Deconstructive Endovascular Treatment of Ruptured Serpentine Basilar Artery Aneurysm by Mid-Basilar Occlusion

No clear treatment course for cerebral aneurysms in the main trunk of the basilar artery (BA) has been established thus far.

A 69-year-old man with a history of hypertension presented to the emergency department with a sudden headache followed by decreased consciousness. Head computed tomography revealed a subarachnoid hemorrhage from the front of the brain stem to the basal cistern, and a lump-like dilation localized in the main trunk of the BA in the front of the midbrain. A rotated 360° large cerebral serpentine aneurysm was observed from the upper BA to the proximal part of the superior cerebellar artery. Endovascular treatment was performed under general anesthesia. To avoid a perforator infarction, short-segment parent artery embolization was performed only at the rupture point and the proximal part of the aneurysm. A magnetic resonance imaging scan 1 day after surgery revealed only microinfarction in the pons just below the embolus. The patient developed mild left hemiparesis postoperatively but soon improved and was discharged from the hospital.

Parent vessel sacrifice carries a risk of perforator injury due to extension of thrombosis from the blind pouch into eloquent perforator vessels. Minimizing this risk requires careful evaluation of anatomy and strategic occlusion, which preserves runoff into relatively large vessels, such as the superior cerebellar artery, the anterior inferior cerebellar artery, or the penetrating branch from the blind pouch, as much as possible.