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

doi:10.1016/S0090-3019(03)00485-3

Surgical Neurology

Volume 61, Issue 3, March 2004, Pages 248-254

https://doi.org/10.1016/S0090-3019(03)00485-3 Get rights and content

Abstract

Yoon SM, Chun YI, Kwon Y, Kwun BD. Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with guglielmi detachable coils.

Background

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.

Case reports

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.

Conclusions

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.

Section snippets

Case reports

From August 1998 to February 2001, five vertebrobasilar junction aneurysms in 4 patients, which were associated with fenestration, were treated with Guglielmi detachable coils (2 men, 2 women, ages 38–67 years). Three patients presented with subarachnoid hemorrhage and 1 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. All procedures were performed under

Discussion

The basilar artery is formed by fusion of the bilateral longitudinal neural arteries during the fifth week of fetal life. During this fusion process, there are temporary bridging arteries connecting the longitudinal neural arteries that regress as fusion is completed. If these bridging arteries persist, they result in fenestration of the basilar artery 2, 7, 16, 19. The lateral walls of the fenestrated artery have a normal intrinsic architecture; however, the medial walls show septation

Conclusion

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 the 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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Internal bands of the basilar artery (BA) have been rarely studied. Because bands could have obvious consequences in patient diagnosis and care, the present multiinstitutional cadaveric study was performed.
The intraluminal bands of BAs were studied in 80 cadaveric specimens derived from India (Group 1) and the United States (Group 2). Their orientation within the vessel was recorded. Measurements included the length of the BA, diameter of the BA, intraluminal band length and thickness, and distance of the band to the vertebrobasilar junction. Selected bands were submitted for histologic analysis.
In Group 1, an intraluminal band (all vertically oriented) was identified in 16.6%. The mean length and thickness of the bands were 2.04 mm and 1.33 mm, respectively. These bands were located at a mean distance of 1.74 mm superior to the vertebrobasilar junction. In Group 2, an intraluminal band was identified in 6%. One band was vertically positioned, and 2 were horizontally positioned. The mean length and thickness of the bands were 2.5 mm and 0.9 mm, respectively. These latter bands were located at a mean distance of 2.23 mm superior to the vertebrobasilar junction. Histologically, the bands were essentially extensions of the tunica media and interna of the artery.
To our knowledge, this study is the first multiethnic study of the prevalence and morphometry of the BA bands. A better understanding of these bands may help reveal their relationship to thrombus and aneurysmal formation and their impact on endovascular procedures.
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Arterial fenestrations are anomalies in embryonic vascular development and considered rare congenital variations. The management of fenestration aneurysms of the lower third of the basilar artery is challenging because of complex morphology. Given its relationship with the skull base and critical neurovascular structures, endovascular treatment is preferred over microsurgery, and allows the use of a range of different endovascular devices and techniques. The Woven EndoBridge (WEB) device was specifically developed for treating wide-neck aneurysms in arterial bifurcations and is a self-expanding braided mesh of nitinol with platinum core. The devicés dense metal mesh disrupts intra-aneurysmal blood flow and promotes intrassacular thrombosis, while the mesh and neck together create a surface favorable to neo-endothelialization. The WEB allows solely endosaccular treatment, without the need for further implants in the lumen of parent vessels, thereby reducing the risk of complications and dispensing with the need for antiplatelet therapy. The present study reports the successful treatment of a basilar artery fenestration aneurysm using the WEB device.
Treatment of fenestrated vertebrobasilar junction-related aneurysms with endovascular techniques
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For the treatment of wide-neck fVBJ-AN (types 2A or 2B), Fujimoto et al. and Yoon et al. [2,24] proposed embolism of the aneurysm with the assistance of a stent, but Albanse et al., Kai et al. and Peluso et al. [22,25,28] proposed the sacrifice of one limb of the fenestration due to considerations of the local hemodynamics. Recanalizations have been reported to be detected more frequently following conventional coiling [18]. Altering the local hemodynamics via the application of stents or the sacrifice of one or both limbs may help to reduce the risk of recurrence.
