In the article we showed the patient, a woman with unruptured giant aneurysm of basilar artery, we showed the done examinations, and therapy dilemmas about what to do in the given case. We found in literature a number of exampleswhich suggest operation treatment, but of embolisation too, some suggest conservative treatment.

•    Aneurysm
•    Basilar artery
•    Treatment
•    Therapy dilemmas

Šapina L, Lojen G, Janjetovi? Ž, Arar ŽV (2016) Basilar Artery Aneurysm. J Neurol Transl Neurosci 4(3): 1074.

Intracranial aneurysms are vascular abnormalities which ruptures presents subarachnoid bleeding. It hap-pens in the age from 35–65 years, and mostly between 55 and 60 years, 60% of ruptured aneurysm are found in women. Giant aneurysms are defined as those wich diameter is 25 mm or bigger, 60% are in anterior, 40% are in posterior circulation with predilecty in vertebrobasilar artheries. Aneurysms originate as effect of prolonged hemodynamic stress, with important role of relationships of anatomic locality, hemodynamics and degenerative factors. Physical excertions and emotional stress are precoursors of rupture [1]. Unhemorrhagical symptoms and the signs of unrup tured aneurysms are manifested as »mass effect«, throm bosis, embolisation, epileptical attacks, irritation of menings. Diagnosis is stated trough neuroradiological treat ment: computed tomography (CT), multi slice-computed tomography of brain (MSCT), multi-slice angiography (MSCT angiography), magnetic angiography (MRA), cerebral angiography-digital subtraction angiography (DSA). Cerebral angiography is »gold standard« for diagnostic and aneurysm evaluation [1]. Most of aneurysms ofbrain arteries with the locality in anterior circulation istreated by titan »clips«, in posterior circulation with »coil« from platinum (Guglielmi), wich is since 1995aknowledged by FDA as sure and effective method oftreatment, made better by biological active material onthe surface polyglicol/polylactat acid which coveres platinum and decreases the risk from aneurysm recanalisation [2–6].

The 63-years-old woman was accepted to the Department of Neurology because of fast lost of sight on both eyes, dull headache in occipital region, afterwards nausea and vomiting. She did not lost consciousness and denied head trauma. Anamnestic: she is hypertonic formany years, at acdeptance a very high value of blood pressure. Neurologic state at acceptance: very slowly, asymmetry of the lower part of the face-skin deep left nasolabial furrow, during examination weakened sight on both eyes, sees only shadows, somatic hypertensive.

The following examinations performed: CT of the brain: Nativ and with aplication of contrast medium:on both sides occipital-encephalomalatia, and new ischaemical lesion right, suprasellar right roundhyperdensal creation which was after aplication of the contrast medium specifically opacific and which initiated aneurysm. Pancerebral angiography: Giant aneurysm of basilar artery- on the right contour medium third part of basilar artery of wide neck. Dilatated typ of ather MSCT angiography: in the area of medium part of basilar artery we see saccular aneurysm with the beginning on the right lateral wall with direction cranial in the lenght 25 mm, dolychoectasy of basilar artery as well as carotid arteries-ACI.

We consulted: neurosurgeon who did not recomend operation for the reason of the Size and statement of an eurysm, and risk conditions, and neuroradiologist who tries to perform endovascular intervention. Tried embolisation was not succesfull, and for that reason conservative treatment was continued. During hospital treatment with antihypertensive and antiagregation therapy, blood pressure was normal value, laboratory parameters were normal. After 4–5 weeks patient had a great headache of pulsatile character, with prompt disturabance of consciousness to deep coma. There wasa doubt of rupture of existed aneurysm. CT of the brain showed great unruptured aneurysm of basilar artery and great recent ischaemic lesion of cerebellum and brain trunk and brain parenchym parietooccipital left, in the area of thalamus, with compression od III and IV ventricle which caused by edema. She died after 24 hours. Autopsy was not done (family overload).

The clinical dilemma what to do with the patientwith unruptured giant aneurysm of basilar artery, with added risk factors for cerebrovascular illness: arterial hypertension, atherosclerosis, adiposity, to decide whether endovascular or operative or conservative treatment?

The examples from literature, as well as from clinical practice showed that the decision is individual, concerning risk factors and the greatness of aneurysm.

The risk of death is to high for non operated aneurysms for the reason of emolisation of intraaneurysmatic situated thromb and followed ischaemia distal from aneurysm and possibility of rupture, and it is 14.5%–40% [7]. The data from literature show always the same dilemma:surgery (operation) or endovascular (coil placing) or consevative treatment [1,7-9,16-20]. The lowest risk for rupturehas the aneurysm located in the anterior circulation if not greater from 10 mm in diameter. The greatest riskfor rupture has aneurysm 10 mm in diameter or bigger located in posterior circulation. The risk can be makelower by very careful anticoagulation, antihypertensivetherapy, avoiding of physical activities and by lowering of other risks, but epidemiological data are not very goodand took about very high grade of individuality, further of death during next 5 years [1,8].

