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OtherINTERVENTIONAL

De Novo Basilar Top Aneurysm in an Elderly Patient Treated with Guglielmi Detachable Coils

Kenta Fujimoto, Ryota Kimura, Jun-ichi Iida, Shoichiro Kawaguchi, Toshisuke Sakaki, Hiroyuki Nakagawa, Kimihiko Kichikawa and Toyohisa Fujita
American Journal of Neuroradiology April 2005, 26 (4) 915-916;

Abstract

Summary: Ruptured de novo aneurysms, compared with the usual subarachnoid hemorrhage, commonly occur in younger patients and are extremely rare in elderly patients. We discuss their etiology and report the case of a ruptured de novo aneurysm in a 77-year-old woman.

The de novo formation of an aneurysm is the occurrence of new aneurysms in a location previously observed to be normal by an angiography or direct surgical exploration. Although the etiology of de novo aneurysms is unclear, carotid ligation, female sex, a history of subarachnoid hemorrhage, smoking, hypertension, and youth are considered to be risk factors, and cases in elderly patients are extremely rare (1–4). In this report, we describe a case of a ruptured de novo basilar top aneurysm in an elderly patient and discuss their etiology.

Case Report

A 77-year-old woman presented with an acute headache followed by nausea and vomiting. At the age of 72, she underwent clipping of the incidental right middle cerebral artery aneurysm, left internal carotid-posterior communicating artery aneurysm and left carotid cave aneurysm (Fig 1A, B). She was nonsmoker, and hypertension was controlled with a calcium antagonist. Neurologic examination yielded normal findings. CT imaging showed an intraventricular hemorrhage (Fig 2), and cerebral angiography revealed a basilar top aneurysm (Fig 3C) that had not been observed in a previous angiography (Fig 1C). No regrowth of the previously treated aneurysms was observed (Fig 3A, B). She underwent successful embolization of the new aneurysm with Guglielmi detachable coils (Fig 3D). Her postoperative course was uneventful, and she was discharged 3 weeks after treatment.

Fig 1.
Fig 1.

Initial cerebral angiograms. Anteroposterior (AP) view of the right carotid angiogram displayed a middle cerebral artery aneurysm (A). The lateral view of the left carotid angiogram displayed an internal carotid-posterior communicating artery aneurysm and a carotid cave aneurysm (B). The vertebral angiogram showed no abnormal findings. (C)

Fig 2.
Fig 2.

CT scan showing an intraventricular hemorrhage.

Fig 3.
Fig 3.

Cerebral angiograms on admission. No regrowth of previously clipped aneurysms was observed. A, AP view of the right carotid angiogram. B, Lateral view of the left carotid angiogram. Vertebral angiography demonstrated a de novo aneurysm at the top of the basilar artery. C, Straight AP view of left vertebral angiogram. D, Successful coil embolization of the aneurysm.

Discussion

De novo formation of aneurysms is the result of the interplay between hemodynamic factors and structural weakness. Several authors have described the clinical characteristics of de novo aneurysms (1–4). The risk factors are considered to be carotid ligation, youth, female sex, a history of subarachnoid hemorrhage, smoking, and hypertension (3, 4). Tonn et al (4) reviewed 50 published cases and reported that the mean age of susceptibility to de novo aneurysms was 43.3 (range, 17–69 years). Patients in whom de novo aneurysms occur are commonly younger than those with the usual subarachnoid hemorrhage (1–4). The occurrence of de novo aneurysms in an elderly patient is extremely rare, and to the best of our knowledge, our patient is the oldest of all reported cases.

In addition, another unusual characteristic of our case lies in the multiplicity of the aneurysms. David et al (5) reported that five of their series of six de novo aneurysms had a history of multiple aneurysms. From reviews of the other previous reports, however, we were unable to uncover a relationship between the multiplicity of aneurysms at the time of the initial episode and formation of the de novo aneurysms. The etiology itself is obscure, but we speculate the possibility that multiple parts of the arterial wall may be “pathologic” in patients with multiple intracranial aneurysms. We maintain that strict follow-up is necessary for patients with known risk factors or multisegmental aneurysms, even if the patient is old, because de novo aneurysms may arise at any time, place, and age.

References

  1. Briganti F, Cirillo S, Caranci F, et al. Development of “de novo” aneurysms following endovascular procedures. Neuroradiology 2002;44:604–609
  2. Rinne JK, Hernesniemi JA. De novo aneurysms: special multiple intracranial aneurysms. Neurosurgery 1993;33:981–985
  3. Sakaki T, Tominaga M, Miyamoto K, et al. Clinical studies of de novo aneurysms. Neurosurgery 1993;32:512–517
  4. Tonn JC, Hoffmann O, Hoffmann E, et al. “De novo” formation of intracranial aneurysms: who is at risk? Neuroradiology 1999;41:674–679
  5. David CA, Vishteh AG, Spetzler RF, et al. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 1999;91:396–401
  • Received May 25, 2004.
  • Accepted after revision July 11, 2004.
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