Basilar Artery Bifurcation Aneurysm: Giant Basilar Bifurcation Aneurysm, Mass Effect, Stent-Assisted Coil Occlusion with a Single Enterprise Stent, Complete Long-Term Occlusion, Good Clinical Outcome
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A 47-year-old man presented with an aggravation of a previously known cervical spine-degeneration related neck pain and a new headache in November 2013. MRI revealed a 26 × 19 mm, eccentric, posterior-oriented basilar bifurcation aneurysm with an ill-defined neck, occupying the interpeduncular fossa with mass effect on the crura cerebri and the midbrain but with no perianeurysmal edema or subarachnoid hemorrhage (SAH). The aneurysm was treated by endovascular coil occlusion with HydroCoils (MicroVention) and bare platinum coils, assisted by a single Enterprise stent (Cerenovus). DSA follow-up over four years confirmed the complete obliteration of the aneurysm, while the P1 segments of each posterior cerebral artery (PCA) remained patent. The main topic of this presentation is the different ways to achieve permanent occlusion in large and giant aneurysms, among them the use of HydroCoils and the merits of stent-assisted coiling.
KeywordsBasilar artery bifurcation aneurysm Giant aneurysm 3D HydroCoils Stent-assisted coiling
A 47-year-old male presented with headache and an aggravation of a known cervical spine-degeneration neck pain in November 2013.
Prevention of increasing mass effect and aneurysm rupture were the goals of the treatment, aiming to occlude the aneurysm while preserving the incorporated PCAs. Endovascular coil occlusion after reconstruction of the basilar artery bifurcation with crossing or single Enterprise stent(s) (Cerenovus) deployment was chosen.
Procedure, 09.12.2013: stent-assisted coil occlusion of a giant basilar artery bifurcation aneurysm
Anesthesia: general anesthesia; 5000 IU heparin (Heparin Natrium, B. Braun) IV
Premedication: 1 × 500 mg ASA (Aspirin, Bayer Vital) PO, 1 × 375 mg clopidogrel (Plavix, Sanofi-Aventis) PO the day before
Access: right femoral artery, 6F sheath 90 cm (Cordis); guide catheter: 6F Fargo 125 cm (Balt Extrusion); microcatheter: Prowler select plus (Cerenovus), Echelon 14; microguidewire: Silver Speed 14 (Medtronic)
Implants: Enterprise stent 4.5 × 22 mm (Cerenovus); 12 coils: 3× HydroFrame18 (20 mm/48 cm, 18 mm/50 cm, 16 mm/44 cm), 3× Cosmos18 (24 mm/68 cm, 22 mm/63 cm, 18 mm/59 cm), 6× VFC (2 × 15–20 mm/60 cm, 15–20 mm/40 cm, 10–15 mm/40 cm, 6–10 mm/30 cm, 3–6 mm/15 cm) (all MicroVention)
Duration: 1st–12th DSA run: 180 min; fluoroscopy time: 88 min
Complication: postprocedural diplopia
Postmedication: 1 × 100 mg ASA PO daily forever, 75 mg clopidogrel PO daily for eight weeks
The patient developed a postinterventional diplopia, which was most likely due to an increased mass effect of the aneurysm after coil occlusion. Double vision improved under temporary steroid medication and is now stable, the vision having been compensated with prism glasses. The headache did not improve, and the patient is still under analgetic medication. It is not clear if the cause of the chronic headache is the severe cervical spine degeneration or the persistent mass effect of the aneurysm.
The endovascular coil occlusion of large and giant wide-necked aneurysms has two critical aspects: the preservation of the efferent arteries and the stable exclusion of the aneurysm from the blood circulation. Several options are available for the protection of the afferent and efferent vessels from inadvertent occlusion during coiling. Among them, conventional stenting as performed in this case, is technically the most straightforward solution (Adeeb et al. 2016). The Y-stenting technique requires access to both efferent arteries and can therefore be challenging with an at least one-digit failure rate, as encountered in the patient reported in this chapter (Limbucci et al. 2016). Bifurcation stenting has the theoretical advantage of modifying the vessel geometry with straightening of the bifurcation (Sağlam et al. 2015). In the presented case, a pCONus device (phenox), a Barrel stent (Medtronic), or a PulseRider (Cerenovus) might have been alternative options for assisted coiling (Signorelli et al. 2017; Mühl-Benninghaus et al. 2017; Sheth et al. 2016). A single Enterprise stent, however, allowed for the protection of the basilar artery bifurcation and for dense coil packing. Dense packing requires the control of the aneurysm neck region including the parent artery. While loose packing is technically less demanding, coil compaction and partial aneurysm perfusion is a frequent consequence. Dense packing, on the contrary, can be a technical challenge and may increase the procedural risks and material consumption. In return though, a more stable aneurysm occlusion can be expected.
Different coil types show a variable liability to coil compaction. Both fibered coils (ev3) and hydrocoils (MicroVention) are more resilient to coil compaction resulting in aneurysm reperfusion than bare coils (Liebig et al. 2004; Brinjikji et al. 2015). In the presented case, the combination of the straightening of the right PCA due to the stent deployment, the dense coil packing during the initial treatment, and the effect of the implanted HydroCoils may have contributed to the persistent occlusion of this giant aneurysm. These effects are, however, difficult to control and anticipate. This is the reason why aneurysm recurrence necessitating multiple retreatments is still a concern with the endovascular coil occlusion of large and giant aneurysms.
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