Case 19 - Basilar Artery Aneurysm, CT, CTA

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

CTA of the head

CTA of the neck

INDICATION: 52-year-old male with subarachnoid hemorrhage

COMPARISON: Outside CT dated 11/5/2017 at 12:46 AM

TECHNIQUE: An unenhanced CT scan of the head was performed. CTA of the circle of Willis after injection of iodinated contrast was obtained. CTA of the carotid arteries and vertebral arteries after injection of iodinated contrast was obtained. MIPs,

Coronal and sagittal reconstructions are available.

FINDINGS:

CT head:

Stable appearance of subarachnoid hemorrhage in the interpeduncular cistern. No evidence of intraventricular extension. No new foci of acute intracranial hemorrhage identified.

Gray-white matter differentiation is preserved.

No large territorial infarct or intracranial fluid collection is identified.

Ventricular system size and configuration is within normal limits.

No evidence of mass effect, midline shift, or herniation.

Bony calvarium is intact.

Mucous retention cysts in the bilateral maxillary sinuses. Remaining paranasal sinuses and mastoid air cells are clear.

Status post right eye enucleation. Left orbit is normal in appearance.

CTA head:

The ACAs, MCAs, PCAs are normal in size and shape without aneurysmal dilatation, dissection or significant stenosis. The anterior commuting artery is unremarkable.

Pedunculated aneurysm measuring 6 mm x 5 mm with 3 mm neck arising from the basilar artery at the origin of the right superior cerebellar artery. SCA's, AICAs, and PICAS are normal in size and shape.

The intracranial vertebral arteries are normal and codominant.

CTA neck:

The partially visualized aorta appears grossly unremarkable.

Left carotid: No evidence of dissection, vascular malformation, or aneurysmal dilatation is identified. Utilizing NASCET criteria there is no significant stenosis of the carotid bulb. There is no evidence of damage of the arterial wall. No extra luminal contrast is identified.

Right carotid: No evidence of dissection, vascular malformation, or aneurysmal dilatation is identified. Utilizing NASCET criteria there is no significant stenosis of the carotid bulb. There is no evidence of damage of the arterial wall. No extra luminal contrast is identified.

Left vertebral artery: No evidence of dissection, vascular malformation, or aneurysmal dilatation is identified. There is no evidence of damage of the arterial wall. No extra luminal contrast is identified. The vertebral arteries are codominant.

Right vertebral artery: No evidence of dissection, vascular malformation, or aneurysmal dilatation is identified. There is no evidence of damage of the arterial wall. No extra luminal contrast is identified. The vertebral arteries are codominant.

The jugular veins and major vessels appear intact.

No evidence of acute fracture or listhesis of the cervical spine. Multilevel degenerative disc disease most pronounced at the C5-C6 level with mild central canal stenosis due to mild disc bulge at this level.

The thyroid appears unremarkable.

The visualized lung apices demonstrate paraseptal emphysema with large bulla, particularly in the right apex.

IMPRESSION:

Pedunculated basilar tip aneurysm measuring 6 x 5 mm with 3 mm neck.

No change in high attenuation subarachnoid hemorrhage in the interpeduncular cistern since study performed approximately 6 hours prior to this examination. No new acute intracranial hemorrhage identified.

Multilevel degenerative disc disease most pronounced at the C5-C6 level with mild central canal stenosis due to mild disc bulge at this level.
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INDICATION: ongoing new hedache

TECHNIQUE: Axial CT scan images were performed from the foramen magnum to the vertex without administration of intravenous contrast.

COMPARISON: None

FINDINGS:

Hemorrhage is seen within the interpeduncular cistern and also seen extending into the suprasellar cistern with minimal sliver of blood also noted within the anterior third ventricle.

There is mild hydrocephalus with prominence of temporal horns bilaterally. Cerebral edema is noted. There is no evidence of transtentorial or transforaminal herniation.

Posterior fossa appears unremarkable.

Right orbital prosthesis is seen with normal appearance of the left globe. Minimal sinus opacification is noted. Bony calvarium is unremarkable with normal appearance of the craniovertebral junction.

