Basilar trunk aneurysm

Basilar trunk aneurysm

Basilar trunk aneurysms (BTAs), are basilar artery aneurysms distal to the basilar origin and proximal to the origin of the superior cerebellar artery.

Most aneurysms of the basilar trunk are fusiform in morphology. Surgical access for these is extremely difficult.

Classification

Case series

52 patients. Mean age was 56 (SD±18) years. Median clinical follow-up was 33 (interquartile range, 8-86) months, and imaging follow-up was 26 (interquartile range, 2-80.5) months. BTAs were classified into 4 causal subtypes: acute dissecting aneurysms, segmental fusiform ectasia, mural bleeding ectasia, and saccular aneurysms. Multiple aneurysms were more frequently noticed among the 13 saccular aneurysms when compared with overall population (P=0.021). There was preponderance of segmental ectasia or mural bleeding ectasia (P=0.045) in patients presenting with transit ischemic attack/stroke or mass effect. Six patients with segmental and 4 with mural bleeding ectasia demonstrated increasing size of their aneurysm, with 2 having subarachnoid hemorrhage caused by aneurysm rupture. None of the fusiform aneurysms that remained stable bled.

BTAs natural histories may differ depending on subtype of aneurysm. Saccular aneurysms likely represent an underlying predisposition to aneurysm development because more than half of these cases were associated with multiple intracranial aneurysms. Intervention should be considered in segmental ectasia and chronic dissecting aneurysms, which demonstrate increase in size over time as there is an increased risk of subarachnoid hemorrhage 1).

Case reports

A 46-year-old male presented with a history of sudden severe headache 1 week back, altered sensorium and right hemiparesis for 2 days. On examination, Glasgow Coma Scale (GCS) was E4V4M6 and the patient had right hemiparesis (power – 4/5). Computed tomography (CT) revealed diffuse subarachnoid hemorrhage (Fisher’s Grade III). CT angiogram revealed distal basilar trunk aneurysm arising between the origin of the left posterior cerebral artery and superior cerebellar artery, ectatic dilatation of distal basilar trunk, and a left middle cerebral artery (MCA) bifurcation aneurysm. Basilar trunk aneurysm was approached through subtemporal route and aneurysm was clipped during adenosine-induced profound hypotension (AIPH) without application of temporary clip. Single bolus 6 mg of adenosine was given, and aneurysm was successfully clipped during AIPH (systolic <60 mmHg). There were no complications related to adenosine. Ectatic part of distal basilar trunk was wrapped with Teflon. The left MCA bifurcation aneurysm was clipped in the same session. At 3-month follow-up, the patient’s sensorium was normal (GCS-E4V5M6) and the right hemiparesis improved (4+/5). Adenosine enhances the safety of clipping these aneurysms by providing transient cardiac arrest or profound hypotension. In developing countries, microsurgical clipping is a cost-effective treatment option for basilar artery aneurysms 2).


A 37-year-old woman with basilar artery fenestration malformation and an aneurysm at the mid-distal junction; her symptoms included sudden headaches with nausea and vomiting.

Head digital subtraction angiography showed fenestration at the junction of the middle and upper portions of the basilar artery associated with an aneurysm, and spontaneous pseudoaneurysm formation could not be excluded.

The patient underwent stent-assisted fenestration and channel occlusion.

Five months later, no abnormalities were found by head magnetic resonance imaging. The stents were well positioned, and no occluded branches or aneurysms were present.

For mid-distal basilar artery fenestration malformation with an aneurysm, occlusion of the lesion channel is relatively safe when there are no perforating vessels in the fenestration channel and the lesion channel is a nondominant channel. Overall, more attention should be paid to the possibility of pseudoaneurysm formation in the diagnosis and treatment of this type of aneurysm 3).


A 61-year-old man presented with dysarthria and left hemiparesis attributable to a basilar trunk dissecting aneurysm. Antiplatelet therapy was instituted, and the patient’s clinical condition markedly improved. However, he developed severe headache, dysarthria, and left hemiparesis 35 days later. Angiography revealed significant enlargement of the aneurysm, and stent-assisted coiling was then uneventfully performed. The patient remained clinically stable with only mild left-sided hemiparesis at the 2-year clinical follow-up 4).

