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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 682-683

Endovascular treatment of ruptured saccular aneurysm from basilar artery fenestration


Department of Neurointervention, King Edward Memorial Hospital, Pune 411 011, India

Date of Submission15-Nov-2012
Date of Decision15-Nov-2012
Date of Acceptance18-Nov-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Lakshmi Sudha Prasanna Karanam
Department of Neurointervention, King Edward Memorial Hospital, Pune 411 011
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.105227

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How to cite this article:
Alurkar A, Karanam LS, Oak S. Endovascular treatment of ruptured saccular aneurysm from basilar artery fenestration . Neurol India 2012;60:682-3

How to cite this URL:
Alurkar A, Karanam LS, Oak S. Endovascular treatment of ruptured saccular aneurysm from basilar artery fenestration . Neurol India [serial online] 2012 [cited 2019 Dec 11];60:682-3. Available from: http://www.neurologyindia.com/text.asp?2012/60/6/682/105227


Sir,

Fenestration refers to localised duplication of the vessel and the reported incidence of the basilar fenestration on angiography is 0.3-0.6%. [1] In basilar artery, fenestration typically occurs at the lower end. [2] Medial wall defects with absent media and discontinuity of elastin make fenestration limb of the artery more prone to aneurysm formation. [2] We describe a case of basilar fenestration with a saccular aneurysm treated successfully with endovascular approach.

A 38-year-old male presented with sudden onset severe headache, vomiting and altered sensorium. Computed tomography scan revealed diffuse subarachnoid haemorrhage [Figure 1]. Digital subtraction angiography showed a narrow necked aneurysm from the fenestrated limb of basilar artery and endovascular treatment was planned. Under general anaesthesia, 5 F guiding (Envoy, Cordis) catheter was placed in the left vertebral artery and aneurysm was accessed with a combination of echelon 10 (ev 3) micro catheter and 0.014 traxcess (Microvention) microwire combination. Then the aneurysm was densely packed with multiple platinum coils [Figure 2]a and b. Post procedure angiogram showed complete exclusion of the aneurysm with good flow in both the loops of fenestration [Figure 2]c. There were no complications during intra or periprocedural period. At one-month follow-up his neurological examination was normal. Control angiogram after one year showed stable occlusion with good flow in both the limbs of fenestration [Figure 2]d.
Figure 1: CT scan showing sub arachnoid hemorrhage predominantly in the prepontine cisterns

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Figure 2: (a) DSA showing the saccular aneurysm from the fenestrated basilar artery (as shown by the arrow) (b) Echelon micro catheter in placed in the sac of aneurysm (shown by the arrow) (c) Post procedure
angiogram with exclusion of the aneurysm from the circulation and both the loops are preserved (d) Control angiogram after one year with stable occlusion of the aneurysm


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Surgical approach of the lower basilar aneurysms is difficult because of the complex surrounding anatomy, proximity of lower cranial nerves and presence of the perforators to the brain stem limiting the adequate surgical exposure. [3] Endovascular treatment can be a good alternative choice in these cases. [4] In some of the previous reported cases, one loop of the fenestration was intentionally or unintentionally sacrificed during the procedure. [5],[6] Angiographically non-visible branches may be present in the loops of the fenestration and hence preserving the loop is important inorder to prevent any adverse effects. In our patient both the loops are preserved during endovascular treatment and control angiogram at one year follow-up showed both the loops with good ante-grade flow. Large wide necked aneurysm at these locations are more difficult to treat and hybrid stent techniques has been recommended for unruptured aneurysms. [7]

 
 ╗ References Top

1.Sanders WP, Sorek PA, Mehta BA. Fenestration of intracranial arteries with special attention to associated aneurysms and other anomalies. AJNR Am J Neuroradiol 1993;14:675-80.  Back to cited text no. 1
    
2.Bentura JE, Figueiredo EG, de Monaco BA, Teixeira MJ. Vertebrobasilar artery junction aneurysm associated with fenestration. Arq Neuropsiquiatr 2010;68:312-4.  Back to cited text no. 2
    
3.Eustacchio S, Klein GE, Pendl G. Ruptured vertebrobasilar junction aneurysm associated with basilar artery fenestration. Acta Neurochir 1997;139:923-7.  Back to cited text no. 3
    
4.Kai Y, Hamada J, Morioka M, Yano S, Fujioka S, Kuratsu J. Endovascular treatment of ruptured aneurysms associated with fenestrated basilar artery-Two case reports. Neurol Med Chir (Tokyo) 2006;46:244-7.  Back to cited text no. 4
    
5.Fujimoto K, Kawai S, Yonezawa T, Masui K, Nishi N, Maekawa M, et al. Basilar trunk aneurysms with associated fenestration treated by using guglielmi detachable coils: Two case reports. J Stroke Cerebrovasc Dis 2007;16:84-7.  Back to cited text no. 5
    
6.Albanese E, Russo A, Ulm AJ. Fenestrated vertebrobasilar junction aneurysm: Diagnostic and therapeutic considerations. J Neurosurg 2009;110:525-9.  Back to cited text no. 6
    
7.Gruber TJ, Ogilvy CS, Hauck EF, Levy EI, Hopkins LN, Siddiqui AH. Endovascular treatment of a large aneurysm arising from a basilar trunk fenestration using the waffle-cone technique. Neurosurgery 2010;67:140-4.  Back to cited text no. 7
    


    Figures

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