Anterior Choroidal Artery Aneurysm: Incidental Anterior Choroidal Artery Aneurysm, Treated by Flow Diversion Using a p64 with Preservation of the Anterior Choroidal Artery
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A 58-year-old female patient with a medical history of arterial hypertension and a negative family history for cerebrovascular diseases presented with a headache. MRI/MRA revealed an incidental aneurysm of the right internal carotid artery (ICA) at the origin of the anterior choroidal artery (AchoA) with a fundus diameter of 4.9 mm and a neck diameter of 2.9 mm. This aneurysm was given endovascular treatment in which a p64 flow diverter (phenox) was implanted. A follow-up DSA after 3 months showed the complete angiographic occlusion of the aneurysm with a minor in-stent stenosis. DSA runs 9 and 12 months after the endovascular treatment confirmed the persistent aneurysm occlusion, the preservation of the AchoA, and the spontaneous regression of the in-stent stenosis. Flow diverter treatment of AchoA aneurysms is the main topic of this chapter.
KeywordsAnterior choroidal artery Flow diversion Microsurgical clipping Complications In-stent stenosis Side branch occlusion p64
A 58-year-old female patient with a medical history of arterial hypertension presented with a headache on the right-hand side, associated with numbness in the right-hand side of her face and right hand. The diagnostic work-up included a cranial MRI/MRA, which revealed an incidental aneurysm of the right ICA at the origin of AchoA.
The prevention of further growth and rupture of this AchoA aneurysm was the goal of the treatment. Based on published data and personal experience, endovascular flow diverter treatment was deemed to be the most suitable treatment option. After discussing the case with the patient and explaining the intended treatment, alternatives, potential risks, and complications, she consented to the endovascular option with flow diversion.
Procedure, 13.05.2016: endovascular flow diversion for the treatment of an incidental aneurysm of the right ICA located at the origin of the AchoA
Anesthesia: general anesthesia; 3000 IU unfractionated heparin (Heparin-Natrium, B. Braun) IV
Premedication: the patient received a loading dose of 1× 300 mg ASA (Aspirin, Bayer Vital) PO and 1× 600 mg clopidogrel (Plavix, Sanofi-Aventis) PO on the day prior to the treatment; a Multiplate test (Roche Diagnostics) confirmed significant dual platelet function inhibition
Access: right common femoral artery, 1× 6F sheath (Terumo); guide catheter: 1× 6F Heartrail II (Terumo); microcatheter: 1× Excelsior XT27 (Stryker); microguidewire: 1× Synchro2 0.014″ 200 cm (Stryker)
Implant: Flow diverter: 1× p64 4/12 mm (phenox).
Duration: 1st–14th DSA run: 42 min; fluoroscopy time: 20 min
Post medication: oral dual antiplatelet medication of 1× 100 mg ASA PO daily and 1× 75 mg clopidogrel PO daily for 1 year, followed by 1× 100 mg ASA PO daily lifelong
The AchoA arises from the posterior aspect of the intradural internal carotid artery distal to the origin of the posterior communicating artery (PcomA) with rare variations in its anatomic origin. Its course is usually divided into a cisternal and a plexal segment, and its vascular supply territory includes the optic tract, internal capsule, globus pallidus, tail of the caudate nucleus, parts of the cerebral peduncle, lateral geniculate body, and parts of the mesial temporal lobe, making it an extremely eloquent vessel despite its small size (Morandi et al. 1996; Tanriover et al. 2014). The clinical manifestations of infarcts in the AchoA territory are variable and include contralateral hemiparesis, hemianesthesia, and homonymous hemianopia (Pezzella and Vadalà 2012; Nadaf et al. 2018).
Aneurysms of the AchoA are relatively uncommon, representing 2–5% of all intracranial aneurysms, and their management can be challenging (Lehecka et al. 2010). Beside the microneurosurgical option, several endovascular techniques have been described for the treatment of aneurysms arising from or at the origin of the AchoA including straightforward coil occlusion, stent-assisted coil embolization with jailing of the coiling microcatheter, coil embolization with the use of low-angled microcatheter to avoid packing the origin of the AchoA, and the placement of a small microcatheter into the AchoA during coil insertion (Friedman et al. 2001; André et al. 2017; Hou et al. 2018; Sheen and Suh 2017; Gimonet et al. 2016).
In a mixed surgical and endovascular series of 47 AchoA aneurysms, André et al. (2017) reported 5 major and 6 minor complications with no significant difference in complication rate between the surgical and endovascular treatments. The majority of endovascular treatments in this series were regular coil occlusion with or without a remodeling balloon. The authors reported four cases of occlusion of the AchoA with one resulting in a major ischemia and subsequent fatal hemorrhage after an IV infusion of abciximab.
The recent advent of FDS for the treatment of wide-necked side-wall aneurysms has offered an effective alternative approach for the treatment of aneurysms arising from the intradural segment of the ICA. In the case of aneurysms arising from the AchoA or its vicinity, the patency of this eloquent vessel is a concern once its orifice has been covered by an FDS. Several reports showed, however, that the concerning AchoAs remained patent with no change of caliber or flow once covered by an FDS (Brinjikji et al. 2015; Kühn et al. 2015; Neki et al. 2015; Raz et al. 2015; Srinivasan et al. 2017; Bhogal et al. 2018). Although late angiographic occlusion of the AchoA after flow diversion has been reported, the authors observed no clinical or radiological evidence of AchoA infarcts (Brinjikji et al. 2015; Raz et al. 2015). Interestingly, despite evident hemodynamic changes or occlusion of other simultaneously covered branches of the ICA such as the PcomA, the ophthalmic artery, and the ACA, there were no such changes reported for the AchoA (Kühn et al. 2015; Srinivasan et al. 2017; Bhogal et al. 2017).
In our experience, the use of FDS for the treatment of AchoA aneurysms is safe and efficacious (Bhogal et al. 2018). The patient in the presented case was treated with a single FDS, which resulted in completely excluding the covered aneurysm while preserving the patency of the AchoA and with no evidence of clinical or radiological infarct in the AchoA territory over the follow-up period of 2 years. Although the first angiographic follow-up showed minor stenosis of the covered ICA, in our experience this is a common and self-limiting phenomenon with no clinical symptoms (Aguilar Pérez et al. 2017).
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