References

1)

Saliou G, Sacho RH, Power S, Kostynskyy A, Willinsky RA, Tymianski M, terBrugge KG, Rawal S, Krings T. Natural history and management of basilar trunk artery aneurysms. Stroke. 2015 Apr;46(4):948-53. doi: 10.1161/STROKEAHA.114.006909. Epub 2015 Feb 24. PubMed PMID: 25712945.
2)

Sai Kiran NA, Kiran Kumar VA, Kumar VA, Agrawal A. Microsurgical Clipping of Distal Basilar Trunk Aneurysm during Adenosine-Induced Profound Hypotension. Asian J Neurosurg. 2019 Nov 25;14(4):1214-1217. doi: 10.4103/ajns.AJNS_157_19. eCollection 2019 Oct-Dec. PubMed PMID: 31903365; PubMed Central PMCID: PMC6896639.
3)

Zhang D, Wang H, Feng Y, Xu N. Fenestration deformity of the basilar artery trunk with an aneurysm: A case report. Medicine (Baltimore). 2019 Jul;98(28):e16393. doi: 10.1097/MD.0000000000016393. PubMed PMID: 31305446; PubMed Central PMCID: PMC6641678.
4)

Fu C, Zhao C, Zhao H, Li D, Yu W. Growing dissecting aneurysm of basilar trunk treated with stent-assisted coiling. J Stroke Cerebrovasc Dis. 2015 Jan;24(1):e5-9. doi: 10.1016/j.jstrokecerebrovasdis.2014.07.033. Epub 2014 Sep 27. PubMed PMID: 25270634.

Video Atlas of Neuroendovascular Procedures

Video Atlas of Neuroendovascular Procedures

Leonardo Rangel-CastillaAdnan SiddiquiElad Levy

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The go-to guide on safely performing state-of-the-art neuroendovascular procedures from top experts!

Unlike traditional textbooks that detail natural historyphysiology, and morphology, Video Atlas of Neuroendovascular Procedures presents basic and complex neuroendovascular procedures and cases with concise text and videos. Renowned neuroendovascular surgeons Leonardo Rangel-CastillaAdnan SiddiquiElad Levy, and an impressive group of contributors have compiled the quintessential neuroendovascular resource. Organized into eight major subtopic sections, this superb video atlas covers a full spectrum of endovascular approaches to diagnose and treat intra- and extracranial neurovascular disease.

The book starts with a section on vascular access and concludes with endovascular complications and management. Forty chapters includes succinct summaries, scientific procedural evidence, the rationale for endovascular intervention, anatomy, required medications, device selection, avoiding complications, and managing potential problems that can arise during procedures. The image-rich clinical cases feature insightful firsthand knowledge and pearls.

Key Features

More than 1,000 relevant, high quality neuroimaging findings and artist illustrations enhance understanding of impacted anatomy and approaches Specific techniques and key steps are brought to life through more than 140 outstanding videos narrated by highly experienced endovascular neurosurgeons — conveniently accessible via smart phones or tablets using QR technology Essential diagnostic procedures such as cerebral and spinal angiography, cerebral venogram, and balloon test occlusion Complex neuroendovascular procedures including various angioplasty and stenting approaches for extracranial vessel disease, carotid and vertebral arteries, and venus sinus; thrombectomy procedures to treat acute ischemic stroke; and coiling, flow diversion, and embolization techniques for intracranial aneurysms, brain/spinal AVMs and fistulas, and select CNS and extracranial tumors The content-rich reference is a must-have for all resident and veteran neurosurgeons, interventional radiologists, and neurologists. Learn to safely perform a wide array of cutting-edge neuroendovascular procedures — from access to closure — and achieve improved outcomes for your patients.

Cerebellar hemangioblastoma

Cerebellar hemangioblastoma

Cerebellar hemangioblastoma is a vascular posterior fossa tumor with a clear border that develops intramedullary to extramedullary.

Classification

Histologically 1) and radiologically 2) , cerebellar HBs are traditionally described as four types:

Type 1 (5% of posterior fossa HBs) is a simple cyst without a macroscopic nodule.

Type 2 is a cyst with a mural nodule (60%).

Type 3, or solid tumors (26%).

Type 4, or solid tumors with small internal cysts (9%), are also seen in the cerebellum and predominate in the spinal cord.

Some authors have stated that type 1 is actually rare.

