ion presentat ase 1 Turkish Neurosurgery 2013, Vol: 23, No: 2, 282-284 Vol: Neurosurgery 2013, Turkish C g Hen , Zhang , 1 e A 68-year-old man presented with a 4-year history with a 4-year of man presented A 68-year-old the left part muscle spasms involving involuntary intermittent, admission, he presented before one month About of his face. onset limb weakness vision lasting with acute and blurred examination On admission, neurological about 5 hours. for and smoker (10/day) left a current HFS. He was revealed ethanol) without history abuser (1400 mL/wk of pure alcohol or hyperlipidemia. of hypertension, diabetes basal ganglia and right both bilateral MRI demonstrated Both Magnetic resonance 1A). lobe infarcts (Figure occipital tomographic and computed (MRA) angiography saccular a large VBD and a marked demonstrated (CTA) k Wen , Liu , 1 Chao , You You , 1 E-mail: [email protected] [email protected] / E-mail: ng ound DI Heng , Lei , r kg ac 2 B Hemifasiyal spazm, İnme, Vertebrobaziler dolikoektazi, Anevrizma Vertebrobaziler spazm, İnme, Hemifasiyal n LI , Ji , 1 Hemifacial spasm, Stroke, Vertebrobasilar dolichoectasia, AneurysmVertebrobasilar Hemifacial spasm, Stroke, n Yua West China Hospital, Sichuan University, Department of Neurosurgery, Cheng Du, China Cheng Du, Department of Neurosurgery, University, Sichuan Hospital, China West Department of Radiology, China Cheng Du, University, Sichuan Hospital, China West 1 2 Fang Fang Accepted: 08.07.2011 / Accepted: 21.06.2011 Received: DOI: 10.5137/1019-5149.JTN.4889-11.1 ER: SÖZCÜKL ANAHTAR Keywords: 282 ÖZ Arka subaraknoid ölümcül enfarktüs Bunların ve tümü kanama arkaya tanımlıyoruz. spazm, serebral hemifasiyal gelen bir hastayı olaylarıyla arterin nedenin baziler Radyolojik inceleme dev bir sakküler görünüyordu. gibi anevrizmasıyla dolikoektazi vertebrobaziler olaylar birlikte ayrı mekanizması ve uzamasıdır sakküler ve arterinbaziler anevrizmadanvertebral dilatasyonu arterve (BA) (VA) VBD, (VBD) gösterdi. olduğunu neden inmeye hemorajik ve/veya iskemik ayrıca ve kraniyal ilerlemesi beyin kökü sinirlerin ve ve kompresyonu nadirdir Bu durum çok farklıdır. riskli Yüksek VBD risk katmanlandırması gereklidir. için daha fazla araştırma inme gelişmesini öngörmek açısından ve zordur Tedavisi olabilir. gerekebilir. girişim cerrahi yakından agresif hastalarda izleme ve We describe a patient presented with sequential events of hemifacial spasm, and fatal subarachnoid hemorrhage. All of All hemorrhage. subarachnoid infarction and fatal of hemifacial spasm, cerebral events with sequential presented describe a patient We dolichoectasia vertebrobasilar the cause was that (VBD) revealed Radiological examination entities. coexisting separate seemingly them are of vertebral artery and elongation VBD is a dilatation aneurysm and basilar arterysaccular with a giant of basilar artery. (VA) which is of (BA) and cranial brainstem of compression in result may very progression its and is condition The rare aneurysm. saccular from mechanism different VBD of is difficult and further on the of such condition risk stratification research treatment The , ischemic and/or hemorrhagic stroke. high-risk patients. be needed for interventions might surgical and aggressive Close monitoring predicting stroke. for Correspondence Zhang address: ABSTRACT Baziler Arter Sakküler Anevrizmasıyla Birlikte Vertebrobaziler Baziler Arter SakkülerVertebrobaziler Anevrizmasıyla Birlikte İnme: Tekrarlayan ve Spazm Hemifasiyal Nedeniyle Dolikoektazi Bir Olgu Sunumu Hemifacial SpasmHemifacial Recurrent and Stroke Due Dolichoectasia Coexisting Vertebrobasilar to with Saccular Aneurysm of the Basilar Artery: A Case Report Hemifacial spasm (HFS) is most commonly caused by caused by Hemifacial spasm (HFS) is most commonly a (RExZ) by of the facial zone exit root compression ectopic and focal demyelination resulting The loop. vascular of muscle activitycause bursts on one side of the excitation from disease and suffering is a common stroke Brain face. seems irrelevant ischemic and hemorrhagic stroke consecutive HFS. In report presented describeto a patient the current we infarction of hemifacial spasm, cerebral events with sequential dolichoectasia vertebrobasilar hemorrhage fatal and to due (VBD) aneurysm with saccular coexisting of basilar artery, and of such condition. and treatment discuss the monitoring we

