• Kristine Ravina, Ben A Strickland, Ian A Buchanan, Robert C Rennert, Paul E Kim, Vance L Fredrickson, and Jonathan J Russin.
• Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
• World Neurosurg. 2019 Mar 1; 123: 113-122.

AbstractLarge broad-based basilar artery (BA) apex aneurysms involving multiple arterial origins are complex lesions commonly not amenable to direct clipping or endovascular management. BA proximal (Hunterian) occlusion with extracranial-to-intracranial bypass is a supported strategy if 1 or both posterior communicating arteries are small. Hunterian ligation risks sudden aneurysm thrombosis and thromboembolism in the perforator-rich BA apex. There currently exist no guidelines for antiplatelet and anticoagulant therapy after Hunterian ligation for complex BA apex aneurysm treatment. We present a literature review and an illustrative case of an 18-year-old man who presented with progressive headaches and was found to have a large unruptured BA apex aneurysm involving the origins of the bilateral superior cerebellar and posterior cerebral arteries. Given the small posterior communicating arteries and complexity of the aneurysm, proximal BA occlusion with unilateral superficial temporal artery-to-superior cerebellar artery bypass was recommended. Despite antiplatelet treatment with acetylsalicylic acid before and after operation, the patient experienced acute ischemia of the brainstem and cerebellum and an embolic left temporal lobe infarct. The patient received dual antiplatelet therapy starting on postoperative day 6, after which he experienced no new infarcts and made a significant neurologic recovery. The current evidence suggests that proximal BA occlusion in complex BA apex aneurysm cases is thrombogenic and can be especially dangerous if thrombosis occurs suddenly in aneurysms without pre-existing intraluminal thrombus. Dual antiplatelet therapy during the first postoperative week presents a possible strategy for reducing the risk of ischemia due to sudden aneurysm thrombosis.Copyright © 2018 Elsevier Inc. All rights reserved.

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