Technical Note Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm Vijay Yanamadala a , Ning Lin b , Hekmat Zarzour b , Kai U. Frerichs b,c , Brian P. Walcott a,⇑ , Ajith J. Thomas d , Ajit S. Puri e a Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA b Department of Neurosurgery, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA c Department of Radiology, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA d Department of Neurosurgery, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA e Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA article info Article history: Received 19 August 2013 Accepted 29 November 2013 Keywords: Aneurysm Endovascular coiling Pseudoaneurysm Subarachnoid hemorrhage abstract Acute intracranial pseudoaneurysms secondary to aneurysmal rupture are a rare entity with no clear evi- dence-based guidelines for treatment to our knowledge. There are numerous examples of successful treatment of pseudoaneurysms both surgically and endovascularly, the latter mainly within the anterior circulation. Risk of pseudoaneurysm rupture in the acute state during endovascular procedures with sub- sequent difficulty in controlling the bleeding without sacrificing the feeder artery has led to some reser- vation in using endovascular treatments more broadly. We report a rare case of a 52-year-old-woman who presented with acute subarachnoid hemorrhage and was found to have a ruptured 5 mm  8 mm bi-lobulated basilar apex aneurysm on CT angiography. Digital subtraction angiography demonstrated an associated anterior pseudoaneurysm that was formed secondary to the aneurysm rupture. The true aneurysm was successfully coiled with careful avoidance of the pseudoaneurysmal sac. Pseudoaneu- rysms are frequently identified for the first time during digital subtraction angiography. Recognizing their presence is essential for treatment planning. Acute pseudoaneurysms associated with true aneurysmal rupture can be safely and successfully treated by endovascular coiling of the true aneurysm. Care must be taken to avoid manipulation of the pseudoaneurysmal sac during the embolization. Ó 2014 Elsevier Ltd. All rights reserved. 1. Introduction Intracranial pseudoaneurysms are unusual and occur in less than 1% of patients with intracranial aneurysms [1,2]. The most common causes of pseudoaneurysm formation include blunt or penetrating head trauma, neoplasm, Marfan’s syndrome and other collagen vascular disorders, dissection, infection, vasculitis, and iatrogenic injury during surgery or endovascular procedures [3,4]. Rarely, rupture of a true cerebral aneurysm can lead to the development of a pseudoaneurysm [5–7]. These lesions are com- monly referred to as ‘‘ghost aneurysms’’ due to their irregular angiographic appearance and changing shape [5]. Pseudoaneu- rysms are challenging to manage and are associated with high morbidity and mortality. Although open and endovascular treat- ments for intracranial pseudoaneurysms have both been reported, the optimal approach for management remains controversial. Herein, we present a rare case of a ruptured basilar artery aneu- rysm associated with an adjacent pseudoaneurysm, both of which were successfully treated with coil embolization. 2. Technical case report 2.1. Clinical features A 52-year-old woman with no past medical history presented with sudden onset of severe headache and subsequent loss of con- sciousness. She was brought to the emergency room intubated and obtunded. Her examination was notable for fixed non-reactive pupils at 1 mm bilaterally and extensor posturing in all four extremities. A non-contrast head CT scan demonstrated diffuse subarachnoid hemorrhage in the basal cisterns with intraventricu- lar extension (Fig. 1A). CT angiogram demonstrated a 4–5 mm basilar apex aneurysm that extended into the suprasellar cistern, although the microanatomy of the aneurysm was not fully distin- guishable. A right frontal external ventricular drain was http://dx.doi.org/10.1016/j.jocn.2013.11.050 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved. ⇑ Corresponding author. Tel.: +1 617 726 2000; fax: +1 617 643 4113. E-mail address: walcott.brian@mgh.harvard.edu (B.P. Walcott). Journal of Clinical Neuroscience 21 (2014) 1637–1640 Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn