Endovascular treatment for basilar tip aneurysms associated with moyamoya disease / 第二军医大学学报

Objective To assess the safety and efficacy of endovascular treatment for basilar tip aneurysms associated with moyamoya disease. Methods Seven patients with basilar tip aneurysms associated with moyamoya disease were treated by endovascular embolization in our department between Oct. 2006 and Jul. 2013. Two patients were treated by pure coiling and the others were treated by stent-assisted coiling. The immediate angiographic result was evaluated by Raymond scale. Postoperative angiographic and clinical follow-ups were obtained in all the 7 cases, and the clinical outcomes were evaluated by the modified Rankin score (mRS). Results All the 7 patients successfully received endovascular embolization without procedure-related complications. Immediate angiographic results showed complete occlusion in 3 cases, neck residual in 2, and partial occlusion in 2. Postoperative angiographic follow-ups were obtained for a mean of (10. 4 ± 3. 5) months, with complete occlusion found in 6 patients and stable in 1 patient. No progressive thrombosis or in-stent occlusion were detected by follow-up angiograms in the stent group. Clinical follow-ups were obtained for a mean of (21. 1 ± 15. 8) months and all the patients reported good outcomes (mRS 0-2). Conclusion Our data suggest that endovascular embolization is a safe and efficient treatment for basilar tip aneurysms associated with moyamoya disease. Stent-assistance might be a safe and effective option for the large or wide-necked aneurysms, though the long-term safety still remains to be confirmed.

Coil Embolization of a Ruptured Basilar Tip Aneurysm Associated with Bilateral Cervical Internal Carotid Artery Occlusion: A Case Report and Literature Review

We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.

Staged Y-shaped Stent Assisted Coil Embolization in a Wide-Neck Basilar Tip Aneurysm: Case Report / 신경중재치료의학

A 67-year-old male presented with a subarachnoid hemorrhage and was found to have a basilar artery (BA) tip aneurysm, which was incorporated to both posterior cerebral arteries (PCAs). First, he was treated with the single stent, which was deployed from P1 segment of the right PCA to BA, and coil embolization was done. Follow-up angiogram at 18 months revealed coil compaction of the aneurysm. Therefore, we accomplished the Y-configured dual stent assisted coil embolization. Follow-up angiogram at 30 months revealed no recanalization of aneurysm and patent blood flow of both PCAs. In conclusion, staged Y-shaped stents assisted coil embolization is an alternative treatment option in a wide-neck basilar tip aneurysm decreasing the extent of coil compaction of aneurysm and preserving an incorporated vessel.

Surgical Approaches to Basilar Tip Aneurysms

In an attempt to decide the surgical approach to basilar tip aneurysms, 27 cases of ruptured aneurysms were retrospectively analysed for size of aneurysm, direction of fundus and height of bifurcation. The fundus pointed superiorly in 18 cases, posteriorly in six, and anteriorly in three. The aneurysm neck was positioned as follows : very high(more than 20mm above midsellar) in one case, high(between 10mm and 20mm above midsellar) in 13, mid(from midsellar to 10mm above it) in nine, low(from midsellar to sellar floor) in two, and very low(below the sellar floor) in two. In 11 cases, surgery followed the conventional pterional approach ; in eight, the orbitozygomatic ; in three, the pterional-anterior temporal ; in two, the subtemporal ; in two, the anterior transpetrosal ; and in one, the temporopolar. In complex aneurysms or basilar bifurcation was at an unusual height, surgery involved a skull-base or modified technique based on a conventional pterional and subtemporal approach. On the basic of our surgical data and related findings, our suggestious are as follows : surgery involving basilar tip aneurysms with an extremely high-positioned neck should follow the transsylvian route above the carotid bifurcation, or use a transventricular or intravascular approach ; in cases with a high positioned-neck, the orbitozygomatic temporopolar or transzygomatic subtemporal approach should be used ; in cases with a normal-positioned neck, the combined pterional-anterior temporal approach, which has a much wider operative field and wider angle of vision than the classic pterional and subtemporal approach ; in cases with a low-positioned neck, the subtemporaltranstentorial) pterional, with resection of the posterior clinoid process ; and in cases with a very low-positioned neck, the transpetrosal approach.

Zygomatic Approach for High Placed Basilar tip Aneurysm: Case Report

The surgical approach to high placed basilar tip aneurysm presents a special technical problem. The author experienced the case of a 70-year-old female who developed subarachnoid hemorrhage due to rupture of superoposteriolry projecting and high placed basilar tip aneurysm. For the purpose of minimal brain retraction and excellent exposure, the author used a technique which was a combination of the detachment of the zygomatic arch and pterional approach. This aneurysm was clipped successfully and easily with the zygomatic approach, but under the anesthesia there was a severe subcutaneous emphysema and pneumothorax which was produced through a tracheostomy site.