Combined endovascular stent implantation and coil embolization for the treatment of a vertebro-basilar fusiform aneurysm: technical case report

We describe a case of the combined application of endovascular stent implantation and Guglielmi detachable coil packing for the treatment of a vertebro-basilar fusiform aneurysm and review the literature on stent placement to treat cerebral aneurysms. A 70-year-old female presented with an acute headache from subarachnoid hemorrhage. A fusiform aneurysm with a broad-based neck and dome, measuring 15 mm, involving the union of the vertebral arteries and the proximal basilar artery was demonstrated on cerebral angiography. The aneurysm was judged to be inoperable and treated conservatively. Twelve days later the patient was transferred to our hospital for endovascular therapy. An intravascular stent (MultiLink) was placed across the base of the aneurysm through the right vertebral artery. After this, coil placement in the aneurysm around the stent was performed via a microcatheter guided from the left vertebral artery. After that a microcatheter was guided from the right vertebral artery through the interstices of the stent into the aneurysm, and additional coils were placed. Final angiography showed subtotal occlusion of the aneurysm and excellent blood flow of the parent artery through the stent. There were no new neurological deficits. Neither rerupture nor ischemic event has occurred. The use of stents provides another treatment for managing the difficult entity of intracranial aneurysms.     

Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with Guglielmi detachable coils

BACKGROUND: Fenestration of vertebrobasilar junction is a rare congenital anomaly and often associated with aneurysm formation. We describe five cases of vertebrobasilar junction aneurysms in four patients associated with fenestration, which were treated with endovascular coil occlusion using Guglielmi detachable coils (GDCs). The importance of preoperative computed tomography (CT) angiography to understand the complex anatomy of fenestration and aneurysm is emphasized. CASE REPORTS: Three patients presented with subarachnoid hemorrhage and one patient presented with headache only. Among 3 patients with subarachnoid hemorrhage, 1 patient was referred for endovascular coil occlusion after clipping of ruptured distal ACA aneurysm. A six-French guiding catheter was placed in the left vertebral artery via right femoral artery, except for 1 patient who had two vertebrobasilar junction aneurysms with complex anatomic relationship, accessed bilaterally. Five vertebrobasilar junction aneurysms with fenestration were treated with endovascular coil occlusion using GDCs. Postoperative angiography demonstrated successful occlusion of aneurysmal sac with preservation of basilar artery. CONCLUSIONS: Vertebrobasilar junction aneurysms are frequently associated with fenestrations. In addition to vertebral angiography on both sides, CT angiography may be a valuable tool for better understanding of complex anatomy of aneurysms associated with fenestration. The surgically difficult aneurysms such as vertebrobasilar junction aneurysm with fenestration can be successfully treated with GDCs.     

Embolization for aneurismal dilatation associated with ruptured dissecting anterior inferior cerebellar artery aneurysm with preservation of the parent artery: case report

We report a rare case of a ruptured dissecting anterior inferior cerebellar artery (AICA) aneurysm treated by endosaccular embolization with a Guglielmi detachable coil (GDC). An 85-year-old female presented with headache. Computed tomographic (CT) scan showed subarachnoid hemorrhage and intraventricular hemorrhage in the fourth ventricule. Cerebral angiography and 3D-CT angiography revealed an aneurysmal dilatation at the anterior pontine segment of the right AICA with a diagnosis of arterial dissection. The right posterior inferior cerebellar artery (PICA) was absent and the right AICA supplied the territory normally nourished by the right PICA. The aneurismal dilatation was occluded by endosacullar embolization with preservation of the AICA. The distal AICA aneurysm is rare and only seven cases treated with endovascular embolization have been reported. In these, six cases were treated by parent artery occlusion with coil and the subsequent three cases presented with ischemic complications. Only one case was treated by endosaccular embolization with GDC. To our knowledge, this is the second report of the distal AICA aneurysm treated by endosaccular embolization with GDC. Distal AICA aneurysms are briefly discussed while reviewing the literature.     

