Background Basilar artery bifurcation aneurysm (BABA) is primarily repaired by endovascular approach due the poor outcomes associated with surgical clipping. However, there are no clear strategies in the treatment of ruptured BABA, when the ruptured aneurysm is a giant and complex in morphology, and presents with a poor Hunt & Hess (H&H) grades and intraventricular haemorrhage (IVH).
Objectives To report the strategies those were utilised in the management of two unusual giant and complex ruptured BABA. We also evaluated the impact of strategies in the function outcome of these patients.
Methods Retrospective review of cases from a prospectively maintained aneurysm database.
Results The first patient is a 61 years old man with history of hypertension and smoking who presented with H&H IV from a ruptured wide neck multi-lobulated giant 33 mm aneurysm in 2008. An extraventricular drainage (EVD) was placed to decompress the hydrocephalus and IVH. Patient’s aneurysm was secured by coiling within 24 hours and the IVH was treated with intraventricular tissue plasminogen activator (TPA). The clinical grade improved over next 3 weeks and underwent stent-assisted (left PCA to BA) coiling prior to the discharge. On 90 days patient became independent and asymptomatic (mRS 0), however follow-up angiogram in 6, 12, 18 & 24 months demonstrated recurrences and underwent successful coiling each time without the change of mRS 0. After the 3dr recurrent event (obscured right PCA by the aneurysm sac became visible), patient underwent uneventful Y-neck reconstruction and coiling of aneurysm using a second stent (BA to right PCA). Meanwhile, patient got married with his long-standing girlfriend and continued to be mRS 0. 2013 angiogram demonstrated persistent obliteration of aneurysm.
The second patient is a 49 years old man who presented in 2011 with H&H II due to a ruptured wide neck multilobulated 38 mm giant aneurysm. Patient reruptured and became comatose with dilated fixed pupils. Patient was immediately resuscitated using hyperventilation, hyperosmolar therapy and EVD. The pupils became normal however H&H remained V. The immediate repeat head scan demonstrated massive IVH with packed ventricles with no brain herniation. Emergent primary coiling of the aneurysm was performed which resulted in complete obliteration of aneurysm associated non-filling of both PCAs. However, posterior communicating arteries were filling both PCAs. Patient received TPA through EVD resulted in complete resolution of IVH. Patient improved was extubated in 48 hours. The mRS became 1 in 90 days, but angiogram demonstrated aneurysm recurrence with recanalisation of PCAs. Patient underwent, stent-assisted coiling of aneurysm with near complete obliteration of aneurysm. However, in 12 months aneurysm recanalised which required Y-stent neck reconstruction and coiling of aneurysm. Patient’s mRS continued to be 1 and aneurysm remained obliterated.
Conclusion Emergent endovascular treatment of giant complex poor grade ruptured BABA aneurysm may open the opportunity to treat life threatening massive IVH using intraventricular TPA and may results in good clinical outcome. Therefore, endovasacular therapy for all poor grade ruptured BABA with IVH should be considered, especially when the poor grades are considered to be related to IVH.
Disclosures Y. Lodi: None. V. Reddy: None. A. Devasenapathy: None. A. Swarnkar: None. K. Sethi: None. D. Gaylon: None. S. Bajwa: None.
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