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

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.

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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)

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Fig 2.

CT scan showing an intraventricular hemorrhage.

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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.