Unusual cisternal coil migration in the follow-up period after aneurysm perforation during endovascular coiling

A 61-year-old woman suffered cisternal coil migration in the follow-up period after endovascular coil embolization for a ruptured cerebral aneurysm. She presented with sudden onset of headache. Computed tomography demonstrated diffuse subarachnoid hemorrhage, and cerebral angiography disclosed a left anterior choroidal artery aneurysm. The aneurysm was treated by endovascular embolization with Guglielmi detachable coils. During the embolization procedure, the microcatheter perforated the aneurysm. For direct closure of the perforation site with coils, the microcatheter was withdrawn and coils were deployed partially in the subarachnoid space and partially in the aneurysm sac. The coil mass was spread in the subarachnoid space around the aneurysm immediately after embolization. The patient was discharged with no neurological deficit. Three months later, follow-up radiography demonstrated obvious reduction in the size and compaction of the coil mass. Magnetic resonance angiography and digital subtraction angiography demonstrated stable occlusion of the aneurysm. The coil mass probably spread in the cistern around the aneurysm and was compacted by the shape memory of the coils and pulsation of the brain and vessels, as the subarachnoid clots around the aneurysm had disappeared. This case suggests that cisternal coil migration should be considered in the follow up of intracranial aneurysm treated with detachable coils.     

Transluminal stent-assisted coil embolization of a vertebral confluence aneurysm: technique report

BACKGROUND: Recent advances in stent technology have allowed for negotiation of often tortuous posterior circulation intracranial vasculature. Stent-assisted coil embolization is a novel treatment for complex wide-necked aneurysms, as stents provide a buttress that allows for coil deposition while preventing coil herniation into the parent vessel lumen. We describe a case of stent-assisted coil embolization of a complex wide-necked vertebral confluence aneurysm. CASE DESCRIPTION: A 61-year-old woman presented with a Hunt-Hess III, Fisher Grade III subarachnoid hemorrhage secondary to a ruptured vertebral confluence aneurysm demonstrated on angiography. The patient underwent emergent angiography and attempted coiling of a vertebral confluence aneurysm. Because of the aneurysm's complex wide neck and the presence of subclavian steal syndrome, the coils repeatedly herniated into the left vertebral and basilar artery lumina. A flexible coronary stent was deployed across the aneurysm neck, preventing coil herniation and allowing for greater coil deposition. The patient tolerated the procedure and underwent repeat coiling 2 months postoperatively because of mild coil compaction. This resulted in 100% occlusion and the patient is neurologically normal except for a sixth nerve palsy which had been present after the hemorrhage. CONCLUSION: Recent advances in stent technology allow negotiation of the tortuous posterior circulation vasculature. Stent-assisted coil embolization of complex, wide-necked vertebral confluence aneurysms may be an alternative intervention for these surgically challenging lesions.     

Coil embolization with a hyperform occlusion balloon for an acutely ruptured wide-necked basilar tip aneurysm: case report

A 54-year-old woman was admitted to our hospital because of severe headache. CT scan demonstrated subarachnoid hemorrhage (SAH), and cerebral angiography revealed a wide-necked basilar tip aneurysm with a bleb and a small basilar artery-left superior cerebellar artery aneurysm. She was treated with coil embolization using a neck remodeling technique one day after SAH. Guiding catheters were introduced into the bilateral vertebral artery via the transfemoral route. A Hyperform occlusion balloon catheter was introduced into the left posterior cerebral artery (PCA) through the left vertebral artery, and was placed at the neck of the basilar tip aneurysm for neck remodeling. Then, the microcatheter for coil deployment was placed in the dome of the aneurysm through the right vertebral artery. The coil was deployed in the aneurysm while the balloon was inflated across the neck. The inflated Hyperform occlusion balloon was partially herniated into the dome of the aneurysm. The distal part of the balloon was positioned in the left PCA segment, and its proximal part was positioned in the basilar artery. The balloon conformed easily to the aneurysmal neck and its surrounding vessel structure. When the balloon was deflated, the coil did not protrude into the parent artery, and was stable in the aneurysm. Angiography immediately after the procedure showed complete occlusion of the aneurysm with patency of both PCAs. The Hyperform occlusion balloon is very compliant and supple, so it easily changes from its cylindrical shape when inflated to expand into the origin of the arterial branches emerging from the aneurysm neck. We think this balloon is a useful device for treating wide-necked aneurysms located at arterial bifurcation.     

