Basilar artery perforator aneurysm

Case contributed by Yves Leonard Voss , 26 Sep 2020
Diagnosis certain
Changed by Yves Leonard Voss, 18 Nov 2020
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Basilar artery perforator aneurysms (BAPA) are a rare entity of intracranial aneurysms. While in many cases of perimesencephalic subarachnoid haemorrhage no cause is found, BAPA are a possible cause and are easily overseen even with extensive diagnostic workup including CT, MRI, MRA and DSA. They are another reasonone of the reasons why in apparently angio-negative SAH a second DSA and performing 3D angiograms are recommended.

Endovascular treatment options are available including Coil occlusion or flow diverter stent implantation. Some cases inIn the literature some cases of larger BAPA have been treated surgically, however. In small aneurysms there are technical difficulties for endovascular and surgical approaches (small neck, proximity of BA perforators or branches and risk of ischaemia).

The natural cause of BAPA seems rather benign and therefore conservative treatment often is a viable option (and frequently the only option anyways).

Case imaging courtesy of Prof. R. Chapot and PD Dr. P. Mosimann (Alfried Krupp Krankenhaus Essen, Germany).

  • -<p>Basilar artery perforator aneurysms (BAPA) are a rare entity of intracranial aneurysms. While in many cases of perimesencephalic subarachnoid haemorrhage no cause is found, BAPA are a possible cause and are easily overseen even with extensive diagnostic workup including CT, MRI, MRA and DSA. They are another reason why in apparently angio-negative SAH a second DSA and performing 3D angiograms are recommended.</p><p>Endovascular treatment options are available including Coil occlusion or flow diverter stent implantation. Some cases in the literature have been treated surgically, however there are technical difficulties (small neck, proximity of BA perforators or branches). The natural cause of BAPA seems rather benign and conservative treatment often is the only option anyways. </p><p>Case imaging courtesy of Prof. R. Chapot (Alfried Krupp Krankenhaus Essen, Germany).</p>
  • +<p>Basilar artery perforator aneurysms (BAPA) are a rare entity of intracranial aneurysms. While in many cases of perimesencephalic subarachnoid haemorrhage no cause is found, BAPA are a possible cause and are easily overseen even with extensive diagnostic workup including CT, MRI, MRA and DSA. They are one of the reasons why in apparently angio-negative SAH a second DSA and performing 3D angiograms are recommended.</p><p>Endovascular treatment options are available including Coil occlusion or flow diverter stent implantation. In the literature some cases of larger BAPA have been treated surgically. In small aneurysms there are technical difficulties for endovascular and surgical approaches (small neck, proximity of BA perforators or branches and risk of ischaemia).</p><p>The natural cause of BAPA seems rather benign and therefore conservative treatment often is a viable option (and frequently the only option anyways).</p><p>Case imaging courtesy of Prof. R. Chapot and PD Dr. P. Mosimann (Alfried Krupp Krankenhaus Essen, Germany).</p>
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4 week follow-UP MRI head
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The 4-week follow-up MRI shows persistent haemosiderin capping in SWI, there is T1 hyperintensity in the saccular aneurysm related to blood products, but no real flow sign in TOF angiography where the saccular signal is rather due to T1 shine through effect. However an angiogram is needed to confirm aneurysm occlusion or persistence.

Further there is a subacute ischaemia of the pons with no diffusion restriction anymore. The patient was asymptomatic for this, it is very probably an ischaemia related to spontaneous occlusion of the aneurysm bearing basilar perforator. 

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4 week follow-up cerebral angiography
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Follow-up cerebral angiogram proves spontaneous occlusion of the basilar artery perforator aneurysm.

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Updates to Study Attributes

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ConventionalCerebral angiogram (DSA) shows hints of a basilar artery perforator aneurysm, easily overlooked! 3D Angiogram is really helpful in detecting these small aneurysms.

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Basilar artery perforator Aneurysm. SWI shows capping. Very subtle finding in TOF angiogram.

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