Endovascular Management of a Ruptured Basilar Perforator Artery Aneurysm Associated with a Pontine Arteriovenous Malformation: Case Report and Review of the Literature.

BACKGROUND: Arteriovenous malformation (AVM)-associated aneurysms are common, reported in 15% of cases. Regarding the ruptured posterior fossa AVMs, associated aneurysms are present in 48% of cases and are the cause of the bleed in 37%. We present a 75-year-old female who presented with a subarachnoid hemorrhage secondary to a ruptured aneurysm arising from a flow-related basilar perforator artery feeder of an anterior pontine AVM. We report the successful treatment of the aneurysm with coil embolization.

CASE DESCRIPTION: A 75-year-old female presented with subarachnoid hemorrhage primarily contained within the posterior fossa. Angiography demonstrated a 2 × 3-mm fusiform aneurysm arising from a basilar perforator feeding pedicle of an anterior 1 × 2-cm pontine AVM. Venous drainage from the AVM was predominantly to the superior petrosal vein. Under roadmap guidance, super-selective catheterization of the basilar perforator aneurysm was performed. Three HydroSoft 3D coils were deployed within the aneurysm, resulting in complete obliteration. The patient was discharged on postbleed day 15 to an inpatient rehabilitation facility. Follow-up angiography at 5 months demonstrated stable complete obliteration. The patient made a complete recovery and was living independently at the time of this report.

CONCLUSIONS: Basilar trunk perforator aneurysms are rare lesions, particularly in the setting of brainstem AVMs. We report successful endovascular treatment of a flow-related ruptured basilar perforator aneurysm associated with an anterior pontine AVM. To the best of our knowledge, this is the second report addressing this scenario. We hope that the information presented here serves to guide future surgical decision making and management.