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Basilar trunk perforator artery aneurysms. Case report and literature review

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Abstract

Perforator artery aneurysms of the basilar trunk are rarely described in the literature. In addition to presenting our own case, we performed a PubMed search to comprehensively illustrate demographics, hemorrhage patterns, and treatment outcomes for these lesions. We found 12 patients with basilar perforator artery aneurysms. Mean patient age was 47.3, and there was a 3:1 male to female predominance. All patients had ruptured aneurysms, though all were clinically low or medium grade (I–III). Six patients had diffuse subarachnoid hemorrhage (SAH), and six had prepontine and/or perimesencephalic hemorrhage patterns. All aneurysms arose off middle or rostral basilar perforator arteries; mean aneurysm size was 4.5 mm. All except one was partially thrombosed, and 4 out of 12 patients did not have their aneurysms detected on initial angiography (33 %). Seven were treated surgically, two were coiled, and three were observed. At last follow-up, all were occluded, and 8 out of 12 patients were neurologically intact (67 %). Of seven patients that were not treated with early intervention, one suffered a rebleed over a combined total of 37.3 months of observation. Two aneurysms amenable to coiling were occluded without complication. Three of seven patients treated surgically had transient complications, though five were neurologically intact at follow-up. Basilar perforator artery aneurysms may be sources of hemorrhage in diffuse or perimesencephalic/prepontine SAH. While endovascular coiling is an excellent option if parent vessel anatomy allows for catheterization, many are unamenable to endovascular treatment. Surgical obliteration via proximal occlusion or trapping is a safe and effective means of treating these aneurysms.

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Authors and Affiliations

  1. Department of Neurological Surgery, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA

    Bradley A. Gross & Rose Du

  2. Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, 02115, USA

    Ajit S. Puri

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  1. Bradley A. Gross
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  2. Ajit S. Puri
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  3. Rose Du
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Correspondence to Rose Du.

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Comments

Yavor Enchev, Varna, Bulgaria

Gross et al. presented a single case of a perforator artery aneurysm of the basilar trunk, which based on their thorough PubMed search represents the 12 such a case up to the present. The patients were predominantly males within the end of their fifth decade during the onset of the symptoms. All patients, due to aneurysm rupture, suffered SAH with Hunt and Hess grades I–III at admitting hospital. CT scans revealed two types of SAH—focal, in the prepontine and/or perimesencephalic cisterns, and diffuse pattern. The aneurysm imaging characteristics included: origin—over the caudal basilar trunk, average size—4.5 mm, partially thrombosed—11 out of 12, and initially angiographically undetectable—one third. Seven patients underwent surgical treatment, two (the largest ones) endovascular coiling, and three observation. At the last follow-up, all aneurysms were occluded as 67 % of the patients were neurologically intact. The two cases with coiling were without any complications. In the group of the surgically treated patients, three cases with transient complications and five neurologically intact were found. Only one case of rebleeding was reported.

The authors concluded that the basilar perforator artery aneurysms may cause focal or diffuse SAH. As these typically small aneurysms may be the source of SAH in some cases of presumed “angiographically negative” perimesencephalic SAH, the infrequent aneurysms suitable for endovascular coiling may be treated with excellent results. However, the majority required open surgical treatment with compatible effectiveness and safety. The basilar perforator aneurysms are extremely rare and with potentially more benign natural history due to their origin from low flow arteries and their propensity to spontaneous thrombosis.

Takeshi Mikami, Sapporo, Japan

The authors reported on basilar trunk perforator artery aneurysms. Because this type of aneurysm is extremely rare and little is known about its natural history, this review is valuable for several reasons. First, a case review of the aneurysms will enable neurosurgeons to understand that aneurysm is one cause of angiographically negative perimesencephalic subarachnoid hemorrhage. Second, treating the lesion may be challenging because of its small size, deep location, and complex surrounding structure. Questions remain regarding the safety of surgical treatment and overall neurological outcomes in patients with basilar trunk perforator artery aneurysms. Notably, the aneurysms in 6 of the 12 patients described in this report were treated without preserving the parent artery, and there were no resulting ischemic complications. The lack of ischemic complications in patients whose parent artery was not preserved suggests that loss of the perforating artery is clinically well tolerated. Collateral flow through the basilar perforating artery is interesting pathophysiological data.

The recent review of lenticulostriate artery aneurysms demonstrates that treatment of these aneurysms can be an appropriate, effective, and safe therapy, and this may also apply to basilar perforating artery aneurysms. Development of the endovascular treatment device has shifted lenticulostriate artery aneurysm treatment to endovascular therapy. Although the authors mentioned that the size of the parent artery is not large enough to allow catheterization, endovascular treatment will be the primary treatment choice for this type of aneurysm in the future, especially if it is not necessary to preserve the parent artery.

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Gross, B.A., Puri, A.S. & Du, R. Basilar trunk perforator artery aneurysms. Case report and literature review. Neurosurg Rev 36, 163–168 (2013). https://doi.org/10.1007/s10143-012-0422-1

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  • DOI: https://doi.org/10.1007/s10143-012-0422-1

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