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NEUROIMAGE
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1738-1739

A Giant Thrombosed Vertebrobasilar Artery System Aneurysm Mimicking Brainstem Lesion


Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India

Date of Submission29-Nov-2021
Date of Acceptance01-Feb-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Gyani J S. Birua
Department of Neurosurgery, NIMHANS, 2nd Floor, Right Wing, Faculty Building, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355091

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How to cite this article:
S. Birua GJ, Sikaria A, Tyagi G, Beniwal M, Srinivas D. A Giant Thrombosed Vertebrobasilar Artery System Aneurysm Mimicking Brainstem Lesion. Neurol India 2022;70:1738-9

How to cite this URL:
S. Birua GJ, Sikaria A, Tyagi G, Beniwal M, Srinivas D. A Giant Thrombosed Vertebrobasilar Artery System Aneurysm Mimicking Brainstem Lesion. Neurol India [serial online] 2022 [cited 2022 Oct 2];70:1738-9. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1738/355091




Giant aneurysms of the vertebrobasilar system are not uncommon,[1] but a complete thrombosed aneurysm of vertebrobasilar aneurysm mimicking brainstem lesion is extremely rare. These aneurysms may induce symptoms suggesting a posterior fossa tumor.[2] Giant aneurysms of the posterior fossa are difficult to diagnose with angiography, especially in the case of complete thrombosis.[3] We are describing images of a giant thrombosed vertebrobasilar artery system aneurysm simulating a brainstem lesion.

A 21-year-old female had been suffering from sharp lancinating pain and paresthesia of the left side of the face for 2 months. She had a history of one episode of sudden excruciating headache 2 years ago, which started suddenly at the occipital region and became holocranial within minutes. However, it was not associated with loss of consciousness, vomiting, vertigo, or visual symptoms, and it subsided within 2 days with an analgesic. Hence, she did not consult a physician for further evaluation.

The patient was evaluated with magnetic resonance imaging (MRI). MRI brain revealed a large (2.4 × 2.4 × 4.4 cm), predominantly cystic lesion with an exophytic component in the pontomedullary part of the brainstem [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h, [Figure 1]i, [Figure 1]j, [Figure 1]k. Magnetic resonance angiography (MRA) revealed markedly attenuated caliber of the bilateral (right > left) vertebral arteries and the basilar artery [Figure 1].
Figure 1: (a) MRI T1W axial section shows a hypointense cystic lesion with an isointense solid area in the brainstem. (b–d) MRI T2W sequences show a large unilocular cystic lesion with few solid nodular areas superiorly and inferiorly. (e) MRI diffusion-weighted image shows no diffusion restriction. (f–h) MRI contrast sequences show a thin peripheral rim of enhancement along with heterogeneous enhancement in its solid components. (i) MRI susceptibility weighted image shows blooming along the periphery of the lesion. (j and k) MRI Constructive Interference in Steady State (CISS) 3D image shows the cystic part of the lesion being relatively less hyperintense as compared to the CSF. (l) MRA shows markedly attenuated caliber of the bilateral vertebral arteries (right more attenuated than the left) and the basilar artery (orange arrow). CSF = cerebrospinal fluid, MRA = magnetic resonance angiography, MRI = magnetic resonance imaging, T1W = T1 weighted, T2W = T2 weighted

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To further evaluate the attenuated bilateral vertebrobasilar arteries and to rule out any possible vascular anomaly, the patient was further evaluated with digital subtraction angiography (DSA), which revealed a fully thrombosed, dissecting giant vertebrobasilar artery system aneurysm [Figure 2].
Figure 2: (a and b) Digital subtraction angiogram shows opacification of the right Posterior Cerebral Artery (PCA) (blue arrow) through a dominant right posterior communicating artery (orange arrow). (c and d) Digital subtraction angiography shows opacification of the left PCA (orange arrow) and the basilar artery (black arrow) through a dominant left posterior communicating artery (blue arrow). (e and f) Digital subtraction an giography of right VA shows hypoplastic VA all along its length with further attenuation of its V4 segment (arrowhead), which is only seen as a faint stream of contrast. (g and h) Digital subtraction angiography of left VA shows hypoplastic VA all along its length with further attenuation of V4 segment (orange arrow). Note the absence of opacification of the rest of the posterior circulation, except for normal parenchymal blush in the left Posterior Inferior Cerebellar Artery (PICA) territory (star). VA = vertebral artery

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Suzuki T, Kaku S, Nishimura K, Teshigawara A, Sasaki Y, Aoki K, et al. Multistage “Hybrid” (Open and endovascular) surgical treatment of vertebral artery-thrombosed giant aneurysm by trapping and thrombectomy. World Neurosurg 2018;114:144-50.  Back to cited text no. 1
    
2.
Drake CG. Giant intracranial aneurysms: Experience with surgical treatment in 174 patients. Clin Neurosurg 1979;26:12-95.  Back to cited text no. 2
    
3.
Spallone A. Giant, completely thrombosed intracranial aneurysm simulating tumor of the foramen magnum. Surg Neurol 1982;18:372-6.  Back to cited text no. 3
    


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