Combined deconstructive and reconstructive treatment of a giant vertebrobasilar fenestration aneurysm

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Abstract

Aneurysms associated with a vertebrobasilar fenestration are rare lesions and can grow to a giant size, presenting significant therapeutic challenges. Endovascular treatment of these aneurysms has traditionally been with coiling; however, flow diverter placement within the fenestration arms has recently proven to be a viable treatment strategy. The authors present a case of a giant vertebrobasilar fenestration aneurysm in a patient presenting with a cranial nerve VI palsy. The lesion was treated by using a combination of flow diverter placement and vertebral artery sacrifice. The nuances of flow diversion therapy for these aneurysms and the management of intra- and postoperative complications are discussed.

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Most cited references 5

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Aneurysms of the vertebrobasilar junction: incidence, clinical presentation, and outcome of endovascular treatment.

J P P Peluso, J Deutekom, Jo Peluso … (2007)

The aim of this retrospective study was to report the incidence, clinical presentation, and midterm clinical and imaging results of endovascular treatment of 10 aneurysms of the vertebrobasilar junction. Between January 1995 and January 2007, 2112 aneurysms were treated in our institution. Ten aneurysms in 10 patients were located on the vertebrobasilar junction and 7 aneurysms (70%) were associated with proximal basilar fenestration. There were 5 men and 5 women, ranging from 29 to 75 years of age. Nine aneurysms presented with subarachnoid hemorrhage, and one was a giant partially thrombosed aneurysm with mass effect on the brain stem. Nine ruptured aneurysms were treated by primary coil occlusion. One giant unruptured aneurysm was initially treated with bilateral vertebral artery occlusion, 2 months later followed by selective coil occlusion of the remaining aneurysm lumen via the posterior communicating artery. At imaging follow-up of 6-30 months in 7 patients, all aneurysms were adequately occluded. In 2 patients, the vertebrobasilar junction and distal vertebral arteries (including the aneurysm) thrombosed completely on follow-up without clinical sequelae. Vertebrobasilar junction aneurysms are rare, with an incidence of 0.5% of treated aneurysms at our institution. Vertebrobasilar junction aneurysms are frequently associated with proximal basilar fenestration. Most patients present with subarachnoid hemorrhage. Endovascular treatment is effective and safe in excluding the aneurysms from the circulation.

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Basilar Artery Fenestration Aneurysms: Endovascular Treatment Strategies Based on 3D Morphology

F.P. Trivelato, L.H. de Castro Afonso, L.B. Manzato … (2016)

Basilar artery is the second most common site of fenestration, after the anterior communicating region. It is believed this variation predisposes a patient to posterior aneurysm formation and increases the complexity of the surgical anatomy. Endovascular management has become the first option to treat these aneurysms. We retrospectively evaluated eight patients, who underwent endovascular treatment for fenestrated basilar artery related aneurysms (fBA-AN). Additionally, based on our findings and on literature review, we developed a treatment strategy based on a proposed classification of fBA-AN.

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Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with Guglielmi detachable coils.

Sang Y. Chun, A. Yoon, K-B Kwun … (2004)

Fenestration of vertebrobasilar junction is a rare congenital anomaly and often associated with aneurysm formation. We describe five cases of vertebrobasilar junction aneurysms in four patients associated with fenestration, which were treated with endovascular coil occlusion using Guglielmi detachable coils (GDCs). The importance of preoperative computed tomography (CT) angiography to understand the complex anatomy of fenestration and aneurysm is emphasized. Three patients presented with subarachnoid hemorrhage and one patient presented with headache only. Among 3 patients with subarachnoid hemorrhage, 1 patient was referred for endovascular coil occlusion after clipping of ruptured distal ACA aneurysm. A six-French guiding catheter was placed in the left vertebral artery via right femoral artery, except for 1 patient who had two vertebrobasilar junction aneurysms with complex anatomic relationship, accessed bilaterally. Five vertebrobasilar junction aneurysms with fenestration were treated with endovascular coil occlusion using GDCs. Postoperative angiography demonstrated successful occlusion of aneurysmal sac with preservation of basilar artery. Vertebrobasilar junction aneurysms are frequently associated with fenestrations. In addition to vertebral angiography on both sides, CT angiography may be a valuable tool for better understanding of complex anatomy of aneurysms associated with fenestration. The surgically difficult aneurysms such as vertebrobasilar junction aneurysm with fenestration can be successfully treated with GDCs.

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Author and article information

Journal

Journal ID (nlm-ta): Neurosurg Focus Video

Journal ID (iso-abbrev): Neurosurg Focus Video

Journal ID (publisher-id): Neurosurg Focus Video

Title: Neurosurgical Focus: Video

Publisher: American Association of Neurological Surgeons

ISSN (Electronic): 2643-5217

Publication date Collection: October 2022

Publication date (Electronic): 1 October 2022

Volume: 7

Issue: 2 , Flow Diversion for Cerebral Aneurysms

Electronic Location Identifier: V7

Affiliations

Departments of [1 ]Neurosurgery and

[2 ]Radiology, Mayo Clinic, Rochester, Minnesota

Author notes

Correspondence Lorenzo Rinaldo: Mayo Clinic, Rochester, MN. rinaldo.lorenzo@ 123456mayo.edu .

INCLUDE WHEN CITING DOI: 10.3171/2022.7.FOCVID2256.

Disclosures Dr. Lanzino: consultant for Superior Medical Editors and Nested Knowledge.

Article

Publisher ID: 2022.7.FOCVID2256

DOI: 10.3171/2022.7.FOCVID2256

PMC ID: 9664490

PubMed ID: 36425263

SO-VID: 58724237-4511-49f5-bbf6-e6e783e70011

License:

This is an open access article distributed under the CC BY license ( http://creativecommons.org/licenses/by/4.0/).

History

Date received : 01 June 2022

Date accepted : 11 July 2022

Page count

Figures: 0, Tables: 0, References: 5, Pages: 2

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