Ruptured dissecting anterior inferior cerebellar artery aneurysm--case report

A 39-year-old woman presented with a rare dissecting aneurysm of the proximal anterior inferior cerebellar artery (AICA). She presented with sudden onset of headache and vomiting, and subsequently became comatose with acute respiratory distress syndrome. Computed tomography showed subarachnoid hemorrhage and ventricular dilation. Left vertebral angiography identified a fusiform aneurysm at the proximal portion of the left AICA. The patient underwent endovascular treatment using Guglielmi detachable coils. The aneurysm was completely embolized. Computed tomography detected no infarcted areas in the regions supplied by the AICA. She was discharged without neurological deficits.     

Topic review: surface modifications enhancing biological activity of guglielmi detachable coils in treating intracranial aneurysms

BACKGROUND: Endovascular therapy with Guglielmi detachable coils is an accepted treatment option for patients with intracranial aneurysms. However, an emerging technology in the realm of endovascular tools is the use of traditional Guglielmi detachable coils with biologically active substances complexed to the coil surface to enhance aneurysm occlusion. METHODS: We review the literature and current trends in modified Guglielmi detachable coils. Surface modifications with extracellular matrix proteins, growth factors, ion impregnation, and genetically altered cells have been used in animal studies to improve the cellular response of Guglielmi detachable coils. Similarly, coronary artery stents have been modified in several different ways to maintain vessel patency, contrary to the goal of endovascular therapy. We comparatively reviewed this literature to add insight into the evolution of the research on modified Guglielmi detachable coils. CONCLUSIONS: Guglielmi detachable coil modifications have the potential to enhance aneurysm obliteration with directed cellular responses. This may allow aneurysm occlusion with coils in less time than untreated coils, thus decreasing the risks of aneurysm enlargement and hemorrhage.     

Case of a ruptured vertebral artery dissecting aneurysm recanalized after internal trapping

A 35-year-old male experienced a sudden onset of severe headache. A CT scan revealed subarachnoid hemorrhage. By cerebral angiography, he was diagnosed as having a ruptured right vertebral artery dissecting aneurysm (VADA). It was successfully treated by endovascular occlusion of the affected site, including the aneurysm and parent artery, by using detachable coils. A follow-up angiography obtained seven months after the first treatment revealed the recanalization of the right vertebral artery and dissected aneurysm in an antegrade fashion. A skull X-ray image was useful for detecting the change in appearance of the coils. The second embolization was successfully performed in the same manner. Based on this rare case, the authors emphasize that a careful angiographic analysis and complete internal trapping of the dissecting site are important in the treatment of the ruptured VADA.     

A case of a persistent primitive proatlantal intersegmental artery with a ruptured basilar bifurcation aneurysm

A case of persistent primitive proatlantal intersegmental artery (PPPIA) associated with a ruptured basilar bifurcation aneurysm was reported. A 44-year-old male with sudden headache was admitted to our hospital. CT scan revealed subarachnoid hemorrhage. Cerebral angiography revealed anomalous anastomosis between the internal carotid artery and the vertebral artery at the proatlantal region. This anastomosis branched off from the left internal carotid artery at the C4 level and joined the horizontal portion of the left vertebral artery. It was thought to be PPPIA. Angiography also revealed an aneurysm of the basilar bifurcation which was responsible for the patient's subarachnoid hemorrhage. The aneurysm was successfully treated by endovascular embolization with Guglielmi detachable coils in an acute stage, and resulted in good outcome. PPPIA with basilar bifurcation aneurysm has not been presented or reported in the literature to date. To our knowledge, this is the first report of such an association of vascular anomalies. The frequency of PPPIA combined with the intracranial aneurysm is relatively high, whereas the occurrence of PPPIA is extremely rare. Therefore, it was suggested that some congenital and/or hemodynamic factors changed by PPPIA may affect the pathogenesis of intracranial aneurysms.     

