Basilar artery aneurysm

The angle widens with age during adulthood, especially in females. This angular widening is associated with basilar bifurcation aneurysms and may predispose individuals to aneurysm initiation by diffusing the flow impingement zone away from the protective medial band region of the flow divider.

The clinical features of a basilar artery aneurysm can vary depending on the size, location, and severity of the aneurysm.

Some common clinical features of a basilar artery aneurysm include:

Headaches: Patients may experience severe and persistent headaches, which can be accompanied by nausea and vomiting.

Vision problems: A basilar artery aneurysm can cause visual disturbances, such as double vision, blurred vision, or partial vision loss.

Neurological deficits: Aneurysms can affect the functioning of the brainstem, leading to neurological symptoms such as numbness, weakness, or paralysis on one or both sides of the body.

Difficulty with coordination and balance: Aneurysms can also affect the cerebellum, which is responsible for coordination and balance. Patients may experience difficulty walking or performing fine motor tasks.

Speech and language problems: A basilar artery aneurysm can affect the areas of the brain responsible for speech and language, leading to difficulty speaking or understanding language.

Seizures: In some cases, a basilar artery aneurysm can cause seizures.

Loss of consciousness: In severe cases, a ruptured basilar artery aneurysm can cause loss of consciousness and coma.

Rare: Painful ophthalmoplegia

(large size, wide base, low bifurcation, and dysmorphic posteriorly projecting domes) frequently fail endovascular treatment.

With the pretemporal transzygomatic transcavernous approach, temporary clips are applied to a perforator-free zone of the basilar trunk, proximal to the superior cerebellar artery.

In the series of Krisht et al. complexity criteria in the 50 aneurysms included large or giant size in 27 patients, wide dysmorphic base in 18 patients, low bifurcation in 21 patients, posteriorly projecting dome in 11 patients, and dolichoectasia of the apex in three patients.

Twenty-five patients presented with subarachnoid hemorrhage. There were 14 men and 36 women between the ages of 32 and 76 years (mean, 52.2 yr). Forty-nine aneurysms (98%) were successfully clipped. There was no procedure-related mortality. Two patients died (one from delayed bowel ischemia and one from a vasospasm-related complication). There were three ischemia-related events, two of which were procedure-related (medial thalamic lacunar infarct, superior cerebellar distribution ischemia) and one which was a third distal middle cerebral cardiac embolus after stopping Coumadin (DuPont Pharmaceuticals, Wilmington, DE) for atrial fibrillation. Transient partial or complete occulomotor palsies occurred in all patients with full recovery as the rule, except in one patient. At discharge, Glascow Outcome Scale scores were 4 or 5 in 88% of the patients. At the 6-month follow-up examination, Rankin Outcome Scale scores were 0 to 2 in 92% of the patients.

The experience reintroduces microsurgery as a safe and more durable treatment option for the management of complex basilar apex aneurysms that tend to have a higher rate of failure with endovascular therapy 1).

A 70-yr-old woman presented with acute onset headache, nausea, and vomiting. A computed tomography (CT) head demonstrated a hyperdense prepontine mass which was further characterized as a partially thrombosed basilar aneurysm on CT angiography. After multiple failed attempts to access the vertebral artery via femoral and radial access the patient was taken to the operating room (OR) for surgical exposure of the right V1 segment and direct cannulation of the vertebral artery. The aneurysm was successfully coiled and the vertebral artery closed primarily. The patient was discharged home without any neurological deficits.

Partially thrombosed mid-basilar aneurysms are difficult to treat both surgically and endovascularly. Endovascular access to the aneurysm was very challenging requiring direct exposure and cannulation of the V1 segment to successfully embolize with coils and discuss the technical limitations of this approach 2).

Krisht AF, Krayenb├╝hl N, Sercl D, Bikmaz K, Kadri PA. Results of microsurgical clipping of 50 high complexity basilar apex aneurysms. Neurosurgery. 2007 Feb;60(2):242-50; discussion 250-2. PubMed PMID: 17290174.
Miller CA, Felbaum DR, Liu AH, Mai J, Alfawaz A, Lynes J, Armonda R. Direct Vertebral Artery Access for Coil Embolization of a Partially Thrombosed Mid-Basilar Trunk Aneurysm: Technical Limitations. Oper Neurosurg (Hagerstown). 2021 Jun 16:opab186. doi: 10.1093/ons/opab186. Epub ahead of print. PMID: 34133747.
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