Basilar artery trunk aneurysm: clinical and angiographic outcomes of endovascular treatment

Management and long-term follow-up of basilar trunk artery aneurysms: a single center experience

Basilar trunk artery (BTA) aneurysm is a serious disease, management of which remains controversial and challenging. We conducted a single-center retrospective cohort study of 67 patients with 72 BTA aneurysms diagnosed and treated at our institution. Finally, 39 participants underwent conservative treatment and 27 received endovascular surgical treatment, including one patient who underwent external carotid artery-radial artery-second segment of the posterior cerebral artery bypass. Data on patient clinical and aneurysm characteristics were collected and risk factors for unfavorable outcome and death analyzed. 33 patients presented with subarachnoid hemorrhage and 15 had a poor Hunt-Hess grade. Mean aneurysm diameter was 14.8 ± 12.6 mm and 28 aneurysms were > 15 mm. The total proportions of favorable outcome and mortality at discharge were 64.2% and 17.9%, respectively, while the corresponding proportions in the surgery groups were 53.6% and 17.9%. Moreover, we conducted long-term follow-up from initial diagnosis to 3 years. 57 patients had ≥ 6 months of follow-up and 31 patients reached 3 years. Mean follow-up time was 23.23 ± 21.58 months. The proportions of patients with unfavorable outcome and death increased in the group undergoing conservative treatment during the 3-year follow-up period. Further, the natural rupture rate increased from 43.3% initial diagnosis to 81.8% at 3 years. Poor Hunt-Hess grade was an important risk factor for unfavorable outcome and death. Undergoing surgery was a protective factor against death at six months; however, the complications rate was higher in the surgery group than that in patients receiving conservative treatment. In conclusion, although BTA aneurysm management remains controversial and unsatisfactory, patients with BTA aneurysm in the surgical intervention group appeared to have better outcomes.

Endovascular Treatment for Ruptured Intracranial Posterior Circulation Aneurysms: Complications and Clinical Outcomes

OBJECTIVE

To analyze the complications and long-term follow-up results of endovascular treatment for ruptured intracranial posterior circulation aneurysms and identify outcome predictors.

METHODS

A total of 194 patients with ruptured intracranial posterior circulation aneurysms treated at our center between January 2014 and June 2023 were included in this retrospective analysis. Factors influencing complications during hospitalization and clinical and angiographic outcomes were analyzed.

RESULTS

Complications occurred in 57 patients (29.4%) during hospitalization. The median clinical follow-up time was 46.5 (interquartile range 26.0-65.3) months, with favorable outcomes observed in 81.4% (158/194) and unfavorable outcomes in 18.5% (36/194) of cases, resulting in an overall mortality rate of 11.9% (23/194). The overall 1-year and 5-year complication-free survival rates were 76.4% and 70.7%, respectively. The overall 1-year and 5-year overall survival rates were 89.5% and 85.4%, respectively. Multifactorial analysis revealed that involvement of the basilar artery (P = 0.032) and perioperative external ventricular drainage (P < 0.001) were independent risk factors for complications during hospitalization, while advanced age (P = 0.030), poor World Federation of Neurosurgical Societies grade (P = 0.003), and use of closed cell design laser cut stents (P = 0.041) were independent risk factors for unfavorable outcomes during follow-up. Among the survivors, angiography follow-up was available for 139 patients, with a follow-up rate of 81.3% (139/171) and a median follow-up time of 8 months (interquartile range 6-12). During this period, 9 patients experienced aneurysm recanalization, and the complete occlusion rate was 85.6% (119/139).

CONCLUSION

Endovascular treatment is feasible and effective for treating ruptured intracranial aneurysms; however, there are still risks of complications and unfavorable clinical outcomes. The involvement of the basilar artery trunk increases the risk of complications, and the use of closed cell design laser cut stents is associated with unfavorable outcomes. Clinicians should be cautious to avoid the risk factors when treating ruptured posterior circulation aneurysms and strive to minimize the occurrence of complications and unfavorable clinical outcomes.

Endovascular treatment of ruptured basilar artery trunk aneurysms: complications and long-term outcomes

OBJECT

Treatment of ruptured basilar artery trunk (BAT) aneurysms is challenging, and is associated with high complication and mortality rates. Herein, we analyzed the complications, long-term outcomes, and outcome predictors of endovascular treatment for ruptured BAT aneurysms.