Case Report Yuan F. et al: Vertebrobasilar Dolichoectasia Coexisting with Saccular Aneurysm

aneurysm of basilar artery (Figure 1B-G). The tortuous ischemic attacks (TIA) or infarction, deep lacunar infarction, vertebrobasilar vessels elongated and enlarged over their intracranial hemorrhage, compression of brainstem and entire course (diameter 6 mm), compressed the left pons and cranial nerves (5). impinged on the left side of the caudal pons in the root exit VBD is also classified as one of vertebrobasilar nonsaccular zone for the (Figure 1C). There was a giant saccular intracranial aneurysms (1), the progression of VBD is aneurysm with plaque (Figure 1B) of basilar artery (diameter associated with a high risk of hemorrhage and even death 10.6mm) located in the ventral pons. After discussion with the (1,2,6,7,8). Saccular aneurysm of basilar artery is very rare and patient, the decision was made not to surgically intervene due of totally different pathogenesis from nonsaccular intracranial to its potential complications. Two months after discharge, aneurysm. To our knowledge, the coexistence of two different the patient presented with intermittent headache and types of aneurysms in basilar artery is very rare and has never elevated blood pressure (180/100mmHg) for a week and died been reported. suddenly due to subarachnoid hemorrhage (SAH). Treatment of VBD is in a dilemma. Antiplatelet therapy may Discussion be considered for the prevention of recurrent ischemic Hemifacial spasm is a common disease with wide range of stroke in patients with current or previous ischemic stroke. aetiologies. The causes of hemifacial spasm are listed in Table However, for the potential risk of bleeding with severe forms I (3). The commonest reason is vascular compression, of which of VBD (7), long-term use of combined antiplatelet agents or the VBD is rare. VBD is ectasia, elongation, and tortuosity of anticoagulants may not be recommended (7) especially in the vertebrobasilar artery, the prevalence of intracranial patient with unruptured aneurysm. Adequate control of blood dolichoectasia is approximately from 0.06% to 5.8% in pressure may be helpful to prevent ischemic or hemorrhagic the general population (5). Widely accepted criteria was stroke in patients with VBD (5). For the management of diameter>4.5 mm in any location along its course (10). The saccular aneurysm of basilar artery, endovascular surgery is clinical manifestations include posterior circulation transient more preferable with minimum invasiveness (4). Symptoms

b

f

a c

d e g

Figure 1: Axial (A) T2 Weighted MRI showing multiple infarcts of bilateral basal ganglia and right occipital lobe (arrows). Gadolinium- enhanced CT (B) and T2 Weighted MRI (C) showing VBD (arrow) compressed the left pons and the root exit zone for the facial nerve (C) and aneurysm (short arrow) with plaque (B). Sagittal (D) and coronal (E) MRA images and Volume rendering technique (VRT) images (F, G) showing VBD (arrow) and the aneurysm (short arrow).