IMPRESSION:

Intrapeduncular cistern and suprasellar cistern subarachnoid hemorrhage with perhaps minimal amount of blood in the anterior third ventricle.

Developing mild hydrocephalus and cerebral edema. No herniation.

CT angiogram of the head is strongly recommended for further evaluation and to exclude an aneurysm as source of hemorrhage.
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Diagnostic Cerebral Angiogram and coil embolization of ruptured right SCA aneurysm

History: The patient is a 52-year-old male who presents with the worst headache of his life. CT head shows diffuse subarachnoid hemorrhage. CT angiogram demonstrated possible posterior circulation aneurysm. Patient presents for diagnostic cerebral angiography and possible endovascular treatment.

Approach:

The technical aspects of the procedure as well as its potential risks and benefits were reviewed with the patient and the patient's surrogate. These risks included but were not limited bleeding, infection, allergic reaction, damage to organs/vital structures, dissection, neurological deficit, stroke, non-diagnostic procedure, and the catastrophic outcomes of heart attack, coma, and death. With an understanding of these risks, informed consent was obtained and witnessed.

The patient was placed in the supine position on the angiography table and the skin of right and left groins were prepped in the usual sterile fashion. The procedure was performed under general anesthesia

A 5- French sheath was introduced in the right common femoral artery using Seldinger technique. A fluoro image was recorded to document catheter position. Once decision was made to proceed with endovascular treatment, the 5 French sheath was exchanged for an 8 French sheath and a right femoral artery.

Heparin bolus: 3000 units total after coil embolization

Contrast agent: Omnipaque 300, 182 ml

Fluoroscopy time: 49.4 Minutes

CATHETERS AND WIRES:

180 cm 0.035" glidewire

6-French Infinity 80 cm

6-French penumbra Select Berenstein catheter

Navien 072 guide catheter

Penumbra 3 Max reperfusion catheter

Fathom 16 microwire

SL 10-45 degree microcatheter

Synchro 2 standard microwire x2

4 x 10 transform balloon

5-French JB-1 glide catheter

Diagnostic length 0.035 glidewire

COILS USED (MRI compatible):

Stryker target XL 6 mm x 20 cm

Stryker target XL 4 mm x 8 cm

Stryker target ultra 3 mm x 10 cm

Stryker target ultra 2 mm x 6 cm

Stryker target ultra 2 mm x 6 cm

Stryker target Nano 1.5 mm x 4 cm (not deployed)

Vessels catheterized:

Right common carotid

Right internal carotid

Right external carotid

Left common carotid

Left internal carotid

Left external carotid

Right subclavian

Right vertebral

Left subclavian

Left vertebral

Basilar artery

Right common femoral

Vessels studied:

Right internal carotid: head: AP, lateral, obliques

Right external carotid artery: Head: AP, lateral

Right vertebral: head: AP, lateral and trans-facial

Left internal carotid: head: AP, lateral, obliques

Left external carotid artery: Head: AP, lateral

Left vertebral: head: AP, lateral

Left vertebral artery: Head: Magnified AP and lateral (pre-embolization)

Left vertebral artery: Head: Magnified AP and lateral (predetachment first coil)

Left vertebral artery: Head: Magnified AP and lateral (post 1 coils)

Left vertebral artery: Head: Magnified AP and lateral (post 2 coils)

Left vertebral artery: Head: Magnified AP and lateral (post 3 coils)

Left vertebral artery: Head: Magnified AP and lateral (post 4 coils)

Left vertebral artery: Head: Magnified AP and lateral (post 5 coils)

Left vertebral artery: Head: AP and lateral (final control)

Procedural Narrative:

A 5-Fr JB-1 glide catheter was advanced over a 0.035 glidewire into the aortic arch and the innominate and right common carotid artery were selected. The catheter was then advanced into the right internal carotid artery and cerebral angiography was performed. The catheter was then withdrawn into the common carotid artery and the right external carotid artery was selected and cerebral angiography was performed. The catheter was then withdrawn into the innominate artery and the right subclavian artery was selected. The right vertebral artery was subsequently selected. Cerebral angiography was performed. The catheter was then withdrawn into the aortic arch and the left common carotid artery was selected. The catheter was advanced into the left internal carotid artery and cerebral angiography was performed. The catheter was withdrawn into the left common carotid artery and the left external carotid artery was selected. Cerebral angiography was performed. The catheter was then withdrawn into the aortic arch and the left subclavian artery was selected. The left vertebral artery was then selected. Cerebral angiography was performed. The catheter was removed without incident. Rotational angiography sequences were then analyzed and reviewed on a separate and independent 3D workstation by Dr. Caplan.

