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Basilar artery ectasia (BAE) can cause numerous neurological signs and symptoms, and awareness of its existence can obviate the need for vertebral angiography. The appearance of BAE on computed tomography is almost pathognomonic, and recognition thereof is important in order to prevent the mistaken diagnosis of a pontine or cerebellopontine angle tumour.
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An 11 year old girl died unexpectedly as a result of spontaneous subarachnoid hemorrhage originating from a ruptured giant fusiform aneurysm of the basilar artery. The aneurysm had developed as a long standing complication of arterial fibromuscular dysplasia. This discussion describes the light and electron microscopic findings in the aneurysm and the histologic examination of abnormalities in the muscular arteries of the viscera.
This case presentation describes the use of emergent neurointerventional procedures to revascularize a patient who developed a symptomatic stroke during coronary artery angiography. Rapid identification of a neurologic deficit in the coronary angiography suite and notification of a skilled neurointerventionalist permit for early revascularization and improved patient outcomes.
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Acute basilar artery occlusion has a mortality rate approaching 90%. The authors describe a case of acute basilar artery occlusion managed successfully with endovascular embolectomy. A 31-year-old man sought treatment for confusion, dysarthria, and right-sided weakness. He soon became unresponsive and was found to have a vertebral artery dissection and an associated basilar artery embolism. The dissection was managed with endovascular stenting, and the basilar artery embolus was removed with a clot retriever at 7 hours. The patient recovered without neurologic deficit.
A case of persistent primitive hypoglossal artery, accompanied by a basilar bifurcation aneurysm, is reported. The persistent primitive hypoglossal artery was seen on the right side and the left vertebral artery was hypoplastic. The right vertebral artery was absent, while a normal sized posterior communicating artery was seen on the right side at the operation on the aneurysm. The combination of a basilar bifurcation aneurysm and a persistent primitive hypoglossal artery is rare. A review of related reports has been made.
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Extreme acceleration and deceleration forces as well as axial loading are exerted at the occipito-cervical junction of drivers involved in high-velocity motor vehicle accidents, especially with fastened seatbelts. Injury at this level, usually lethal, can go unrecognized despite modern emergency management of the unconscious patient. A precise neurologic and radiographic workup of damage to this area is often not possible or overlooked in the initial phase of such severe trauma. We describe a patient with multiple injuries who sustained a left vertebral artery occlusion associated with a left-sided lateral mass fracture of C1 and a basilar artery occlusion resulting in a locked-in syndrome after an automobile accident.
Basilar artery occlusion (BAO) is generally associated with a high mortality rate and a poor functional outcome in survivors. Recently, we encountered a patient with BAO, initially manifesting as vertigo and rebound nystagmus, subsequently followed by bilateral sudden deafness and dysarthria and terminating in a coma state within an interval of 6 h. A review of his history showed he had had two episodes of transient vertigo 2 weeks before the major stroke, and the neurological decline of BAO was heralded by the vertiginous symptoms. Restated, patients with BAO often have transient vertiginous attacks preceding fatal stroke. Therefore, those with vertigo and nystagmus may be signaling a forthcoming stroke event, something that should be considered for clinicians seeing vertiginous patients.
Basilar artery occlusion is assumed to carry a grave prognosis, with mortality rates of up to 90%. Diagnosis is often delayed, or even missed, as a result of the variety of clinical presentations seen with this condition. The pathogenesis of occlusion can be secondary to both local atherothrombosis or cardioembolism. The use of noninvasive imaging such as magnetic resonance imaging and computed tomography angiography has improved recognition of clinical syndromes associated with occlusion. Although no randomized studies have been performed, recanalization of the vascular occlusion, particularly with thrombolytic agents, appears to result in improved outcomes in selected patients. However, the optimum timing for therapy is unclear, and reperfusion therapy may need to be combined with definitive vascular treatment of underlying vascular stenosis. Increasing awareness of this condition may reveal the natural history to be more diverse than previously recognized.
