Basilar Trunk Aneurysm: Blunt Head Trauma, Dissecting Aneurysm of the Proximal Basilar Trunk Causing a Subarachnoid Hemorrhage, Reconstruction of the Basilar Artery with Three Telescoping Flow Diverters Anchored in the Left Vertebral Artery, Followed by Coil Occlusion of the Right V4 Segment
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A 5-year-old girl suffered a head injury following a fall and presented with an acute headache, sixth nerve palsy, and a subarachnoid hemorrhage (SAH), graded as Hunt and Hess III, Fisher IV. A traumatic dissecting aneurysm of the proximal basilar trunk was treated by the endovascular implantation of three flow diverters which were deployed telescopically from the distal basilar artery into the left V4 segment, together with the coil occlusion of the right distal V4 segment to prevent an endoleak from this side. The postprocedural course was uneventful and the cranial nerve palsy resolved completely. Angiographic and MRI/MRA follow-up examinations after six months confirmed the almost complete occlusion of the aneurysm with only residual inflow of contrast medium at the origin of perforating basilar arteries. Prior to the availability of flow diverting stents, the treatment of dissecting intracranial artery aneurysms had been challenging. Flow diversion is technically easier than stent-assisted coil occlusion or stent grafting, especially in the case of a fusiform dissecting aneurysm. Placing a flow diverter into a dissected artery reconstructs the lacerated vessel segment itself. The main topics of this report are the treatment of dissected vessel segments with flow diversion in an acute situation and in the pediatric population.
KeywordsBasilar trunk Dissecting aneurysm Flow diversion p64 Pipeline Embolization Device (PED) Pediatric SAH
Five-year-old, female, acute blunt head trauma, sixth nerve palsy, SAH, Hunt and Hess III, Fisher IV
The goal of the endovascular treatment was to prevent the re-rupture of the dissected vessel and to preserve this segment of the basilar trunk, avoiding ischemic damage of the brainstem. Flow diverter placement from the distal BA into the left VA and coil occlusion of the right distal V4 segment was the treatment chosen.
Procedure, 28 February 2017: endovascular reconstruction of the dissected basilar artery using flow diverters and deconstruction of the right V4 segment
Anesthesia: general anesthesia, 3000 IU heparin (Heparin-Natrium, B. Braun) IV
Premedication: 1 × 250 mg ASA (Aspirin i.v., Bayer Vital) IV, 1 × 90 mg ticagrelor (Brilique, AstraZeneca) PO, both given on the day of treatment, 4 h before the procedure was started
Access: left femoral artery, 5F sheath (Terumo); guide catheter: 5F Envoy MPD (Codman); microcatheters: Excelsior XT 27 (Stryker) for the flow diverters, Excelsior SL 10 (Stryker) for the coils; microguidewire: Synchro2 0.014″ 200 cm (Stryker)
Implants: flow diverter, 2× p64 3.5/18 mm (phenox), 1× Pipeline Flex Shield 3.75/20 mm (Medtronic); coils, 1× Microplex 10 Compass Complex 3.5/45 mm (MicroVention, Terumo), 1× Cosmos Complex 3/60 mm (MicroVention, Terumo), 1× Helix Axium 2/60 mm (Medtronic)
Duration: 1st–23rd DSA run: 81 min; fluoroscopy time: 42 min
Postmedication: 1 × 50 mg ASA (Aspirin) PO daily for life, 2 × 45 mg ticagrelor (Brilique) PO daily for one year
The cranial nerve palsy resolved within six months after the endovascular treatment. The girl returned to her previous normal condition and started elementary school.
Basilar artery dissections and dissecting aneurysms in children are rare lesions (Nakatomi et al. 1999; Scazzeri et al. 1997) but are overrepresented in this population in comparison to adults (Krings et al. 2010). Ruptured vertebrobasilar dissecting aneurysms in general are associated with a high risk of early re-hemorrhage and a poor prognosis (Mizutani et al. 1995). Basilar artery dissections in particular can cause SAH and/or brainstem infarction and differ from V4 dissections both clinically and in the therapeutic options available (Yoshimoto et al. 2005). In the past, the treatment of basilar artery dissections was based on stent-assisted coil occlusion (Lee et al. 2016) or stent reconstruction (van Oel et al. 2013; Bhogal et al. 2015). The recent development of flow diverting stents has provided a new tool for the reconstruction of intracranial artery dissections. The low porosity of these stents will act to not only redirect blood away from the dissection but also tack the dissection flap down against the arterial wall. Promising results have been reported by several authors (Cerejo et al. 2017; Fischer et al. 2012; Kühn et al. 2016; Prasad et al. 2014; Saliou et al. 2016; Zarzecka et al. 2014). The occlusion of one vertebral artery is an important step to avoid competing flow and endoleak phenomena (Bhogal et al. 2017). The follow-up imaging after the flow diversion of dissecting aneurysms should be based on DSA and MRI/MRA examinations.
- Bhogal P, Brouwer PA, Söderqvist ÅK, Ohlsson M, Andersson T, Holmin S, Söderman M. Patients with subarachnoid haemorrhage from vertebrobasilar dissection: treatment with stent-in-stent technique. Neuroradiology. 2015;57(6):605–14. https://doi.org/10.1007/s00234-015-1505-9.CrossRefPubMedGoogle Scholar
- Bhogal P, Pérez MA, Ganslandt O, Bäzner H, Henkes H, Fischer S. Treatment of posterior circulation non-saccular aneurysms with flow diverters: a single-center experience and review of 56 patients. J Neurointerv Surg. 2017;9(5):471–81. https://doi.org/10.1136/neurintsurg-2016-012781.CrossRefPubMedGoogle Scholar
- Fischer S, Vajda Z, Aguilar Perez M, Schmid E, Hopf N, Bäzner H, Henkes H. Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology. 2012;54(4):369–82. https://doi.org/10.1007/s00234-011-0948-x.CrossRefPubMedGoogle Scholar
- Kühn AL, Kan P, Massari F, Lozano JD, Hou SY, Howk M, Gounis MJ, Wakhloo AK, Puri AS. Endovascular reconstruction of unruptured intradural vertebral artery dissecting aneurysms with the pipeline embolization device. J Neurointerv Surg. 2016;8(10):1048–51. https://doi.org/10.1136/neurintsurg-2015-012028.CrossRefPubMedGoogle Scholar
- Lee CJ, Lee KW, Chen WL, Chiu CC. Images diagnosis and emergent endovascular treatment of acute hemorrhagic basilar artery dissection: a case report. Acta Neurol Taiwanica. 2016;25(2):45–50.Google Scholar
- Prasad V, Gandhi D, Jindal G. Pipeline endovascular reconstruction of traumatic dissecting aneurysms of the intracranial internal carotid artery. J Neurointerv Surg. 2014;6(10):e48. https://doi.org/10.1136/neurintsurg-2013-010899.rep.CrossRefPubMedGoogle Scholar
- van Oel LI, van Rooij WJ, Sluzewski M, Beute GN, Lohle PN, Peluso JP. Reconstructive endovascular treatment of fusiform and dissecting basilar trunk aneurysms with flow diverters, stents, and coils. AJNR Am J Neuroradiol. 2013;34(3):589–95. https://doi.org/10.3174/ajnr.A3255.CrossRefPubMedGoogle Scholar
- Zarzecka A, Gory B, Turjman F. Implantation of two flow diverter devices in a child with a giant, fusiform vertebral artery aneurysm: case report. Pediatr Neurol. 2014;50(2):185–7. https://doi.org/10.1016/j.pediatrneurol.2013.09.014.CrossRefPubMedGoogle Scholar