Basilar Artery Bifurcation Aneurysm: Acute SAH, Ruptured Wide Neck Basilar Bifurcation Aneurysm, Coil Occlusion Assisted by Crossing Solitaire Stents, Symptomatic Vasospasm, Intra-arterial Nimodipine Infusion, Poor Clinical Outcome
A medium-sized, wide-necked ruptured aneurysm of the basilar artery bifurcation was treated by endovascular coil occlusion assisted by crossing Solitaire stents (Medtronic). The initial clinical status of the patient was Hunt and Hess IV with a Fisher grade of IV. Three days after the subarachnoid hemorrhage, a routine CT examination showed an infarction of the left thalamus. Angiographic vasospasm was found 9 days after the subarachnoid hemorrhage and was treated by intra-arterial nimodipine (Nimotop S, Bayer Vital) infusion. Despite the angiographic improvement of the vasospasm, follow-up MRI showed bilateral frontal lobe infarcts. An attempted exchange of the external ventricular drainage 17 days after the subarachnoid hemorrhage and under dual platelet inhibition failed and caused a minor right basal ganglia hemorrhage. A ventricular-peritoneal shunt was installed 4 weeks after the subarachnoid hemorrhage. Follow-up angiography showed an asymptomatic reperfusion of the basilar bifurcation aneurysm, which prompted an uneventful recoiling 11 months after the subarachnoid hemorrhage. Bilateral small intradural aneurysms of the internal carotid arteries were treated by flow diversion using Pipeline (PED, Medtronic). Follow-up angiography examinations confirmed the complete exclusion of all three aneurysms from the brain circulation 17 months after the subarachnoid hemorrhage and 4 months after the last flow diverter treatment. Two years after the subarachnoid hemorrhage the patient was still suffering from severe cognitive deficits with amnesia. Thirty months after the subarachnoid hemorrhage an ischemic stroke with right hemianopia and dysarthria occurred and was due to emboli into the posterior circulation related to intermittent atrial fibrillation. The combination of a massive subarachnoid hemorrhage and the subsequent cerebral vasospasm left the patient with a minor hemiparesis and persistent cognitive deficits, which prevented him from his previously independent life (mRS 3). The main topics of this report are the crossing stent technique and the management of severe vasospasm.
KeywordsBasilar artery aneurysm Crossing Solitaires Aneurysm recurrence Vasospasm Antiaggregation
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