Flow diversion and microvascular plug occlusion for the treatment of a complex unruptured basilar/superior cerebellar artery aneurysm: case report

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The authors present the unusual case of a complex unruptured basilar artery terminus (BAT) aneurysm in a 42-year-old symptomatic female patient presenting with symptoms of mass effect. Due to the fusiform incorporation of both the BAT and left superior cerebellar artery (SCA) origin, simple surgical or endovascular treatment options were not feasible in this case. A 2-staged (combined deconstructive/reconstructive) procedure was successfully performed: first occluding the left SCA with a Pipeline embolization device (PED) coupled to a microvascular plug (MVP) in the absence of antiplatelet coverage, followed by reconstruction of the BAT by deploying a second PED from the right SCA into the basilar trunk. Six-month follow-up angiography confirmed uneventful aneurysm occlusion. The patient recovered well from her neurological symptoms. This case report illustrates the successful use of a combined staged deconstructive/reconstructive endovascular approach utilizing 2 endoluminal tools, PED and MVP, to reconstruct the BAT and occlude a complex aneurysm.

ABBREVIATIONS AICA = anterior inferior cerebellar artery; BA = basilar artery; BAT = basilar artery terminus; ICA = internal carotid artery; MPED = minimally porous endoluminal device; MVP = microvascular plug; PCA = posterior cerebral artery; PCoA = posterior communicating artery; PED = Pipeline embolization device; PICA = posterior inferior cerebellar artery; SCA = superior cerebellar artery; VA = vertebral artery.

Article Information

Correspondence Howard A. Riina: NYU Langone Hospital, New York, NY. howard.riina@nyumc.org.

INCLUDE WHEN CITING Published online June 29, 2018; DOI: 10.3171/2018.1.JNS172465.

Disclosures Dr. Shapiro reports a consultant relationship with Medtronic.

© AANS, except where prohibited by US copyright law.

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    Initial diagnostic workup. A and B: Axial T2-weighted (A) and sagittal contrast-enhanced T1-weighted (B) MR images showing the BAT aneurysm. C–I: Angiographic images. Anteroposterior and lateral views of the right ICA (C and D), left ICA (E and F) and left VA (G–I) confirmed the presence of a complex fusiform aneurysm with partial filling through the left PCoA from the left ICA. J and K: 3D rotational angiography of the left VA; anterior (J) and posterior (K) views. Figure is available in color online only.

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    Stage 1. A–C: Balloon test occlusion of the BA and sequential angiograms of the left ICA (A) and left VA (B and C) performed for evaluation of collateral reconstitution of the basilar apex. D–F: Left ICA (D and E) and left VA (F) angiograms confirming complete occlusion of the SCA component of the aneurysm after placement of a PED and MPV for mechanical occlusion of the left SCA.

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    Stage 2. A–D: Left ICA (A and B) and left VA (C and D) angiograms obtained 8 weeks after the stage 1 procedure showing an increase of the BAT component of the aneurysm and complete occlusion of the previously treated SCA component. E–H: After 3D rotational angiography of the left VA (E), a microwire (F) and the PED (G) were placed in the right SCA (H). I–L: Control angiography of the left ICA (I and J) and left VA (K and L) demonstrated no evidence of residual filling of the aneurysm from either the anterior or the posterior circulation. Figure is available in color online only.

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    Overview of the treatment strategy and device construct showing the initial anatomy before treatment (A), stage 1 (B), stage 2 (C), and after treatment (D). The asterisk (*) indicates the aneurysm. L = left; PeA = Percheron artery; R = right. Figure is available in color online only.

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    Postoperative axial diffusion-weighted MR image (A) showing no infarct and 6-month follow-up angiography (B) showing the construct including PEDs and MVP in the region of the previously known complex fusiform aneurysm. Left VA injection (C and D) and both right (E and F) and left ICA (G and H) injections showed no evidence of residual aneurysm filling.

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    A and B: Axial T2-weighted MR images obtained before any treatment (A) and at approximately 6 months after stage 2 treatment (B), showing regression of the aneurysm after treatment. C and D: Angiographic images obtained directly after stage 2 treatment (C) and approximately 6 months later (D), showing the device construct.

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