Surgical treatment of a basilar perforator aneurysm not accessible to endovascular treatment

Abstract

Aneurysms originating from perforatoring branches of the midbasilar artery are extremely rare. Rupture of such an aneurysm resulted in a subarachnoid hemorrhage with a prepontine clot in a 44 year old male who presented with an acute confusional state. After coil embolization had failed, the partially thrombosed aneurysm was wrapped and coagulated via a combined supra-/infratentorial subtemporal presigmoid approach in prone position. The postoperative course was complicated by a tension pneumatocephalus and liquorrhea. Additional aneurysms of the anterior communicating artery and right middle cerebral artery were clipped several months later. The patient recovered well, and except for slight gait ataxia no other deficit remained.

Spontaneous resolution of perforator aneurysms of the posterior circulation

“…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.…”

“…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.…”

“…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).…”

Petrosal approaches to posterior circulation aneurysms

“…55 In our review of the literature, we found 34 cases of posterior circulation aneurysms treated via the standard retrolabyrinthine posterior petrosal approach reported in 14 studies over the course of 2 decades (Table 3). 3,6,11,12,14,22,24,32,40,42,43,50,54,56 All aneurysms were completely occluded. In addition, although early morbidity was high (62%; 41% in the form of cranial nerve deficits), it was often transient.…”

Non‐invasive visualization of basilar artery perforators with 7T MR angiography

“…They are also essential for the relay of sensory information between the cerebellum and cerebrum; as well as the regulation of respiration (1,2). The anatomic distribution of the pontine arteries (PAs), therefore, has been considered a crucial component of the arterial system in the lower brain, especially for surgical or endovascular treatment (3,4).…”