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December 03, 2019; 93 (23) Resident & Fellow Section

Teaching Video NeuroImages: High blood flow velocity in the parent artery prior to basilar tip aneurysm rupture

Fei Peng, Miaoqi Zhang, Xin Feng, Yunduo Li, Rui Li, Aihua Liu
First published December 2, 2019, DOI: https://doi.org/10.1212/WNL.0000000000008585
Fei Peng
From the Beijing Neurosurgical Institute (F.P., A.L.) and Beijing Tiantan Hospital (F.P., A.L.), Capital Medical University; China National Clinical Research Center for Neurological Diseases (F.P., A.L.), Beijing; Department of Biomedical Engineering (M.Z., Y.L., R.L.), Center for Biomedical Imaging Research, Tsinghua University; and Department of Neurosurgery (X.F.), Beijing Hospital, National Center of Gerontology, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, China.
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Miaoqi Zhang
From the Beijing Neurosurgical Institute (F.P., A.L.) and Beijing Tiantan Hospital (F.P., A.L.), Capital Medical University; China National Clinical Research Center for Neurological Diseases (F.P., A.L.), Beijing; Department of Biomedical Engineering (M.Z., Y.L., R.L.), Center for Biomedical Imaging Research, Tsinghua University; and Department of Neurosurgery (X.F.), Beijing Hospital, National Center of Gerontology, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, China.
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Xin Feng
From the Beijing Neurosurgical Institute (F.P., A.L.) and Beijing Tiantan Hospital (F.P., A.L.), Capital Medical University; China National Clinical Research Center for Neurological Diseases (F.P., A.L.), Beijing; Department of Biomedical Engineering (M.Z., Y.L., R.L.), Center for Biomedical Imaging Research, Tsinghua University; and Department of Neurosurgery (X.F.), Beijing Hospital, National Center of Gerontology, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, China.
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Yunduo Li
From the Beijing Neurosurgical Institute (F.P., A.L.) and Beijing Tiantan Hospital (F.P., A.L.), Capital Medical University; China National Clinical Research Center for Neurological Diseases (F.P., A.L.), Beijing; Department of Biomedical Engineering (M.Z., Y.L., R.L.), Center for Biomedical Imaging Research, Tsinghua University; and Department of Neurosurgery (X.F.), Beijing Hospital, National Center of Gerontology, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, China.
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Rui Li
From the Beijing Neurosurgical Institute (F.P., A.L.) and Beijing Tiantan Hospital (F.P., A.L.), Capital Medical University; China National Clinical Research Center for Neurological Diseases (F.P., A.L.), Beijing; Department of Biomedical Engineering (M.Z., Y.L., R.L.), Center for Biomedical Imaging Research, Tsinghua University; and Department of Neurosurgery (X.F.), Beijing Hospital, National Center of Gerontology, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, China.
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Aihua Liu
From the Beijing Neurosurgical Institute (F.P., A.L.) and Beijing Tiantan Hospital (F.P., A.L.), Capital Medical University; China National Clinical Research Center for Neurological Diseases (F.P., A.L.), Beijing; Department of Biomedical Engineering (M.Z., Y.L., R.L.), Center for Biomedical Imaging Research, Tsinghua University; and Department of Neurosurgery (X.F.), Beijing Hospital, National Center of Gerontology, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, China.
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Citation
Teaching Video NeuroImages: High blood flow velocity in the parent artery prior to basilar tip aneurysm rupture
Fei Peng, Miaoqi Zhang, Xin Feng, Yunduo Li, Rui Li, Aihua Liu
Neurology Dec 2019, 93 (23) 1018-1019; DOI: 10.1212/WNL.0000000000008585

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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).

Figure 1
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Figure 1 Coronal and sagittal digital subtraction angiography (DSA) images and axial head CT

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

Figure 2
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Figure 2 Velocity vector fields, streamline and velocity diagram throughout cardiac cycles

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

Table1

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

References

  1. 1.↵
    1. Hennerici M,
    2. Rautenberg W,
    3. Sitzer G,
    4. Schwartz A
    . Transcranial Doppler ultrasound for the assessment of intracranial arterial flow velocity: part 1: examination technique and normal values. Surg Neurol 1987;27:439–448.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Dyverfeldt P,
    2. Bissell M,
    3. Barker AJ, et al
    . 4D flow cardiovascular magnetic resonance consensus statement. J Cardiovasc Magn Reson 2015;17:72.
    OpenUrlCrossRefPubMed
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