Basilar Artery Bifurcation Aneurysm: Giant Incidental Basilar Artery Bifurcation Aneurysm, Treated by Stent-Assisted Coil Occlusion Using Two Crossing pCONus1 Aneurysm Bridging Devices and Two Crossing Solitaire Stents Deployed in Telescoping Fashion; Four Treatment Sessions, Resulting in Permanent Aneurysm Occlusion and Good Clinical Outcome
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A 25-year-old man presented with a 9-month history of headaches. CT and MRI/MRA revealed a giant, partially thrombosed aneurysm of the basilar artery bifurcation. The origins of both posterior cerebral arteries (PCA) and both superior cerebellar arteries (SCA) arose from the aneurysm sac, which developed from a diffuse enlargement of the basilar artery bifurcation and extended posteriorly. The attempt to catheterize the PCAs for a Y-stenting procedure failed. Access to the PCAs was not possible without crossing the aneurysm sac, which might have mobilized thrombus material from there downstream. In the first treatment session, two pCONus1 devices were implanted into the aneurysm sac in a crossing fashion. The stent petals defined a boundary between the aneurysm sac and the basilar artery bifurcation for the subsequent coil occlusion. Coil compaction required two additional treatment sessions. During the second procedure, the catheterization of the left PCA succeeded, and a Solitaire stent was deployed from there to the distal segment of the basilar artery trunk. The attempted access to the right PCA failed on the same day but was possible in the following third treatment session, which allowed the deployment of a second, crossing Solitaire stent from the right PCA to the trunk of the basilar artery. The reconstruction of the basilar artery bifurcation with two crossing pCONus1 devices and two crossing Solitaire stents allowed the complete and stable coil occlusion of the aneurysm sac. The entire aneurysm treatment was tolerated without a permanent neurological deficit. The combined use of multiple extra- and intrasaccular implants for the treatment of complex aneurysms is the main topic of this chapter.
KeywordsBasilar artery bifurcation Stent-assisted coil occlusion Crossing pCONus1 bifurcation stents Crossing Solitaire stents
A 25-year-old male patient presented with chronic headache of 9 months duration. His medical history was unremarkable apart from arterial hypertension.
The goal of the endovascular treatment was to prevent a future subarachnoid hemorrhage due to the rupture of the basilar artery bifurcation aneurysm and to avoid further aneurysm growth. Microsurgical clipping of the aneurysm sac was not considered to be a viable option. Since an increase in the space-occupying effect of the aneurysm sac after the endovascular treatment and a need for dual antiplatelet medication appeared possible, an external ventricular drain was inserted on the day prior to the first endovascular treatment session and was removed 4 days later. The concept of the endovascular treatment included a reconstruction of the basilar artery bifurcation with a protection of the origins of both PCAs and SCAs and a permanent and complete interruption of the blood circulation within the aneurysm sac. A certain technical challenge was anticipated, but stent-assisted coil occlusion was the ultimate goal.
Procedure #1, 05.06.2013: stent-assisted coil occlusion of an unruptured giant basilar artery bifurcation aneurysm using two crossing pCONus1 bifurcation stents
Anesthesia: general anesthesia; 1× 5000 IU unfractionated heparin (Heparin Natrium, B. Braun) IV, 2× 1 mg glyceryl trinitrate (Nitrolingual infus., Pohl Boskamp) IA, 1× 1000 mg thiopental (Trapanal, Nycomed) IV, 2× 40 mg dexamethasone (Fortecortin, Merck Serono) IV, 1× 1500 mg cefuroxime (Cefuroxim-ratiopharm 1500 mg p.i., ratiopharm) IV
Premedication: 1× 500 mg ASA (Aspirin i.v. 500 mg, Bayer Vital) IV and 1× 180 mg ticagrelor (Brilique, AstraZeneca) in the morning 6 h prior to the procedure; Multiplate test (Roche Diagnostic) confirmed the dual platelet function inhibition
Access: both femoral arteries, 2× 6F sheaths (Terumo), closure of the puncture sites with Angio-Seal (Terumo); guide catheters: 2× 6F Envoy XB (Codman Neurovascular); microcatheters: 2× Prowler Select Plus 90° (Cerenovus) (for 2× pCONus1), 1× Echelon10 90° (Medtronic) (for coils); microguidewire: Traxcess 0.014″ (MicroVention)
Implants: 2 bifurcation stents, 2× pCONus1 4/25/15 mm (phenox); 15 coils, Deltamaxx-18 Cerecyte, 1× 18/55, 4× 24/60, 4× 22/60, 1× 20/60, 1× 12/42, 3× 7/33, 1× 6/25 (Codman Neurovascular)
Duration: 1st–12th DSA run: 150 min; fluoroscopy time: 53 min
Post-medication: 1× 100 mg ASA PO daily for life, 2× 90 mg ticagrelor PO daily for life, 2× 3000 IU certoparin (Mono-Embolex, Aspen) SC daily for 1 week, 3× 4 mg dexamethasone PO for 4 weeks followed by tapering the dosage, 2× 150 mg ranitidine (Ranitidin, 1A Pharma) for 6 weeks. Multiplate tests after the first treatment confirmed dual platelet function inhibition. Two months later, the patient complained of dyspnea, which was most likely related to the intake of ticagrelor and which ceased after the medication was changed (with an overlap of 3 days) to 1× 75 mg clopidogrel PO daily.
