A systematic review of non-trunk basilar perforator aneurysms: is it worth chasing the small fish?

Abstract

Background and purposeNon-trunk basilar artery perforator aneurysms (BAPAs) are rare intracranial vascular pathologies that have long been underdiagnosed, under-reported, and under-analyzed. We performed a systematic review of the efficacy and safety endpoints between conservative and active treatment approaches for non-trunk BAPAs.MethodsMajor databases were analyzed for relevant publications between 1995 and 2019. Studies comparing the outcomes between conservative and active treatment approaches such as coiling, stenting, clipping, liquid embolization, and flow diversion were included. Mortality rate, rate of permanent neurological deficit as determined by the modified Rankin Score (mRS), rate of second treatment occurrence, and perioperative complication rate were also assessed.ResultsA total of 24 studies, including 54 patients with 56 non-trunk BAPAs, were included. The mean maximum aneurysm diameter was 2.70 mm (range 1–10). A diagnosis was achieved with the initial DSA in 50.0% (27/54) of the patients. A conservative approach was used in 16 patients while active treatment was used in the other 38. Thirteen of 15 (86.7%) patients in the conservative group and 27/34 (79.4%) in the active treatment group had an mRS score 0–2. A non-significant higher odds of a positive outcome was observed in the conservative group (OR 1.51, 95% CI 0.50 to 4.54). The event-related mortality rate was 3.55% (3/54) with one procedure-related death in the active treatment group.ConclusionsIn patients with non-trunk BAPAs unamenable to active treatment, conservative approaches may result in acceptable functional outcomes and low morbidity. Small sample sizes and under-reporting of outcomes warrant further study.

Flow Diverter Treatment of Ruptured Basilar Artery Perforator Aneurysms

“…The re-evaluation showed that all negative results in the initial DSA examinations were true negatives. Nonetheless, in our series, only 28% of the aneurysms were diagnosed on the initial angiographic imaging study, which is in line with recent systematic reviews of non-trunk BAPAs by Granja et al [1] and of posterior circulation perforator aneurysms by Gardijan et al [14] reporting diagnosis of the aneurysm on the first DSA study in 50% and 39%, respectively. In absence of a confirmed rebleeding, we tried to perform the repeat DSA after confirmation of resolution of SAH-related vasospasm, using transcranial Doppler.…”

“…Perforating artery aneurysms of the anterior circulation are a rare subtype of intracranial aneurysms (prevalence < 1%) [1,2]. Basilar artery perforator aneurysms (BAPAs) are even less common, with a recent systematic literature review by Granja et al [1] describing only 56 cases of nontrunk type BAPAs since their initial description in 1996 [3]. Categorizing BAPAs is a challenging task due to a potential overlap with so-called blister-like aneurysms of the basilar artery trunk.…”

“…Perforating artery aneurysms of the anterior circulation are a rare subtype of intracranial aneurysms (prevalence < 1%) [ 1 , 2 ]. Basilar artery perforator aneurysms (BAPAs) are even less common, with a recent systematic literature review by Granja et al.…”

“…BAPAs are a rare cause of subarachnoid hemorrhage (SAH). Their diagnosis requires a high degree of suspicion as they are often easily missed due to their small size (85% ≤ 3 mm), partial thrombosis and small caliber feeding vessels on initial CTA, MRA, and even DSA studies [ 1 , 2 , 5 ]. Given the rarity of these aneurysms and their natural history, an ideal approach to treatment remains poorly defined.…”

A giant basilar artery perforator aneurysm

“…and are extremely rare [1] . About 80 cases have been reported in literature thus far, and their diagnosis and management are challenging [2] , [3] , [4] , [5] . Because of their small size, detection on computed tomography angiography (CTA), magnetic resonance angiography (MRA) imaging, and digital subtraction angiography (DSA) is difficult and often repeated DSA is needed to confirm the diagnosis.…”