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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

  • Marta Aguilar Pérez
  • Muhammad AlMatter
  • Hans HenkesEmail author
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Abstract

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.

Keywords

Basilar artery bifurcation Stent-assisted coil occlusion Crossing pCONus1 bifurcation stents Crossing Solitaire stents 

Patient

A 25-year-old male patient presented with chronic headache of 9 months duration. His medical history was unremarkable apart from arterial hypertension.

Diagnostic Imaging

Non-contrast CT (NCCT) of the head revealed a giant aneurysm between the cerebral peduncles with a calcified aneurysm wall. T2WI MRI demonstrated a partial thrombosis of the aneurysm sac and the compression of the adjacent pons and mesencephalon. Diagnostic DSA showed the integration of the origins of both superior cerebellar arteries (SCA) and posterior cerebral arteries (PCA) into the enlarged, dilated basilar artery bifurcation. There was no defined aneurysm neck. On T2WI MRI the largest diameter of the aneurysm sac including the intrasaccular thrombus was 27 mm. The aneurysm sac was surrounded by minor edema of the adjacent brainstem. The largest diameter of the perfused part of the aneurysm sac on DSA was 23 mm. Injection of both internal carotid arteries (ICA) showed only minimal supply of the posterior circulation through the posterior communicating arteries (PcomA) (Fig. 1).
Fig. 1

Diagnostic imaging in a young man with a giant, unruptured aneurysm of the basilar artery bifurcation. On NCCT the aneurysm sac is hyperdense with a calcification of the aneurysm wall (a). T2WI MRI confirms the intrasaccular thrombus and the compression of the pons and mesencephalon adjacent to the aneurysm sac (b, c). On 2D DSA the intrasaccular thrombus is causing the irregular contour of the aneurysm sac (d, e). The rotational DSA with 3D reconstruction shows the integration of the origins of both SCAs and PCAs into the enlarged and dilated basilar artery bifurcation (f). Injection of both ICAs demonstrated only small caliber PcomAs bilaterally (g, h)

Treatment Strategy

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.

Treatment

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)

Course of treatment: Access to the aneurysm was gained via both vertebral arteries (VA). The direct catheterization of the PCAs was attempted with a combination of an Echelon10 90° microcatheter and a Traxcess14 microguidewire but proved impossible. In order not to mobilize thrombus from the aneurysm to the dependent vasculature, catheterization of the PCAs through the aneurysm sac was avoided. Trispan (Target Therapeutics) was no longer available at this time, and the largest size of the pCONus1 as a neck-bridging device was only 15 mm. We therefore deployed two pCONus1 devices in a crossing mode, creating a wire mesh from the device petals at the entrance level of the aneurysm sac. In order to stabilize this construct, both pCONus1 remained undetached until the end of the procedure. Once both pCONus1 were in place, the aneurysm sac beyond the wire mesh was catheterized with an Echelon10 microcatheter. During the insertion of 15 Deltamaxx-18 Cerecyte coils, the coil retention afforded by the two pCONus1 devices was sufficient to protect the basilar artery bifurcation from inadvertent occlusion. The procedure was completed as intended (Fig. 2)
Fig. 2

First endovascular treatment session of a giant, wide-necked aneurysm of the basilar artery bifurcation. Injection of the left VA shows the aneurysm as it was already known from the previous diagnostic angiography (posterior-anterior view (a), lateral view (b)). Since the attempted direct access to the PCAs had failed, two pCONus1 devices, each with 15 mm petal wingspan, were deployed in a Y-crossing fashion with their distal ends at the entrance level of the aneurysm sac (c). The subsequent coil occlusion (d) was possible without further difficulties. The coil retention inside the aneurysm by the crossing pCONus1 devices was sufficient to protect the SCA and PCA origins (e, f)

Duration: 1st–12th DSA run: 150 min; fluoroscopy time: 53 min

Complications: none

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.

Clinical Outcome

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.

