Evaluation and treatment of fusiform basilar artery aneurysm: A case report and article review
Yi-Yang Hsiao, MD 1 , Chao-Yu Shen, MD 1 , Ying-Chi Fan, MD 1 ,
1 Chung Shan Medical University Hospital
Yi-Yang Hsiao , MD
Chung Shan Medical University Hospital
1. Introduction: Fusiform aneurysms on the basilar artery are rare. Patient with the fusiform aneurysm of basilar artery has higher risk of stroke than others. When should patient accepted advance therapy rather than conservative treatment ? What kinds of therapy is better for those patient ? We present a case with huge fusiform basilar artery aneurysm . Through this case discussion, we have also compiled relevant literature on the evaluation and treatment of fusiform aneurysms on the basilar artery. 2. Case report: A 53-year-old woman presented with the sudden onset of double vision, left eye ptosis and EOM limitation and headache since 2016/03/30. Brain MRI revealed left midbrain infarction and basilar artery aneurysm(2.6cm X 1.0cm). After discuss with patient the risk of aneurysm rupture and ischemia stroke . She want observation and follow up at Neurology OPD. On 2020/05, she presented with the new onset of headache, dizziness, diplopia and unsteady gait. She was followed up the MRI which revealed the increased in the size of a fusiform basilar artery aneurysm(4.1cm X 2.7 cm) with brainstem compression. DSA showed diffuse fusiform dilation of basilar artery and involved from basilar tip to VB junction(4.8cm X 2.3 cm) on 2020/06/29 . Therefore she agreed to underwent the TAE with stent-assisted coiling. Her condition was stable after TAE and stent insertion. However , Sudden onset consciousness disturbance with unstable vital signs 12 hours later. Brain CTA was done immediately. No intracranial hemorrhage was noted. After hydration, anticoagulant and antiplatelet therapy. Her vital signs became stable. However the sequela of diplopia, dysarthria, right central facial palsy, left limb weakness and trunkle ataxia lasting until she discharge.
Discussion and conclusion: 1. Should patient with fusiform aneurysm of basilar artery follow up Brain MRI every year or only patient with new focal symptoms? We suggest follow transcranial carotid doppler (TCD) or Brain MRI per year if patient without new focal neurological signs. Brain MRA or angiography should be done if patient has new focal neurological signs. 2. When does patient need aggressive treatment of fusiform aneurysm of basilar artery ? We reviewed some articles and found that treatment can be considered if the patient had one or more of following conditions: (1) Size of 5mm or more (2) Size under 5mm at high risk of rupture (3) Symptomatic intracranial aneurysm (brainstem compression) (4) History of previous subarachnoid hemorrhage (5) Aneurysm undergoing increase in size or change in morphology during follow up (6) Age less than 50 years, hypertension and multiple aneurysms (7) Aneurysm with high aspect ratio(ratio of aneurysm height to neck width) 3. What’s common complication of fusiform aneurysm of basilar artery treatment with TAE ? We reviewed several articles and found that coiling might have high procedure-related stroke rate. And during aneurysm coiling, thromboembolic events and intraprocedure aneurysm ruptures were 2 types of complications which most often occurred. Besides there are some other complications: (1) Inflammatory response due to coiled and thrombosed aneurysm, (2) Mass effect, (3) Local inflammation by chemical ingredients or contamination of the coils. 4. How can we lower the incidence of those complication ? The guideline suggest: (1) Dual antiplatelet at least one month if no active bleeding. Some study revealed IV heparin after TAE for 1~3 days will lower ischemic stroke rate of those patient. (2) Controlled SBP below 140 mmHg and monitor Intracranial pressure. (3) Head up to 30 degree may decrease brainstem compression by coiling.