The endovascular procedure was well tolerated and the patient did not show any neurological deficit. The external ventricular drain was removed 3 days later. The patient was discharged home 7 days after the treatment. Ten months after the first treatment, the patient presented with progressive severe dysarthria, nausea, dysmetria, and ataxia.
The now rapidly progressive recanalization of the partially coiled aneurysm was not unexpected and prompted the second treatment session 11 months after the first procedure.
Procedure #2, 02.05.2014: stent implantation from the left PCA to the basilar artery trunk as a preparation for further coil treatment of an already partially coiled and now significantly reperfused giant, wide-necked aneurysm of the basilar artery bifurcation
Anesthesia: general anesthesia; 1× 5000 IU unfractionated heparin IV, 1× 500 mg ASA IV
Premedication: 1× 100 mg ASA PO daily and 1× 75 mg clopidogrel (Plavix, Sanofi-Aventis) PO daily as an ongoing medication; Multiplate test confirmed the dual platelet function inhibition
Access: right femoral artery, 1× 6F sheath (Terumo), closure of the puncture site with Exoseal (Cordis); guide catheter: 1× 6F Envoy MPC (Codman Neurovascular); microcatheter: 1× Prowler Select Plus J; microguidewire: Synchro2 0.014″ 200 cm (Stryker)
Implant: 1 stent: 1× Solitaire AB 3/30 (Medtronic)
Duration: 1st–8th DSA run: 31 min; fluoroscopy time: 17 min
Post-medication: 1× 100 mg ASA PO daily for life, 1× 75 mg clopidogrel PO daily for life; Multiplate tests after the second treatment confirmed dual platelet function inhibition
The pre-existing neurological deficit of the patient remained unchanged after the stent implantation. He was discharged home 3 days after the treatment.
MRI after the second treatment session showed neither ischemic nor hemorrhagic complications.The next treatment session, with the intention of complete aneurysm occlusion, was scheduled 3 weeks later.
Procedure #3, 22.05.2014: stent implantation from the right PCA to the basilar artery trunk, crossing three stent shafts, as a preparation for complete coil occlusion of an already partially coiled and now significantly reperfused giant, wide-necked aneurysm of the basilar artery bifurcation
Anesthesia: general anesthesia; 1× 3000 IU unfractionated heparin IV, 1× 500 mg ASA IV, 2× 1 mg glyceroltrinitrate IA, 1× 1000 mg thiopental IV, 1× 40 mg dexamethasone IV
Premedication: 1× 100 mg ASA PO daily and 1× 75 mg clopidogrel PO daily as an ongoing medication; Multiplate test confirmed the dual platelet function inhibition
Access: right femoral artery, 1× 6F sheath (Terumo), closure of the puncture site with Exoseal; guide catheter: 1× 6F Guider Softip (Boston Scientific); microcatheters: 1× Prowler Select Plus J (for the stent), Excelsior SL10 (Stryker) (for coiling); microguidewire: Synchro2 0.014″ 200 cm (Stryker).
Implant: 1 stent: 1× Solitaire AB 3/30; 33 coils, 3× MicroPlex10 6/8, 12× HydroCoil10 4/10, 2× HydroCoil10 5/15, MicroPlex10 1× 4/8, 2× 5/8, 2× 5/6, 3× 3/6, 5× 4/4, 1× 3/8, 2× 2/6 (all MicroVention)
Duration: 1st–13th DSA run: 180 min; fluoroscopy time: 73 min
Post-medication: 1× 100 mg ASA PO daily for life, 1× 75 mg clopidogrel PO daily for life; Multiplate tests before and after the third treatment confirmed dual platelet function inhibition
The pre-existing neurological deficit of the patient was unchanged immediately after the stent-assisted coil occlusion. He was discharged home 4 days after the treatment. During follow-up visits in 2015 through 2017, the pre-existing neurological symptoms had completely resolved (mRS 0).
