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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

  • Christina M. WendlEmail author
  • Marta Aguilar Pérez
  • Gerhard Schuierer
  • Hans Henkes
Living reference work entry
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Abstract

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.

Keywords

Basilar trunk Dissecting aneurysm Flow diversion p64 Pipeline Embolization Device (PED) Pediatric SAH 

Patient

Five-year-old, female, acute blunt head trauma, sixth nerve palsy, SAH, Hunt and Hess III, Fisher IV

Diagnostic Imaging

Diagnostic imaging was performed as a workup for acute headache, sixth nerve palsy, and somnolence after a fall with blunt head trauma. CT/CTA showed an SAH around the brainstem with blood in the ventricles and a dissecting aneurysm of the proximal basilar trunk without ischemic lesions of the brainstem (Fig. 1).
Fig. 1

CT (ac) in a 5-year-old girl after a blunt head trauma reveals a minor prepontine SAH and an intraventricular hemorrhage. CTA showed a dissecting aneurysm of the proximal basilar artery (d, e; circles)

Treatment Strategy

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.

Treatment

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)

Course of treatment: The left VA was catheterized with a 5F guide catheter. DSA confirmed a dissecting aneurysm of the proximal basilar trunk of 11 mm length and 8 mm maximum diameter. An Excelsior XT 27 microcatheter was inserted through the dissected vessel segment into the distal basilar artery. From distal to proximal, two p64 flow diverters were telescopically deployed from the basilar artery into the left VA, fully covering the dissecting aneurysm. Finally, a Pipeline Embolization Device (PED) flow diverter with Shield Technology was placed inside the two p64 flow diverters in order to enhance the flow modulation effect. The following DSA run confirmed the full coverage of the dissected segment of the BA with a delayed washout of the contrast medium from the aneurysm sac. Following this, an Excelsior SL 10 microcatheter was placed in the right V4 segment distal to the origin of the posterior inferior cerebellar artery (PICA). Three coils were densely packed to prevent the inflow of blood underneath the flow diverters into the dissecting aneurysm. The final DSA run confirmed the complete occlusion of the distal right V4 segment with the perfusion of the right PICA preserved (Fig. 2).
Fig. 2

Endovascular flow diverter treatment of a dissecting aneurysm of the basilar trunk. DSA confirmed the dissecting proximal BA aneurysm (ac). A first p64 3.5/18 was anchored in the basilar trunk distal to the aneurysm (df). A second p64 3.5/18 was telescopically deployed – proximal to the first device – and anchored in the distal segment of the left VA (fh). Finally, a PED Flex Shield 3.75/20 was deployed inside the two p64s, covering the entire length of the BA dissection (i). Injecting the left VA confirmed significant contrast stagnation inside the aneurysm (j, k). Then, the distal segment of the right VA was occluded with coils (l). The final DSA runs confirmed the occlusion of the right distal V4 segment and the flow diverter effect on the proximal BA aneurysm (m, n)

  • Duration: 1st–23rd DSA run: 81 min; fluoroscopy time: 42 min

  • Complications: none

  • Postmedication: 1 × 50 mg ASA (Aspirin) PO daily for life, 2 × 45 mg ticagrelor (Brilique) PO daily for one year

Clinical Outcome

The cranial nerve palsy resolved within six months after the endovascular treatment. The girl returned to her previous normal condition and started elementary school.

Follow-Up Examinations

DSA and MRI/MRA follow-up examinations after six months showed an almost complete resolution of the aneurysm. Only small residual ectasias at the origin of the rami ad pontem remained (Fig. 3).
Fig. 3

DSA (ac) and MRI/MRA (df) follow-up examinations six months after the flow diverter reconstruction of the proximally dissected basilar trunk and coil occlusion of the right V4 segment. The right V4 segment is occluded (a), and the dissecting aneurysm is obliterated (b), with two minor remnants at the origins of the rami ad pontem (c). T2WI MRI (d, e) shows no ischemic injury of the brainstem. On the MRA TOF source images, no flow outside the flow diverters is recognized (f)

Discussion

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.

Cross-References

Notes

References

  1. 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
  2. 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
  3. Cerejo R, Bain M, Moore N, Hardman J, Bauer A, Hussain MS, Masaryk T, Rasmussen P, Toth G. Flow diverter treatment of intracranial vertebral artery dissecting pseudoaneurysms. J Neurointerv Surg. 2017;9(11):1064–8.  https://doi.org/10.1136/neurintsurg-2017-013020.CrossRefPubMedGoogle Scholar
  4. 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
  5. Krings T, Geibprasert S, terBrugge KG. Pathomechanisms and treatment of pediatric aneurysms. Childs Nerv Syst. 2010;26(10):1309–18.  https://doi.org/10.1007/s00381-009-1054-9.CrossRefPubMedGoogle Scholar
  6. 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
  7. 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
  8. Mizutani T, Aruga T, Kirino T, Miki Y, Saito I, Tsuchida T. Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery. 1995;36(5):905–11; discussion 912-3CrossRefPubMedGoogle Scholar
  9. Nakatomi H, Nagata K, Kawamoto S, Furusho JI. Basilar artery occlusion due to spontaneous basilar artery dissection in a child. Acta Neurochir. 1999;141(1): 99–104.CrossRefPubMedGoogle Scholar
  10. 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
  11. Saliou G, Power S, Krings T. Flow diverter placement for management of dissecting ruptured aneurysm in a non-fused basilar artery. Interv Neuroradiol. 2016;22(1):58–61.  https://doi.org/10.1177/1591019915617324.CrossRefPubMedPubMedCentralGoogle Scholar
  12. Scazzeri F, Mascalchi M, Calabrese R, Quilici N. Case report. MRI and MR angiography of basilar artery dissection in a child. Neuroradiology. 1997;39(9): 654–7.CrossRefPubMedGoogle Scholar
  13. 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
  14. Yoshimoto Y, Hoya K, Tanaka Y, Uchida T. Basilar artery dissection. J Neurosurg. 2005;102(3):476–81.CrossRefPubMedGoogle Scholar
  15. 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

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Christina M. Wendl
    • 1
    Email author
  • Marta Aguilar Pérez
    • 2
  • Gerhard Schuierer
    • 1
  • Hans Henkes
    • 2
  1. 1.Zentrum für NeuroradiologieUniversitätsklinikum und Bezirksklinikum RegensburgRegensburgGermany
  2. 2.Neuroradiologische KlinikNeurozentrum, Klinikum StuttgartStuttgartGermany

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