Microsurgical clipping of ruptured basilar artery perforator aneurysms in the endovascular era: A single-center experience

BACKGROUND

Basilar artery perforator aneurysms (BAPAs) are a rare subset of intracranial aneurysms, accounting for <1% of cases. The natural history of BAPAs is unknown, and a standardized management approach is lacking. This report presents the largest cohort of surgically treated BAPAs to date, addressing gaps in the literature and guiding management strategies.

METHODS

A single-center retrospective analysis was conducted utilizing a prospectively maintained, IRB-approved database, which included a series of seven consecutive patients treated for BAPAs. The dataset included patient characteristics, surgical details, postoperative outcomes, complication rates, and imaging and clinical follow-up data. It also featured case illustrations.

RESULTS

A total of seven patients were included, all presenting with subarachnoid hemorrhage. The median age was 60 years (IQR: 56.5, 69), and 57% were female. The most common location of the perforators was mid-basilar (43%). Five cases (71.4%) had aneurysms that went undetected on the initial angiogram. All patients underwent microsurgical clipping as their treatment. Post-surgery, oculomotor nerve palsy was observed in four patients (57.1%), and three (42.8%) experienced hemiparesis, which improved during their hospital stay. Follow-up diagnostic angiograms revealed a complete aneurysm occlusion of all aneurysms with no residual filling.

CONCLUSION

Microsurgical clipping is an effective treatment option for BAPAs when observation and endovascular interventions are not feasible. Treatment decisions should be guided by presentation, aneurysm characteristics, and overall risk profile. A multicenter registry is needed to establish standardized management guidelines. A multidisciplinary, tailored approach is recommended to optimize individual patient outcomes.

Basilar artery perforator aneurysms: a comparison with non-perforator saccular aneurysms

BACKGROUND

Basilar artery perforator aneurysms (BAPAs) are rare. There is no systematic description of their presentation, imaging, natural history and outcomes and how these compare to conventional non-perforator aneurysms. Thus, the authors in this study aimed to compare BAPAs to non-perforator aneurysms.

METHODS

Cases were identified from a prospective neurovascular database, notes and imaging retrospectively reviewed and compared to a consecutive series of patients with non-perforator aneurysms. Blood volume on CT and vessel wall imaging (VWI) were compared to controls.

RESULTS

9/739 patients with aneurysmal subarachnoid haemorrhage (aSAH) harboured BAPAs. Compared to 103 with aSAH from posterior circulation aneurysms, they were more likely to be male (6/9, p = 0.008), but of equal severity (4/9 poor grade, p = 0.736) and need of CSF drainage (5/9, p = 0.154). Blood volume was similar to controls (30.2 ml vs 26.7 ml, p = 0.716). 6/9 BAPAs were initially missed on CTA. VWI showed thick (2.9 mm ± 2.7) bright enhancement (stalk ratio 1.05 ± 0.12), similar to controls with ruptured aneurysms (0.95 ± 0.23, p = 0.551), and greater than unruptured aneurysms (0.43 ± 0.11, p < 0.001). All were initially managed conservatively. Six thrombosed spontaneously. Three grew and had difficult access with few good endovascular options and were treated through a subtemporal craniotomy without complication. None rebled. At 3 months, all presenting in poor grade were mRS 3-4 and those in good grade mRS 1-2.

CONCLUSIONS

Despite their small size, BAPAs present with similar volume SAH, WFNS grade and hydrocephalus to other aneurysms. They are difficult to identify on CTA but enhance strikingly on VWI. The majority thrombosed. Initial conservative management reserving treatment for growth was associated with no rebleeds or complications.

Spontaneous subarachnoid hemorrhage caused by ruptured aneurysm of basilar trunk perforator: a case report and literature review

Background

Aneurysm of basilar perforator was rarely reported in the literature. It is difficult to treat due to its small size and deep-seated location. Excessive treatment may cause complications that resulted from ischemic events of parent perforators. Therefore, it is important to make clinical strategy for such patients to improve the prognosis.

Case presentation

One case, who presented as spontaneous subarachnoid hemorrhage, despite the negative result in computed tomography angiography firstly, was diagnosed angiographically as a ruptured aneurysm of the basilar perforator. A good clinical outcome of the case was achieved during the follow-up after conservative observation for 2 months, as well as the disappearance of previous lesion from angiography.

Conclusions

Aneurysm located at perforator of basilar trunk was rare and difficult to treat. Conservative observation for certain cases with periodic angiography follow-up was considered in order to prevent the patients from potential iatrogenic effects.

Comparison between stenting and conservative management of posterior circulation perforator aneurysms: Systematic review and case series

PURPOSE

Posterior circulation perforator aneurysms (PCPAs) are a rare type of intracranial aneurysms whose natural history and optimal clinical management are still largely unexplored. This study aims to report our experience with treating ruptured PCPAs and to provide a systematic review of the literature to compare the two most established treatment options, endovascular stenting, and conservative management including administration of antifibrinolytic drugs and watchful waiting.

