Basilar Artery Bifurcation Aneurysm: Acute SAH, Ruptured Wide Neck Basilar Bifurcation Aneurysm, Medina and Coil Occlusion Assisted by pCONus2, Early Interruption of Antiaggregation Without Sequelae
- 93 Downloads
A large, wide necked ruptured aneurysm of the basilar artery bifurcation was treated by endovascular Medina- (Medtronic) and coil occlusion assisted by pCONus2 (phenox). This combination of implants allowed the interruption of the blood circulation inside the aneurysm despite a neck width of 9 mm. The procedure has been carried out under dual antiaggregation with acetylsalicylic acid (ASA; Aspirin i.v., Bayer Vital) and ticagrelor (Brilique, AstraZeneca). Immediately after the treatment, a minor perfusion of the aneurysm dome was still visible, which had ceased 3 days later. The administration of ticagrelor had been inadvertently stopped 1 month after the treatment, while the administration of 100 mg ASA PO daily was continued. A thromboembolic complication did not occur. The patient, whose clinical condition was initially Hunt and Hess III, recovered significantly within 2 months in the hospital and having 2 months of rehabilitation. Angiographic follow-up 3 and 12 months after the treatment confirmed a stable obliteration of the aneurysm. The use of pCONus2 and Medina is the main topic of this report.
KeywordsBasilar artery bifurcation aneurysm SAH pCONus2 Medina Antiaggregation
54-year-old, female, spontaneous subarachnoid hemorrhage (SAH), Hunt and Hess III, Fisher III
The primary goals of the treatment were the prevention of a recurrent SAH and of further aneurysm growth. Neither the location nor the size of the aneurysm made it suitable for microsurgical clipping. The very wide aneurysm neck with a diameter of 9 mm prevented straight coil occlusion. A crossing stent strategy was not appealing since significant difficulty of the catheterization of the right PCA was anticipated. Using detachable coils for aneurysm occlusion, the only choice for many years, would have resulted in a foreseeable coil compaction and retreatment procedures. We were therefore looking for a more stable intrasaccular implant with a hemodynamic effect and resilience to compaction or deformation.
Procedure, 06.02.2017: pCONus2 assisted Medina- and coil occlusion of a ruptured basilar artery bifurcation aneurysm
Anesthesia: general anesthesia; 3000 IU unfractionated heparin (Heparin-Natrium, B. Braun) IV
Premedication: 1× 500 mg ASA (Aspirin i.v., Bayer Vital) IV, 1× 180 mg ticagrelor (Brilique, AstraZeneca) PO via a nasogastric tube, given 4 h prior to the start of the endovascular procedure
Access: Both femoral arteries, 2× 5F sheaths (Terumo); guide catheter: 2× 5F Envoy MPD (Codman); microcatheters: 1× Excelsior XT27 (Stryker) for pCONus2 (phenox), 1× Prowler select plus 45° (Codman) for Medinas (Medtronic), 1× Echelon10 45° (Medtronic) for coils; microguidewires: 2× pORTAL 0.014″ (phenox)
Implants: 1× pCONus2 4/15/10 (4 mm shaft diameter, 15 mm shaft length, 10 mm crown diameter, wingspan of the six petals); 3× Medina (2× 9/13 framer, 1× 8/10 framer); 13 coils (Axium (Medtronic), 7/20, 10/30, 9/30, 8/20, 5/20, 5/20, 5/15, 3/8, 3/8, 2/8, 2/8, 2/6, 2/6)
Duration: 1st–33rd DSA run: 110 min; fluoroscopy time: 51 min
Postmedication: intended was 1× 100 mg ASA PO daily lifelong, 2× 90 mg ticagrelor PO daily for 3 months; while the administration of ASA was continued as proposed, the administration of ticagrelor was stopped 1 month after the endovascular procedure.
The patient recovered during the following weeks, the external ventricular drainage was replaced by a permanent shunt on March 27, 2017, and transfer for rehabilitation was on April 18, 2017.
An early follow-up DSA was performed 2 days after the treatment (February 8, 2017), when posthemorrhagic vasospasm in the anterior circulation was treated successfully. The aneurysm fundus and dome were meanwhile completely occluded. The residual perfusion of the aneurysm dome, which was visible at the end of the endovascular procedure, had ceased (Fig. 3f).
