Detection of Angiographically Occult Ruptured Basilar Sidewall Perforator Aneurysm by Vessel Wall MR Imaging

Basilar artery perforator aneurysms are rare with a prevalence of less than 1%. These are particularly challenging to detect given their small size and tendency to intermittently thrombose. We describe a case of a ruptured basilar artery sidewall perforator aneurysm that was angiographically occult on computed tomographic angiogram and cerebral catheter angiogram. One day after the initial diagnostic work-up, intracranial vessel wall MR imaging (VWI) was performed which revealed a small outpouching along the right posterolateral basilar arterial wall with a punctate enhancing focus suggestive of a thrombosed basilar perforator artery aneurysm. Thrombus within the small aneurysm sac likely contributed to the poor opacification of the aneurysm sac on conventional lumen-based imaging techniques. Ruptured aneurysms have high morbidity and mortality due to their tendency to rebleed, making their expedient detection and treatment imperative. This case highlights the role VWI can play in detecting small ruptured aneurysms that intermittently thrombose and are otherwise challenging to diagnose with conventional vessel imaging.