An unusual case of spontaneous subarachnoid haemorrhage — A ruptured aneurysm of a basilar perforator artery

Abstract

A 51-year-old gentleman with no significant past medical history presented with a WFNS grade 1 subarachnoid haemorrhage. Initial angiographic investigations revealed no cause, but repeat tests showed a small basilar perforator aneurysm. Following a failed attempt at endovascular treatment, a craniotomy and excision of the aneurysm was performed. Post-operatively the patient made a good recovery. This case highlights the importance of delayed repeat catheter angiography in selected patients with suspicious initial CT head results.

Spontaneous resolution of perforator aneurysms of the posterior circulation

“…Since first described by Ghogawala et al in 1996, 17 cases have been reported. [2][3][4][5][6][8][9][10]12 Since the beginning of 2012, at our institution we have encountered 3 ruptured perforator aneurysms of the posterior circulation. Those cases are reported in detail below.…”

“…Just as in 1 of the cases presented in this paper, basilar perforators can be inaccessible to catheterization 3,6,8 due to their small diameter, distal localization, and low blood flow. Surgery is often chosen as the first line of treatment, [4][5][6]8,12 including direct clipping, clipping of the parent vessel of the aneurysm, excision, trapping, wrapping, and coagulation. Endovascular techniques consist of coiling, stenting, or embolization.…”

“…This may explain why the shape of the aneurysm is often not described. 3,5,6,[8][9][10] Two facts may suggest an intracranial dissection: 1) the shape of the aneurysm often described as dolichoectatic (fusiform), or with a large base; and 2) variation in the size of the aneurysm between closely repeated angiograms (as in Case 2).…”

“…This phenomenon could explain diagnostic difficulties encountered with an initial negative angiogram in 55% (11/20) of the cases. 3,4,8,9,12 The imaging protocol needs to be rigorous with repeated angiograms, immobile patients, and conventional and 3D rotational angiograms. Bilateral injection of vertebral arteries can avoid flow artifacts in the basilar artery.…”

Treatment of tiny intracranial aneurysms with guidewire manipulation

“…Nevertheless, re-rupture occurred in one of seven cases in our review that was not treated early [5]. Oft-seen proximal clip occlusion or trapping approach was employed in treating these aneurysms [5,6], but the vessel was small, diseased, and often less collateralized by frequently seen anastomoses. In addition, given the extremely fragile wall of aneurysm, the surgical management can be complicated and risky; these aneurysms are candidates for endovascular therapy.…”