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Progressive Thrombosis of a Dolicho-Basilar Artery and Fusiform Aneurysm Resulting in Diffuse Ischemic and Hemorrhagic Complications

Published online by Cambridge University Press:  04 April 2024

Vincent Brissette Open the ORCID record for Vincent Brissette [Opens in a new window] ,
Marina Saad ,
Devavrat Nene ,
Christine Van Winssen Open the ORCID record for Christine Van Winssen [Opens in a new window] ,
Ange Boubacar Diouf ,
Marlise P. dos Santos Open the ORCID record for Marlise P. dos Santos [Opens in a new window] ,
Robert Fahed Open the ORCID record for Robert Fahed [Opens in a new window]  and
Célina Ducroux Open the ORCID record for Célina Ducroux [Opens in a new window]
Vincent Brissette*
Affiliation:
Department of Medicine (Neurology), The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
Marina Saad
Affiliation:
Department of Medicine (Neurology), The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
Devavrat Nene
Affiliation:
Department of Medicine (Neurology), The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
Christine Van Winssen
Affiliation:
Department of Medicine (Neurology), The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
Ange Boubacar Diouf
Affiliation:
Department of Medical Imaging, The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
Marlise P. dos Santos
Affiliation:
Department of Radiology, Radiation Oncology and Medical Physics, Department of Surgery, Section of Neuroradiology, Section of Interventional Neuroradiology, Division of Neurosurgery, University of Ottawa, Brain and Mind Research Institute, Ottawa Hospital Research Institute, Ottawa, ON, Canada
Robert Fahed
Affiliation:
Department of Medicine (Neurology), The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada Department of Medical Imaging, The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
Célina Ducroux
Affiliation:
Department of Medicine (Neurology), The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
*
Corresponding author: Vincent Brissette; Email: vbrissette@toh.ca
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Abstract

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Keywords

interventional neuroradiologystroke imagingstroke
Type
Neuroimaging Highlight
Information
Canadian Journal of Neurological Sciences , First View , pp. 1 - 2
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2024. Published by Cambridge University Press on behalf of Canadian Neurological Sciences Federation

A 54-year-old male presented acutely with dense right-sided hemiplegia and dysarthria (NIHSS 12). Initial CT angiogram revealed diffuse intracranial dolichoectasia with fusiform vertebrobasilar circulation and a partially occlusive basilar artery thrombus (Figure 1). He was treated with Tenecteplase but did not undergo endovascular treatment (EVT) given its lack of evidence in dolichoectasia. He aspirated vomitus and was intubated. MRI angiogram 24 hours later showed progression of the mural thrombosis of the distal basilar artery, infarction secondary to basilar artery perforators and right superior cerebellar artery occlusions, Reference Dobrocky, Piechowiak and Goldberg1 cortical subarachnoid hemorrhage and basilar artery wall enhancement (Figure 2). This patient died secondary to brainstem damage. Outcomes associated with vertebrobasilar dolichoectasia and fusiform aneurysms are potentially catastrophic. Consensus surrounding acute management is lacking. There is limited evidence for thrombolysis, and EVT is technically challenging with high complication rates, Reference Wang and Yu2 highlighting the need for further research to better understand effects on prognosis.

Figure 1. (A) Unenhanced CT: tortuous fusiform dilatation of the mid-basilar segment with hyperdense mural thrombus; (B) Computed Tomography Angiogram (CTA), axial plane: fusiform dolichoectatic basilar artery, red arrows on thrombus; (C) CTA, coronal plane: dolichoectatic basilar artery, red arrows on thrombus, and (D) patent basilar tip.

Figure 2. MRI (A) Longitudinal relaxation time (T1)-Volumetric interpolated breath-hold examination (VIBE) post contrast demonstrated interval progression of thrombus to distal basilar artery segment compared to CTA performed 2 days earlier, despite thrombolysis; (B) DWI: acute pontocerebellar infarcts; (C) Fluid-attenuated inversion recovery (FLAIR) post contrast: basilar artery wall circumferential mural enhancement (inflammation versus slow flow), and (D) acute subarachnoid hemorrhage.

Author contributions

VB participated in the data collection and analysis and wrote the manuscript. MS, DN, CVW, ABD and MP dos S participated in the review of the manuscript. RF and CD participated in the data collection and analysis, and in the review of the manuscript.

Funding statement

No targeted fundings reported.

Competing interests

The authors report no disclosures relevant to the manuscript.

References

Dobrocky, T, Piechowiak, E, Goldberg, J, et al. Absence of pontine perforators in vertebrobasilar dolichoectasia on ultra-high resolution cone-beam computed tomography. J Neurointerv Surg. 2021;13:580–584.CrossRefGoogle ScholarPubMed
Wang, Y, Yu, J. Prospects and dilemmas of endovascular treatment for vertebrobasilar dolichoectasia. Front Neurol. 2022;13:895527.CrossRefGoogle ScholarPubMed
Figure 0

Figure 1. (A) Unenhanced CT: tortuous fusiform dilatation of the mid-basilar segment with hyperdense mural thrombus; (B) Computed Tomography Angiogram (CTA), axial plane: fusiform dolichoectatic basilar artery, red arrows on thrombus; (C) CTA, coronal plane: dolichoectatic basilar artery, red arrows on thrombus, and (D) patent basilar tip.

Figure 1

Figure 2. MRI (A) Longitudinal relaxation time (T1)-Volumetric interpolated breath-hold examination (VIBE) post contrast demonstrated interval progression of thrombus to distal basilar artery segment compared to CTA performed 2 days earlier, despite thrombolysis; (B) DWI: acute pontocerebellar infarcts; (C) Fluid-attenuated inversion recovery (FLAIR) post contrast: basilar artery wall circumferential mural enhancement (inflammation versus slow flow), and (D) acute subarachnoid hemorrhage.