De novo vertebral artery dissecting aneurysm after contralateral vertebral artery occlusion--two case reports

Two patients developed de novo vertebral artery dissecting aneurysm after contralateral vertebral artery occlusion. A 36-year-old man presented with brainstem ischemia and was treated non-surgically. Subsequent angiography showed spontaneous vertebral artery occlusion at the site of dissection. A 45-year-old man developed subarachnoid hemorrhage due to vertebral artery dissecting aneurysm. He underwent endovascular occlusion of the vertebral artery proximal to the dissecting aneurysm. These patients developed de novo dissecting aneurysm on the contralateral vertebral artery at 13 months and 11 days after unilateral vertebral artery occlusion, respectively. These cases strongly suggest that changes in hemodynamic stress due to unilateral vertebral artery occlusion are related to de novo dissecting aneurysm on the contralateral side. The risk of de novo dissecting aneurysm may be increased by proximal occlusion or trapping of dissecting aneurysm of the contralateral vertebral artery.     

Endovascular coil trapping for ruptured vertebral artery dissecting aneurysms by using double microcatheters technique in the acute stage

Summary ?Background. In the treatment of vertebral artery (VA) dissecting aneurysms, only proximal occlusion of the VA does not necessarily prevent rerupture. We evaluated the efficacy of coil trapping for the ruptured VA dissecting aneurysms using the double microcatheters technique. Methods. We treated 11 patients who presented with subarachnoid haemorrhage (SAH) due to rupture of a VA dissecting aneurysm which did not involve the posterior inferior cerebellar artery at the site of dissection. All patients tolerated the balloon occlusion test. Within 3 days of the SAH, the dissection site was trapped with a Guglielmi detachable coil (GDC) using the double microcatheters technique. The proximal and distal sites of the dissecting aneurysm were embolized simultaneously. Findings. GDC trapping at the affected site was successful in all 11 patients. Radiographic findings showed complete occlusion of the dissection site and patency of the unaffected artery. Although one patient experienced transient dysphagia, there were no major complications. Interpretation. The double microcatheters technique is effective for coil trapping of ruptured VA dissecting aneurysms in selected patients. The risks posed by this simple technique are minimal, even in the acute stage. Published online May 26, 2003     

Dissecting aneurysm of the radiculomedullary artery originating from extracranial vertebral artery dissection in a patient with rheumatoid cervical spine disease: an unusual cause of subarachnoid hemorrhage. Case report

The authors report the case of a 65-year-old woman with atlantoaxial subluxation caused by rheumatoid arthritis. The patient had been hospitalized because of an infection after a total-knee replacement, when she suddenly lost consciousness and became apneic after an episode of intractable neck pain. Cranial computed tomography scanning demonstrated subarachnoid hemorrhage (SAH), and angiography revealed a dissecting aneurysm of the radiculomedullary artery that had originated from an extracranial vertebral artery dissection at the level of the atlantoaxial joint. Although coil embolization for the parent artery, including the dissecting aneurysm, was performed successfully, the patient died of worsening infection. The authors believe that the SAH occurred because of a ruptured dissecting aneurysm in the intradural portion of the radiculomedullary artery.     

