Vertebrobasilar Junction Aneurysm Research Articles

Far Lateral Approach and Occipital Artery to Posterior Inferior Cerebellar Artery Bypass With Staged Flow Diversion for Treatment of De Novo Vertebrobasilar Junction Aneurysm: 2-Dimensional Operative Video

Intracranial aneurysms refractory to endovascular treatment often require complex cerebral revascularization strategies, including combined open-endovascular techniques. 1-3 An adolescent girl presented with headache, and a fusiform right V4 vertebral artery aneurysm was diagnosed. Initial treatment was attempted with coil embolization. Surveillance imaging at 3 years after embolization demonstrated a de novo vertebrobasilar junction (VBJ) aneurysm with involvement of the right anterior inferior cerebellar artery-posterior inferior cerebellar artery (PICA) origin. The VBJ aneurysm was initially observed. Enlargement was noted at 1 year, and secondary treatment was attempted with left V3 segment coil occlusion to induce flow reversal. Follow-up demonstrated progressive VBJ aneurysm enlargement, prompting attempted left occipital artery (OA)-PICA bypass at an outside facility, which was unsuccessful. The patient was referred to our institution. After her parents gave informed consent, she underwent right OA-PICA bypass on the contralateral side through far lateral craniotomy with inside-out harvest of the donor vessel. 4 After trapping and arteriotomy of the recipient PICA, an OA-PICA end-to-side anastomosis was performed using a running continuous technique. 5 Intraoperative indocyanine green videoangiography and postoperative digital subtraction angiography confirmed patency of the bypass. The patient tolerated the procedure well and remained neurologically intact. On postoperative day 3, a staged transcirculation flow diversion device was placed to facilitate progressive thrombosis of the aneurysm. 6,7 Follow-up angiography at 1 year demonstrated complete occlusion of the aneurysm. This video demonstrates successful multimodal management of a complex de novo VBJ aneurysm after a series of refractory endovascular treatments and unsuccessful cerebral revascularization techniques.

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.

Reverse Y stenting in the management of vertebrobasilar junction fenestrated aneurysm: A novel technique.

Fenestrated aneurysm at vertebrobasilar junction (VBJ) is very rare and can occur due to non-fusion of longitudinal neural axis forming basilar artery in the early stage of embryonic life. Due to defects in tunica media and weakness in its wall, these fenestrations are more likely to develop an aneurysm. Various treatment strategies are required for the management of these types of aneurysms including simple coiling, stent-assisted coiling, balloon remodeling technique, and more recently kissing flow diverters. Herein, we report the case of ruptured fenestrated VBJ aneurysm which was managed successfully with novel reverse Y stenting with coiling.

Ruptured vertebrobasilar junction aneurysm supplied by reversed flow from the anterior spinal artery: Illustrative case report.

In patients with vertebral artery (VA) occlusion, spontaneous flow reversal may occur in the anterior spinal artery (ASA) as a source of compensatory supply to the posterior circulation. Turbulent flow and increased flux through these small arteries may predispose to luminal damage and intracranial aneurysm formation. We report a novel case of a ruptured ASA-VA junction aneurysm in a patient with chronic bilateral VA occlusion, successfully treated with endovascular embolization. A 62-year-old female with uncontrolled hypertension presented with acute-onset headache, emesis, neck stiffness, and decreased level of consciousness. Head computed tomography demonstrated diffuse cisternal subarachnoid hemorrhage with intraventricular extension and ventriculomegaly. Computed tomography angiography showed left VA atresia and chronic right VA occlusion just distal to the posterior inferior cerebellar artery origin, as well as a complex, bilobed aneurysm at the ASA-VA junction. Angiography demonstrated flow reversal from the ASA into the distal stump of the occluded right VA, which in turn filled the aneurysm. Of note, the patient's posterior circulation was predominantly supplied by the dilated ASA, and associated collaterals from ASA and right VA stump. The aneurysm was accessed and embolized using superselective microcatheterization over a soft microguidewire through the right cervical VA perforators supplying retrograde flow into and through the ASA. ASA-VA aneurysms are exceedingly rare, and generally associated with atypical flow dynamics. Dynamic treatment strategies may be needed, especially in the setting of subarachnoid hemorrhage.

