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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

  • Harald SahlEmail author
  • Hans Henkes
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Abstract

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.

Keywords

Basilar artery bifurcation aneurysm SAH pCONus2 Medina Antiaggregation 

Patient

54-year-old, female, spontaneous subarachnoid hemorrhage (SAH), Hunt and Hess III, Fisher III

Diagnostic Imaging

The patient was healthy when she presented with severe headache and confusion. Emergency CT and CTA in the hospital showed a SAH and a large wide-necked aneurysm of the basilar artery bifurcation (Fig. 1). The clinical condition on admission was Hunt and Hess III, the SAH grading was Fisher III. An external ventricular drainage was inserted. Diagnostic DSA on February 5, 2017, confirmed the basilar artery bifurcation aneurysm with a fundus diameter of 15 mm and a neck width of 9 mm (Fig. 2). The origins of both posterior cerebral arteries (PCAs) and of the left superior cerebellar artery (SCA) were incorporated in the aneurysm neck. Upon selective injection of both internal carotid arteries (ICAs) no posterior communicating arteries (PcomAs) were opacified.
Fig. 1

CT (a) and CTA (b) of a 54-year-old patient with spontaneous SAH. The basal cisterns (a) are filled with fresh clot and the lateral ventricles are enlarged. CTA (b) shows a large wide-necked aneurysm of the basilar artery bifurcation with a fundus diameter of about 15 mm

Fig. 2

Diagnostic DSA performed on February 5, 2017 lateral view (a), posterior–anterior view (b). The trunk of the basilar artery shows posthemorrhagic vasospasm. Both posterior cerebral arteries are integrated into the neck of a large aneurysm of the basilar artery bifurcation. The rupture site is on the anterior–superior aspect of the aneurysm dome

Treatment Strategy

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.

Treatment

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)

Course of treatment: Both vertebral arteries (V2 segments) were catheterized with 5F guide catheters and microcatheters (Fig. 3); DSA confirmed the previously known large aneurysm of the basilar artery bifurcation with a fundus diameter of 15 mm and a neck width of 9 mm; the daughter aneurysm as the presumed site of rupture was on the anterior-superior aspect of the aneurysm dome; the trunk of the BA showed some posthemorrhagic vasospasm; via the left vertebral artery an Excelsior XT27 catheter was inserted to the center of the aneurysm; the pCONus2, with 10 mm wingspan slightly larger than the aneurysm neck diameter, was deployed there, avoiding any contact with the daughter aneurysm; once the six petals of the pCONus2 were fully open, the device was gently pulled to a more proximal position; by opening the shaft of the pCONus2 was the device fixated with its petals at the level of the aneurysm neck; the pCONus2 remained undetached until the end of the procedure (Fig. 3b); via the right vertebral artery, a Prowler Select Plus microcatheter was introduced into the aneurysm fundus; the passage of the petals of the pCONus2 was possible without displacing them; since the diameter of the aneurysm fundus (15 mm) was larger than the available Medinas (9 mm), three framing Medinas were intermingled to create a spherical structure (Fig. 3c); the space inside and outside of this sphere was densely filled with 13 coils of appropriate size (Fig. 3d); the final DSA run showed some remaining opacification of the aneurysm dome, and both PCA origins were not compromised.
Fig. 3

Endovascular treatment of a large, ruptured basilar artery bifurcation aneurysm. An Excelsior XT27 catheter is introduced via the left vertebral artery, a Prowler select plus catheter comes from the right vertebral artery (a). A pCONus2 4/15/10 (shaft diameter/shaft length/petal diameter) is deployed at the level of the aneurysm orifice (b). Using the support of the pCONus2 petals, three Medinas (2 × 9/13, 1 × 8/10, 3 framer) were used to create a spherical structure inside the aneurysm (c). Result after the implantation of additional 13 Axium coils into the space between and around the Medinas (d). The final DSA run on February 6, 2017, shows residual opacification of the aneurysm dome (e) lateral view, which was thrombosed 2 days later (f) lateral view

Duration: 1st–33rd DSA run: 110 min; fluoroscopy time: 51 min

Complications: none

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.

Clinical Outcome

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.

Follow-up Examinations

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).

