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AJNR Am J Neuroradiol 20:149–150, January 1999
Complete Duplication or Extreme Fenestration
of the Basilar Artery
Jonas H. Goldstein, Richard Woodcock, Huy M. Do, C. Douglas Phillips, and Jacques E. Dion
 -  headache without radiological evidenco of aneurysm로 입원한 증례

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Complete
duplication of the basilar artery, with each vertebral
artery continuing separately to form a posterior cerebral
artery, has been described previously (5, 6).
5. Adachi, B. Das Arteriensystem der Japaner. Kyoto, Japan:
Kaiserlich-Japanischen Univerita¨t zu Kyoto; 1928
6. Krayenbu¨hl H, Yasargil G. Die vaskula¨ren Erkrankungen im
Gebiet der Arteria vertebralis und Arteria basialis; eine anatomische
und pathologische, klinische und neuroradiologische
Studie. Stuttgart: Thieme; 1957
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The embryology of the basilar artery has been
well described by Padget (7).
7. Padget DH. The development of the cranial arteries in the human
embryo. Contrib Embryol 1948;32:205–261
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true or complete duplication is extremely
rare (4–6).
4. Newton TH, Potts DG. Radiology of the Skull and Brain: Angiography.
St Louis: Mosby; 1974;69:1775–1795
5. Adachi, B. Das Arteriensystem der Japaner. Kyoto, Japan:
Kaiserlich-Japanischen Univerita¨t zu Kyoto; 1928
6. Krayenbu¨hl H, Yasargil G. Die vaskula¨ren Erkrankungen im
Gebiet der Arteria vertebralis und Arteria basialis; eine anatomische
und pathologische, klinische und neuroradiologische
Studie. Stuttgart: Thieme; 1957
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According to Padget [10], fusion of the embryonic longitudinal
neural arteries into a basilar artery occurs in a
craniocaudal direction by the fifth gestational week.
Fenestration of the basilar artery is the result of fusion
failure of the embryonic longitudinal neural arteries.
10. Padget DH (1948) The development of
the cranial arteries in the human embryo.
Contrib Embryol 32:205–261
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there have only been a few reported cases of complete duplication (or
longitudinal nonfusion) of the basilar artery (6–10).
6. Adachi B. Das arteriensystem der Japaner. Kyoto: Kaiserlich-Japanischen
Univeritat zu Kyoto; 1928
7. Goldstein JH, Woodcock R, Do HM, et al. Complete duplication or
extreme fenestration of the basilar artery. AJNR Am J Neuroradiol
1999;20:149–150
8. Krayenbuhl H, Yasargil G. Die vaskularen erkrankungen im gebiet der
arteria vertebralis und arteria basialis: eine anatomische und pathologische,
klinische und neuroradiologische studie. Stuttgart: Thieme; 1957
9. Newton TH, Potts DG, eds. Radiology of the skull and brain: angiography.
St. Louis: Mosby; 1974:1775–1795
10. Uchino A, Sawada A, Takase Y, et al. Extreme fenestration of the
basilar artery associated with cleft palate, nasopharyngeal mature
teratoma, and hypophyseal duplication. Eur Radiol 2002;12:2087–
2090

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Vascular anomalies and variants are common in patients undergoing imaging studies, and patients with these anomalies are generally asymptomatic.
Remnants of fetal carotid-basilar circulation are rarely identified. We report a rare case of persistent type 2 bilateral proatlantal arteries, in which the patient presented with dizziness.