Attention was then turned towards the embolization portion of this procedure. Under real-time fluoroscopy, the penumbra select catheter and Infinity guide catheter were advanced into the aortic arch over a 0.035" guidewire. The left subclavian artery was selected. The Infinity guide catheter was then advanced over the select catheter and glidewire into the left subclavian artery. The select catheter and glidewire were removed without incident. Under roadmap guidance, the Navien 072 distal intracranial catheter, 3 Max reperfusion catheter, and fathom 16 microwire were coaxially introduced. Under roadmap guidance, the 3 Max catheter was advanced over a microwire into the distal left vertebral artery. The Navien catheter was then tracked over the 3 Max catheter to its final position in the distal left vertebral artery and the 3Max and wire were removed. Preembolization angiography was performed. Under roadmap guidance, a SL 10 microcatheter was advanced over a microwire into the basilar artery. A transform supra compliant balloon was also advanced over a Synchro 2 standard microwire and positioned within the mid basilar artery, with the microwire advanced into the right posterior cerebral artery. The aneurysm was then accessed by the SL 10 microcatheter over a wire. Coil embolization was then performed using coils of a variety of shapes and sizes as listed above. Intermittent control angiography was performed. Once adequate embolization was performed, the coiling catheter and balloon were removed without incident. Final control angiography was then performed from the guide catheter. All catheters and wires were removed without incident. The intermediate catheter and sheath were then removed synchronously. Dr. Caplan was present and actively participated in the entirety of the case.

Interpretation:

Right internal carotid: head: Injection reveals the presence of a widely patent ICA, M1, and A1 segments and their branches. There is no significant stenosis, occlusion, aneurysm or vascular malformation visualized. The parenchymal and venous phases are unremarkable. The venous sinuses are widely patent.

Right external carotid artery: head: The visualized branches of the right external carotid artery are unremarkable.

Left internal carotid: head: Injection reveals the presence of a widely patent ICA, A1, M1 branches. There is no significant stenosis, occlusion, aneurysm, or vascular malformation visualized. An infundibulum is noted at the origin of the posterior communicating artery. The parenchymal and venous phases are unremarkable. The venous sinuses are widely patent.

Left external carotid artery: head: The visualized branches of the left external carotid artery are unremarkable.

Right vertebral: Injection reveals the presence of a widely patent right vertebral artery. This leads to a widely patent basilar artery that terminates in bilateral P1. A saccular aneurysm is seen at the origin of the right superior cerebellar artery.

The basilar apex appears normal without aneurysmal dilatation. This aneurysm has a secondary dilatation and dome irregularity. The aneurysm measures approximately 7.6 mm x 6.3 mm. There is moderate contrast stasis within the aneurysm. There is no significant stenosis, occlusion, or vascular malformation visualized. The parenchymal and venous phases are unremarkable. The venous sinuses are widely patent.

Left vertebral: Left vertebral artery is dominant on this injection. This artery leads to a widely patent basilar artery that terminates in bilateral P1. Again visualized in greater detail is a saccular aneurysm measuring approximately 7.6 mm x 6.3 mm in the origin of the right superior cerebellar artery. The aneurysm is posteriorly projecting. The bilateral superior cerebellar arteries are patent. Again visualized is contrast stasis within the aneurysm. The parenchymal and venous phases are unremarkable. The venous sinuses are widely patent.

3D rotational angiogram: Using a separate and distinct workstation at a distinct time from any previous procedures, CT angiographic images were reviewed. This included multiplanar and 3D reformatted images. Again visualized and in further detail is the right superior cerebellar artery aneurysm with dome irregularity and secondary dilatation.

