Neurovascular Cases

What’s the diagnosis?

There is a giant, partially-thrombosed basilar apex aneurysm with mass effect on the midbrain and obstruction of the cerebral aqueduct causing mild obstructive hydrocephalus. MRI brain is especially useful to evaluate the partially-thrombosed component of the aneurysm. Arteriographic injections show the component of the aneurysm that still actively fills with blood. The patient's symptoms are well explained by early hydrocephalus and mass effect on the brainstem.

Differential Diagnosis

  1. Giant, unruptured, partially-thrombosed basilar apex aneurysm
  2. Obstructive hydrocephalus due to mass effect on the cerebral aqueduct

What's your treatment plan?

  • The patient is symptomatic from a giant aneurysm that is causing mass effect on the brainstem but also obstructive hydrocephalus. The hydrocephalus is easily addressed by placing a ventriculoperitoneal shunt and this was done first.

In this case, the patient's obstructive hydrocephalus was treated initially with placement of a right frontal ventriculoperitoneal shunt. Once the patient's surgery was completed, they were loaded on antiplatelet agents in preparation for an endovascular treatment of the aneurysm itself. A flow diverter was used to re-direct blood flow away from the basilar apex; a pipeline embolization device was deployed from the right posterior cerebral artery into the basilar artery. Because the left vertebral artery was tortuous at its origin and could not easily be straightened, the coiling catheter was placed through a left posterior communicating artery transcirculation approach into the aneurysm instead.