Fenestrated vertebrobasilar junction-related aneurysms (fVBJ-AN) are uncommon and endovascular management strategies have become the first options for the treatment of these lesions. This clinical study aimed to report our experience in the endovascular management of these lesions and to review the literature. We retrospectively reviewed 10 consecutive patients harboring 12 fVBJ-AN between January 2007 and December 2014. The demographic, angiographic and clinical data were reviewed. Additionally, a literature review was performed. Endovascular management strategies were successfully applied in all 10 patients. Post-procedural angiograms indicated total occlusion in eight (66.7%) aneurysms, a residual neck in one (8.3%) aneurysm, and three residual aneurysms (25%). No procedure-related complications were observed. Follow-up angiograms were obtained in eight patients and revealed nine occluded aneurysms and one improved aneurysm; two patients were lost to angiographic follow-up. Clinical follow-ups were obtained in all patients (until July 2015), and the modified Rankin Scale scores at 69.5 months (range 17–101 months) of follow-up were 0 in eight patients and 1 in two patients. Endovascular management strategies provided a high occlusion rate and an acceptable complication rate and are thus efficacious in the treatment of fVBJ-AN. Further studies are necessary to validate the utility of these treatments due to the low incidence of fVBJ-AN.
Stent-Assisted Coiling of Aneurysm in a Persistent Primitive Lateral Vertebrobasilar System
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Surgical treatment of these aneurysms is difficult as they are located in deep corridors, and reaching them would mean transgressing the lower cranial nerves and the lateral part of medulla. Also, there are important brainstem perforators arising from both limbs of fenestration20,21 and PICA can sometimes arise from the long limb, as is seen in our case, making parent vessel sacrifice not a feasible option. Embolization of basilar fenestration aneurysms using endovascular coiling has been reported previously.17,18,21-23
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Although patient 7 developed transient double vision and patient 8 suffered left VA occlusion, the treatment outcome was rated as mRS-1 for both patients. An fBA–AN is rare; only 73 patients have been reported.1–23 In our series, the incidence of fBA–AN among 2206 intracranial aneurysms was 0.36% and consistent with earlier reports.1
Aneurysms associated with a fenestrated basilar artery are rare, and treatment strategies have yet to be established. A direct surgical approach to the basilar artery is challenging because the surrounding anatomy is complex. We retrospectively compared the clinical features and treatment outcomes of eight patients (seven female, one male) with aneurysms associated with a fenestrated basilar artery after clipping or coil embolisation and reviewed the literature. Of the eight aneurysms, four were ruptured; seven aneurysms were located at the proximal part of the basilar artery and one aneurysm was located at the middle of the basilar artery. Six aneurysms were surgically treated. Four aneurysms were embolised with Guglielmi detachable coils, two aneurysms were clipped via the transcondylar or temporopolar approach, and two aneurysms were not treated. All six surgically treated patients had good outcomes. We found that both coil embolisation and direct clipping to treat aneurysms associated with a fenestrated basilar artery have advantages and disadvantages. To obtain favourable outcomes, the selected treatment modality must consider the patient’s age and clinical condition, the aneurysm size and shape, the direction of the dome, the relationship with perforators, and the neurosurgeon’s expertise.

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View full text

AneurysmVertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with guglielmi detachable coils

Abstract

Background

Case reports

Conclusions

Section snippets

Case reports

Discussion

Conclusion

Comput Radiol

Treatment of basilar artery bifurcation aneurysms by using Guglielmi detachable coilsa 6-year experience

J Neurosurg

Saccular aneurysm associated with segmental duplication of the basilar arterya morphological study

J Neurosurg

Saccular aneurysms in basilar artery fenestration

AJNR Am J Neuroradiol

Fenestration of the vertebrobasilar junction

Acta Neurochir (Wien)

Endovascular embolization of 150 basilar tip aneurysms with Guglielmi detachable coilsresults of the Food and Drug Administration multicenter clinical trial

J Neurosurg

The layered fabric of cerebral artery fenestrations

Stroke

The vertebral arterydevelopmental pathology

J Neurosurg Sci

Vertebrobasilar junction aneurysms associated with fenestrationtreatment with Guglielmi detachable coils

AJNR Am J Neuroradiol

Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils

J Neurosurg

Three-dimensional computerized tomography angiography in the diagnosis of cerebrovascular disease

J Neurosurg

Aneurysm
Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with guglielmi detachable coils