In the decision of therapeutic treatment very impor-tant role has the configuration of aneurysm. If it is longish and narrow, it is better for coil, and otherwise not [10,16-20]. ISAT study has prooved that therapeutic decision of ruptured intracranial aneurysm is same good endovascularand neurosurgical treatment, but concerning risks fromnew bleeding is more frequent of endovascular treatment [11]. Recovering of the patient with the damage of posterior circulation, whether if it is infarct of aneurysm,need very careful physical therapy with limited posi-bilities of recovery of neurological atacks: walk-balance,sight, sensory funcitions [12-15].

Diagnosis will be given trought non invasive and invasive diagnostic treatment, near interdisciplinary cooperation of neurologist and neurosurgeon with radiologist neuroradiologist, anesthesiologist, as well as doctor known risk factors and possible decisions, to get the highest quality of life of such patients.The patient from our description died for the reasonof massive ischaemic cerebral infarct which developed as consequence of mobilisation of intraaneurysmatic situated thromb distal from aneurysm 24 hours after starting of headache, and after that comma statement and not for the reason of rupture of aneurysm. Unfortunatelly, autopsy was not done (family overload).

1. Aminoff MJ, Daroff RB. Encyclopedia of the neurological sciences. 1:161-185.

2. Bendszus M, Bartsch AJ, Solymosi L. Endovascular occlusion of aneurysms using a new bioactive coil: a matched pair analysis with bare platinum coils. Stroke. 2007; 38: 2855-2857.

3. Bendszus M, Solymosi L. Cerecyte coils in the treatment of intracranial aneurysms: a preliminary clinical study. AJNR Am J Neuroradiol. 2006; 27: 2053-2057.

4. Ogilvy CS, Carter BS. Stratification of outcome for surgically treated unruptured intracranial aneurysms. Neurosurgery. 2003; 52: 82-87. 

5. Ogilvy CS, Hoh BL, Singer RJ, Putman CM. Clinical and radiographic outcome in the management of posterior circulation aneurysms by use of direct surgical or endovascular techniques. Neurosurgery. 2002; 51: 14-21.

6. Pierot L, Bonafé A, Bracard S, Leclerc X. French Matrix Registry Investigators. Endovascular treatment of intracranial aneurysms with matrix detachable coils: immediate posttreatment results from a prospective multicenter regis. AJNR Am J Neuroradiol. 2006; 27: 1693-1699.

7. Meyer-Lindenberg A, Mewes J, Biniek R. Megadolicho basilar artery as indication of intensive care relevant vertebrobasilar ischemia. Nervenarzt. 1997; 68: 674-7.

8. Ammerer HP, Dobner T, Ive-Schappelwein, Loyddinum, J Neurol Neurochir Psychiatr. 2003; 4: 14.

9. National Institute of Neurological Disorders and Stroke. Cerebral aneurysm fact sheet.

10. Johnston SC, Gress DR, Kahn JG. Which unruptured cerebral aneurysms should be treated? A cost-utility analysis. Neurology. 1999; 52: 1806- 1815.

11. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J , et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial. Lancet. 2002; 360: 1267-1274.

12. Barker FG, Amin-Hanjani S, Butler WE, Hoh BL, Rabinov JD, Pryor JC , et al. Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States. Neurosurgery. 2004; 54: 18-28.

13. Clinchot DM, Kaplan P, Murray DM, Pease WS. Cerebral aneurysms and arteriovenous malformations: implications for rehabilitation. Arch Phys Med Rehabil. 1994; 75: 1342-1351.

14. Ng YS, Stein J, Salles SS, Black-Schaffer RM. Clinical characteristics and rehabilitation outcomes of patients with posterior cerebral artery stroke. Arch Phys Med Rehabil. 2005; 86: 2138-2143.

15. Zorowitz RD. Ambulation in a wheelchair-bound stroke survivor using a walker with body weight support: a case report. Top Stroke Rehabil. 2005; 12: 50-55.

16. Zhu YQ, Li MH, Fang C, Tan HQ, Wang W, Zhang PL, et al. Application of the Willis covered stent in the treatment of aneurysm in the cisternal segment of the internal carotid artery: a pilot comparative s. J Endovasc Ther. 2010; 17: 55-65.

17. Tan HQ, Li MH, Li YD, Fang C, Wang JB, Wang W , et al. Endovascular reconstruction with the Willis covered stent for the treatment of large or giant intracranial aneurysms. Cerebrovasc Dis. 2011; 31: 154-162.

18. Wang JB, Li MH, Fang C, Wang W, Cheng YS, Zhang PL, et al. Endovascular treatment of giant intracranial aneurysms with willis covered stents: technical case report. Neurosurgery. 2008; 62: 1176- 1177.

19. Wehman JC, Hanel RA, Levy EI, Hopkins LN. Giant cerebral aneurysms: endovascular challenges. Neurosurgery. 2006; 59: 125-138.

20. van Rooij WJ, Sluzewski M. Endovascular treatment of large and giant aneurysms. AJNR Am J Neuroradiol. 2009; 30: 12-18.