Basilar Perforator Artery Aneurysm: Spontaneous Subarachnoid Hemorrhage Caused by the Rupture of a Small Aneurysm of a Pontine Perforating Vessel Originating from the Upper Basilar Artery Trunk; Conservative Management, with Fatal Outcome after Recurrent Hemorrhages and Due to Severe Vasospasm
A 62-year-old male patient presented to a local hospital with an acute onset of headache and nuchal stiffness. Non-contrast cranial CT (NCCT) showed subarachnoid hemorrhage (SAH) in the basal cisterns and also a minor intraventricular hemorrhage (Hunt and Hess I, Fisher IV). The patient was transferred to our hospital for further treatment. A diagnostic angiogram (DSA) performed on the following day did not reveal the site of the bleeding, notably there was no aneurysm present. The contour of the V4 segment of the left vertebral artery (VA) appeared irregular and a dissection was suspected and presumed to be the source of the SAH. Therefore, a second DSA examination was planned 10 days after the bleeding. However, 2 days later the patient deteriorated clinically. NCCT images showed repeat bleeding with early hydrocephalus. After placement of an external ventricular drain (EVD) the patient improved significantly. However, the patient refused to have a second DSA examination. Another 9 days later, and 12 days after the first hemorrhage, the patient suddenly became comatose. The CCT scan showed a third episode of hemorrhage with herniation of the cerebellar tonsils and occlusive hydrocephalus. The patient underwent a DSA at this stage, which showed vasospasm of the basilar artery (BA) and the cerebellar arteries and a small aneurysm of a perforating pontine artery. A dissection of the left VA was not confirmed. Another 4 h after the DSA the patient deteriorated further and bilateral pupils became dilated. MRI revealed early signs of severe ponto-cerebellar infarct with downward tonsillar herniation. NCCT on the following day confirmed ascending transtentorial herniation. A sequence of three recurrent SAHs, post-hemorrhagic vasospasm of the BA artery and cerebellar arteries and eventually a ponto-cerebellar infarct had occurred. The patient died 4 h after the final NCCT scan. Autopsy revealed a small aneurysm of a perforating pontine artery originating from the basilar artery. The phenomenon of small aneurysms of perforating pontine arteries, their natural history and management options are the topics of this chapter.
KeywordsBasilar perforator artery Small aneurysm SAH Posterior circulation Conservative management Recurrent aneurysm hemorrhage Vasospasm
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