PMC4857316_01
Computed tomography (CT) on admission showing subarachnoid hemorrhage.
10.1177_2050313X15578318-fig1.jpg
PMC4857316_01_10.1177_2050313X15578318-fig1.jpg
fig1-2050313X15578318
Coma Scale and Hunt and Hess grading of 13 and 3 with World Federation of Neurosurgical Societies (WFNS) grade 2. Computed tomography (CT) demonstrated subarachnoid hemorrhage (Figure 1), and three-dimensional computed tomographic angiography (3DCTA) demonstrated an aneurysm, which was 4 mm in diameter at the tip of the basilar artery.
(Left) Three-dimensional computed tomographic angiography (3DCTA) showing an aneurysm at the tip of basilar artery. (Right) CT showing the distance (22 mm) between the tip of posterior clinoid process and aneurysmal neck.
10.1177_2050313X15578318-fig2.jpg
PMC4857316_01_10.1177_2050313X15578318-fig2.jpg
fig2-2050313X15578318
The height from the posterior clinoid process to the aneurysm was 22 mm (Figure 2).
(Left) Three-dimensional computed tomographic angiography (3DCTA) (posterior view) showing the origin of right vertebral artery narrow and curved. (Right) Digital subtraction angiography showing crooked left vertebral artery.
10.1177_2050313X15578318-fig3.jpg
PMC4857316_01_10.1177_2050313X15578318-fig3.jpg
fig3-2050313X15578318
When endovascular surgery was first attempted, the microcatheter could not reach the aneurysm because of a crooked vertebral artery (Figure 3).
Sagittal view of magnetic resonance imaging (MRI) showing the basilar apex aneurysm pushing up the third ventricle floor (arrow).
10.1177_2050313X15578318-fig4.jpg
PMC4857316_01_10.1177_2050313X15578318-fig4.jpg
fig4-2050313X15578318
We adopted the trans-lamina terminalis and trans-third ventricle approach, after confirming the pathway to the basilar tip aneurysm on a sagittal view with a magnetic resonance imaging (MRI) (Figure 4).
Intraoperative photographs. (Left) Opened lamina terminalis (arrow) and bilateral A1. (Right) The sclerosed yellow basilar artery (BA) with temporary clip (arrow head) and aneurysmal neck (arrow) at the back of opened third ventricle floor.
10.1177_2050313X15578318-fig5.jpg
PMC4857316_01_10.1177_2050313X15578318-fig5.jpg
fig5-2050313X15578318
We confirmed the position of the floor of the third ventricle and also the mesencephalic aqueduct behind the opened lamina terminalis (Figure 5, left). On opening the floor of the third ventricle, we could confirm the sclerosed yellow basilar artery and the basilar tip aneurysm (Figure 5, right).
Postoperative temperature chart.
10.1177_2050313X15578318-fig6.jpg
PMC4857316_01_10.1177_2050313X15578318-fig6.jpg
fig6-2050313X15578318
The patient's level of consciousness gradually improved after the procedure; however, hypothermia persisted to day 6 post-surgery (Figure 6).
Postoperative 3DCTA showed the absence of aneurysm.
10.1177_2050313X15578318-fig7.jpg
PMC4857316_01_10.1177_2050313X15578318-fig7.jpg
fig7-2050313X15578318
We warmed the patient with an electric blanket for 3 consecutive days. 3DCTA did not show cerebral vasospasm, and we confirmed that the aneurysm was absent on the sixth postoperative day (Figure 7).