Flow Diverter Treatment of Ruptured Basilar Artery Perforator Aneurysms : A Multicenter Experience

Abstract

Purpose: Ruptured basilar artery perforator aneurysms (BAPAs) represent a very rare cause of subarachnoid hemorrhage and an under-reported subtype of cerebral aneurysm. There is no consensus for the optimal treatment strategy (conservative vs. surgical vs. various endovascular approaches). We aim to present a multicenter experience of BAPA treatment using flow-diverter (FD) stents.

Methods: At five tertiary neurovascular centers, all cases of ruptured BAPAs treated by FD were retrospectively collected. Baseline imaging and clinical characteristics, complications, as well as early and long-term angiographic and clinical outcome (mRS) were analyzed.

Results: Eighteen patients (mean age, 57 years; SD, ±10.7 years) with acute SAH related to a BAPA were treated using 18 FD stents. Aneurysms were detected on initial imaging study in 28%; delayed diagnosis was triggered by clinical deterioration due to rebleeding in 15%. No rebleeding after FD was seen, 28% developed FD-related ischemic complications. At long term (n = 16), overall mortality was 13% (2/16), and favorable outcome (mRS 0-2) was 81% (13/16). All BAPAs (n = 13) were completely occluded at long-term angiographic follow-up.

Conclusion: In our multicenter experience, FD treatment of ruptured BAPAs appears to have comparable safety and efficacy outcomes to FD treatment of other ruptured posterior circulation aneurysms as well as to the conservative management of BAPAs. This treatment strategy for a ruptured BAPA achieved a high rate of angiographic occlusion and favorable clinical outcome; however, as the conservative management also seems to offer similar clinical outcomes an individualized treatment decision is warranted. Future prospective studies comparing both approaches are required.

Keywords: Angiogram-negative subarachnoid bleeding; Perimesencephalic subarachnoid bleeding; Subarachnoid hemorrhage.

Conflict of interest statement

F. Seker, C. Maurer, N. Kocer, A. Jamous, D. Behme, C. Taschner and H. Urbach declare that they have no competing interests. A. Berlis: financial interests: Stryker, Microvention, Medtronic, Sequent Medical (Proctor and service-related fees), phenox (lecture honorary, CEC), and Penumbra (lecture honorary). Nonfinancial interests: none. M. Möhlenbruch: financial interests: consultancy: Medtronic, MicroVention, Stryker Neurovascular, phenox*; grants/grants pending: Balt, MicroVention*; payment for lectures including service on speakers bureaus: Medtronic, MicroVention, Stryker Neurovascular. Nonfinancial interests: none. S. Elsheikh: financial interests: research grants from Bracco Suisse S.A., Medtronic, Cerenovus. Travel grant from Medtronic. Nonfinancial interests: none. S. Meckel: financial interests: consultant to Acandis GmbH, Microvention, Stryker, and Novartis Pharma GmbH, speaker fees (modest)/travel grant from Medtronic. Nonfinancial interests: none.

© 2022. The Author(s).

Figures

Fig. 1

DSA of the basilar artery lateral view (a) showing a small circular BAPA (arrow) located on the dorsal aspect of the basilar artery (patient #2). DSA, ap view (b), with a high contrast zoomed insert showing the aneurysm (arrows) projected behind the basilar artery. 6‑month follow-up DSA lateral view of the same patient showing complete occlusion (O’Kelly-Marotta occlusion score D) of the BAPA

Fig. 2

DSA of the basilar artery ap view (a) showing a possible active bleeding from a ruptured BAPA (patient #3). The patient suffered from two episodes of clinical worsening in the 2 h before the DSA. DSA ap view following implantation of the FD (b) with reduction of the contrast extravasation. Axial DW MR image (c) showing an increased signal intensity in the left paramedian area of the pons due to acute perforator artery occlusion. 6‑month follow-up DSA (d) showing complete occlusion (O’Kelly-Marotta occlusion score D) of the BAPA