ACTA NEUROCHIRURGICA
ActaNeurochirurgica 49, 87--93 (1979)
9 by Springer-Verlag 1979
Division of Neurosurgery, Institute of Brain Diseases, Tohoku University S&ool of Medicine, Sendal, Japan
A Case of Giant Aneurysm
of the Basilar Artery
By
R. Katakura, T. Yoshimoto, and J. Suzuki With 6 Figures
Summary A case of a giant aneurysm, 66mm across at its largest diameter, at the bifurcation of the basilar artery, with agenesis of the internal carotid artery, verified by angiography and autopsy, is reported. Keywords: Giant aneurysm; Basilar artery; Agenesis of internal carotid artery.
Introduction
A so-called giant aneurysm is usually considered to be 25 mm or more across in its largest diameter. According to Morley 7, giant aneurysms are observed in 5 % of all patients with cerebral aneurysms, 800/0 of them on the internal carotid and 7% on the vertebrobasilar systems. We have studied a patient in whom a giant aneurysms, 66 mm across at its largest diameter, was discovered at the bifurcation of the basilar artery, with agenesis of the internal carotid artery. This aneurysm is the largest aneurysm in this situation reported in the literature. The clinical course and autopsy findings in this patient are presented. Case Report Present illness: A 41-year-old woman began to notice gradual disorientation and difficulty in counting. In December 1974 she entered hospital. On admission, she had impaired intelligence (IQ 60), and disturbances of memory and orientation. Neurologically, she had right hemiparesis and hemiparaesthesia. Ophthalmological examination revealed anisocoria (right > left), right homonymous hemianopia, and bilateral optic atrophy.
0001-6268/79/0049/0087/8 01.40
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R. Katakura et al.:
Roentgenological findings: Plain X-ray film of the skull showed no abnormal shadow such as calcification. Left carotid angiography (Fig. 1) showed a defect of the internal carotid artery at its origin, and one part of the abnormally dilated basilar artery. Right carotid angiography showed elongation of the internal carotid and middle cerebral arteries, but no filling on the opposite side. Vertebral angiography (Figs. 2 and 3) revealed a giant bulbar aneurysm at the termination
Fig. 1. The lateral view of the left carotid angiogram showed the defect of the internal carotid artery and the dilated basilar artery (-+) of the basilar artery. Five seconds after injection there was still retention of contrast medium in the aneurysm (Fig. 4). Clinical course: Intracranial direct surgery was not undertaken, because the aneurysm was too large and was in a situation, where surgery was considered to be difficult and dangerous. Psychological symptoms and optic atrophy in this patient were considered to be caused by hydrocephalus due to the giant aneurysm, which compressed the third ventricle upwards. Therefore, a ventriculo-peritoneal shunt was performed. Conray ventriculography was undertaken through the shunt. It was found that the ventricle was not very large, but the third ventricle was
A Case of Giant Aneurysm of the Basilar Artery
89
shifted and elevated, and there was stenosis of the foramen of monro (Fig. 5). Postoperatively, psychological symptoms improved. She was discharged from hospital on 10 February 1975. However, in July she was found to have fallen down on the floor, and was transferred to hospital in deep coma. She died three days later. Autopsy findings: A large haematoma was found from the basilar artery to the brain stem. The basilar artery was dilated, and gray in colour.
Fig. 2. The A-P view of the left vertebral angiogram showed the giant aneurysm, the tortuosity of the vertebral artery, and the elongated and dilated basilar artery On coronal section at the level of the mamillary body (Fig. 6), the third ventricle and the lateral ventricles were filled with haematoma, which extended from the surroundings of the aneurysm to the sylvian fissure. A giant aneurysm, 66 mm at its largest diameter, which intruded into the left basal ganglia and compressed the internal capsule, was present. As observed on Conray ventriculography, the third ventricle was elevated and deformed. tt was confirmed that there was agenesis of the left internal carotid artery from its origin in the neck.