Follow-Up Examinations

MRI on days 2, 6, and 12 after the above-described procedure showed small foci of diffusion restriction in both cerebellar hemispheres without clinical relevance. There was no increase of the perianeurysmal edema, and contrast-enhanced MPRAGE MRI demonstrated the residual aneurysm perfusion adjacent to the basilar artery bifurcation. DSA follow-up 2 months and 8 months after the first treatment demonstrated coil compaction and an increase of the residual aneurysm perfusion, which did not, however, justify retreatment at this time. Another 2 months later, 10 months after the first treatment session, MRI showed a significant reperfusion of the aneurysm sac due to coil compaction with contrast enhancement of the aneurysm wall and increasing perianeurysmal edema causing neurological symptoms (Fig. 3).
Fig. 3

Follow-up imaging after the first endovascular treatment session of a giant, wide-necked aneurysm of the basilar artery bifurcation using two crossing pCONus1 bifurcation devices and Cerecyte coils. T2WI MRI (a, c) and contrast-enhanced MPRAGE MRI (b) acquired during the first week after the initial treatment show the unchanged perianeurysmal edema and the residual perfusion of the aneurysm. Follow-up DSA 2 months later reveals a minor coil compaction (d, e, f). The next examination 8 months after the treatment showed a further, but still not critical, reperfusion of the aneurysm on MRI (T2WI (g)) and DSA (lateral view (h), left anterior oblique view (i), right anterior oblique view (j)). Another 2 months later, and 10 months after the first treatment, MRI revealed an increasing perianeurysmal edema with massive contrast enhancement of the aneurysm wall (FLAIR (k), T2WI (l), contrast-enhanced MPRAGE (m)). The required retreatment was scheduled 3 weeks later following the preferences of the patient. At this time, 11 months after the initial treatment, the perianeurysmal edema and the contrast enhancement of the aneurysm wall had further increased (FLAIR (n), T2WI (o)) contrast-enhanced MPRAGE (p). DSA confirmed a significant increase of the aneurysm reperfusion (q)

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.

Treatment

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)

Course of treatment: Access to the aneurysm was achieved via the right VA. The direct catheterization of the left PCA, which was not possible during the first treatment session, was now facilitated by the pCONus1 devices and coils inside the aneurysm. Once the left PCA was catheterized, a Solitaire stent was deployed from there to the distal segment of the basilar artery trunk. The subsequent catheterization of the right PCA with the Synchro2 microguidewire was possible; the attempt to insert the Prowler Select Plus microcatheter, however, failed. The second treatment session was terminated at this point with the intention to undertake another attempt heading for the right PCA shortly (Fig. 4)
Fig. 4

Second treatment session for the coil occlusion of a giant, wide-necked basilar artery bifurcation aneurysm. Eleven months after the first treatment, significant coil compaction and aneurysm reperfusion had occurred. Due to the incorporation of both SCAs and PCAs into the aneurysm neck, a complete coil occlusion would have required a prior protection of said arteries. During the second treatment session, the way from the basilar artery bifurcation to the left PCA was visualized angiographically (right anterior oblique view (a, b, c)). This allowed the catheterization of the left PCA with subsequent deployment of a Solitaire stent. The right PCA was thereafter catheterized with a microguidewire (left anterior oblique view (d)). The attempted insertion of the microcatheter, however, failed

Duration: 1st–8th DSA run: 31 min; fluoroscopy time: 17 min

Complications: none

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

Clinical Outcome

The pre-existing neurological deficit of the patient remained unchanged after the stent implantation. He was discharged home 3 days after the treatment.

Follow-Up Examinations

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.

