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

  • Marta Aguilar Pérez
  • Muhammad AlMatter
  • Hans Henkes
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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 nine 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 four 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 four 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.


Basilar artery aneurysm Crossing Solitaires Aneurysm recurrence Vasospasm Antiaggregation 


  1. Abla AA, Wilson DA, Williamson RW, Nakaji P, McDougall CG, Zabramski JM, Albuquerque FC, Spetzler RF. The relationship between ruptured aneurysm location, subarachnoid hemorrhage clot thickness, and incidence of radiographic or symptomatic vasospasm in patients enrolled in a prospective randomized controlled trial. J Neurosurg. 2014;120(2):391–7. CrossRefPubMedGoogle Scholar
  2. Becske T, Potts MB, Shapiro M, Kallmes DF, Brinjikji W, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ, Woo HH, Lopes DK, Berez AL, Cher DJ, Siddiqui AH, Levy EI, Albuquerque FC, Fiorella DJ, Berentei Z, Marosföi M, Cekirge SH, Nelson PK. Pipeline for uncoilable or failed aneurysms: 3-year follow-up results. J Neurosurg. 2017;127(1):81–8. CrossRefPubMedGoogle Scholar
  3. Bhogal P, Loh Y, Brouwer P, Andersson T, Söderman M. Treatment of cerebral vasospasm with self-expandable retrievable stents: proof of concept. J Neurointerv Surg. 2017;9(1):52–9. CrossRefPubMedGoogle Scholar
  4. de Oliveira Manoel AL, Mansur A, Silva GS, Germans MR, Jaja BN, Kouzmina E, Marotta TR, Abrahamson S, Schweizer TA, Spears J, Macdonald RL. Functional outcome after poor-grade subarachnoid hemorrhage: a single-center study and systematic literature review. Neurocrit Care. 2016;25(3):338–50.CrossRefPubMedGoogle Scholar
  5. Fargen KM, Mocco J, Neal D, Dewan MC, Reavey-Cantwell J, Woo HH, Fiorella DJ, Mokin M, Siddiqui AH, Turk AS, Turner RD, Chaudry I, Kalani MY, Albuquerque F, Hoh BLA. Multicenter study of stent-assisted coiling of cerebral aneurysms with a Y configuration. Neurosurgery. 2013;73(3):466–72. CrossRefPubMedGoogle Scholar
  6. Henkes H, Fischer S, Mariushi W, Weber W, Liebig T, Miloslavski E, Brew S, Kühne D. Angiographic and clinical results in 316 coil-treated basilar artery bifurcation aneurysms. J Neurosurg. 2005;103(6):990–9.CrossRefPubMedGoogle Scholar
  7. Henkes H, Fischer S, Liebig T, Weber W, Reinartz J, Miloslavski E, Kühne D. Repeated endovascular coil occlusion in 350 of 2759 intracranial aneurysms: safety and effectiveness aspects. Neurosurgery. 2006;58(2):224–32. Discussion 224–32.CrossRefPubMedGoogle Scholar
  8. Murayama Y, Takao H, Ishibashi T, Saguchi T, Ebara M, Yuki I, Arakawa H, Irie K, Urashima M, Molyneux AJ. Risk analysis of unruptured intracranial aneurysms: prospective 10-year cohort study. Stroke. 2016;47(2):365–71. CrossRefPubMedGoogle Scholar
  9. Musahl C, Henkes H, Vajda Z, Coburger J, Hopf N. Continuous local intra-arterial nimodipine administration in severe symptomatic vasospasm after subarachnoid hemorrhage. Neurosurgery. 2011;68(6):1541–1547. Discussion 1547. Scholar
  10. Nagashima H, Kobayashi S, Tanaka Y, Hongo K. Endovascular therapy versus surgical clipping for basilar artery bifurcation aneurysm: retrospective analysis of 117 cases. J Clin Neurosci. 2004;11(5):475–9.CrossRefPubMedGoogle Scholar
  11. Nguyen TN, Hoh BL, Amin-Hanjani S, Pryor JC, Ogilvy CS. Comparison of ruptured vs unruptured aneurysms in recanalization after coil embolization. Surg Neurol. 2007;68(1):19–23.CrossRefPubMedGoogle Scholar
  12. Osawa M, Hongo K, Tanaka Y, Nakamura Y, Kitazawa K, Kobayashi S. Results of direct surgery for aneurysmal subarachnoid haemorrhage: outcome of 2055 patients who underwent direct aneurysm surgery and profile of ruptured intracranial aneurysms. Acta Neurochir. 2001;143(7):655–63. Discussion 663–4.CrossRefPubMedGoogle Scholar
  13. Pandey AS, Koebbe C, Rosenwasser RH, Veznedaroglu E. Endovascular coil embolization of ruptured and unruptured posterior circulation aneurysms: review of a 10-year experience. Neurosurgery. 2007;60(4):626–36. Discussion 636–7.CrossRefPubMedGoogle Scholar
  14. Pérez MA, Bhogal P, Moreno RM, Wendl C, Bäzner H, Ganslandt O, Henkes H. Use of the pCONus as an adjunct to coil embolization of acutely ruptured aneurysms. J Neurointerv Surg. 2017;9(1):39–44. CrossRefPubMedGoogle Scholar
  15. Piotin M, Blanc R, Spelle L, Mounayer C, Piantino R, Schmidt PJ, Moret J. Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke. 2010;41(1):110–5. CrossRefPubMedGoogle Scholar
  16. Qian Z, Feng X, Kang H, Wen X, Xu W, Zhao F, Jiang C, Wu Z, Li Y, Liu A. Ruptured wide-necked aneurysms: is stent-assisted coiling during posthemorrhage days 4-10 safe and efficient? World Neurosurg. 2017;101:137–43. CrossRefPubMedGoogle Scholar
  17. Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, Lamoureux J, Chagnon M, Roy D. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke. 2003;34(6):1398–403.CrossRefPubMedGoogle Scholar
  18. Wermer MJ, van der Schaaf IC, Algra A, Rinkel GJ. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: an updated meta-analysis. Stroke. 2007;38(4):1404–10.CrossRefPubMedGoogle Scholar
  19. White PM, Wardlaw JM. Unruptured intracranial aneurysms. J Neuroradiol. 2003;30(5):336–50.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Marta Aguilar Pérez
    • 1
  • Muhammad AlMatter
    • 1
  • Hans Henkes
    • 1
  1. 1.Neuroradiologische KlinikNeurozentrum, Klinikum StuttgartStuttgartGermany

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