METHODS

Between January 2011 and July 2023, 36 patients with 36 ruptured BAT aneurysms underwent endovascular treatment at our institution. The postprocedural complications and clinical and angiographic outcomes were subsequently reviewed, and the risk factors for postprocedural complications were evaluated.

RESULTS

All 36 aneurysms in 36 patients were treated successfully. The median clinical follow-up time was 47.0 (IQR: 10.5, 84.5) months. Overall, complications occurred in 10 (27.8%) patients, including 3 (8.3%) deaths. Ischemic events occurred in seven (19.4%) patients, while three (8.3%) patients had shunt-dependent hydrocephalus, of whom one (2.8%) patient had both shunt-dependent hydrocephalus and ischemic events. The cumulative survival rates at 3 and 5 years were 94.1% and 87.8%, respectively. The cumulative 3- and 5-year complication-free survival rates were 75.0% and 70.0%, respectively. Multivariate Cox regression analysis revealed that diabetes mellitus (HR:8.76, 95%CI:2.35-32.69, p=0.001), and Glasgow coma scale score ≤ 12 before the procedure (HR:5.04, 95%CI:1.40-18.12, p=0.013) were associated with overall postprocedural complications. The complete aneurysm occlusion rate was 61.5% at a median angiography follow-up time of 6.0 (IQR: 5.0, 6.0) months.

CONCLUSIONS

Endovascular treatment is a safe and feasible option for treating ruptured BAT aneurysms. The rate of favorable outcomes at the final follow-up was satisfactory. However, postprocedural complications, particularly ischemic events, should be carefully considered.

Current research status and future of endovascular treatment for basilar artery aneurysms

Aneurysms occurring along the basilar artery (BA) account for <1% of all intracranial aneurysms. Endovascular treatment (EVT) in particular is recommended for large unruptured BA aneurysms and ruptured BA aneurysms. Given that EVT techniques vary, a detailed review of EVT for BA aneurysms is necessary. In this review, the following issues were discussed: the anatomy and anomalies of the BA, the classification of BA aneurysms, the natural history of BA aneurysms, the status of open surgery, the use of EVT for various types of BA aneurysms and the deployment of new devices. According to the findings of this review and based on our experience in treating BA aneurysms, traditional coiling EVT is still the optimal therapy for most BA aneurysms. However, in some BA aneurysms, flow diverter (FD) deployment can be used. In addition, there are also some new devices, such as intrasaccular flow disruptors and stent-like devices that can be used to treat BA aneurysms. In general, EVT can yield good clinical and angiographic outcomes for patients with BA aneurysms. In addition, recent new devices and techniques, such as new-generation FDs generated via surface modification and virtual reality simulation techniques, show promise for EVT for BA aneurysms. These devices and techniques may further improve EVT outcomes for BA aneurysms.

Endovascular Management of Basilar Artery Aneurysms: A Consecutive Series of 124 Patients

BACKGROUND

Currently, there is no established criterion for determining when interventional treatment is necessary or which strategy is appropriate for basilar artery (BA) aneurysms. Through this study, we aimed to propose an algorithm that can effectively determine the optimal endovascular treatment (EVT) option for BA aneurysms.

METHODS

We enrolled patients with BA aneurysms from June 2016 to December 2022 and performed procedures based on the algorithm. The analysis included demographic, clinical, and aneurysmal characteristics, procedural details, complications, angiographic outcomes, and clinical outcomes.

RESULTS

This study included 124 patients (mean age 55.0 years) with a BA aneurysm who underwent EVT. Of these, 21 aneurysms were treated in the setting of subarachnoid hemorrhage. The majority of the aneurysms were located at the basilar apex (74), followed by the basilar trunk (30) and vertebrobasilar junction (20). Coiling was used in 18.5% of the cases, while stent-assisted coiling embolization was chosen for 58.9%. Overlapping stents were used in 12.9%, flow diverter implantation in 3.2%, Y/T stent techniques in 4.8%, and stent adjunctive coiling with unilateral vertebral artery occlusion in only 1.6%. Procedure-related complications occurred in 15 patients (12.1%). The patients had a modified Rankin Scale score of 0.74 ± 1.62; 98 (86.7%) had a good prognosis with modified Rankin Scale scores ranging from 0 to 2 at the last follow-up. Digital subtraction angiography was performed on 105 (84.7%) patients, revealing that 101 (81.5%) achieved complete or near-complete occlusion.