Left vertebral artery: Head: Magnified AP and lateral (pre-embolization): Injection reveals the presence of a widely patent vertebral artery leads to a patent basilar artery and unremarkable basilar apex with patent PCA and SCA bilaterally. The right superior cerebellar artery aneurysm with secondary dilatation and dome irregularity is again visualized. This aneurysm again measures approximately 7.6 mm x 6.3 mm. The visualized portions of the capillary and venous phases are unremarkable.

Left vertebral artery: Head: Magnified AP and lateral (post deployment angiography after 1 coil): Injection reveals the presence of a widely patent right vertebral artery leads to a patent basilar artery and unremarkable basilar apex with patent PCA and SCA bilaterally. Coil mass visualized within the aneurysm. There is contrast stasis within the aneurysm. The aneurysm continues to fill on this injection. There is no evidence of contrast extravasation or coil prolapse. The visualized portions of capillary and venous phases are otherwise unremarkable.

Left vertebral artery: Head: Magnified AP and lateral (post deployment angiography after 2 coils): Injection reveals the presence of a widely patent left vertebral artery leads to a patent basilar artery and unremarkable basilar apex with patent PCA and

SCA bilaterally. Coil mass visualized within the aneurysm. There is progressive occlusion of the aneurysm dome. There is no evidence of contrast extravasation or coil prolapse. The visualized portions of capillary and venous phases are otherwise unremarkable.

Left vertebral artery: Head: Magnified AP and lateral (post deployment angiography after 3 coils): Injection reveals the presence of a widely patent left vertebral artery leads to a patent basilar artery and unremarkable basilar apex with patent PCA and

SCA bilaterally. Coil mass visualized within the aneurysm. Continued occlusion of the aneurysm dome is seen. There is no evidence of contrast extravasation or coil prolapse. The visualized portions of capillary and venous phases are otherwise unremarkable.

Left vertebral artery: Head: Magnified AP and lateral (post deployment angiography after 4 coils): Injection reveals the presence of a widely patent left vertebral artery leads to a patent basilar artery and unremarkable basilar apex with patent PCA and

SCA bilaterally. Coil mass visualized within the aneurysm. Continued occlusion of the aneurysm is seen. There is no evidence of contrast extravasation or coil prolapse. The visualized portions of capillary and venous phases are otherwise unremarkable.

Left vertebral artery: Head: Magnified AP and lateral (post deployment angiography after 5 coils): Injection reveals the presence of a widely patent left vertebral artery leads to a patent basilar artery and unremarkable basilar apex with patent PCA and

SCA bilaterally. Coil mass visualized within the aneurysm. Aneurysm dome is completely occluded. There is no evidence of contrast extravasation or coil prolapse. The visualized portions of capillary and venous phases are otherwise unremarkable.

Left vertebral artery: Head: AP and lateral (Final Control): Injection reveals the presence of a widely patent left vertebral artery leads to a patent basilar artery and unremarkable basilar apex with patent PCA and SCA bilaterally. Coil mass visualized within the aneurysm. Aneurysm dome is completely occluded. There is no evidence of contrast extravasation or coil prolapse. The visualized portions of capillary and venous phases are otherwise unremarkable.

Disposition:

The 8-Fr femoral sheath was then removed and the arteriotomy was closed using an 8 French Angio-Seal. Manual compressive pressure was held for 15 minutes due to small hematoma. The procedure was well tolerated and no early complications were observed.

The patient was extubated in the angiography suite and following commands in all 4 extremities. He was transferred back to the ICU to be positioned flat in bed for 5 hours of observation.

Impression:

1. 7.6 mm x 6.3 mm right superior cerebellar artery saccular aneurysm with secondary dilatation and dome irregularity. This is the source of the patient's subarachnoid hemorrhage.

2. Successful coil embolization with dome occlusion of the right SCA aneurysm. Bilateral PCA and SCAs remain widely patient. No contrast extravasation or coil prolapse.

The results of this procedure were shared with the patient and the patient's family and NCCU team. Patient will resume subarachnoid protocol and start heparin 500 units per hour systemically. We'll also start aspirin 81 mg tomorrow.