Ruptured dissecting aneurysm of the vertebral artery missed by initial angiography; case report]

Dissecting aneurysm of the intracranial arteries is a well known clinical entity, and its angiographic findings are also well recognized. We encountered a case with dissecting aneurysm of the vertebral artery presented with subarachnoid hemorrhage (SAH). The initial angiography was normal but repeated angiography demonstrated a dissecting aneurysm. This case is reported here, and the relevant literature is reviewed. A 46-year-old woman had been well until she complained of headache. She was admitted to a local hospital and found to have SAH. She was transferred to our clinic for further examination. On admission the patient was drowsy but able to be aroused. Her neurological state was normal except for a mildly stiff neck. Computed tomography (CT) demonstrated massive SAH in the basal cistern and intraventricular hemorrhage in all ventricles. CT also demonstrated acute hydrocephalus. Four-vessel cerebral angiography was performed using transfemoral catheterization. No definite abnormalities, except for a small aneurysm in the cavernous portion of the right internal carotid artery, were found. Because aneurysm in the cavernous portion could not cause SAH, we could not define the origin of the SAH. However, retrospectively, a slightly irregular wall of the left intracranial vertebral artery was evident. Repeated angiography performed 28 days later revealed aneurysmal dilatation of this left vertebral artery. Double density of the contrast material was found in the aneurysmal dilatation. Retention of the contrast medium was also seen in the late capillary phase. From these angiographic findings, the aneurysm was diagnosed as being a dissecting aneurysm. Direct surgical attack on the vertebral aneurysm was performed via a left suboccipital craniectomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Antegrade recanalization of a completely embolized vertebral artery after endovascular treatment of a ruptured intracranial dissecting aneurysm. Report of two cases

Occlusion of the parent artery is a traditional method of treatment of unclippable cerebral aneurysms. Surgical or endovascular occlusion of the parent artery proximal to the aneurysm has been recommended for the treatment of dissecting aneurysms located in the vertebrobasilar circulation. Nevertheless, occlusion of the parent artery may not result in permanent exclusion of the aneurysm from the systemic circulation because, occasionally, postoperative rebleeding occurs after proximal occlusion. Alternatively, endovascular occlusion of the affected site, including the aneurysmal dilation, and parent artery, is a safe and reliable treatment for dissecting aneurysms. The authors present two rare cases of ruptured vertebral artery (VA) dissecting aneurysms that were treated by endovascular occlusion of the affected site including the aneurysm and parent artery by using Guglielmi detachable coils. In both cases the VA recanalized in an antegrade fashion during the follow-up period. Based on these unique cases, the authors suggest that a careful angiographic follow up of dissecting aneurysms is required, even in patients successfully treated with endovascular occlusion of the affected artery and aneurysm.     

Fusiform aneurysm of the vertebral artery presenting hemifacial spasm treated by intravascular embolization: case report

BACKGROUND: A rare case of fusiform vertebral artery aneurysm causing hemifacial spasm was successfully treated by intravascular embolization.CASE DESCRIPTION: A 53-year-old man presented with left hemifacial spasm persisting for 2 years. No other clinical symptoms were observed. Vertebral angiography revealed a fusiform aneurysm of the left vertebral artery, and thin-slice spoiled gradient-recalled acquisition magnetic resonance imaging demonstrated the aneurysm compressing the root exit zone of the left facial nerve. The parent artery was occluded together with the aneurysm by intravascular embolization with Guglielmi detachable coils (GDCs). The patient is free of left hemifacial spasm without any complication.CONCLUSION: Hemifacial spasm caused by aneurysms, especially fusiform aneurysms, is quite rare but can be treated by parent artery occlusion and coiling the aneurysm with GDCs.     