A first regular clinical and DSA follow-up examination was scheduled 3 months after the treatment (May 3, 2017), which confirmed the stable occlusion of the aneurysm (Fig. 4). The clinical condition of the patient had improved to mRS 2. The second follow-up examination (February 2, 2018) confirmed the stable aneurysm occlusion.
Fig. 4

Follow-up DSA 3 months later confirmed the stable occlusion of the aneurysm. (a) is the final DSA run on February 8, 2017, while (b) is the corresponding image from the first follow-up DSA on May 3, 2017

Discussion

The main issues of this basilar bifurcation aneurysm were the very wide neck (9 mm) and the anticipated risk of aneurysm reperfusion after coil treatment. Several technical solutions for neck bridging were considered. The result of a coil occlusion using dual catheter technique appeared difficult to predict, with a substantial risk of coil displacement. Y-stenting was dismissed since the right PCA would foreseeably have been difficult to catheterize. For the same reason both PulseRider (Mukherjee et al. 2017; Spiotta et al. 2017) and eCLIPs (Marotta et al. 2017) appeared unsuitable. Access to the left PCA and deployment of a Barrel stent (Mühl-Benninghaus et al. 2016) would have been feasible, yet the protection of the origin of the right PCA was uncertain. The advantage of a pCONus (Lubicz et al. 2016; Pérez et al. 2017; Signorelli et al. 2017) for neck coverage was the fact that the catheterization of the right PCA was not required. The pCONus1 (Ulfert et al. 2016) is a dedicated device for the assisted coil occlusion of wide necked bifurcation aneurysms. The stent consists of two major components: shaft and crown. It is attached to a 0.016″ stainless steel insertion wire, from which it can be detached by electrolysis. The embodiment of the shaft is as such that the device can be deployed and retrieved into the microcatheter. The crown consists of four petals. The nominal shaft diameter is 4 mm, the shaft length is either 20 or 25 mm. The wingspan of the petals is available from 5 mm to 15 mm (Fig. 5a). A smaller model size provides 3 mm shaft diameter and a 4 mm distal crown. The implanted pCONus2 is a derivative of the pCONus1 with a shorter shaft (15 mm), an independently articulating crown from the shaft and six instead of four distal petals. The available span of the petals goes from 5 mm to 15 mm (Fig. 5b). The pCONus2 was chosen because a more robust retention of Medinas and coils exerted by the six petals was expected. The fact that the inadvertent withdrawal of ticagrelor was tolerated without thrombus formation might be taken as a hint for a low surface thrombogenicity of the device surface.
Fig. 5

pCONus bifurcation device (phenox). pCONus1 (a) has a straight shaft and a distal crown with four petals. pCONus2 (b) comes with a shorter shaft (15 mm), an articulation between shaft and crown and six distal petals

Occlusion of the aneurysm with coils, assisted by a neck-bridging device, would have been possible. The stability of coil occlusion of large and giant basilar bifurcation aneurysms, however, is poor (Cho et al. 2017; Tsurumi et al. 2013). The WEB (Fiorella et al. 2017), a braided nitinol sphere, is available with a maximum diameter of 11 mm, which would have been far too small for this aneurysm. The Medina Embolization Device (Sourour et al. 2017) is a mechanically detachable flat nitinol mesh with an integrated platinum coil. During the insertion via a 0.021” ID microcatheter, the Medina is straightened and folded (Fig. 6a). In an unconstrained condition, the Medina forms a sphere (Fig. 6b). The intended mode of action is intrasaccular flow disruption rather than physical filling. The implant per se is significantly more rigid than a platinum coil. The resilience of Medina against compaction and deformation under the influence of continuous blood pulsation is expected but so far not well confirmed.
Fig. 6

Medina Embolization Device, MED (Medtronic). The MED is a three-dimensional complex metallic structure. The core wire is radiopaque and has an imprinted 3D shape. Flat petals, made from nitinol, surround it. The MED can be introduced through a 0.021″ ID microcatheter. It can be deployed, withdrawn, and mechanically detached from the insertion wire. In an aneurysm, MED forms a spherical structure. The device is available with a nominal diameter between 5 and 9 mm. The “framing” version is more robust and intended to form an outer shell while the softer “filler” version is used to occlude the remaining space in between

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.

Cross-References

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© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Institut für Nuklearmedizin und RadiologieKlinikum BraunschweigBraunschweigGermany
  2. 2.Neuroradiologische Klinik, NeurozentrumKlinikum StuttgartStuttgartGermany

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