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Brain computed tomography scans demonstrate a diffuse and thick subarachnoid hemorrhage in the bilateral sylvian fissures, the anterior interhemispheric fissure, the basal cistern and the posterior fossa, including the perimesencephalic region.
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Figure 1: Brain computed tomography scans demonstrate a diffuse and thick subarachnoid hemorrhage in the bilateral sylvian fissures, the anterior interhemispheric fissure, the basal cistern and the posterior fossa, including the perimesencephalic region.

Mentions: A brain computed tomography (CT) scan demonstrated diffuse and thick subarachnoid hemorrhage (SAH) in the bilateral sylvian fissures, the anterior interhemispheric fissure, the basal cistern and the posterior fossa, including the perimesencephalic region (Fig. 1). Subsequent carotid angiography showed complete occlusion of both ICAs, the so called 'bottle neck appearance' or 'beak shape,' at the level of the carotid bulb without appreciable intracranial filling and there were small collaterals from both external carotid arteries through the middle meningeal arteries to the anterior cranial fossa (Fig. 2). Vertebral artery angiography demonstrated that both hemispheres were seen filling in an antegrade fashion from the upper basilar artery and both posterior cerebral arteries through an extensive network of collateral vessels to the ICA bifurcations. A 6 × 4 mm aneurysm was also observed at the basilar artery bifurcation (Fig. 3). Perfusion CT scans revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to acetazolamide (Fig. 4). The abdominal CT aortograms did not demonstrate any other extracranial pathological vascular findings, including renal artery stenosis and fibromuscular dysplasia (figures not shown).

Coil Embolization of a Ruptured Basilar Tip Aneurysm Associated with Bilateral Cervical Internal Carotid Artery Occlusion: A Case Report and Literature Review

Kim SS, Park DH, Lee NJ, Kang SH, Lim DJ, Chung YG - J Cerebrovasc Endovasc Neurosurg (2012)

Bottom Line: Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries.The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ.An abdominal CT aortogram showed no other extracranial vessel abnormalities.

Affiliation: Department of Neurosurgery, Anam Hospital, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea.

ABSTRACT
We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.

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