 62-year-old man presented with headache, dizziness, and a remote parietal cortical infarction. Magnetic resonance angiography (MRA) of the head and neck was subsequently obtained. The MRA images revealed bilateral persistent type 2 proatlantal arteries (Figure ​Figure1a1a, short white arrows) originating from the bilateral external carotid arteries (Figure ​(Figure1a1a, long white arrows) and eventually contributing to and forming the vertebrobasilar circulation (Figure 1a, 1b, yellow arrows). Moreover, the V1 and V2 segments of the bilateral vertebral arteries were atretic. The patient's presenting symptoms were not attributed to this vascular variant, and he was discharged home with resolution of the presenting symptoms.
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Anatomical variations of the posterior circulation: case reports and a review of literature.
Consoli A, Cuccuini M, Lorenzini F, Bianchi A, Grazzini G, Scarpini G, Vitali I, Lacono A, Mangiafico V, Pellicano G, Capaccioli L.
Ital J Anat Embryol. 2012;117(1):13-22. Review.
PMID:22893996[PubMed - indexed for MEDLINE]
The intracranial vascular anatomical variations, although rare, represent a interesting field of research, since many anomalous variants are possible and in most cases they remain asymptomatic. The capability of the cerebral circulation to adapt to several flow changes is confirmed by the fact that in several cases these anatomical variation compensate for an eventual unsuccessful development of the normal circulation, expecially in the posterior section of cerebral circulation.
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Preval‎ence of fenestrated basilar artery with magnetic resonance angiography: a transversal study.
Arraez-Aybar LA, Villar-Martin A, Poyatos-Ruiperez C, Rodriguez-Boto G, Arrazola-Garcia J.
Surg Radiol Anat. 2013 Aug;35(6):487-93. doi: 10.1007/s00276-012-1053-5. Epub 2012 Dec 19.
PMID:23250566[PubMed - in process]
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Human basilar artery abnormalities in the prenatal and postnatal period.
Vasović L, Trandafilović M, Jovanović I, Ugrenović S, Antović A, Karadžić R, Stojanović I.

World Neurosurg. 2013 Mar-Apr;79(3-4):593.e15-23. doi: 10.1016/j.wneu.2012.06.033. Epub 2012 Jun 21.

PMID:22728664[PubMed - indexed for MEDLINE]
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Surgical anatomy of the vertebrobasilar territory and posterior circle of Willis.
Idowu OE, Malomo AO, Akang EU.
West Afr J Med. 2010 Jul-Aug;29(4):230-4.
PMID:20931509[PubMed -

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Variants of BA are very rare. The distal BA may be hypoplastic if the PCA has a fetal origin. A fenestrated BA can be identified and is associated with increased incidence of saccular aneurysms.[ [Osborn AG. Normal vascular anatomy. In Diagnostic neuroradiology. Mosby 1994;143-145.] 

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The fusion of the neural arteries associated with

the regression of the bridging vessels might be a possible explanation for the basilar

artery fenestration. This condition is usually observed in the proximal segment of

the vessel because of incomplete fusion of the longitudinal arteries, which proceeds

in cranio-caudal direction, while the distal segment is rarely interested. Furthermore,

it was supposed that vertebro-basilar junction fenestration might be secondary to

the persistence of the rostral part of a primitive lateral vertebrobasilar anastomosis.

Consoli A,,,,,Anatomical variatins  Italian journal

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Duplication of the basilar artery can result from

a failure of the fusion of these embryonic precursors.

[ 2. Padget DH. The development of the cranial arteries in the human embryo. Contrib Embryol 1948;32:205-261.]

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Compared with the partial or segmental types, true or

complete duplication-type fenestrations are reported to

be extremely rare.3,4 Only one case report of autopsy

findings of duplication-type basilar artery fenestration

and associated brainstem infarction has appeared in the

literature.5 

[3. Goldstein JH, Woodcock R, Do HM, Phillips CD, Dion

JE. Complete duplication or extreme fenestration of the

basilar artery. AJNR Am J Neuroradiol 1999;20:149-150.

4. Uchino A, Kato A, Takase Y, Kudo S. Basilar artery

fenestrations detected by MR angiography. Radiat Med

2001;19:71-74.

