Abstract
An 80-year-old female patient presented with a persistent occipital headache over the course of a year, with no clear cause. She had no focal neurological deficit on clinical examination. An MRI scan showed a large 19 mm unruptured saccular aneurysm of the distal basilar artery (BA) at the origin of the left superior cerebellar artery (SCA) with compression of the subjacent pons. DSA confirmed the presence of a thrombosed dissecting saccular aneurysm of the distal BA, with its neck incorporating the origin of the left SCA. In order to remodel the aneurysm, to reduce rupture risk, and to decrease mass effect, a flow diverting stent was inserted. To reduce the risk of basilar perforator and posterior circulation side-branch vessel occlusion, a higher-porosity LEO stent was placed rather than a lower-porosity flow diverting stent. Repeated MRI/MRA examinations at 3 and 12 months confirmed the successful treatment of the aneurysm, with a sustained reduction in size and mass effect. The current treatment considerations for aneurysms located within the basilar artery territory and reaching a balance between flow diversion and the risk of perforator infarction is the main topic of this chapter.
This is a preview of subscription content, log in via an institution to check access.
References
Augsburger L, Farhat M, Reymond P, Fonck E, Kulcsar Z, Stergiopulos N, Rüfenacht DA. Effect of flow diverter porosity on intraaneurysmal blood flow. Klin Neuroradiol. 2009;19(3):204–14. https://doi.org/10.1007/s00062-009-9005-0.
Awad AJ, Mascitelli JR, Haroun RR, De Leacy RA, Fifi JT, Mocco J. Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion. Neurosurg Focus. 2017;42(6):E14. https://doi.org/10.3171/2017.3.FOCUS1748.
Aydin K, Barburoglu M, Sencer S, Berdikhojayev M, Coskun B, Akpek S. Flow diversion with low-profile braided stents for the treatment of very small or uncoilable intracranial aneurysms at or distal to the circle of Willis. AJNR Am J Neuroradiol. 2017;38(11):2131–7. https://doi.org/10.3174/ajnr.A5362.
Bhogal P, Ganslandt O, Bäzner H, Henkes H, Pérez MA. The fate of side branches covered by flow diverters-results from 140 patients. World Neurosurg. 2017;103:789–98. https://doi.org/10.1016/j.wneu.2017.04.092.
Bouillot P, Brina O, Ouared R, Lovblad KO, Farhat M, Pereira VM. Particle imaging velocimetry evaluation of intracranial stents in sidewall aneurysm: hemodynamic transition related to the stent design. PLoS One. 2014;9(12):e113762. https://doi.org/10.1371/journal.pone.0113762.
Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke. 2013;44(2):442–7. https://doi.org/10.1161/STROKEAHA.112.678151.
Cagnazzo F, Cappucci M, Dargazanli C, Lefevre PH, Gascou G, Riquelme C, Morganti R, Mazzotti V, Bonafe A, Costalat V. Flow-diversion effect of LEO stents: aneurysm occlusion and flow remodeling of covered side branches and perforators. AJNR Am J Neuroradiol. 2018;39(11):2057–63. https://doi.org/10.3174/ajnr.A5803.
Cebral JR, Castro MA, Burgess JE, Pergolizzi RS, Sheridan MJ, Putman CM. Characterization of cerebral aneurysms for assessing risk of rupture by using patient-specific computational hemodynamics models. AJNR Am J Neuroradiol. 2005;26(10):2550–9.
Fiorella D, Albuquerque FC, Deshmukh VR, Woo HH, Rasmussen PA, Masaryk TJ, McDougall CG. Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms. Neurosurgery. 2006;59(2):291–300; discussion 291-300. https://doi.org/10.1227/01.NEU.0000223650.11954.6C.
Fischer S, Vajda Z, Aguilar Perez M, Schmid E, Hopf N, Bäzner H, Henkes H. Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology. 2012;54(4):369–82. https://doi.org/10.1007/s00234-011-0948-x.
Kallmes DF, Ding YH, Dai D, Kadirvel R, Lewis DA, Cloft HJ. A new endoluminal, flow-disrupting device for treatment of saccular aneurysms. Stroke. 2007;38(8):2346–52. https://doi.org/10.1161/STROKEAHA.106.479576.
Kulcsár Z, Ernemann U, Wetzel SG, Bock A, Goericke S, Panagiotopoulos V, Forsting M, Ruefenacht DA, Wanke I. High-profile flow diverter (silk) implantation in the basilar artery: efficacy in the treatment of aneurysms and the role of the perforators. Stroke. 2010;41(8):1690–6. https://doi.org/10.1161/STROKEAHA.110.580308.
Lieber BB, Stancampiano AP, Wakhloo AK. Alteration of hemodynamics in aneurysm models by stenting: influence of stent porosity. Ann Biomed Eng. 1997;25(3):460–9.
Lopes DK, Jang DK, Cekirge S, Fiorella D, Hanel RA, Kallmes DF, Levy EI, Lylyk P. Morbidity and mortality in patients with posterior circulation aneurysms treated with the pipeline embolization device: a subgroup analysis of the international retrospective study of the pipeline embolization device. Neurosurgery. 2018;83(3):488–500. https://doi.org/10.1093/neuros/nyx467.
Lylyk P, Ferrario A, Pasbón B, Miranda C, Doroszuk G. Buenos Aires experience with the Neuroform self-expanding stent for the treatment of intracranial aneurysms. J Neurosurg. 2005;102(2):235–41. https://doi.org/10.3171/jns.2005.102.2.0235.
Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR, Berez AL, Tran Q, Nelson PK, Fiorella D. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery. 2009;64(4):632–42; discussion 642-3; quiz N6. https://doi.org/10.1227/01.NEU.0000339109.98070.65.
Marinković SV, Gibo H. The surgical anatomy of the perforating branches of the basilar artery. Neurosurgery. 1993;33(1):80–7.
Mazur MD, Kilburg C, Wang V, Taussky P. Pipeline embolization device for the treatment of vertebral artery aneurysms: the fate of covered branch vessels. J Neurointerv Surg. 2016;8(10):1041–7. https://doi.org/10.1136/neurintsurg-2015-012040.
Natarajan SK, Lin N, Sonig A, Rai AT, Carpenter JS, Levy EI, Siddiqui AH. The safety of pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center. J Neurosurg. 2016;125(1):111–9. https://doi.org/10.3171/2015.6.JNS1565.
Phillips TJ, Wenderoth JD, Phatouros CC, Rice H, Singh TP, Devilliers L, Wycoco V, Meckel S, McAuliffe W. Safety of the pipeline embolization device in treatment of posterior circulation aneurysms. AJNR Am J Neuroradiol. 2012;33(7):1225–31. https://doi.org/10.3174/ajnr.A3166.
Pumar JM, Arias-Rivas S, RodrÃguez-Yáñez M, Blanco M, Ageitos M, Vazquez-Herrero F, Castiñeira-Mourenza JA, Masso A. Using Leo plus stent as flow diverter and endoluminal remodeling in endovascular treatment of intracranial fusiform aneurysms. J Neurointerv Surg. 2013;5(Suppl 3):iii22–7. https://doi.org/10.1136/neurintsurg-2013-010661.
Rice BJ, Peerless SJ, Drake CG. Surgical treatment of unruptured aneurysms of the posterior circulation. J Neurosurg. 1990;73(2):165–73. https://doi.org/10.3171/jns.1990.73.2.0165.
Saatci I, Yavuz K, Ozer C, Geyik S, Cekirge HS. Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol. 2012;33(8):1436–46. https://doi.org/10.3174/ajnr.A3246.
Sadasivan C, Cesar L, Seong J, Rakian A, Hao Q, Tio FO, Wakhloo AK, Lieber BB. An original flow diversion device for the treatment of intracranial aneurysms: evaluation in the rabbit elastase-induced model. Stroke. 2009;40(3):952–8. https://doi.org/10.1161/STROKEAHA.108.533760.
Szikora I, Berentei Z, Kulcsar Z, Marosfoi M, Vajda ZS, Lee W, Berez A, Nelson PK. Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol. 2010;31(6):1139–47. https://doi.org/10.3174/ajnr.A2023.
Tateshima S, Tanishita K, Hakata Y, Tanoue SY, Viñuela F. Alteration of intraaneurysmal hemodynamics by placement of a self-expandable stent. Laboratory investigation. J Neurosurg. 2009;111(1):22–7. https://doi.org/10.3171/2009.2.JNS081324.
van Rooij WJ, Sluzewski M. Perforator infarction after placement of a pipeline flow-diverting stent for an unruptured A1 aneurysm. AJNR Am J Neuroradiol. 2010;31(4):E43-4. https://doi.org/10.3174/ajnr.A2034.
Wakhloo AK, Mandell J, Gounis MJ, Brooks C, Linfante I, Winer J, Weaver JP. Stent-assisted reconstructive endovascular repair of cranial fusiform atherosclerotic and dissecting aneurysms: long-term clinical and angiographic follow-up. Stroke. 2008;39(12):3288–96. https://doi.org/10.1161/STROKEAHA.107.512996.
Wang C, Tian Z, Liu J, Jing L, Paliwal N, Wang S, Zhang Y, Xiang J, Siddiqui AH, Meng H, Yang X. Flow diverter effect of LVIS stent on cerebral aneurysm hemodynamics: a comparison with Enterprise stents and the pipeline device. J Transl Med. 2016;14(1):199. https://doi.org/10.1186/s12967-016-0959-9.
Zenteno MA, Santos-Franco JA, Freitas-Modenesi JM, Gómez C, Murillo-Bonilla L, Aburto-Murrieta Y, DÃaz-Romero R, Nathal E, Gómez-Llata S, Lee A. Use of the sole stenting technique for the management of aneurysms in the posterior circulation in a prospective series of 20 patients. J Neurosurg. 2008;108(6):1104–18. https://doi.org/10.3171/JNS/2008/108/6/1104.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Nature Switzerland AG
About this entry
Cite this entry
Makalanda, H.L.D., Lie, G., Wong, K., Bhogal, P. (2019). Basilar Artery Trunk Aneurysm: Unruptured Saccular Aneurysm of the Distal Basilar Artery Trunk at the Origin of the Left Superior Cerebellar Artery with Brainstem Compression, LEO Stent-Induced Flow Diversion of the Aneurysm with Resolution of the Mass Effect and No Perforator Occlusion, and Good Clinical Outcome with Midterm Follow-Up. In: Henkes, H., Lylyk, P., Ganslandt, O. (eds) The Aneurysm Casebook. Springer, Cham. https://doi.org/10.1007/978-3-319-70267-4_128-1
Download citation
DOI: https://doi.org/10.1007/978-3-319-70267-4_128-1
Received:
Accepted:
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-70267-4
Online ISBN: 978-3-319-70267-4
eBook Packages: Springer Reference MedicineReference Module Medicine