OBJECTIVE AND IMPORTANCE: Effective treatment for unclippable giant vertebrobasilar aneurysms remains unclear. We present the first reported case of a giant vertebrobasilar aneurysm being successfully treated with trapping of the aneurysm and internal carotid artery to basilar artery bypass with a saphenous vein graft that was performed with the patient under hypothermic circulatory arrest. CLINICAL PRESENTATION: A 15-year-old female patient with a history of probable subarachnoid hemorrhage and chronic headaches presented with a relatively acute exacerbation of her headache, nausea, vomiting, and weakness. Imaging studies revealed a 4 x 4 x 3-cm vertebrobasilar aneurysm, supplied by an angiographically dominant right vertebral artery and causing significant brain stem compression. INTERVENTION: Initially, a petrosal approach with a hearing-preserving partial labyrinthectomy was used to perform a right external carotid artery to posterior cerebral artery bypass with saphenous vein. Delayed occlusion of the right vertebral artery with an intraluminal balloon was planned; however, intraoperative angiography revealed poor graft flow, presumably because of the small size of the posterior cerebral artery. Postoperative graft occlusion was anticipated. During this same time interval, the patient deteriorated neurologically. Brain imaging failed to reveal evidence of cerebral infarction. The patient underwent subsequent surgery. After a total petrosectomy, the aneurysm was trapped, an aneurysmectomy was performed, and, with the patient under deep hypothermic circulatory arrest, a new interposition saphenous vein graft was inserted between the internal carotid and basilar arteries. Excellent flow was observed angiographically. At her 4-month follow-up examination, the patient had improved to near baseline. CONCLUSION: We present a technically challenging but safe and definitive treatment option for an unclippable giant vertebrobasilar aneurysm. Using cranial base approaches and hypothermic circulatory arrest techniques, aneurysmal trapping and successful bypass grafting directly into the basilar artery was performed.
BACKGROUND AND PURPOSE: There are limited data on the prognosis of patients with angiographically proved symptomatic stenosis of the intracranial vertebral artery or basilar artery. METHODS: We studied 68 patients with 50% to 99% stenosis of one of the following arteries: intracranial vertebral (n = 31), basilar (n = 28), posterior cerebral (PCA) (n = 6), or posterior inferior cerebellar (PICA) (n = 3). All patients had previous transient ischemic attack or stroke in the territory of the stenotic artery and were treated with warfarin (n = 42) or aspirin (n = 26). Follow-up was by chart review and personal or telephone interview. RESULTS: During a median follow-up of 13.8 months, 15 patients (22%) had an ischemic stroke (4 fatal), 3 patients (4.5%) had a fatal myocardial infarction (MI) or sudden death, and 6 patients (9%) had a nonfatal MI. Stroke rates in any vascular territory (per 100 patient-years of follow-up) were 15.0 in patients with basilar artery stenosis, 13.7 in patients with vertebral artery stenosis, and 6.0 in patients with PCA or PICA stenosis. Stroke rates in the same territory as the stenotic artery (per 100 patient-years of follow-up) were 10.7 in patients with basilar artery stenosis, 7.8 in patients with vertebral artery stenosis, and 6.0 in patients with PCA or PICA stenosis. CONCLUSIONS: Patients with symptomatic intracranial vertebral artery or basilar stenosis are at high risk of stroke, MI, or sudden death. Further studies are needed to clarify optimal therapy for these patients.
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In some cases, basilar artery aneurysms cannot be repaired surgically and the basilar artery is occluded near the neck of the aneurysm to stop flow into the aneurysm. After the operation, the aneurysm can fill only by flow through the posterior communicating arteries (PCoAs). Hemodynamically if the flow were the same in both PCoAs and there were no phase lag in the pressures, there would be no pressure gradient for flow to go across the neck of the aneurysm and therefore the aneurysm would thrombose. We have assumed that the diameter of the artery is roughly proportional to the flow that goes through it chronically. We measured the diameters of the PCoAs in 25 patients who had hunterian ligation of the basilar artery. We also measured the maximal width, height, and depth of the aneurysms on angiograms obtained before and after operation. Eleven aneurysms thrombosed completely and had a diameter ratio of greater than 0.6; 10 aneurysms thrombosed partially and had a diameter ratio of 0.46 approximately 1.0; 4 aneurysms did not change and had a diameter ratio of less than 0.45. The ratio of the sizes of the PCoAs pre- and postoperatively was comparable in most cases, so we believe that it is possible to predict reasonably accurately from this simple measurement whether the aneurysm is likely to thrombose if the basilar artery is ligated.
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