90
R. Katakura et al.:
Discussion
An intracranial giant aneurysm rarely presents with subarachnoid haemorrhage, and often causes space-occupying symptoms. Many patients with giant aneurysms of the basilar artery have unilateral signs of cranial nerve and pyramidal tract disturbance. High incidence of psychological symptoms and decrease in intelligence is
Fig. 3. The lateral view of the left vertebral angiogram showed the giant aneurysm arising from the basilar artery
characteristic of giant aneurysm of the basilar artery t, 2, 4, 6 In our patient, the first symptoms were psychological and, in addition, during the process of the disease she had right motor haemiparesis and paresis of the left oculomotor nerve. This patient was similar to other patients reported by various investigators. The treatment for such a giant aneurysm of the basilar artery is considered to be difficult because it is deep and is extremely large. Once it ruptures, it very often causes death. Even if it is not ruptured, compression of the brain stem can be fatal 7. However, there are only a few reports of intracranial direct surgery on giant aneurysms of the basilar artery. Fox 5 reported that symptoms were improved by incision of the tentorium for decompression, and then
A Case of Giant Aneurysm of the Basilar Artery
91
partial resection of the aneurysm was performed at a second operation. Suzuki 11 reported a patient who died 14 days after the trapping of aneurysm which was performed due to an enlarged aneurysm neck; and Sundt s0 reported that resection of an aneurysm could performed successfully under hypothermic an-
Fig. 4. The A-P view of the left vertebral angiogram, five seconds after injection of contrast medium, showed remaining contrast medium aesthesia. On the other hand, there are reports in which the vertebral artery or the basilar artery was ligated to promote thrombus in an aneurysm s, 9. Among 21 patients with giant aneurysms of the basilar artery, Drake a ligated one or both vertebral arteries in 14 patients, and the basilar artery in 7 patients, and obtained satisfactory results. Clearly there are various methods of treatment for giant aneurysm of the basilar artery. A satisfactory result could not always be obtained, and therefore further studies are required.
Fig. 5. The lateral view of the Conray ventriculograph. The third ventricle is compressed and elevated, and the lateral ventricle is slightly enlarged
Fig. 6. Coronal section of the brain. The giant aneurysm which arose from the basilar artery, was just beneath the third ventricle and extended towards the left basal ganglia. The haematoma extended to the ventricles and Sylvian fissure
R. Katakura et al.: A Case of Giant Aneurysm of the Basilar Artery
93
With regard to an aneurysm associated with an agenesis of the internal carotid artery, it is known that an aneurysm of the anterior communicating artery is occasionally associated with anomalies such as absence or hypoplasia of the unilateral A1. In this patient, it cannot be denied that changes in the status of blood flow caused by agenesis of an internal carotid artery may be involved in the mechanism of growth of the aneurysm. From the fact that a congenital arterial defect was present, the giant aneurysm observed in this patient was also considered to be a kind of vascular anomaly, differing from a cerebral saccular aneurysm. References
1. Boht, J., Frenske, A., Reulen, H. J., Schindler, E., Giant aneurysm of the vertebral artery causing compression of the lower medulla oblongata. J. Neurol. 214 (1977), 289--293. 2. Bull, J., Massive aneurysms of the base of the brain. Brain 92 (1969), 535--580. 3. Drake, C. G., Ligation of the vertebral (unilateral or bilateral) or basilar artery in the treatment of large intracranial aneurysms. J. Neurosurg. 43 (1975), 255--274. 4. Duvoison, R. G., Yahr, M. D., Posterior fossa aneurysms. Neurology 15 (1965), 231--241. 5. Fox, J. L., Tentorial section for decompression of the brain stem and large basilar aneurysm. Case report. J. Neurosurg. 28 (1968), 74--77. 6. Matsumoto, M., Miura, N., Takizawa, T., Yasuma, T., Matsuzawa, H., Tsukamoto, Y., Large aneurysm of the vertebro-basilar system: Report of a case and diagnostic review of the case in literatures. Brain Nerve (Tokyo) 23 (1971), 457--469. 7. Morley, T. P., Barr, H. W. K., Giant intracranial aneurysms: diagnosis, course, and management. Clin. Neurosurg. 16 (1969), 73--94. 8. Mount, L. A., Taverns, J. M., Ligation of the basilar artery in treatment of an aneurysm at the basilar artery bifurcation. J. Neurosurg. 19 (1962), 167-170. 9. Shintani, A., Zervas, N. T., Consequence of iigation of the vertebral artery. J. Neurosurg. 36 (1972), 447--450. 10. Sundt, T., Pluth, J. R., Gronert, G. A., Excision of giant basilar aneurysm under profound hypothermia. Report of case. Mags Clinic Proc. 47 (1972), 631--634. 11. Suzuki, S., Onuma, T., Suzuki, J., Giant aneurysm of the basilar artery: Report of a case. Brain Nerve (Tokyo) 22 (1970), 455--458. Authors' address: R. Katakura, Division of Neurosurgery, Institute of Brain Diseases, Tohoku University School of Medicine, 5-13-1, Nagamachi, Sendal, Japan.