Treatment

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)

Course of treatment: Again access to the aneurysm was achieved via the right VA. The direct catheterization of the right PCA, which was not possible during the first and second treatment session, was now accomplished without difficulty. Once the right PCA was catheterized, a Solitaire stent was deployed from there to the distal segment of the basilar artery trunk. The catheterization of the perfused segment of the basilar bifurcation artery through the four stent shafts was well controlled. The still-perfused compartment of the aneurysm was occluded with the 33 above-listed coils. The coil retention exerted by the two crossing pCONus1 and by the two crossing Solitaire stents allowed for a dense packing of the coils without compromise of the basilar artery bifurcation (Fig. 5)
Fig. 5

The third treatment session, aiming at complete stent-assisted coil occlusion of a wide-necked giant basilar bifurcation aneurysm. The injection of the right VA confirms the patency of the left PCA 3 weeks after the implantation of a Solitaire stent (lateral view (a)). Then the right PCA was catheterized, and another Solitaire stent was implanted (left anterior oblique views (b), a Synchro2 microguidewire inside the right PCA (c), after stent deployment (d) and after coil occlusion (e); lateral view after stent and coil insertion (f))

Duration: 1st–13th DSA run: 180 min; fluoroscopy time: 73 min

Complications: none

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

Clinical Outcome

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).

Follow-Up Examinations

MRI 2 days after the third treatment session demonstrated several foci of diffusion restriction in both cerebellar hemispheres without clinical relevance. MRI and DSA follow-up 5 weeks later showed persistent perianeurysmal edema, contrast enhancement of the aneurysm wall, and residual perfusion of the anterior aspect of the aneurysm (Fig. 6).
Fig. 6

MRI and DSA follow-up 5 weeks after the third treatment session, with the intention of stent-assisted coil occlusion of a giant, wide-necked basilar bifurcation aneurysm. T2WI MRI shows persistent perianeurysmal edema (a). Contrast-enhanced MPRAGE (b) demonstrate the residual perfusion of the anterior aspect of the aneurysm, which is equally shown by DSA (lateral view (c))

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.

Treatment

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)

Course of treatment: Access to the aneurysm was achieved via the left VA. The still-perfused compartment on the anterior aspect of the aneurysm was catheterized and occluded with 10 coils. The coil retention by the crossing stents allowed very dense coil packing (Fig. 7)
Fig. 7

The fourth treatment session, still aiming at complete coil occlusion of a giant, wide-necked aneurysm of the basilar artery bifurcation. The perfused compartment on the anterior aspect of the aneurysm (arrow) was catheterized and occluded with 10 coils (lateral views prior (a) and after (b) coil insertion)

Duration: 1st–10th DSA run: 82 min; fluoroscopy time: 19 min

Complications: none

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

Clinical Outcome

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.

Follow-Up Examinations

The follow-up imaging protocol included MRI (Fig. 8) and DSA (Fig. 9) examinations. Both modalities confirmed the stable occlusion of the aneurysm after four treatment sessions performed between June 2013 and July 2014.
Fig. 8

MRI follow-up after the stent-assisted coil occlusion of a giant, wide-necked aneurysm of the basilar artery bifurcation. On the day following the treatment session #4, there is still edema adjacent to the aneurysm sac and contrast enhancement of the aneurysm wall but no more perfusion of the aneurysm visible (T2WI (a), contrast-enhanced MPRAGE (b)). Eight months later, in March 2015, less contrast enhancement of the vessel wall but reperfusion at the anterior aspect of the aneurysm is visible (T2WI (c), contrast-enhanced MPRAGE (d)). The MRI examination 13 months later, in April 2017, shows that the reperfusion of the aneurysm is not progressing and the aneurysm wall is no longer contrast enhancing (T2WI (e), contrast-enhanced MPRAGE (f))

Fig. 9

The so far last treatment session #4 had been performed in July 2014. DSA follow-up examinations in March 2015 (lateral view (a), left anterior oblique view (b), right anterior oblique view (c)), in February 2016 (lateral view (d), left anterior oblique view (e), right anterior oblique view (f)), and in April 2017 (lateral view (g), left anterior oblique view (h), right anterior oblique view (i)) confirmed the complete occlusion of the aneurysm

Discussion

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.

Cross-References

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Marta Aguilar Pérez
    • 1
  • Muhammad AlMatter
    • 1
  • Hans Henkes
    • 1
    Email author
  1. 1.Neuroradiologische KlinikNeurozentrum, Klinikum StuttgartStuttgartGermany

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