A 70-year-old asymptomatic man presented with moyamoya disease (MMD)–associated basilar tip aneurysm (BTA) noted on digital subtraction angiography (figure 1, A–D). 4D-flow MRI revealed a concentrated inflow jet with high velocity compared with previous studies1 (video 1 and figure 2, A–F). Considering the high risk of endovascular treatment, the patient chose conservative treatment. After 1 month, the aneurysm ruptured (figure 1, E–F).
Coronal (A) and sagittal (B) DSA images reveal moyamoya vessels (arrows), vertebral artery (arrowheads), and basilar tip aneurysm (stars). Coronal (C) and sagittal (D) DSA images show left internal carotid artery (ICA) (triangle), occlusion of right ICA (arrow), left anterior cerebral artery (arrowhead), and left middle cerebral artery (star). Axial head CT (E, F) demonstrates subarachnoid and ventricular hemorrhage.
Video 1
Streamlines (i.e., lines of tangent to instantaneous velocity vectors) at peak systole were calculated and color-encoded using velocity amplitude (0–0.75 m/s). There was one jet-like stream that reached the top of the aneurysm dome, spun anticlockwise around the dome, and finally entered into 2 posterior cerebral arteries.Download Supplementary Video 1 via http://dx.doi.org/10.1212/008585_Video_1
Velocity vector fields in peak systole (A, B) reveal inflow (arrowhead) and outflow (arrow). Lateral view of streamline (C) shows the narrowed impacted zone (arrowhead). Streamline at peak systole (D) demonstrates blood flow direction (arrow). Velocity diagram (E, F) demonstrates maximum velocity variation throughout cardiac cycles of basilar artery and left posterior cerebral aneurysm, respectively.
The compensatory reaction due to internal carotid artery occlusion (figure 1D) could induce increased flow, leading to BTA formation and rupture. 4D-flow MRI can provide comprehensive hemodynamics with accurate blood flow and velocity.2 MMD-derived concentrated inflow jet with high velocity can expedite aneurysm rupture, which mandates prompt operation.
Study funding
This work was supported by the Natural Science Foundation of China (no. 81771233) and the Natural Science Foundation of Beijing, China (no. 7142032).
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Appendix Authors
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
↵* These authors contributed equally to this work as co-first authors.
↵‡ These authors contributed equally to this work as co-last authors.
Teaching slides links.lww.com/WNL/B6
- © 2019 American Academy of Neurology
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