Endovascular treatment outcomes of vertebrobasilar junction aneurysms: Systematic review and meta-analysis.

Vertebrobasilar junction (VBJ) aneurysms represent a relatively rare and often anatomically complex subgroup of saccular aneurysms. This systematic review and meta-analysis aimed to assess the safety and efficacy of endovascular treatment (EVT) of VBJ aneurysms. PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched from inception to 20 December 2022. We included primary studies assessing the long-term clinical and angiographic outcomes for VBJ aneurysms treated with endovascular techniques. We excluded surgically managed studies. All data were analyzed using R software version 4.2.1. We calculated pooled prevalence rates and their corresponding 95% confidence intervals (CI). In this meta-analysis, a total of 76 VBJ aneurysms from seven studies were included for quantitative analysis. The results showed that the rate of adequate occlusion (complete + near complete occlusion) was 94.1% (95% CI = 76.71-98.71), and the rate of complete occlusion was 77.7% (95% CI = 63.07-87.65). A modified Rankin Scale (mRS) score of 0-2 was achieved in 93.9% of patients (95% CI = 67.65-99.14). The mortality rate was found to be 5.9% (95% CI = 0.97-28.55), and the retreatment rate was 4.6% (95% CI = 1.50-13.36). The overall ischemic complication rate was 4.7% (95% CI = 0.73-25.4), while the overall hemorrhagic complication rate was 4.6% (95% CI = 1.5-13.36). The treatment of VBJ aneurysms with EVT is effective in achieving curative treatment and is associated with good clinical outcomes and low mortality rates. These findings provide important insights into the clinical and angiographic outcomes and the complication rates of EVT for VBJ aneurysms.

Incidental Finding of A Fenestrated Vertebrobasilar Junction Aneurysm

We report the case of a sacculara neurysm of the fenestrated vertebrobasilar junction in a 57-year-old woman, incidentally discovered. The diagnosis was made on CT brain angiography which found the an atomical variant and the aneurysm. Vertebrobasilar junction aneurysms are uncommon but often associated with a fenestration of the basilar artery. We detail the radiological features illustrating this association.

Reconstructive Endovascular Treatment of Basilar Trunk and Vertebrobasilar Junction Aneurysms: A Review of 77 Consecutive Cases.

BackgroundBasilar trunk and vertebrobasilar junction (BTVBJ) aneurysms have a poor prognosis and are challenging to treat.ObjectiveThis study aimed to evaluate the efficacy of reconstructive endovascular treatment for BTVBJ aneurysms and explore a treatment selection paradigm.MethodsClinical and angiographic data from 77 patients with 80 BTVBJ aneurysms who underwent endovascular treatment with flow diverters (FDs) or conventional stent-assisted coiling between January 2016 and December 2020 were retrospectively analyzed. Aneurysm characteristics and treatment outcomes were compared between treatment groups.ResultsAmong the 77 study patients, 34 (44.2%) were treated with FDs and 43 (55.8%) with conventional stent-assisted coiling. Overall, 72.7% of patients achieved favorable clinical outcome at follow-up. The rate of procedure-related complications was 23.4%. The aneurysm occlusion rate at last follow-up did not differ between the FD and conventional stent groups (79.2% vs. 77.1%, p = 0.854). Although the occlusion rate immediately after the procedure was lower in the FD group (29.4%), incidence of progressive occlusion was significantly higher (62.5 vs. 5.7%; p < 0.001). The proportion of patients with large and giant aneurysms (≥10 mm) was significantly higher in the FD group (70.6 vs. 34.8%; p = 0.002). In patients with large or giant aneurysms, favorable clinical outcome at last follow-up was achieved in 75% of patients in the FD group but only 43.8% of patients in the conventional stent group (p = 0.046). Moreover, the complication rate was lower in the FD group, but the difference was not significant (20.8 vs. 37.5%; p = 0.247). The same analyses were performed for patients with small aneurysms (<10 mm) but no significant differences between the two groups were observed.ConclusionEndovascular treatment of small BTVBJ aneurysms using either FDs or conventional stents was feasible and effective. In patients with large or giant aneurysms, treatment using FDs achieved higher rates of occlusion and favorable clinical outcome at last follow-up than conventional stent-assisted coiling.

