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Basilar artery trunk saccular aneurysms: morphological characteristics and management

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Abstract

The purpose of this retrospective study was to report the morphological characteristics and results of surgical and endovascular treatment of basilar artery (BA) trunk saccular aneurysms. Twenty-two patients with 22 BA trunk saccular aneurysms underwent surgery including endovascular intervention. In this series, BA trunk aneurysms showed characteristic features such as so-called lateral aneurysm (41%), multiple aneurysms (32%), including two de novo aneurysms, and various vascular anomalies. Eleven craniotomies for neck clipping were performed for 11 ruptured aneurysms. However, in one of these cases, we abandoned neck clipping, because of concern for neck tearing, and embolized it later. Five ruptured and five unruptured aneurysms were successfully treated by endovascular surgery. Another one incompletely embolized aneurysm had grown to a huge size, and the patient underwent a Hunterian ligation with a flow reconstruction. The unusually high incidence of various associated vascular anomalies suggests that focal wall weakness must be based on the mechanism of aneurysm initiation. Most patients presented with subarachnoid hemorrhage. The pretreatment neurological state was predictive for clinical outcome. And, clinical outcomes in this series were not affected by the choice of treatment. However, considering that three of 11 surgical cases needed subsequent treatment, endovascular surgery should be considered as a first choice.

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Authors and Affiliations

  1. Department of Neurosurgery, Neurological Institute, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan

    Takashi Higa, Hiroshi Ujiie, Koichi Kato & Tomokatsu Hori

  2. Department of Neurosurgery, Asahikawa Red Cross Hospital, Asahikawa, Japan

    Hiroyasu Kamiyama

Authors
  1. Takashi Higa
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  2. Hiroshi Ujiie
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  4. Hiroyasu Kamiyama
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  5. Tomokatsu Hori
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Correspondence to Takashi Higa.

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Kazuhiko Nozaki, Otsu, Japan

Aneurysms of basilar artery trunk are still difficult to obtain complete cure by open surgery, and recent advancements in endovascular surgery bring favorable outcomes in some selected patients. The authors summarized a relatively large series of basilar artery (BA) trunk saccular aneurysms from 22 patients (more than 11 mm in diameter in six cases) who underwent open surgery and/or endovascular surgery at their institute with relatively good clinical outcomes. Their treatment strategy has changed since 1996, after which endovascular surgery is the first choice. Adequate skull base techniques and preservation of perforators are mandatory for complete direct clipping of these lesions, and flow alteration techniques should be the last choice considering surgical morbidity and curability. Lateral type of aneurysms seems to be suitable for endovascular surgery in terms of curability, and further development in materials such as coils and stents may increase amenable cases for endovascular surgery. Although the authors discussed about the possible relationship between the incidences of vascular anomaly and aneurysms, the vascular anomaly itself does not necessarily mean the weakness and fragility of vascular walls. They also discussed about multiplicity and vascular wall fragility, but it is difficult to conclude that basilar trunk saccular aneurysms occur based on vascular fragility because of small sample size. Basilar artery trunk aneurysms are still challenging diseases, and surgical indication should be cautiously applied depending on location and morphology of aneurysms and patient’s conditions.

Peter Vajkoczy, Berlin, Germany

The treatment of basilar artery trunk aneurysms still remains one of the major challenges in modern neurosurgery and interventionell neuroradiology. In the present study, Prof. Hori and his colleagues report on their experiences in treating 22 patients presenting with basilar artery trunk saccular aneurysms, most of them following rupture and SAH. Half of the patients have been treated by surgery applying skull approaches and advanced clipping strategies. The others have been treated by endovascular surgery. The authors have to be congratulated for their excellent clinical and morphological results. This applies both to surgical and endovascular treatment. Their study clearly demonstrates what modern subspecialized and interdisciplinary neurosurgery can provide excellent treatment results to patients presenting with these challenging lesions. The authors clearly state that today endovascular surgery should be the treatment modality no. 1 for saccular aneurysms along the basilar trunk, especially since the surgical approach by itself is often associated with significant comorbidities, and clipping of the aneurysm is most often limited by the narrow space. Therefore, complete obliteration of the aneurysm can often not be provided by surgery. In contrast, the endovascular approach is clearly the less invasive strategy, and particularly in this region along the basilar artery trunk, the rate of incomplete aneurysm obliteration is comparable to microsurgery. On the other hand, this study again demonstrates that, in case of basilar artery trunk aneurysms that are not well suited for endovascular therapy, microsurgery still remains an excellent therapeutic option.

Carl Muroi, Zurich, Switzerland

This study is about a single center experience in treating a rare type of aneurysm. The authors present good result in treating basilar artery trunk aneurysm by either surgical clipping and/or endovascular coiling. The authors report that the outcome was not affected by the choice of treatment, though it must be assumed that the clipping group is similar to a “historical control group” since after introduction of endovascular surgery the majority was rather coiled than clipped. Therefore, the follow-up period of the “clipping group” must be assumed to be longer than the “coiling group,” which ranged from 9 to 72 months with a mean of 28.8 months. The incidence of recanalization and/or rebleeding after coiling might rise when the follow-up period becomes equal to the “clipping group.” This circumstance makes the comparison of these groups and its interpretation a little bit difficult in my opinion.

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Higa, T., Ujiie, H., Kato, K. et al. Basilar artery trunk saccular aneurysms: morphological characteristics and management. Neurosurg Rev 32, 181–191 (2009). https://doi.org/10.1007/s10143-008-0163-3

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