Volume 70, Issue 2, March 2024, 101544Author links open overlay panel, Highlights•

In cases of aneurysms located in the distal part of the BAPs, we should be aware of the potential for diagnostic errors due to the anatomical proximity between the BAP and the SCA. In such situations, it is crucial to consider open surgery as a viable option if endovascular treatment is unsuccessful, especially in case of the aneurysm located at the distal segment of basilar artery.

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In cases of angiogram-negative subarachnoid hemorrhage (SAH), it is necessary to perform repeated imaging examinations, particularly repetitive DSA, over an adequate period.

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During BAPA surgery, to achieve clipping while preserving the BAP, the surrounding BAP was adequately dissected around the aneurysm by deploying a temporary clip. Once the aneurysm neck was completely dissected, the clip was carefully placed across the neck of the aneurysm without compromising the BAP.

AbstractBackground and importance

The diagnosis of basilar artery perforator aneurysm is difficult due to their small size, with high rates of negative angiography. Furthermore, due to the considerable variation of basilar artery perforator (BAP), even if an aneurysm originates from a BAP, it is often difficult to clearly identify its origin on angiography.

Clinical presentation

A 46-female patient presented with World Federation of Neurological Surgeons Scale 1 subarachnoid hemorrhage. Initial imaging study, including digital subtraction angiography (DSA), revealed no vascular lesions. Two-week after admission, DSA revealed an aneurysm arising from the left superior cerebellar artery (SCA). Endovascular coil embolization was planned first. However, aneurysm selection using microcatheter was failed. Then, surgical approach was done via pre-temporal approach. We identified SCA, but there was no aneurysm. Further dissection revealed an aneurysm arising from basilar artery perforator, which was overlapped by SCA. The parent artery of the aneurysm arose from juxtaproximal to the orifice of left SCA, and crossed SCA at the juxtadistal to the aneurismal sac. Complete clip occlusion was done preserving BAP. After the surgery, the patient developed diplopia without extraoccular movement limitations. Two-month after the surgery, she was fully recovered without any neurologic deficits.

Conclusion

It is crucial to adequately consider the possibility of open surgery as a viable option in case that endovascular treatment of aneurysms originated from the distal segment of basilar artery proves unsuccessful.

Section snippetsBackground and importance

Ruptured basilar artery perforator aneurysms (BAPAs), defined as microaneurysms which developed in basilar perforator arteries (BAP) without direct involvement of the basilar trunk, represent a rare cause of subarachnoid hemorrhage (SAH) [1], [2]. Their natural history is poorly known, and treatment options are controversial since only a few cases have been reported in the literature [1]. The diagnosis of BAPAs is difficult due to their small size, with high rates of negative angiography.

Clinical presentation

A 46-year-old female presented with a sudden bursting headache accompanied by nausea and vomiting. She was alert on admission, and there was no neurologic deficit (World Federation of Neurological Surgeons Scale 1). A brain computed tomography (CT) revealed SAH of modified Fisher Grade 1 (Fig. 1A). A brain CT angiography (CTA) and Digital subtraction angiography (DSA) were immediately done and no vascular lesion was detected (Fig. 1B). Non aneurysmal SAH was suspected and the patient was

Discussion

We present a case of SAH due to a ruptured BAPA. BAPAs are rare and may lead to severe SAH. The diagnosis of BAPAs is challenging and could be overlooked in many cases. Their diagnosis is difficult because it consists of tiny and often partially thrombosed lesions fed by a small-diameter artery [2], [5], [6]. Some author reported that only 22% of ruptured aneurysms were revealed on initial imaging [7]. In the present case, the BAPA was not visualized on the initial DSA, and the lesion was shown

Conclusion

In cases of aneurysms located in the distal part of the BAPs, we should be aware of the potential for diagnostic errors due to the anatomical proximity between the BAP and the SCA. In such situations, it is crucial to consider open surgery as a viable option if endovascular treatment is unsuccessful.

Conflict of interest

The authors declare that they have no known competing financial or personal relationships that could be viewed as influencing the work reported in this paper.

Funding

This work did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship.

References (18)P. Bhogal et al.Basilar artery perforator aneurysms: report of 9 cases and review of the literature

J Clin Neurosci

(2019)

S. Finitsis et al.Basilar perforator aneurysms: presentation of 4 cases and review of the literature

World Neurosurg

(2017)

M.F. Granja et al.A systematic review of non-trunk basilar perforator aneurysms: is it worth chasing the small fish?

J Neurointerv Surg

(2020)

S. Lescher et al.Evaluation of the pontine perforators of the basilar artery using digital subtraction angiography in high resolution and 3D rotation technique

AJNR Am J Neuroradiol

(2014)

S.V. Marinkovic et al.The surgical anatomy of the perforating branches of the basilar artery

Neurosurgery

(1993)

C.S. Mathieson et al.An unusual case of spontaneous subarachnoid haemorrhage - a ruptured aneurysm of a basilar perforator artery

Br J Neurosurg

(2010)

S.R. Satti et al.Basilar artery perforator aneurysms (BAPAs): review of the literature and classification

J Neurointerv Surg

(2017)

T.J. Buell et al.Posterior circulation perforator aneurysms: a proposed management algorithm

J Neurointerv Surg

(2018)

I. Nguyen et al.Angiographically occult subarachnoid hemorrhage: yield of repeat angiography, influence of initial CT bleed pattern, and sources of diagnostic error in 242 consecutive patients

AJNR Am J Neuroradiol

(2022)

There are more references available in the full text version of this article.

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