Incidental Finding of a Fenestrated Vertebrobasilar Junction Aneurysm

Basilar artery fenestration is a rare anatomical variation resulting from the failed fusion of the two vertebral arteries during embryonic life. In order of frequency, it is the second most common location of vascular fenestrations after the anterior communicating artery. Vertebrobasilar junction aneurysms are uncommon but often associated with basilar artery fenestration. We report the case of a fenestrated vertebrobasilar junction saccular aneurysm in a 57-year-old woman. The diagnosis was incidentally made on CT angiography which found the anatomical variant and the aneurysm. The radiological features illustrating this association are detailed here and a brief discussion of its pathogenesis and management was made. Vertebrobasilar junction aneurysms are rare and their presence should suggest an associated basilar fenestration.

Treatment of ruptured subclavian steal flow-related vertebrobasilar junction aneurysms: Case report on surgical and endovascular considerations from two cases.

IntroductionSubclavian steal phenomenon causes retrograde flow through the vertebral artery, ipsilateral to the affected subclavian artery, which rarely leads to flow-related vertebrobasilar junction (VBJ) aneurysms.Case descriptionsWe describe two cases of subarachnoid hemorrhage from such ruptured aneurysms in which the retrograde flow direction in the vertebral artery complicated surgical and endovascular treatment.DiscussionReversed flow in the vertebral artery, ipsilateral to the stenotic subclavian artery leads to a lack of proximal control in surgical clipping of these VBJ aneurysms and jeopardizes stability of coil and stent placement in endovascular aneurysm treatments in this setting.Conclusion: From these 2 experiences over 7 years, treatment considerations emerged for future cases.

Vertebrobasilar Junction Aneurysm Associated with Subclavian Steal: Yet another Hemodynamic Cause for Aneurysm Development and Associated Challenges

Vertebrobasilar Junction Aneurysm Associated with Subclavian Steal: Yet another Hemodynamic Cause for Aneurysm Development and Associated Challenges

Treatment of Acutely Ruptured Cerebral Aneurysms With the Woven EndoBridge (WEB) Flow Disruptor: A Multicenter Experience

Abstract INTRODUCTION Coiling has become the first-line treatment option for acutely ruptured aneurysms 1 to 3. However, coiling of wide-necked bifurcation aneurysms is challenging and stent-assisted coiling requires dual anti-platelet therapy. The Woven EndoBridge (WEB) flow disruptor has been recently Food and Drug Administration (FDA)-approved for bifurcation aneurysms and is designed to achieve intrasaccular flow diversion without the need for antiplatelet therapy. However, its use has been mostly reserved for unruptured aneurysms. Here, we present our series of ruptured aneurysms that were treated with the WEB-device post FDA approval. METHODS We performed a review of the first cohort of patients with acute subarachnoid hemorrhage (SAH) from ruptured aneurysms who underwent endovascular treatment with the WEB-device at Thomas Jefferson and Iowa University Hospitals and identified 7 patients. RESULTS All 7 patients were female and the mean age was 71 yr (range 57-81). Hunt and Hess grades ranged from 2 to 5. The aneurysms treated included anterior communicating, posterior communicating, posterior-inferior cerebellar (PICA), basilar apex, and vertebrobasilar junction (VBJ). In 6 of the 7 aneurysms, 1 WEB device was sufficient to achieve adequate obliteration; the VBJ aneurysm was 14 mm in size and required 2. The majority of patients underwent treatment via transfemoral access followed by transradial. One patient underwent direct carotid puncture due to vessel tortuosity. Aneurysm rebleeding was not encountered in any of the WEB-treated aneurysms. One patient had an intraoperative rupture of their PICA aneurysm after dislodgment of the WEB device. There were no treatment-related deaths, but one patient died of cardiopulmonary failure. CONCLUSION Our series shows that the WEB device can be safely used in ruptured bifurcation aneurysms of various sizes in the anterior and posterior circulation. It does not require adjunctive stent use and is a valuable alternative to stent-assisted coiling as it obviates the need for anti-platelet therapy.