Clinical features

Diagnosis

Differential diagnosis

Several primary pathologic entities in diverse anatomic locations have the potential to simulate metastatic neoplasms histologically. Their misinterpretation as such may result in needless and extensive clinical evaluations that are intended to detect a presumed malignancy at another site. More importantly, mistakes of this type can deprive patients of surgical excisions that could be curative 3).

In adults with only cerebellar masses, cerebellar hemangioblastoma and cerebellar metastases are the 2 most important differential diagnoses.

High b value DWI reflects diffusion more accurately than does regular b value. Results showed that ADC calculation by high b value (b = 4000) DWI at 3-T magnetic resonance imaging is clinically useful for differentiating hemangioblastomas from brain metastases 4).

Arterial spin labelled imaging can aid in distinguishing hemangioblastoma from metastasis in patients with only cerebellar masses 5).


Coexistence of hemangioblastomas and AVMs is extremely rare, and only 3 cases have been reported previously in the literature 6).

Treatment

Radiation treatment

Effectiveness is dubious. May be useful to reduce tumor size or to retard growth, e.g. in patients who are not surgical candidates, for multiple small deep lesions, or for inoperable brainstem HGB. Does not prevent regrowth following subtotal excision.

Gamma Knife Radiosurgery as well as LINAC have also been employed to successfully treat recurrence and control tumor growth of cerebellar hemangioblastomas.

A retrospective chart review revealed 12 patients with a total of 20 intracranial hemangioblastomas treated with GKRS from May 1998 until December 2014. Kaplan-Meier plots were used to calculate the actuarial local tumor control rates and rate of recurrence following GKRS. Univariate analysis, including log rank test and Wilcoxon test were used on the Kaplan-Meier plots to evaluate the predictors of tumor progression. Two-tailed p value of <0.05 was considered as significant. Median follow-up was 64months (2-184). Median tumor volume pre-GKRS was 946mm3 (79-15970), while median tumor volume post-GKRS was 356mm3 (30-5404). Complications were seen in two patients. Tumor control rates were 100% at 1year, 90% at 3years, and 85% at 5years, using the Kaplan-Meier method. There were no statistically significant univariate predictors of progression identified, although there was a trend towards successful tumor control in solid tumors (p=0.07). GKRS is an effective and safe option for treating intracranial hemangioblastoma with favorable tumor control rates 7).


Suzuki et al. emphasize the usefulness of embolization with N-butyl cyanoacrylate for hemangioblastoma with ruptured feeder aneurysm, by which the aneurysm and the feeder could be simultaneously embolized 8).

Outcome

Surgical treatment may be curative in cases of sporadic HGB, not in VHL.

Solitary hemangioblastomas are for the most part considered benign, curable by total resection, except in those cases associated with von Hippel Lindau disease.

Despite extensive literature describing the diagnosis, treatment, and prognosis of these lesions, 9) individual cases still present a surgical quandary given their frequently eloquent location and high degree of vascularity.

Case series

Bründl et al. retrospectively analyzed the clinical, radiological, surgical, and histopathologic records of 24 consecutive patients (11 men, 13 women; mean age 51.3 years) with HBL of the posterior cranial fossa, who had been treated between 2001 and 2012.

Mean time to diagnosis was 14 weeks. The extent of resection (EOR) was total in 20 and near total in 4 patients. Four patients required revision within 24 h because of relevant postoperative bleeding. One patient died within 14 days. One patient required permanent shunting. At discharge, 75% of patients [n = 18, modified Rankin scale (mRS) 0-1] showed no or at least resolved symptoms. Mean follow-up was 21 months. Two recurrences were detected during follow-up.

In comparison to other benign entities of the posterior fossa, time to diagnosis was significantly shorter for HBL. This finding indicates the rather aggressive biological behavior of these excessively vascularized tumors. In this series, however, the rate of complete resection was high, and morbidity and mortality rates were within the reported range 10).


Cerebrospinal fluid dissemination of cerebellar hemangioblastoma was found dominantly in non-Von Hippel Lindau disease patients. The diagnosis was made 10 years after the initial surgery. Irradiation therapy was performed, but the patients died about 2 years after the diagnosis was given. Molecular targeted therapies including vascular proliferation suppression have been attempted lately, but no effective therapy has been established. Early diagnosis of dissemination as well as combination of aggressive excision and stereotactic radiosurgery are considered to be appropriate for current interventions 11).