ActaNeurochirurgica 49, 87--93 (1979)
9 by Springer-Verlag 1979
Division of Neurosurgery, Institute of Brain Diseases, Tohoku University S&ool of Medicine, Sendal, Japan
A Case of Giant Aneurysm
of the Basilar Artery
By
R. Katakura, T. Yoshimoto, and J. Suzuki With 6 Figures
Summary A case of a giant aneurysm, 66mm across at its largest diameter, at the bifurcation of the basilar artery, with agenesis of the internal carotid artery, verified by angiography and autopsy, is reported. Keywords: Giant aneurysm; Basilar artery; Agenesis of internal carotid artery.
Introduction
A so-called giant aneurysm is usually considered to be 25 mm or more across in its largest diameter. According to Morley 7, giant aneurysms are observed in 5 % of all patients with cerebral aneurysms, 800/0 of them on the internal carotid and 7% on the vertebrobasilar systems. We have studied a patient in whom a giant aneurysms, 66 mm across at its largest diameter, was discovered at the bifurcation of the basilar artery, with agenesis of the internal carotid artery. This aneurysm is the largest aneurysm in this situation reported in the literature. The clinical course and autopsy findings in this patient are presented. Case Report Present illness: A 41-year-old woman began to notice gradual disorientation and difficulty in counting. In December 1974 she entered hospital. On admission, she had impaired intelligence (IQ 60), and disturbances of memory and orientation. Neurologically, she had right hemiparesis and hemiparaesthesia. Ophthalmological examination revealed anisocoria (right > left), right homonymous hemianopia, and bilateral optic atrophy.
0001-6268/79/0049/0087/8 01.40
88
R. Katakura et al.:
Roentgenological findings: Plain X-ray film of the skull showed no abnormal shadow such as calcification. Left carotid angiography (Fig. 1) showed a defect of the internal carotid artery at its origin, and one part of the abnormally dilated basilar artery. Right carotid angiography showed elongation of the internal carotid and middle cerebral arteries, but no filling on the opposite side. Vertebral angiography (Figs. 2 and 3) revealed a giant bulbar aneurysm at the termination
Fig. 1. The lateral view of the left carotid angiogram showed the defect of the internal carotid artery and the dilated basilar artery (-+) of the basilar artery. Five seconds after injection there was still retention of contrast medium in the aneurysm (Fig. 4). Clinical course: Intracranial direct surgery was not undertaken, because the aneurysm was too large and was in a situation, where surgery was considered to be difficult and dangerous. Psychological symptoms and optic atrophy in this patient were considered to be caused by hydrocephalus due to the giant aneurysm, which compressed the third ventricle upwards. Therefore, a ventriculo-peritoneal shunt was performed. Conray ventriculography was undertaken through the shunt. It was found that the ventricle was not very large, but the third ventricle was
A Case of Giant Aneurysm of the Basilar Artery
89
shifted and elevated, and there was stenosis of the foramen of monro (Fig. 5). Postoperatively, psychological symptoms improved. She was discharged from hospital on 10 February 1975. However, in July she was found to have fallen down on the floor, and was transferred to hospital in deep coma. She died three days later. Autopsy findings: A large haematoma was found from the basilar artery to the brain stem. The basilar artery was dilated, and gray in colour.
Fig. 2. The A-P view of the left vertebral angiogram showed the giant aneurysm, the tortuosity of the vertebral artery, and the elongated and dilated basilar artery On coronal section at the level of the mamillary body (Fig. 6), the third ventricle and the lateral ventricles were filled with haematoma, which extended from the surroundings of the aneurysm to the sylvian fissure. A giant aneurysm, 66 mm at its largest diameter, which intruded into the left basal ganglia and compressed the internal capsule, was present. As observed on Conray ventriculography, the third ventricle was elevated and deformed. tt was confirmed that there was agenesis of the left internal carotid artery from its origin in the neck.