CONCLUSIONS

The criteria for EVT of BA aneurysms based on multi-characteristics were safe and effective. However, further evidence from large cohort studies is needed.

Open surgical treatment of basilar artery aneurysms in the interventional therapy era

PURPOSE

The purpose of this study was to describe the effectiveness and evaluation of open surgical treatment of basilar artery aneurysms in the context of interventional therapy era, including surgical clipping and blood reconstruction, by retrospectively analyzing the clinical data of basilar artery aneurysms in our center.

METHODS

Patients with basilar artery aneurysms who were treated at our center were retrospectively included according to the inclusion and exclusion criteria. The basic clinical data, surgical approach, clinical follow-up and prognosis of the enrolled patients were analyzed in detail. In this study, the mRS score was applied to assess the neurological prognosis of the patients, and the relevant data were statistically analyzed using SPSS.

RESULTS

A total of 104 eligible patients treated at our center from January 2010 to August 2023 were included in this study, of which 67 were treated by open surgery and 37 by bypass. For the 67 patients with open surgical clipping, the mean age was 60.0 (52.0, 65.0) years. The maximum diameter of the aneurysms ranged from 2.0 mm to 54.0 mm, with a mean of 13.9 (10.0, 19.0) mm. The mean follow-up time was 38 (20, 58) months. At the last follow-up, 61 (91.0%) completely obliterated aneurysms and 6 (9.0%) incompletely obliterated aneurysms were found. The prognosis was good in 59 (88.1%) patients and poor in 8 (11.9%). After surgical clipping, the difference between complete and incomplete postoperative aneurysm elimination was statistically significant between the favorable and poor prognosis groups (P < 0.001). For the 37 bypass group patients, the mean age was 52.0 (45.5, 59.0) years. The maximum diameter of the aneurysm ranged from 10.5 mm to 55.0 mm, with a mean of 28.55 ± 12.08 mm. Bypass combined with proximal occlusion was performed in 18 (48.6%) patients, and bypass only was performed in 19 (51.4%) patients. Clinical follow-up was 19.0 (10.5, 43.0) months. There were 19 (51.4%) patients with complete elimination of the aneurysm, 13 (35.1%) with incomplete elimination of the aneurysm, and 5 (13.5%) with aneurysm stabilization. The prognosis was good in 32 (86.5%) patients and poor in 5 (13.5%) patients.

CONCLUSION

Treatment of basilar artery aneurysms is challenging. In the context of the rapidly evolving interventional therapy era, open surgery including surgical clipping and bypass is an ideal option for complex basilar artery aneurysms not amenable to intervention.

Management of basilar fenestration aneurysms: a systematic review with an illustrative case report

BACKGROUND

Basilar artery (BA) fenestration aneurysm (BAFA) is a rare phenomenon commonly accompanying other aneurysms. Treatment is challenging, and few cases have been reported. This review investigated the management outcomes of BAFAs.

METHODS

Publication databases were searched to identify studies evaluating outcomes of endovascular treatment (EVT) and microsurgical treatment of BAFAs from inception through 2021. Outcomes (clinical, angiographic, postoperative complications, and retreatment rates) were collected and analyzed. The authors present their case of a patient treated for a BAFA.

RESULTS

Including the authors' case, 184 patients with 209 BAFAs were reported in 68 studies. Most patients (130/175; 74.3%) presented with ruptured aneurysms, most commonly involving the proximal segment of the BA. Most BAFAs were small (52/103, 50.5%) and saccular (119/143, 83.2%). Most patients underwent EVT (143/184, 77.7%); the rest underwent microsurgery. Postoperative complications after EVT occurred in 10 (8.3%) of 120 patients, with 4 of the 10 experiencing strokes. At clinical follow-up, most EVT patients (74/86, 86.0%) showed good outcomes; 3.9% (2/51) had died. Most aneurysms managed with EVT (56/73, 76.7%) showed complete occlusion at follow-up; 7.3% (8/109) were retreated. Postoperative complications occurred in 62.2% (23/37) of microsurgical patients; 5 (21.7%) of the 23 experienced strokes. All patients showed good clinical outcomes at follow-up. Most aneurysms (22/28, 78.6%) treated microsurgically showed complete occlusion at angiographic follow-up, with no retreatment required.