5. Berry AD 3rd, Kepes JJ, Wetzel MD. Segmental

duplication of the basilar artery with thrombosis. Stroke

1988;19:256-260. ]

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In the present case, the lesion was a true duplicationtype

fenestration, with each lumen sharing the medial

wall. This finding was consistently observed from the

joining portion of the two vertebral arteries to the top of

the basilar artery, and each of the posterior cerebral

arteries was branched from the adjoined portion of the

basilar artery.  전북대 본문

Even though a causative linkage between arterial fenestration

and cerebral ischemia was not established, a reliable

diagnosis of the vascular condition in the affected lesion

was important clinically. 전북대 본문

The posterior cerebral artery and the superior

cerebellar artery on each respective side arose separately

from the split basilar artery. The circle of Willis was otherwise

normal.  Manohar Shroff,  AJNR Am J Neuroradiol  의 본문

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Another case of extreme fenestration of the basilar

artery was reported in a retrospective MR angiographic

study.4 In that study, 10 basilar artery fenestrations were

observed from 600 brain reviews (1.7%) and one case showed a total duplication. The shape of the fenestration

was different in the proximal and distal parts of the

basilar artery; in the proximal two-thirds of the artery,

a true duplication-type fenestration that shared the

medial wall was noted, but in the distal one-third of the

artery, the artery was fully separated, with each basilar

artery terminating in a posterior cerebral artery. However,

it was not mentioned whether this finding was

combined with a brainstem infarction.

4. Uchino A, Kato A, Takase Y, Kudo S. Basilar artery

fenestrations detected by MR angiography. Radiat Med

2001;19:71-74.

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As reported in literature, segmental duplication

of the basilar artery can occur as a result of

failure of fusion of the neural arteries and of regression

of the bridging arteries that connect the longitudinal

arteries (17).

17. Sanders WP, Sorek PA, Mehta BA. Fenestration of intracranial

arteries with special attention to associated aneurysms and other

anomalies. AJNR Am J Neuroradiol 1993;14:675–680

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In cases of pituitary duplication, we postulate that

segmental duplication of the basilar artery is related

to the split of the rostral end of the notochord.

Manohar Shroff,  AJNR Am J Neuroradiol  의 본문 discussion

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세르비아 논문
Fenestration occurs most commonly at
the VBJ (11, 15, 28) or at proximal end of the
BA (14, 19, 22, 24) but may involve the BA
anywhere along its course (41).
11. De Caro R, Parenti A, Munari PF: Fenestration of the
vertebrobasilar junction. Acta Neuropathol 108:85-
87, 1991.
15. Ezaki Y, Kazekawa K, Tsutsumi K: A vertebrobasilar
junction aneurysm associated with fenestration
treated by intra-aneurysmal embolization. Acta
Neurochir 145:807-809, 2003.
28. Lesley WS, Rajab MH, Case RS: Double origin of the
posterior inferior cerebellar artery: association with
intracranial aneurysm on catheter angiography.
AJNR Am J Roentgenol 189:893-897, 2007.
14. Eustachio S, Klein GE, Pendl G: Ruptured vertebrobasilar
junction aneurysm associated with basilar
artery fenestration. Acta Neurochir 139:923-927,
1997.
19. Fujimoto K, Kawai S, Yonezawa T, Masui K, Nishi N,
Maekawa M, Uranishi R: Basilar trunk aneurysms
with associated fenestration treated by using Guglielmi
detachable coils: two cases reports. J Stroke
Cerebrovasc Dis 16:84-87, 2007.
22. Hattori T, Inoue S, Sakai N: Fenestration of the basilar
artery associated with persistent primitive trigeminal
artery. Case report. Neurol Med Chir (Tokyo)
37:841-843, 1997.
24. Islak C, Kocer N, Kantarci F, Saatci I, Uzma O, Canbaz
B: Endovascular management of basilar artery
aneurysms associated with fenestrations. AJNR Am
J Neuroradiol 23:958-964, 2002.
41. Tasker AD, Byrne JV: Basilar artery fenestration in
association with aneurysms of the posterior cereb
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세르비아 논문
Middle and distal
basilar fenestrations also have been described
in this report (1a-b and 2a) and by
other authors (18, 24, 29, 31, 43).
18. Foroni LHL, Figueiredo EG, Teixeira MJ, Caldas JGMP,
Leszczynski A, Rivau FR: Saccular aneurysms at middle
basilar trunk fenestration. Arq Neuro-Psiquiatr 2010;68
Available at: http://www.scielo.br/scielo.php?script

