) deaths. Ischemic complications occurred in 10 (29.4%) patients, and 4 (11.8%) patients experienced hemorrhagic events. The incidences of favorable outcomes at discharge and last follow-up were 85.3% and 75.8%, respectively. The cumulative survival rates at 1 and 3 years were 86.5% and 71.4%, respectively. Unilateral vertebral artery sacrifice was associated with postprocedural complications (hazard ratio: 3.74, 95% confidence interval: 1.06-13.25, p = 0.041). The postprocedural complication rates were comparable between patients treated with FD and stent-assisted coiling (5/13, 38.5% vs. 7/21, 33.3%, p > 0.99). Angiography follow-up was available for 21 patients, and complete aneurysm occlusion was observed in 16/21 (76.2%) aneurysms. Endovascular treatment might be a feasible option for treating large BTAs. However, clinicians should be alerted to procedure-related complications, especially ischemic complications that cause disability or death. Unilateral vertebral artery sacrifice might be associated with postprocedural complications.

Ischemic stroke in the intensive care unit: About 75 cases

Stroke is characterized by the sudden onset of a focal neurological deficit and is a frequent and potentially serious pathology that constitutes a medical and, sometimes, surgical emergency. The objective of this work is to elucidate the epidemiological, clinical, paraclinical, therapeutic and evolutionary aspects of the cerebral vascular accident in the environment of intensive care unit in order to define the factors of bad prognosis: This is a retrospective study including all patients hospitalized in A1 intensive care unit of HASSAN II University Hospital of Fes for acute ischemic stroke(AIS) over a period of 7 years since 2014 until 2020. We collected 75 patients over a period of 7 years (2014-2020), 55% of our patients are male, the average age is 65.52 years. Arterial hypertension, heart disease and diabetes are the main risk factors, and hemiplegia is the main focal neurological sign encountered. Sylvian cerebral infarcts (territory of the middle cerebral artery) predominate (64%), followed by the territory of the posterior cerebral artery (9.3%) and the basilar trunk (4.3%). The main prognostic factors related to mortality were: initial GCS, presence of vital distress, mechanical ventilation, inhalation, infection and cerebral involvement. A hemicraniectomy was performed in 16% of our patients with an estimated mortality of 57%. Stroke represents: The first cause of acquired motor disability in adults; The second cause of major cognitive impairment after Alzheimer's disease. The improvement of the prognosis depends on the quality of primary and secondary prevention and on the rapidity of diagnostic and therapeutic management in the acute phase.

Human Basilar Arterial Plaque Detected by Near-Infrared Spectroscopy: Clinical Image

A patient in their 70s presented with weakness of the left limb and aphasia. Left vertebral angiography showed acute basilar artery occlusion. After mechanical thrombectomy, basilar artery trunk stenosis was evident and catheter-based near-infrared spectroscopy (NIRS) showed lipid-rich atherosclerotic plaque extending to almost 220° of the vessel circumference in the culprit lesion. Loading doses of dual antiplatelet therapy and aggressive medical treatment were started because additional intervention might have increased risk of plaque protrusion and thrombotic reocclusion. The patient presented with minor stroke caused by restenosis of the basilar artery 4 months later; balloon angioplasty and stenting were performed without thromboembolic complications. The patient was discharged without any new neurologic deficits. NIRS visualizes the distribution of lipids in the culprit lesion and the plaque burden of residual stenosis, identifies mechanisms of in situ thrombosis, and provides suggestions for the timing of additional interventions.

Congenital and acquired anomalies of the basilar artery: A pictorial essay.

The basilar artery is one of the two cases in our body where an arterial vessel is formed by the union of two others - the vertebral arteries. It provides vascular supply to essential structures for the main vital functions; the posterior cerebral arteries originate from it as terminal branches, and form part of the anastomotic circle of Willis. Congenital and acquired anomalies of the basilar trunk are described. We provide a schematic and detailed representation of normal anatomical variants - mainly represented by the fenestrated basilar artery or the persistence of carotid-basilar anastomosis; course anomalies are also illustrated, with reference to neuro-vascular conflicts and dolichoectasia. Among congenital anomalies, this pictorial review also shows the variants of the basilar origin, such as in the case of basilar trunk arising from only one of the two vertebral arteries, and the calibre changes - which are represented by aneurysm and hypoplasia. The latter appears to be a risk factor for posterior circulation stroke, when associated with a bilateral posterior foetal variant.Among the acquired forms, this pictorial essay describes some clinical cases of dissections, non-congenital aneurysms, thrombosis and tumour with vascular encasing or compression of basilar artery. CT angiography and MRI allow us to study the posterior intracranial circulation in detail, providing useful pre-treatment information. Therefore, knowledge of congenital or acquired anomalies of the basilar artery is essential for radiologists, neuroradiologists and neurosurgeons.

Vestibulo-Cochlear Symptoms Revealing Vertebro-Basilar Dolicho-Ectasia

Introduction: Vertebrobasilar dolichoectasia (VBD) are uncommon arteriopathies defined by increased length and caliber of one or more intracranial arteries. The clinical picture is polymorphic. They are most often associated with ischemic or hemorrhagic stroke, but this pathology can also cause symptoms of cranial nerve compression. Objective: We report the case of a vertebro-basilar dolichoectasia collected in the radiology department of Ibn Tofail Hospital in Marrakech, revealed by vestibulo-cochlear symptoms and diagnosed by brain MRI. In the light of this observation, we review this uncommon pathology and the contribution of magnetic resonance imaging in its diagnosis. Case report: The patient was 68 years old and had a history of severe sleep apnea syndrome. He presented with rotatory vertigo, tinnitus and hypoacusis on the left side of the head for 3 months. The neurological examination was normal and the examination of the ENT sphere revealed bilateral sensorineural hearing loss and left hyporeflexia. A cerebral MRI was performed as part of the etiological workup, which revealed elongation and dilation of the vertebral arteries measuring 3.9 mm on the left and 5.2 mm on the right, with loops of which the left crossed the homolateral cochleovestibular nerve 7 mm from its emergence, responsible for a deviation of its path, and the glossopharyngeal nerve 4 mm from its emergence. It also showed an elongation and dilatation of the basilar trunk measuring 6.8 mm, presenting a loop lateralized to the left at the level of its origin (Smoker's Grade 2) with a bifurcation opposite the floor of the V3 (Smoker's Grade 2).Thus, the diagnosis of a DEVB responsible for a vascular-nervous conflict was retained. The indication for surgical management was given but was refused by the patient due to the deep location of the arteriopathy. Discussion and conclusion: DEVB is a rare and progressive condition with cranial nerve compression as a possible complication. Brain MRI is...

Appearance and rupture of a dissection aneurysm of the basilar trunk in a SARS- CoV-2 patient

The article describes a clinical case of a dissection aneurysm of the basilar artery in a SARS-COV-2 patient. The patient was treated in the hospital for infectious diseases due to bilateral poly-segmental pneumonia complicating a COVID-19 infection. A focal neurological deficit suddenly appeared and rapidly progressed, including paresis of the abducens nerve, bulbar disorders, and a right-sided hemiparesis. During the course of treatment, the patient underwent CT and CT angiography of the cerebral arteries several times. During the first examination, no pathology of the cerebral vessels was discovered. During the examination 10 days later, a fusiform aneurysm of the basilar artery trunk with a daughter sac was detected. Its rupture led to massive subarachnoid hemorrhage and an unfavorable outcome. The occurrence of primary symptoms in this patient could be due to a violation of the blood flow in the short branches of the basilar trunk in the area of the dissection.