CONCLUSION

BAFAs are often symptomatic; thus, treatment is challenging. By the 2000s, treatment had moved from microsurgical to endovascular modalities, with good clinical and angiographic outcomes.

Reconstructive endovascular treatment for basilar artery trunk aneurysms: complications and clinical and angiography outcomes

BACKGROUND

Basilar artery trunk aneurysms (BTAs) are rare intracranial aneurysms. We aim to investigate the procedural complications and clinical and angiographic outcomes of BTAs treated with reconstructive endovascular treatment (EVT).

METHODS

We retrospectively reviewed the data of 111 patients with BTAs who underwent reconstructive EVT during 2013-2022. The factors associated with procedural complications and clinical and angiographic outcomes were analyzed.

RESULTS

The study included 81 men and 30 women (median age 60 years). Overall, 26 (23.4%) cases presented with subarachnoid hemorrhage and 85 (76.6%) presented with unruptured aneurysms. Periprocedural ischemic and hemorrhagic complications occurred in 29 (26.1%) and 4 (3.6%) cases, respectively. The rate of favorable clinical outcomes was 83.8% (92/111) and the mortality rate was 14.4% (16/111). Angiographic follow-up data were available for 77/95 (81.1%) survivors; 57 (74.0%) and 20 (26%) aneurysms exhibited complete and incomplete obliteration, respectively. Old age, high Hunt and Hess grades (IV-V), hemorrhagic complications, and increased aneurysm size were independent risk factors for unfavorable clinical outcomes (p<0.05). Increased aneurysm size and incomplete aneurysm occlusion on immediate angiography were independent risk factors for incomplete occlusion during follow-up (p<0.05).

CONCLUSION

Reconstructive EVTs are a feasible and effective treatment for BTAs but are associated with a high risk of ischemic and hemorrhagic complications and a high mortality rate. Larger aneurysms may predict unfavorable clinical outcomes and aneurysm recurrence during follow-up. Hemorrhagic complications may predict unfavorable clinical outcomes, whereas immediate complete aneurysm occlusion may predict total occlusion during follow-up.

Prognostic Factors in Patients with Unruptured Vertebral and Basilar Fusiform Aneurysms Treated with Endovascular Procedures : A Single Center Retrospective Analysis

PURPOSE

Large vertebral and basilar fusiform aneurysms (VFA) are sometimes difficult to cure by endovascular treatment (EVT). We aimed to elucidate indicators of poor outcomes of EVT in patients with VFAs.

METHODS

Clinical data from 48 patients with 48 unruptured VFAs in the Hyogo Medical University were retrospectively analyzed. The primary outcome was defined as satisfactory aneurysm occlusion (SAO) according to Raymond-Roy grading scale. The secondary and safety outcomes were a modified Rankin scale (mRS) score of 0-2 at 90 days, retreatment, major stroke, and aneurysm-related death after EVT.

RESULTS

The EVT included stent-assisted coiling (n = 24; 50%), flow diverter (n = 19; 40%), and parent artery occlusion (n = 5; 10%). The SAO was less frequently observed in large or thrombosed VFAs at 12 months (64%, p = 0.021 and 62%, p = 0.014, respectively), especially when the aneurysms were both large and thrombosed (50%, p = 0.0030). Retreatment was more common in large aneurysms (29%, p = 0.034), thrombosed (32%, p = 0.011), and large thrombosed aneurysms (38%, p = 0.0036). Although the proportion of mRS 0-2 at 90 days and major stroke showed no significant differences, that of post-treatment rupture was significantly larger in large thrombosed VFAs (19%, p = 0.032). Aneurysm-related death occurred by aneurysm rupture and was more frequent in large thrombosed VFA (19%, p = 0.032). Multivariate analysis showed SAO at 12 months was less common (adjusted odds ratio, OR: 0.036, 95% confidence interval, CI 0.00091-0.57; p = 0.018), and retreatment was more common (adjusted OR 43, 95% CI 4.0-1381; p = 0.0012) in large thrombosed VFA.

CONCLUSION

The large thrombosed VFAs were associated with poor outcomes after EVT including flow diverter.

Complications after endovascular treatment of large basilar trunk aneurysms

BACKGROUND AND PURPOSE

Large basilar trunk aneurysms (BTAs) have a poor natural history if left untreated and always pose a significant challenge to endovascular treatment. The present study aimed to analyze the complications after endovascular treatment of large BTAs.

