Basilar Artery Bifurcation Aneurysm: Ruptured Wide-Necked Basilar Bifurcation Aneurysm Presenting with Atypical Clinical Signs and Symptoms, Treated with a WEB Device After a Failed Attempt at Coil Occlusion
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A 40-year-old male patient was referred to our emergency room with non-specific symptoms such as becoming progressively more agitated and a change in personality. While taking his medical history with his wife, she described a sudden onset of symptoms during sexual intercourse which then worsened. A scheduled CT scan revealed a basal subarachnoid hemorrhage graded at Hunt and Hess II, Fisher IV, due to a ruptured wide-neck basilar bifurcation aneurysm. After an initial unsuccessful treatment attempt using just a coil to occlude the aneurysm, the patient was successfully treated with a WEB device. The treatment of basilar artery bifurcation aneurysms with efferent arteries incorporation using a Woven EndoBridge (WEB) is the main topic of this chapter.
KeywordsBasilar artery bifurcation Wide-necked bifurcation aneurysm Coil occlusion failed attempt Woven EndoBridge WEB
A 40-year-old male patient, previously healthy, was admitted to our emergency room because of progressive agitation, a change in personality, and a headache, which he described as moderate at best. Initially, both a toxicological screening and psychiatric examination were scheduled. Once the patient’s wife arrived at the hospital, she reported that the symptoms had started suddenly during sexual intercourse that morning. In the meantime the patient had developed a progressive impairment in consciousness. Further examinations revealed a spontaneous SAH, graded at Hunt and Hess II, Fisher IV.
The goal of the treatment was to occlude the aneurysm in order to prevent a re-rupture. Therefore, it was decided to perform immediate endovascular treatment (EVT). As due to weekend staffing levels, the attending neuroradiology consultant decided to attempt treatment by coil occlusion.
Procedure #1, 19.11.2015: endovascular treatment attempt on a wide-necked basilar artery bifurcation aneurysm by coil occlusion
Anesthesia: general anesthesia; 3000 IU unfractionated heparin (Heparin-Natrium, B. Braun) IV, 250 mg ASA (Aspirin i.v., Bayer Vital) given IV after the first coil had been deployed
Access: right femoral artery; 6F 10 cm sheath (Terumo); guide catheter: 6F Vista brite tip (Cordis); microcatheter: Excelsior SL10 (Stryker); microguidewire: Traxcess 0.014″ 200 cm (MicroVention)
Implant: HydroFrame 18 6/19 (MicroVention), inserted into the aneurysm and then withdrawn
Duration: 1st–23rd DSA run: 55 min; fluoroscopy time: 17.5 min
Procedure #2, 20.11.2015: endovascular treatment of a ruptured wide-necked aneurysm of the basilar artery bifurcation using a WEB
Anesthesia: general anesthesia; 3000 IU unfractionated heparin (Heparin-Natrium, B. Braun) IV; 250 mg ASA (Aspirin i.v., Bayer Vital) IV after the WEB detachment
Premedication: 250 mg ASA (Aspirin i.v., Bayer Vital) IV, given the previous day
Access: right femoral artery, 6F 10 cm sheath (Terumo); guide catheter: 6F Vista brite tip; microcatheter: VIA 27 (MicroVention); microguidewire: Traxcess 0.014″ 200 cm (MicroVention)
Implant: WEB SL 7/3 (MicroVention)
Duration: 1st–9rd DSA run: 30 min; fluoroscopy time: 9 min
The patient was extubated the following day and had no new neurological or functional deficit. The external ventricular drain was removed after 10 days. The patient was discharged to an outpatient rehabilitation unit 1 week later with no neurological deficit (mRS 0).
Treating wide-necked aneurysms is sometimes challenging for the interventionist when using elaborate remodeling techniques such as balloon- or stent-assisted coiling. As an added complication, as an SAH deriving from a ruptured aneurysm requires immediate treatment, it is not possible to carry out either an extensive antiplatelet regime or comprehensive testing beforehand. Although stent-assisted coiling (in our case Y-stenting or similar) or using an intraluminal device to cover the neck (e.g., pCONus, phenox) would have been feasible in this case, these require a substantial antiaggregation regimen (including Gp IIb/IIIa antagonists), which could potentially complicate further therapy such as ventricular drainage. In contrast, the WEB device (Woven Endobridge, MicroVention) is a sheer intrasaccular flow disruptor, which modifies the blood flow at the level of the aneurysm neck and induces aneurysmal thrombosis. The nitinol braided device is self-expanding, retrievable, and thermally detachable. As there is no potential thrombogenic material in the parent vessel, antithrombotic agents are not routinely required. The optimum size of the implant is determined using vertical 3DRA images. Several iterations of the WEB device have been developed over the last years. The latest update introduced smaller devices (down to 3/2 mm) and low-profile devices that are compatible with a 0.017″ ID microcatheter (for a WEB device up to 7 mm wide). To date, several studies have suggested that the WEB device is both safe and effective in treating incidental (Pierot et al. 2016) and ruptured (Liebig et al. 2015) wide-necked aneurysms. Interim adequate aneurysm occlusion rates have been reported at around 85% with perioperative morbidity rates of around 2% (Asnafi et al. 2016). Follow-up imaging after WEB implantation should be done by DSA since MRI/MRA examinations can be misleading (Nawka et al. 2018).
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