Arterial reconstruction by direct surgical clipping of a basilar artery dissecting aneurysm after failed vertebral artery occlusion: technical case report and literature review

OBJECTIVE AND IMPORTANCE: Dissecting aneurysms of the basilar artery are rare lesions with significant morbidity and mortality. Their management is controversial and often difficult. Although the rebleeding rate is high, clip reconstruction carries prohibitive risk because of the damage to the parent vessel induced by the dissection and the lack of tissue to gather. An enlarging pseudoaneurysm in the chronic phase, however, may have sufficient tissue for clip reconstruction. We present a case in which this strategy was used successfully. CLINICAL PRESENTATION: A 45-year-old woman presented 3 months after an initial presentation with a subarachnoid hemorrhage from a dissecting aneurysm of the basilar trunk at an outside institution. The aneurysm had grown compared with previous angiograms. INTERVENTION: The dominant vertebral artery was sacrificed. Despite this, the aneurysm continued to enlarge. Given the progressive enlargement of the aneurysm, the decision was made to proceed with arterial reconstruction by direct surgical clipping of the saccular component of the dissecting aneurysm. The patient made an excellent recovery with a durable result. CONCLUSION: Although clipping an intracranial pseudoaneurysm in the acute phase may carry a prohibitive risk, clipping such an aneurysm in the chronic phase may occasionally be warranted. To our knowledge, this is the first case reported in the literature in which direct surgical clipping was used as the primary mode of treatment for a basilar artery dissecting aneurysm that enlarged despite occlusion of the dominant vertebral artery. We review the literature on this rare pathological entity and discuss our management strategy.     

Bilateral abducens nerve palsies in treated cases of subarachnoid hemorrhage

Isolated abducens nerve palsies associated with the rupture of intracranial aneurysms have rarely been reported. We report two cases of isolated bilateral abducens nerve palsies occurring after subarachnoid hemorrhage due to the rupture of an intracranial aneurysm. Case 1: A 49-year-old woman had bilateral abducens nerve palsies following subarachnoid hemorrhage due to the rupture of the left vertebral artery-posterior inferior cerebellar artery aneurysm. Case 2: A 55-year-old man had bilateral abducens nerve palsies following subarachnoid hemorrhage due to dissecting aneurysm of the right vertebral artery. Case 1 and 2 were treated with surgical clipping of the aneurysm and internal occlusion of the parent artery. In both cases, bilateral abducens nerve palsies achieved almost full recovery several months after treatment. It is speculated that the main causes of palsies are compression and stretching of the bilateral abducens nerves by a thick clot in the prepontine cistern. Although most of the abducens palsies may be reversible and have good prognosis, it is important that they are kept in mind as isolated symptoms of subarachnoid hemorrhage.     

Cerebral aneurysm regrowth and coil unraveling after incomplete Guglielmi detachable coil embolization: serial angiographical and histological findings

A 69-year-old woman suffered subarachnoid hemorrhage due to rupture of an aneurysm at the tip of the basilar artery. The aneurysm was treated by endovascular treatment using Guglielmi detachable coils but the aneurysm dome could not be completely packed. Serial angiography at 10 and 18 months after embolization showed progressive regrowth of the aneurysm with loosening and unraveling of the packed coils. The patient died accidentally after head injury and autopsy was performed. Examination of the aneurysm showed further regrowth and "relative coil compaction" of the coil mass. Histological examination of the resected aneurysm showed no endothelialized membrane in the orifice and only minimal organized thrombus in the body of the aneurysm.     

Development of a dissecting aneurysm on the vertebral artery immediately after occlusion of the contralateral vertebral artery: A case report

A 49 year old female presented with subarachnoid hemorrhage due to a ruptured dissecting aneurysm on the left vertebral artery (VA). Following an occlusion test, we performed proximal occlusion of the left VA with detachable balloons. However, a dissecting aneurysm on the right VA developed three weeks later. After an occlusion test had showed no change in cerebral blood flow, auditory brain stem response, or neurological status, proximal occlusion of the right VA was performed. The patient has returned to normal life without neurological deficits. Bilateral dissecting aneurysms of the VA are quite common, but de novo VA dissecting aneurysms or enlargement of such aneurysms after occlusion of contralateral VA are rare. This case suggests that hemodynamic stress may be a causal factor in the development of VA dissecting aneurysms. Careful pre- and post-operative neuroradiological examination of the contralateral VA are required in patients under-going VA occlusion for dissecting aneurysms.