Ruptured basilar artery perforator aneurysm mimicking superior cerebellar artery aneurysm

The diagnosis of basilar artery perforator aneurysm is difficult due to their small size, with high rates of negative angiography. Furthermore, due to the considerable variation of basilar artery perforator (BAP), even if an aneurysm originates from a BAP, it is often difficult to clearly identify its origin on angiography.

A 46-female patient presented with World Federation of Neurological Surgeons Scale 1 subarachnoid hemorrhage. Initial imaging study, including digital subtraction angiography (DSA), revealed no vascular lesions. Two-week after admission, DSA revealed an aneurysm arising from the left superior cerebellar artery (SCA). Endovascular coil embolization was planned first. However, aneurysm selection using microcatheter was failed. Then, surgical approach was done via pre-temporal approach. We identified SCA, but there was no aneurysm. Further dissection revealed an aneurysm arising from basilar artery perforator, which was overlapped by SCA. The parent artery of the aneurysm arose from juxtaproximal to the orifice of left SCA, and crossed SCA at the juxtadistal to the aneurismal sac. Complete clip occlusion was done preserving BAP. After the surgery, the patient developed diplopia without extraoccular movement limitations. Two-month after the surgery, she was fully recovered without any neurologic deficits.

It is crucial to adequately consider the possibility of open surgery as a viable option in case that endovascular treatment of aneurysms originated from the distal segment of basilar artery proves unsuccessful.