gms | German Medical Science

Objective: Fusiform vertebrobasilar aneurysms are rare and may have a disastrous clinical course. Surgical or endovascular treatment options are usually limited. We describe the clinical features of 40 consecutive patients and discuss possible therapeutic options.

Methods: We retrospectively evaluated clinical presentation, treatment procedures, and outcome of 40 consecutive patients with the diagnosis of fusiform vertebrobasilar aneurysm, which were seen at neurosurgical, neurological and neuroradiological departments of our clinic between March 2006 and October 2016. Currently, follow up is available for 22 patients (55%) with a median duration of 27.5 months.

Results: The median age was 68 years (min 21, max 90). Men (n=29, 72.5%) were affected more than twice as frequently as women (n=11, 27.5%). The median maximal diameter of aneurysms was 13 mm (min 6, max. 29 mm). While 14 patients (35%) were asymptomatic, 13 patients (32.5%) presented with embolic ischemic events of thalamus or brainstem, 6 patients (15%) presented with supratentorial embolic strokes and 4 (10%) patients were symptomatic due to brain stem compression. Aneurysm rupture occurred in 3 patients at the initial presentation (7.5%). At the time of the first diagnosis, 18 patients (45%) were significantly disabled with modified Rankin score (mRS) ≥3. Arterial Hypertension and global atherosclerotic vascular changes were observed in 26 (65%) and 14 (35%) cases, respectively. Eight patients (20%) exhibited additional intracranial aneurysms, in 6 patients (15%) abdominal or thoracic aortic aneurysms were diagnosed. During the follow up, the clinical status of 13 patients (32.5%) impaired with decline in mRS score, 10 patients (25%) died due to aneurysm-associated complications. Severe disability (mRS 4 and 5) and death events were significantly more frequent in patients with symptomatic aneurysms (p=0.03). Eleven patients (27.5%) underwent invasive treatment: endovascular therapy (stenting with or without aneurysm coiling) was applied in 8 cases, surgical treatment (superficial temporal artery-posterior cerebral artery low flow bypass) in 3 cases. Other 29 patients were conservatively treated by either antiplatelet or anticoagulation therapy. During the follow up, 5 events (62,5%) of severe disability or death are documented in the endovascular group vs. 1 event (33%) in the surgical group vs. 5 events (37.5%) among conservatively treated symptomatic aneurysms.

Conclusion: Rupture of fusiform vertebrobasilar artery aneurysms is rare. Patients frequently present with already disabling symptoms due to aneurysm-associated embolic ischemia or mass effect. The natural history is aggressive, first of all for initially symptomatic aneurysms. Surgical treatment can be considered for carefully selected patients despite significant perioperative morbidity.