Introduction Subarachnoid hemorrhages (SAH) are most commonly caused by trauma, ruptured cerebral aneurysm, and benign perimesencephalic hemorrhage. We report two cases of basal cistern SAH that were initially angiographically negative, however follow-up delayed angiography demonstrated an 2 mm aneurysm arising from a sub-millimeter pontine artery perforator, distinct from the basilar artery. In each case, treatment was placement of two overlapping Neuroform stents in the basilar artery.
Case presentation A 46-year-old man presents with SAH centered in the pre-pontine cistern. Initial angiography was negative and the patient clinically did well, however subsequent angiography at 6 weeks demonstrated a 2 mm aneurysm arising from a pontine artery perforator. A 61-year-old female presented to with a SAH. Similarly, the initial angiography was negative, however subsequent angiography demonstrated a 2 mm aneurysm arising from a pontine artery perforator.
Discussion In both cases, the patients' aneurysm originated from a small pontine artery perforator and the basilar artery was clearly distinct. In the first case (in 2006) had treatment options of observation, surgical exploration, or stenting of the basilar artery. The perforator was too small to catheterize with a microcatheter. Placement of overlapping Neuroform stents did not change aneurysm opacification initially, however at follow-up angiography, the aneurysm no longer opacified despite the artery being patent (Abstract P-013 figure 1A). The second case occurred in 2011, and therefore flow diversion with Pipeline was possible, however we chose to place overlapping Neuroform stents, which resulted aneurysm occlusion while maintaining vessel potency (Abstract P-013 figure 1B).
Conclusion Aneurysms arising from a basilar artery perforator are extremely rare, however successful treatment is possible. Although we treated with conventional microstents, newer flow diversion devices also offer a reasonable treatment option.
Competing interests R Turner: Microvention, Codman. ev3, Penumbra, Mindframe. A Turk: None. I Chaudry: None. E Nyberg: None. A Spiotta: None. D Fiorella: None.
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