Aneurysms with persistent filling after failed treatment with the Pipeline embolization device.

The Pipeline embolization device (PED) has become a valuable tool in the treatment of cerebral aneurysms. Although failures with PED treatment have been reported, the characteristics and course of these aneurysms remain a topic of uncertainty. Electronic medical records and imaging studies were reviewed for all patients treated with the PED between July 2010 and March 2015 to identify characteristics of patients and aneurysms with residual filling after PED treatment. Of 316 cases treated at a single institution, 281 patients had a long-term follow-up. A total of 52 (16.4%) aneurysms with residual filling were identified and constituted the study population. The mean patient age in this population was 58.8 years. The mean aneurysm size was 10.1 mm ± 7.15 mm. Twelve aneurysms were fusiform (23%). Of the aneurysms with residual filling, there were 20 carotid ophthalmic (CO) aneurysms (20% of all CO aneurysms treated), 10 other paraclinoid aneurysms (16.4% of all paraclinoid aneurysms), 7 posterior communicating artery (PCoA) aneurysms (21.9% of all PCoA aneurysms), 7 cavernous internal carotid artery (ICA) aneurysms (14.9% of all cavernous ICA aneurysms), 4 vertebrobasilar (VB) junction aneurysms (14.8% of all VB junction aneurysms), and 3 middle cerebral artery (MCA) aneurysms (25% of all MCA aneurysms). Eleven patients underwent placement of more than one PED (21.2%), with a mean number of devices of 1.28 per case. Eight of 12 aneurysms were previously treated with a stent (15.4%). Nineteen patients underwent re-treatment (36.5%); the 33 patients who did not undergo re-treatment (63.5%) were monitored by angiography or noninvasive imaging. In multivariate analysis, age older than 65 years (OR 2.65, 95% CI 1.33-5.28; p = 0.05), prior stent placement across the target aneurysm (OR 2.94, 95% CI 1.15-7.51; p = 0.02), aneurysm location in the distal anterior circulation (MCA, PCoA, and anterior choroidal artery: OR 2.72, 95% CI 1.19-6.18; p = 0.017), and longer follow-up duration (OR 1.06, 95% CI 1.03-1.09; p < 0.001) were associated with incomplete aneurysm occlusion. While the PED can allow for treatment of large, broad-necked aneurysms with high efficacy, treatment failures do occur (16.4%). Aneurysm size, shape, and previous treatment may influence treatment outcome.

How I do it: surgical clipping of vertebrobasilar junction aneurysms through a far-lateral transcondylar approach

Vertebrobasilar junction aneurysms occur rarely, but have a higher rupture rate than supratentoral aneurysms, and higher morbidity and mortality. Their location ventral to the neuroaxis makes them a challenging surgical lesion. In this paper, we share our experience with the surgical technique for the management of these complex aneurysms. An in-depth understanding of the anatomy of these aneurysms, careful preoperative planning, and a meticulous surgical technique, including knowledge of every detail of the procedure-positioning, an advanced skull base technique, and careful aneurysm dissection and clipping-is essential for a successful outcome of the surgery.