sci_arttext&pid
S0004-282X2010000200030. Accessed
July 3, 2012.
24. Islak C, Kocer N, Kantarci F, Saatci I, Uzma O, Canbaz
B: Endovascular management of basilar artery
aneurysms associated with fenestrations. AJNR Am
J Neuroradiol 23:958-964, 2002.
29. Massoud TF, Guglielmi G, Vinuela F, Duckwiler
GR: Endovascular treatment of multiple aneurysms
involving the posterior intracranial circulation.
AJNR Am J Neuroradiol 17:549-554, 1996.
31. Nagashima H, Okudera H, Orz Y, Kobayashi S, Nakagawa
F: Endovascular treatment of basilar trunk
aneurysm associated with fenestration of the basilar
artery. Neurosurg Rev 22:219-221, 1999.
43. Uchino A, Kato A, Takase Y, Kudo S: Basilar artery
fenestrations detected by MR angiography. Radiat
Med 19:71-74, 2001.
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세르비아 노눈
According
to previous classification, we can note
that Hoffman and Wilson (23), Saatci et al.
(36), and Wenbin et al. (51) described very
large basilar fenestrations. A case of completely
duplicated BA with connections at
the proximal and distal ends can represent a
subtype of large fenestration. This case has
been described as in a full-term female
infant (44) and in a 55-year-old woman as
well (53).
23. Hoffman WF, Wilson CB: Fenestrated basilar artery
with an associated saccular aneurysm. Case report. J
Neurosurg 50:262-264, 1979.
36. Saatci I, Cekirge HS, Karcaaltincaba M, Basgun N,
Berker M, Timurkaynak E, Ozcan OE: Endovascular
treatment of kissing aneurysms at the fenestrated
basilar artery. Case report with literature review.
Surg Neurol 58:54-58, 2002.
51. Wenbin LI, Minghua LI, Daniel HG, Wu DH, Tytle
TL, Karatas R, Karatas Y, Yun WTC: Fenestrated
basilar artery associated with multiple aneurysms. J
Huazbong Univ Sci Technolog Med Sci 23:418-9,
426, 2003.
44. Uchino A, Sawada A, Takase Y, Fujita I, Kudo S:
Extreme fenestration of the basilar artery associated
with cleft palate, nasopharyngeal mature teratoma,
and hypophyseal duplication. Eur Radiol 12:2087-
2090, 2002.
53. Woo S-R, Seo M-W, Kim Y-H, Kwak H-S, Han Y-M,
Chung G-H, Jeong S-K: Extreme duplication-type,
nonseparated fenestration of the basilar artery in a
patient with pontine infarction: confirmation with
virtual arterial endoscopy. J Clin Neurol 2:74-77,
2006.
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세르비아
Later facts given by many
authors (12, 16, 17, 48) are the reasons for our
new hypothesis that a basilar fenestration is a
vascular developmental variant of the basilar
trunk in relation to the maintenance of vascular
symmetry in the midline on the human
brain.
12. De Caro R, Serafini MT, Galli S, Parenti A, Guidolin
D, Munari PF: Anatomy of segmental duplication in
the human basilar artery. Possible site of aneurysm
formation, in: Abstract. Clin Neuropathol 14:303-
309, 1995.
16. Finlay HM, Canham PB: The layered fabric of cerebral
artery fenestrations. Stroke 25:1799-1806, 1994.
17. FinlayHM,Whittaker P, Canham PB: Collagen organization
in the branching region of human brain
arteries. Stroke 29:1595-1601, 1998.

48. Vasovic´ L, Milenkovic´ Z, Pavlovic´ S: Comparative
morphological variations and abnormalities of circles
of Willis: a minireview including two personal
cases. Neurosurg Rev 25:247-251, 2002.