Case reports

Cerebellar hemangioblastoma in von Hippel-Lindau disease

References

1)

Richard S, Campello C, Taillandier L, Parker F, Resche F. Haemangioblastoma of the central nervous system in von Hippel-Lindau disease. French VHL Study Group. J Intern Med. 1998 Jun;243(6):547-53. Review. PubMed PMID: 9681857.
2)

Lee SR, Sanches J, Mark AS, Dillon WP, Norman D, Newton TH. Posterior fossa hemangioblastomas: MR imaging. Radiology. 1989 May;171(2):463-8. PubMed PMID: 2704812.
3)

Wick MR. Primary lesions that may imitate metastatic tumors histologically: A selective review. Semin Diagn Pathol. 2017 Nov 17. pii: S0740-2570(17)30137-5. doi: 10.1053/j.semdp.2017.11.010. [Epub ahead of print] Review. PubMed PMID: 29174934.
4)

Onishi S, Hirose T, Takayasu T, Nosaka R, Kolakshyapati M, Saito T, Akiyama Y, Sugiyama K, Kurisu K, Yamasaki F. Advantage of High b Value Diffusion-Weighted Imaging for Differentiation of Hemangioblastoma from Brain Metastases in Posterior Fossa. World Neurosurg. 2017 May;101:643-650. doi: 10.1016/j.wneu.2017.01.100. Epub 2017 Feb 4. PubMed PMID: 28179177.
5)

Kang KM, Sohn CH, You SH, Nam JG, Choi SH, Yun TJ, Yoo RE, Kim JH. Added Value of Arterial Spin-Labeling MR Imaging for the Differentiation of Cerebellar Hemangioblastoma from Metastasis. AJNR Am J Neuroradiol. 2017 Nov;38(11):2052-2058. doi: 10.3174/ajnr.A5363. Epub 2017 Sep 14. PubMed PMID: 28912280.
6)

Monserrate Marrero JA, Monserrate Marrero AE, Pérez Berenguer JL, Álvarez EL, Corona JM, Feliciano C. Cerebellar Arteriovenous Malformation with Coexistent Hemangioblastoma. World Neurosurg. 2019 Nov 9;134:495-500. doi: 10.1016/j.wneu.2019.10.197. [Epub ahead of print] PubMed PMID: 31712111.
7)

Silva D, Grabowski MM, Juthani R, Sharma M, Angelov L, Vogelbaum MA, Chao S, Suh J, Mohammadi A, Barnett GH. Gamma Knife radiosurgery for intracranial hemangioblastoma. J Clin Neurosci. 2016 Jul 12. pii: S0967-5868(16)30013-3. doi: 10.1016/j.jocn.2016.03.008. [Epub ahead of print] PubMed PMID: 27422585.
8)

Suzuki M, Umeoka K, Kominami S, Morita A. Successful treatment of a ruptured flow-related aneurysm in a patient with hemangioblastoma: Case report and review of literature. Surg Neurol Int. 2014 Sep 26;5(Suppl 9):S430-3. doi: 10.4103/2152-7806.141887. eCollection 2014. PubMed PMID: 25324977; PubMed Central PMCID: PMC4199150.
9)

Cushing H, Bailey P. Tumors arising from blood vessels in the brain: angiomatous malformations and hemangioblastomas. Springfield, IL: Charles C Thomas; 1928.
10)

Bründl E, Schödel P, Ullrich OW, Brawanski A, Schebesch KM. Surgical resection of sporadic and hereditary hemangioblastoma: Our 10-year experience and a literature review. Surg Neurol Int. 2014 Sep 22;5:138. doi: 10.4103/2152-7806.141469. eCollection 2014. Review. PubMed PMID: 25317353; PubMed Central PMCID: PMC4192902.
11)

Akimoto J, Fukuhara H, Suda T, Nagai K, Hashimoto R, Michihiro K. Disseminated cerebellar hemangioblastoma in two patients without von Hippel-Lindau disease. Surg Neurol Int. 2014 Oct 7;5:145. doi: 10.4103/2152-7806.142321. eCollection 2014. PubMed PMID: 25324974; PubMed Central PMCID: PMC4199185.
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