90
R. Katakura et al.:
Discussion
An intracranial giant aneurysm rarely presents with subarachnoid haemorrhage, and often causes space-occupying symptoms. Many patients with giant aneurysms of the basilar artery have unilateral signs of cranial nerve and pyramidal tract disturbance. High incidence of psychological symptoms and decrease in intelligence is
Fig. 3. The lateral view of the left vertebral angiogram showed the giant aneurysm arising from the basilar artery
characteristic of giant aneurysm of the basilar artery t, 2, 4, 6 In our patient, the first symptoms were psychological and, in addition, during the process of the disease she had right motor haemiparesis and paresis of the left oculomotor nerve. This patient was similar to other patients reported by various investigators. The treatment for such a giant aneurysm of the basilar artery is considered to be difficult because it is deep and is extremely large. Once it ruptures, it very often causes death. Even if it is not ruptured, compression of the brain stem can be fatal 7. However, there are only a few reports of intracranial direct surgery on giant aneurysms of the basilar artery. Fox 5 reported that symptoms were improved by incision of the tentorium for decompression, and then
A Case of Giant Aneurysm of the Basilar Artery
91
partial resection of the aneurysm was performed at a second operation. Suzuki 11 reported a patient who died 14 days after the trapping of aneurysm which was performed due to an enlarged aneurysm neck; and Sundt s0 reported that resection of an aneurysm could performed successfully under hypothermic an-
Fig. 4. The A-P view of the left vertebral angiogram, five seconds after injection of contrast medium, showed remaining contrast medium aesthesia. On the other hand, there are reports in which the vertebral artery or the basilar artery was ligated to promote thrombus in an aneurysm s, 9. Among 21 patients with giant aneurysms of the basilar artery, Drake a ligated one or both vertebral arteries in 14 patients, and the basilar artery in 7 patients, and obtained satisfactory results. Clearly there are various methods of treatment for giant aneurysm of the basilar artery. A satisfactory result could not always be obtained, and therefore further studies are required.
Fig. 5. The lateral view of the Conray ventriculograph. The third ventricle is compressed and elevated, and the lateral ventricle is slightly enlarged
Fig. 6. Coronal section of the brain. The giant aneurysm which arose from the basilar artery, was just beneath the third ventricle and extended towards the left basal ganglia. The haematoma extended to the ventricles and Sylvian fissure
R. Katakura et al.: A Case of Giant Aneurysm of the Basilar Artery
93
With regard to an aneurysm associated with an agenesis of the internal carotid artery, it is known that an aneurysm of the anterior communicating artery is occasionally associated with anomalies such as absence or hypoplasia of the unilateral A1. In this patient, it cannot be denied that changes in the status of blood flow caused by agenesis of an internal carotid artery may be involved in the mechanism of growth of the aneurysm. From the fact that a congenital arterial defect was present, the giant aneurysm observed in this patient was also considered to be a kind of vascular anomaly, differing from a cerebral saccular aneurysm. References
1. Boht, J., Frenske, A., Reulen, H. J., Schindler, E., Giant aneurysm of the vertebral artery causing compression of the lower medulla oblongata. J. Neurol. 214 (1977), 289--293. 2. Bull, J., Massive aneurysms of the base of the brain. Brain 92 (1969), 535--580. 3. Drake, C. G., Ligation of the vertebral (unilateral or bilateral) or basilar artery in the treatment of large intracranial aneurysms. J. Neurosurg. 43 (1975), 255--274. 4. Duvoison, R. G., Yahr, M. D., Posterior fossa aneurysms. Neurology 15 (1965), 231--241. 5. Fox, J. L., Tentorial section for decompression of the brain stem and large basilar aneurysm. Case report. J. Neurosurg. 28 (1968), 74--77. 6. Matsumoto, M., Miura, N., Takizawa, T., Yasuma, T., Matsuzawa, H., Tsukamoto, Y., Large aneurysm of the vertebro-basilar system: Report of a case and diagnostic review of the case in literatures. Brain Nerve (Tokyo) 23 (1971), 457--469. 7. Morley, T. P., Barr, H. W. K., Giant intracranial aneurysms: diagnosis, course, and management. Clin. Neurosurg. 16 (1969), 73--94. 8. Mount, L. A., Taverns, J. M., Ligation of the basilar artery in treatment of an aneurysm at the basilar artery bifurcation. J. Neurosurg. 19 (1962), 167-170. 9. Shintani, A., Zervas, N. T., Consequence of iigation of the vertebral artery. J. Neurosurg. 36 (1972), 447--450. 10. Sundt, T., Pluth, J. R., Gronert, G. A., Excision of giant basilar aneurysm under profound hypothermia. Report of case. Mags Clinic Proc. 47 (1972), 631--634. 11. Suzuki, S., Onuma, T., Suzuki, J., Giant aneurysm of the basilar artery: Report of a case. Brain Nerve (Tokyo) 22 (1970), 455--458. Authors' address: R. Katakura, Division of Neurosurgery, Institute of Brain Diseases, Tohoku University School of Medicine, 5-13-1, Nagamachi, Sendal, Japan.