Since further growth of the aneurysm with increasing mass effect was expected unless complete occlusion could be achieved, another treatment session was proposed and accepted by the patient.
Procedure #4, 10.07.2014: completing of the stent-assisted coil occlusion of an already partially coiled giant, wide-necked aneurysm of the basilar artery bifurcation
Anesthesia: general anesthesia; 1× 3000 IU unfractionated heparin IV, 1× 1 mg glyceryl trinitrate IA.
Premedication: 1× 100 mg ASA PO daily and 1× 75 mg clopidogrel PO daily as an ongoing medication; Multiplate test confirmed the dual platelet function inhibition
Access: right femoral artery, 1× 6F sheath (Terumo), closure of the puncture site with Exoseal; guide catheter: 1× 6F Heartrail II (Terumo); microcatheter: Excelsior SL10 45° (Stryker), Echelon 10 90° (Medtronic); microguidewire: Synchro2 0.014″ 200 cm (Stryker)
Implant: 10 coils: HydroCoil10 2× 5/15, MicroPlex10 2× 4/8, 2× 3/8, 2× 3/6, 2× 2/6 (MicroVention)
Duration: 1st–10th DSA run: 82 min; fluoroscopy time: 19 min
Post-medication: 1× 100 mg ASA PO daily for life, 1× 75 mg clopidogrel PO daily for life; Multiplate tests before and after the fourth treatment confirmed dual platelet function inhibition
The entire management of this giant, complex aneurysm was accomplished without a permanent neurological deficit. In September 2018, more than 5 years after the first treatment, the patient is asymptomatic and able to work.
The endovascular treatment of large and giant intracranial aneurysms involving the origin of efferent arteries can present a technical dilemma. Incomplete occlusion with the risk of further growth and (recurrent) hemorrhage stands against the inadvertent occlusion of efferent arteries, causing an ischemic stroke. The ideal solution would be a hemodynamically active implant in the branching parent (e.g., a bifurcation flow diverter) (Peach et al. 2014), which was not available in 2013 and is still expected in 2018. Therefore other solutions are required and all of them are off the beaten track.
The Solitaire stent was the first device for stent-assisted coiling that could be withdrawn after complete deployment (Liebig et al. 2006). Several authors published their results with this stent using “conventional” techniques (Clajus et al. 2013; Gory et al. 2013, 2014; Huded et al. 2014; Jeong and Seung 2015; Klisch et al. 2009, 2010; Lee et al. 2013; Li et al. 2015, 2016; Lubicz et al. 2010; Zhang et al. 2015). As an alternative, the Solitaire stent can also be used for Y-stenting (Martínez-Galdámez et al. 2012; Nas et al. 2015a; Sarabia and Arrese 2012) and for the so-called “waffle-cone” technique (Guo et al. 2014; Nas et al. 2015b; Park et al. 2012; Rahal et al. 2014). The waffle-cone mode (i.e., the distal end of the stent is placed inside the aneurysm sac) is an option, if microcatheter access to the efferent artery or arteries is either dangerous or simply not possible. The main drawback of Solitaire, if used this way, is the straight distal end of the stent, which does not open beyond the stent shaft diameter once deployed in the aneurysm. The pCONus is also meant to be used in the “waffle-cone” mode. The distal petals, however, open up and allow for improved coil retention inside the aneurysm. The main advantage of the pCONus is the use without a need to catheterize the efferent arteries of a wide-necked aneurysm. Data on pCONus-assisted coiling was published by several authors, using this device for both unruptured (Aguilar-Pérez et al. 2014; Fischer et al. 2016; Gory et al. 2015, 2017; Lubicz et al. 2016; Ulfert et al. 2018) and ruptured (Pérez et al. 2017) aneurysms. The pCONus is well-suited to the assisted coiling of wide-necked aneurysms. A reconstruction of the vessel bifurcation, however, is beyond the purpose of this device. Two pCONus1 have been deployed in a crossing mode for the assisted coiling of two neighboring aneurysms (Mpotsaris et al. 2014). The combination of a pCONus and a Solitaire turned out to be useful for the protection of an efferent vessel originating from the sac of a wide-necked aneurysm (Bhogal et al. 2017). In the case presented here, the initially attempted Y-stenting failed because the microcatheter deviated into the giant aneurysm lumen rather than following the tortuous course of the PCAs. The crossing deployment of two pCONus1 devices allowed for the initial occlusion of the aneurysm sac. The coil retention required to reconstruct the basilar artery bifurcation, however, was only obtainable through Y-stenting, which again was only possible after the aneurysm sac had been occluded with coils.
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