METHODS

This was a retrospective, observational, cohort study. Between January 2015 and September 2022, 9116 patients with intracranial aneurysms came to our institution for management, of which 34 patients with 34 large (≥10 mm) BTAs were treated with endovascular treatment. Postprocedural complications, clinical, and angiographic outcomes were evaluated.

RESULTS

All 34 patients (34 aneurysms) were successfully treated, of which 13 aneurysms were treated with flow diversion (FD), and 21 aneurysms were treated with stent-assisted coiling. Neurological complications occurred in 12 (35.3%) patients, with 7 (20.6%) deaths. Ischemic complications occurred in 10 (29.4%) patients, and 4 (11.8%) patients experienced hemorrhagic events. The incidences of favorable outcomes at discharge and last follow-up were 85.3% and 75.8%, respectively. The cumulative survival rates at 1 and 3 years were 86.5% and 71.4%, respectively. Unilateral vertebral artery sacrifice was associated with postprocedural complications (hazard ratio: 3.74, 95% confidence interval: 1.06-13.25, p = 0.041). The postprocedural complication rates were comparable between patients treated with FD and stent-assisted coiling (5/13, 38.5% vs. 7/21, 33.3%, p > 0.99). Angiography follow-up was available for 21 patients, and complete aneurysm occlusion was observed in 16/21 (76.2%) aneurysms.

CONCLUSIONS

Endovascular treatment might be a feasible option for treating large BTAs. However, clinicians should be alerted to procedure-related complications, especially ischemic complications that cause disability or death. Unilateral vertebral artery sacrifice might be associated with postprocedural complications.

Interventional treatment of basilar trunk artery aneurysms associated with situs inversus totalis: A case report

Basilar trunk artery aneurysm (BTAA) has an overall low incidence in intracranial aneurysm, but its rupture is associated with high morbidity and mortality in older people. Situs inversus totalis (SIT) is a rare congenital abnormality characterized by visceral rotation and vascular abnormalities. It has been described in several uncommonly clinical cases, along with middle cerebral artery aneurysms and large carotid cavernous aneurysms. However, the association between interventional embolization for BTAA and SIT has not been reported. We described the angiography findings and interventional treatment of the association of BTAA with SIT.

Reconstructive Endovascular Treatment of Basilar Trunk and Vertebrobasilar Junction Aneurysms: A Review of 77 Consecutive Cases

Background

Basilar trunk and vertebrobasilar junction (BTVBJ) aneurysms have a poor prognosis and are challenging to treat.

Objective

This study aimed to evaluate the efficacy of reconstructive endovascular treatment for BTVBJ aneurysms and explore a treatment selection paradigm.

Methods

Clinical and angiographic data from 77 patients with 80 BTVBJ aneurysms who underwent endovascular treatment with flow diverters (FDs) or conventional stent-assisted coiling between January 2016 and December 2020 were retrospectively analyzed. Aneurysm characteristics and treatment outcomes were compared between treatment groups.

Results

Among the 77 study patients, 34 (44.2%) were treated with FDs and 43 (55.8%) with conventional stent-assisted coiling. Overall, 72.7% of patients achieved favorable clinical outcome at follow-up. The rate of procedure-related complications was 23.4%. The aneurysm occlusion rate at last follow-up did not differ between the FD and conventional stent groups (79.2% vs. 77.1%, p = 0.854). Although the occlusion rate immediately after the procedure was lower in the FD group (29.4%), incidence of progressive occlusion was significantly higher (62.5 vs. 5.7%; p < 0.001). The proportion of patients with large and giant aneurysms (≥10 mm) was significantly higher in the FD group (70.6 vs. 34.8%; p = 0.002). In patients with large or giant aneurysms, favorable clinical outcome at last follow-up was achieved in 75% of patients in the FD group but only 43.8% of patients in the conventional stent group (p = 0.046). Moreover, the complication rate was lower in the FD group, but the difference was not significant (20.8 vs. 37.5%; p = 0.247). The same analyses were performed for patients with small aneurysms (<10 mm) but no significant differences between the two groups were observed.

Conclusion

Endovascular treatment of small BTVBJ aneurysms using either FDs or conventional stents was feasible and effective. In patients with large or giant aneurysms, treatment using FDs achieved higher rates of occlusion and favorable clinical outcome at last follow-up than conventional stent-assisted coiling.