The clinical experience with Medina is currently limited. The device is frequently not suitable for an aneurysm occlusion as a sole implant (Bhogal et al. 2017). Together with coils and/or extrasaccular flow diverters, good results have been published (Aguilar Perez et al. 2017). Anecdotal reports mentioned a more stable occlusion achieved by Medina than by detachable coils. In the case presented here, the combination of pCONus2, Medina, and coils allowed a sufficient and so far stable aneurysm occlusion, despite unfavorable anatomical conditions.
- Bhogal P, Brouwer PA, Yeo L, Svensson M, Söderman M. The Medina Embolic Device: Karolinska experience. Interv Neuroradiol. 2017; https://doi.org/10.1177/1591019917733125.
- Cho YD, Jeon JP, Yoo DH, Cho WS, Kang HS, Kim JE, Han MH. Growth-related major recanalization of coiled aneurysms: incidence and risk factors. Neurosurgery. 2017. https://doi.org/10.1093/neuros/nyx176.
- Fiorella D, Molyneux A, Coon A, Szikora I, Saatci I, Baltacioglu F, Sultan A, Arthur A, WEB-IT Study Investigators. Demographic, procedural and 30-day safety results from the WEB intra-saccular therapy study (WEB-IT). J Neurointerv Surg. 2017;pii: neurintsurg-2016-012841. https://doi.org/10.1136/neurintsurg-2016-012841.
- Marotta TR, Riina HA, McDougall I, Ricci DR, Killer-Oberpfalzer M. Physiological remodeling of bifurcation aneurysms: preclinical results of the eCLIPs device. J Neurosurg. 2017;1–7. https://doi.org/10.3171/2016.10.JNS162024.
- Mühl-Benninghaus R, Simgen A, Reith W, Yilmaz U. The Barrel stent: new treatment option for stent-assisted coiling of wide-necked bifurcation aneurysms-results of a single-center study. J Neurointerv Surg. 2016;pii: neurintsurg-2016-012718. https://doi.org/10.1136/neurintsurg-2016-012718.
- Mukherjee S, Chandran A, Gopinathan A, Putharan M, Goddard T, Eldridge PR, Patankar T, Nahser HC. PulseRider-assisted treatment of wide-necked intracranial bifurcation aneurysms: safety and feasibility study. J Neurosurg. 2017;127(1):61–8. https://doi.org/10.3171/2016.2.JNS152334.CrossRefPubMedGoogle Scholar
- Signorelli F, Sturiale CL, La Rocca G, Albanese A, D’Argento F, Mattogno P, Puca A, Visocchi M, Marchese E, Pedicelli A. Giant basilar artery aneurysm involving the origin of bilateral posterior cerebral and superior cerebellar arteries: neck reconstruction with pCONus-assisted coiling. Acta Neurochir Suppl. 2017;124:129–34. https://doi.org/10.1007/978-3-319-39546-3_20.CrossRefPubMedGoogle Scholar
- Sourour NA, Vande Perre S, Maria FD, Papagiannaki C, Gabrieli J, Pistocchi S, Bartolini B, Degos V, Carpentier A, Chiras J, Clarençon F. Medina® embolization device for the treatment of intracranial aneurysms: safety and angiographic effectiveness at 6 months. Neurosurgery. 2017. https://doi.org/10.1093/neuros/nyx161.
- Spiotta AM, Derdeyn CP, Tateshima S, Mocco J, Crowley RW, Liu KC, Jensen L, Ebersole K, Reeves A, Lopes DK, Hanel RA, Sauvageau E, Duckwiler G, Siddiqui A, Levy E, Puri A, Pride L, Novakovic R, Chaudry MI, Turner RD, Turk AS. Results of the ANSWER trial using the PulseRider for the treatment of broad-necked, bifurcation aneurysms. Neurosurgery. 2017;81(1):56–65. https://doi.org/10.1093/neuros/nyx085.CrossRefPubMedGoogle Scholar
- Ulfert C, Pfaff J, Schönenberger S, Bösel J, Herweh C, Pham M, Bendszus M, Möhlenbruch M. The pCONus device in treatment of wide-necked aneurysms: technical and midterm clinical and angiographic results. Clin Neuroradiol. 2016;1–8. https://doi.org/10.1007/s00062-016-0542-z