Stent-assisted coiling of a ruptured vertebrobasilar junction aneurysm via direct vertebral artery puncture

A 78-year-old patient was admitted with subarachnoid hemorrhage caused by rupture of a broad-based vertebrobasilar junction aneurysm. Direct endovascular access to the vertebrobasilar circulation was not possible due to chronic...

Transclival Approach, Clipping and Drainage of a Giant Vertebrobasilar Aneurysm: Case Report

Introduction: Transclival approach for clipping vertebrobasilar junction aneurysms has been described since 1966; however, there is not register in the current literature using this approach for clipping and drainage of giant vertebrobasilar aneurysms, mainly because its inherent complications. Approach is intended to avoid brainstem and cranial nerves retraction. Endovascular treatment has not provide enough satisfactory results concerning to brainstem decompression.

Modified Far Lateral Approach for Posterior Circulation Aneurysms: An Institutional Experience

The modified far lateral approach is a modified version of the far lateral approach without drilling of the condyle. This approach can be used for accessing aneurysms anterior and anterolateral to the brainstem and craniovertebral junction. We describe the surgical outcome and complications of the modified far lateral approach for vertebrobasilar, proximal posterior inferior cerebellar artery, and vertebral artery aneurysms. The records of 26 patients with vertebrobasilar aneurysms who underwent surgery using the modified far lateral approach from 1994 to 2015 were retrospectively reviewed to analyze the clinical outcomes. Mean age of patients was 61 years (range, 38-84 years), and 18 patients were women. The most common presenting symptoms were sudden-onset headache (77%) and dizziness (35%). Of patients, 21 (81%) had saccular aneurysms, and 5 (19%) had fusiform aneurysms. The modified far lateral approach was used in 16 patients with posterior inferior cerebellar artery aneurysms, 6 patients with vertebral artery aneurysms, 2 patients with basilar aneurysms, 1 patient with a vertebrobasilar junction aneurysm, and 1 patient with an anterior inferior cerebellar artery aneurysm. All aneurysms were clipped successfully. Follow-up data were available for 25 patients (median duration 67 months). At last follow-up, 22 patients had a good recovery (modified Rankin Scale score 1-3), and 3 patients had a poor outcome (modified Rankin Scale score 4-6). Four patients developed lower cranial nerve palsy, and 7 patients developed new-onset hydrocephalus. The modified far-lateral approach without condyle resection and vertebral artery mobilization is associated with low procedure-related morbidity and comparable outcomes to the more extensive traditional approach.

Fenestra Obscura: Flow Diverter Reconstruction of a Complex Vertebrobasilar Aneurysm Through an Obscured Fenestration Limb: Technical Case Report.

Basilar fenestration aneurysms are rare, challenging intracranial vascular lesions with atypical anatomy. The posterior circulation represents a difficult therapeutic dilemma because of the close proximity of crucial life-sustaining brainstem structures. The use of flow diverter technology has been very limited in posterior circulation vessels. We present the case of a 49-year-old female patient, who was diagnosed with a symptomatic large vertebrobasilar junction aneurysm, which was initially thought to be a proximal basilar dilatation. The aneurysm was later verified to arise from the proximal end of a basilar fenestration, distended by the aneurysm fundus. The small-caliber fenestration limbs were the only connection to the distal basilar artery, but were stretched laterally and concealed by the aneurysm fundus. This complex lesion was successfully treated by flow diverter deployment through one of the fenestration limbs, followed by coiling of the aneurysm fundus, and sacrificing the contralateral vertebral artery. A 6-month follow-up angiogram showed remodeling of the basilar artery and complete occlusion of the aneurysm with good clinical outcome. Careful diagnostic workup, multidisciplinary discussions, and the innovative use of versatile endovascular technology were crucial to achieve an optimal result in this case. This is the first report of a successful basilar artery reconstruction for the treatment of a large atypical vertebrobasilar junction fenestration aneurysm by deployment of a flow diverter device directly in a small, obscured fenestration limb.