METHODS

We performed a systematic review of the literature following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Major databases were searched for case reports and case report series written in the English language between 1995 and 2020. Additionally, we retrospectively reviewed our stroke center database for cases of ruptured PCPAs between January 2014 and July 2020. Endovascular stenting and conservative treatment were compared using endpoints, including favorable outcome rate (mRS 0-2), occlusion rate, mortality rate, periinterventional complication rate, and re-hemorrhage rate.

RESULTS

We identified 31 patients treated endovascularly using stents and 33 patients treated conservatively, with the administration of antifibrinolytic drugs in 3 of them. Our analysis showed no statistically significant difference between the groups, except for the occlusion rate.

CONCLUSIONS

The optimal management strategy of PCPAs is still unknown, but stenting can be considered as an effective occlusion method with an acceptable complication rate. Preventive ventricular drainage may be necessary due to the high hydrocephalus rate encountered in ruptured PCPAs.

A systematic review of non-trunk basilar perforator aneurysms: is it worth chasing the small fish?

BACKGROUND AND PURPOSE

Non-trunk basilar artery perforator aneurysms (BAPAs) are rare intracranial vascular pathologies that have long been underdiagnosed, under-reported, and under-analyzed. We performed a systematic review of the efficacy and safety endpoints between conservative and active treatment approaches for non-trunk BAPAs.

METHODS

Major databases were analyzed for relevant publications between 1995 and 2019. Studies comparing the outcomes between conservative and active treatment approaches such as coiling, stenting, clipping, liquid embolization, and flow diversion were included. Mortality rate, rate of permanent neurological deficit as determined by the modified Rankin Score (mRS), rate of second treatment occurrence, and perioperative complication rate were also assessed.

RESULTS

A total of 24 studies, including 54 patients with 56 non-trunk BAPAs, were included. The mean maximum aneurysm diameter was 2.70 mm (range 1-10). A diagnosis was achieved with the initial DSA in 50.0% (27/54) of the patients. A conservative approach was used in 16 patients while active treatment was used in the other 38. Thirteen of 15 (86.7%) patients in the conservative group and 27/34 (79.4%) in the active treatment group had an mRS score 0-2. A non-significant higher odds of a positive outcome was observed in the conservative group (OR 1.51, 95% CI 0.50 to 4.54). The event-related mortality rate was 3.55% (3/54) with one procedure-related death in the active treatment group.

CONCLUSIONS

In patients with non-trunk BAPAs unamenable to active treatment, conservative approaches may result in acceptable functional outcomes and low morbidity. Small sample sizes and under-reporting of outcomes warrant further study.

Should we treat aneurysms in perforator arteries from the basilar trunk? Review of 49 cases published in the literature and presentation of three personal cases

Basilar trunk perforator artery aneurysms are rare. Their diagnosis and treatment are difficult, controversial, and challenging. Analysis of 52 cases (49 documented in the literature and three personal cases) clearly shows a re-bleeding rate of 15% in patients whose aneurysm has not been occluded and 0% in treated patients ( p < 0.05). The most effective treatment, and the one that presents the least complication, is double-stenting across the basilar trunk.

Super-selective coil embolization of a basilar perforator artery aneurysm previously treated by the stent-in-stent technique, using an extremely soft bare coil delivered through a one-marker microcatheter

Background Aneurysms of the perforating arteries arising from the basilar artery trunk are rare and represent a therapeutic challenge. Methods A basilar perforator aneurysm was initially treated by the stent-in-stent technique. Enlargement of the aneurysm was seen on follow up and the sac was secondarily coiled using two extremely soft bare coils, delivered through a one-marker microcatheter. Results At 6 months, the patient had a modified Rankin Scale score of 0 and cerebral arteriography demonstrated complete occlusion of the lesion. Conclusions We describe, as far as we are aware, the first case of basilar perforator aneurysm occlusion using extremely soft bare coils, inserted through the mesh of two stents previously placed in the basilar trunk.

Basilar artery perforator aneurysms (BAPAs): review of the literature and classification

Basilar artery perforator aneurysms (BAPAs) are an uncommon subtype of perforating artery aneurysms, with only 18 published cases since their initial description in 1996 by Ghogawala et al To date, there are only seven published cases of ruptured BAPAs treated using endovascular techniques. Given the rarity of these aneurysms, the natural history and ideal approach to treatment has not been established. We describe a new endovascular approach to treating these aneurysms using staged telescoping stents, summarize all published cases of BAPAs, and present a unique classification system to enable future papers to standardize descriptions.

An unusual aneurysm of a basilar perforating artery presenting with a subarachnoid haemorrhage

A 65-year-old man had a perimesencephalic subarachnoid haemorrhage with normal angiography initially. After a rebleed 5 days later, a repeat angiogram revealed a pea-like aneurysm a short distance behind and below the basilar bifurcation. It was not amenable to endovascular treatment and the feeding vessel was coagulated and divided at open surgery via a sub temporal approach. He developed a right hemiparesis and dysphasia, from which he slowly recovered. Basilar perforating artery aneurysms are extremely rare, with only 4 previous cases reported.