Abstract
INTRODUCTION/PURPOSE: Posterior circulation aneurysms account for 10‐15% of unruptured intracranial aneurysms and are more prone to rupture than those of anterior circulation. Giant basilar artery aneurysms pose significant risk as 80% of symptomatic patients become severely disabled or die within 5 years at a 50% five‐year rupture rate. Complications, including cranial neuropathies, hydrocephalus, quadriparesis, and respiratory failure, are related to local mass effect. Neurointerventional device limitations and their unique anatomy restrict conventional flow diversion, open surgical access, or parent vessel reconstruction. In this report, we highlight the novel management of a giant basilar artery aneurysm with deconstructive vertebral artery (VA) sacrifice and VA‐to‐VA pipeline embolization. MATERIALS/METHODS: Case report. RESULTS/CASE DESCRIPTION: An elderly male with hypertension and tobacco use presented with vomiting and dizziness. CTA revealed a 22mm basilar artery aneurysm. Angiogram revealed a giant, nearly‐completely thrombosed, complex neck semisaccular basilar aneurysm between the vertebrobasilar junction and AICAs. It exceeded flow diverter diameters and was not treated. He developed quadriplegia, dysphagia, and respiratory failure. MRI revealed aneurysmal enlargement with partial thrombosis, brainstem and fourth ventricular compression, and hydrocephalus. He required VPS, tracheostomy, and gastrostomy. Repeat angiogram demonstrated near‐complete aneurysmal thrombosis and bilaterally patent PICAs. He underwent right distal VA coil embolization as a pre‐operative adjunct to aneurysm clipping. Deemed a high‐risk neurosurgical candidate, he was instead discharged and re‐admitted 1‐month post‐embolization to evaluate treatment efficacy with a repeat angiogram. Despite coiling, the aneurysm had grown with partial recanalization and associated progressive brainstem edema. VA‐to‐VA pipeline embolization was performed by placing 3 pipeline embolization devices from the right V4 to the left V4 across the vertebrobasilar junction with collateral flow to the distal posterior circulation via the right PICA. Post‐operative course included cerebellar and occipital infarcts. CONCLUSION: This report is, to our knowledge, the first VA‐to‐VA pipeline embolization for the management of a giant basilar artery aneurysm. Growth despite aneurysmal thrombosis and hydrocephalus requiring VPS remain under‐appreciated complications of these aneurysms. [Image: see text]