E-046 complex flow diverter treatment of an atypical large aneurysm at an obscured basilar artery fenestration

Introduction Basilar fenestration aneurysms are rare, challenging intracranial vascular lesions with atypical anatomy. The posterior circulation represents a difficult therapeutic dilemma due to the close proximity of crucial life sustaining brainstem structures. Flow diverter technology became available a few years ago, however, its use has been limited in the posterior circulation. Methods We present the case of a 49-year-old female with a history of smoking, who was diagnosed with a symptomatic, large vertebrobasilar junction (VBJ) aneurysm. Initially thought to be a proximal basilar dilatation, the aneurysm was later found to arise from an obscured and distended basilar fenestration. The small caliber fenestration limbs were the only access to the distal basilar artery, but stretched laterally and concealed by the aneurysm fundus. Results We successfully treated this complex lesion by flow diverter deployment through one of the obscured fenestration limbs, followed by coiling of the aneurysm fundus, and sacrificing the contralateral vertebral artery. A six-month follow-up angiogram showed remodeling of the basilar artery, and complete occlusion of the aneurysm. The patient had an excellent clinical outcome. Conclusion To our knowledge, direct flow diverter deployment in a small fenestration limb for the treatment of a VBJ aneurysm with reconstruction of the basilar artery has not been reported. Careful diagnostic workup, multidisciplinary discussions, and the innovative use of versatile endovascular technology were crucial to achieve an optimal result in our case. Further studies are necessary to establish the safety and long-term efficacy of this treatment method. Disclosures G. Toth: None. M. Bain: None. F. Hui: None.

Vertebro-basilar junction aneurysms: a single centre experience and meta-analysis of endovascular treatments.

Vascular lesions of the vertebrobasilar junction (VBJ) are challenging in neurosurgical practice, and their gold-standard therapy is still under debate. We describe the operative strategies currently in use for the management of these complex vascular lesions and discuss their rationale in a literature meta-analysis and single centre blinded retrospective study. The single centre study included a review of initial presentation, angiographic features and clinical outcome (with modified Rankin Scale [mRS] scores) over a long-term follow-up. In our series, small aneurysms were effectively treated by endosaccular coil embolization, whereas a strategy including flow-diverter devices combined with endosaccular coil embolization was the option of choice in large and giant aneurysms, leading to satisfactory outcomes in most cases. Our Medline review showed that endovascular treatment was chosen in most VBJ cases, whereas the microsurgical option was assigned to only a few cases. Among the endovascular treatments, the most common techniques used for the treatment of VBJ aneurysms were: coiling, stent-assisted coiling and flow diversion. Our study highlights that aneurysm morphology, location and patient-specific angio-architecture are key factors to be considered in the management of VBJ aneurysms. Most case series, including our own, show that parent artery reconstruction using a flow-diverter device is a feasible and successful technique in some cases of giant and complex aneurysms (especially those involving the lower third of the basilar artery) while a "sit back, wait and see" approach may represent the safest and most reasonable option.

Surgical Management of Symptomatic Posterior Circulation Aneurysms

Surgical treatment of posterior circulation aneurysms is more difficult than surgical treatment of anterior circulation aneurysms and poses a greater technical challenge for the practicing neurosurgeon. There are different surgical options available for the surgical treatment of posterior circulation aneurysms despite the use of the pterional approach to anterior circulation aneurysms. We present our surgical experiences with three cases of posterior circulation aneurysms. Three cases of posterior circulation aneurysms were treated by surgical clipping. We preferred pterional approach for posterior cerebral artery aneurysms, infratentorial supracerebellar approach for superior cerebellar aneurysm, and the combined lateral supracerebellar infratentorial retrosigmoid approach for vertebrobasilar junction aneurysm. The morbidity and mortality associated with open surgery for posterior circulation aneurysms are higher because of the location of the aneurysms within the posterior fossa. For neurosurgeons, the surgical treatment of posterior circulation aneurysms can be challenging.