David A Omahen1, J Max Findlay. 1. Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Canada T6G 2B7.
Abstract
OBJECTIVE AND IMPORTANCE: Fusiform aneurysms of the vertebrobasilar arteries that progressively enlarge causing symptomatic brainstem compression are dangerous and their treatment is difficult. A patient with such an aneurysm treated successfully with staged, microsurgical occlusions of the proximal vertebral arteries is described, and the literature pertaining to this rare condition is briefly reviewed. CLINICAL PRESENTATION: A 48-year-old man with a fusiform basilar trunk aneurysm of uncertain etiology presented initially with transient ischemic attacks (TIAs) of the posterior circulation that ceased with anticoagulation. Four years later he presented again with progressive ataxia, dysphagia and dysphonia due to considerable enlargement of the aneurysm causing brainstem compression. INTERVENTION: Staged microsurgical vertebral artery occlusions proximal to the aneurysm were performed. The second (left) vertebral artery was clipped only after the patient passed its temporary occlusion with an endovascular test balloon. The aneurysm subsequently thrombosed, the distal basilar artery kept patent by a single (left) posterior communicating artery. The patient's clinical condition improved markedly over a number of months as the aneurysm mass atrophied. CONCLUSION: Giant vertebrobasilar aneurysms are rare but treacherous lesions, sometimes justifying aggressive management. Carefully selected patients with progressive and severe symptoms due to brainstem compression may tolerate proximal vertebral artery occlusions, provided there is adequate collateral flow to the basilar termination and all of its perforating branches.
OBJECTIVE AND IMPORTANCE: Fusiform aneurysms of the vertebrobasilar arteries that progressively enlarge causing symptomatic brainstem compression are dangerous and their treatment is difficult. A patient with such an aneurysm treated successfully with staged, microsurgical occlusions of the proximal vertebral arteries is described, and the literature pertaining to this rare condition is briefly reviewed. CLINICAL PRESENTATION: A 48-year-old man with a fusiform basilar trunk aneurysm of uncertain etiology presented initially with transient ischemic attacks (TIAs) of the posterior circulation that ceased with anticoagulation. Four years later he presented again with progressive ataxia, dysphagia and dysphonia due to considerable enlargement of the aneurysm causing brainstem compression. INTERVENTION: Staged microsurgical vertebral artery occlusions proximal to the aneurysm were performed. The second (left) vertebral artery was clipped only after the patient passed its temporary occlusion with an endovascular test balloon. The aneurysm subsequently thrombosed, the distal basilar artery kept patent by a single (left) posterior communicating artery. The patient's clinical condition improved markedly over a number of months as the aneurysm mass atrophied. CONCLUSION: Giant vertebrobasilar aneurysms are rare but treacherous lesions, sometimes justifying aggressive management. Carefully selected patients with progressive and severe symptoms due to brainstem compression may tolerate proximal vertebral artery occlusions, provided there is adequate collateral flow to the basilar termination and all of its perforating branches.