Turkish Neurosurgery 2013, Vol: 23, No: 2, 282-284 283 Yuan F. et al: Vertebrobasilar Dolichoectasia Coexisting with Saccular Aneurysm

Table I: List of Causes of Hemifacial Spasm

Vessels Artery, Vein, Developmental venous anomaly, Arterivenous malformation, Aneurysm, Pontine infarction, VBD Mass Epidermoid, Vestibular schwannoma, Lipoma, Arachnoid cyst, Meningioma, Cholesteatoma, Parotid gland tumors, Fourth ventricle gangliolioma, Pontine glioma Trauma Central or peripheral facial nerve trauma Others Chari I malformation, Paget’s disease, , Hypothyroidism, Idiopathic intracranial hypertension (pseudotumor cerebri), Trigeminal neuralgia (tic convulsif/tic douloureux) caused by compression of facial nerve (hemifacial spasm) References may be alleviated by decompressive surgery (9). However, 1. Flemming KD, Wiebers DO, Brown RD Jr, Link MJ, Huston due to their potential complications, such surgical treatments J 3rd, McClelland RL, Christianson TJ: The natural history should be cautious. For the progression of VBD or aneurysm of radiographically defined vertebrobasilar nonsaccular is associated with a high morbidity and mortality (8), close intracranial aneurysms. Cerebrovasc Dis 20:270-279, 2005 observation and follow-up neuroimaging is recommended to 2. Flemming KD, Wiebers DO, Brown RD Jr, Link MJ, Nakatomi H, monitor the progression and the appearance of new ischemic Huston J 3rd, McClelland R, Christianson TJ: Prospective risk or hemorrhagic lesions. However, the appropriate timing of hemorrhage in patients with vertebrobasilar nonsaccular and modality of serial imaging studies, the timing of surgical intracranial aneurysm. J Neurosurg 101:82-87, 2004 intervention and how to intervene have been unclear. 3. Galvez-Jimenez N, Hanson MR, Desai M: Unusual causes of This presented case suffered from sequential events of hemifacial spasm. Semin Neurol 21:75-83, 2001 hemifacial spasm, cerebral infarction and fatal hemorrhage 4. Higa T, Ujiie H, Kato K, Kamiyama H, Hori T: Basilar artery due to VBD coexisting with a giant saccular aneurysm of trunk saccular aneurysms: Morphological characteristics and basilar artery. Further research is required to refine the risk management. Neurosurg Rev 32:181-191; discussion 191, stratification of VBD for predicting stroke. Close monitoring 2009 and aggressive surgical interventions might be needed for 5. Kwon HM, Lee YS: Dolichoectasia of the intracranial arteries. high-risk patients. Curr Treat Options Cardiovasc Med 13:261-267, 2011 Consent: Written informed consent was obtained from the 6. Mangrum WI, Huston J 3rd, Link MJ, Wiebers DO, McClelland patient for publication of these case reports. RL, Christianson TJ, Flemming KD: Enlarging vertebrobasilar nonsaccular intracranial aneurysms: Frequency, predictors, Competing interests: None and clinical outcome of growth. J Neurosurg 102:72-79, 2005 Authors’ contributions: Yuan Fang drafted the manuscript. 7. Passero SG, Calchetti B, Bartalini S: Intracranial bleeding Lin Ji processed the images. Ding Lei, Chao You and Wenke in patients with vertebrobasilar dolichoectasia. Stroke 36: Liu examined the patient. Heng Zhang examined the patient 1421-1425, 2005 and helped to revise the manuscript. Both authors read and 8. Passero SG, Rossi S: Natural history of vertebrobasilar approved the final manuscript. dolichoectasia. Neurology 70:66-72, 2008 Acknowledgment 9. Perlmutter DH, Petraglia AL, Barbano R, Schwalb JM: Microvascular decompression in patient with atypical Conflict of interest statement: This work was undertaken at features of hemifacial spasm secondary to compression by a West China Hospital/Sichuan University, which exclusively tortuous vertebrobasilar system: Case report. Neurosurgery received a portion of funding from the National Natural 66, E1212; discussion E1212, 2010 Science Foundation of China (No. 81001117). 10. Smoker WR, Corbett JJ, Gentry LR, Keyes WD, Price MJ, McKusker S: High-resolution computed tomography of the basilar artery: 2. Vertebrobasilar dolichoectasia: Clinical- pathologic correlation and review. AJNR Am J Neuroradiol 7:61-72, 1986

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