Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery

Case report and review of the literature

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✓ The authors demonstrate the technical feasibility of using intravascular stents in conjunction with electrolytically detachable coils (Guglielmi detachable coils [GDCs]) for treatment of fusiform, broad-based, acutely ruptured intracranial aneurysms and review the literature on endovascular approaches to ruptured aneurysms and cerebral stent placement. A 77-year-old man presented with an acute subarachnoid hemorrhage of the posterior fossa. A fusiform aneurysm with a broad-based neck measuring 12 mm and involving the distal vertebral artery (VA) and proximal third of the basilar artery (BA) was demonstrated on cerebral angiography. The aneurysm was judged to be inoperable. Six days later a repeated hemorrhage occurred. A 15-mm-long intravascular stent was placed across the base of the aneurysm in the BA and expanded to 4 mm to act as a bridging scaffold to create a neck. A microcatheter was then guided through the interstices of the stent into the body and dome of the aneurysm, and GDCs were deposited for occlusion.

The arteriogram obtained after stent placement demonstrated occlusion of the main dome and body of the aneurysm. The coils were stably positioned and held in place by the stent across the distal VA and BA fusiform aneurysm. Excellent blood flow to the distal BA and posterior cerebral artery was maintained through the stent. There were no new brainstem ischemic events attributable to the procedure. No rebleeding from the aneurysm had occurred by the 10.5-month follow-up evaluation, and the patient has experienced significant neurological improvement.

Certain types of intracranial fusiform aneurysms may now be treated by combining intravascular stent and GDC placement for aneurysm occlusion via an endovascular approach. This is the first known clinical application of this novel approach in a ruptured cerebral aneurysm.

Article Information

Address reprint requests to: Randall T. Higashida, M.D., Departments of Radiology and Neurological Surgery, Division of Interventional Neuroradiology, University of California San Francisco Medical Center, 505 Parnassus Avenue, L-352, San Francisco, California 94143–0628.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: Initial diagnostic cerebral arteriogram of the right VA, frontal projection, demonstrating the fusiform BA aneurysm (straight arrows). The inflow arises from the distal right VA and the outflow is at the level of the AICAs (curved arrows). The base of the aneurysm is 12 mm in length, and the dome and body are triangular. Right: After a second SAH, severe vasospasm has developed in the distal VA (curved arrow). Note a new daughter aneurysm has developed at the dome of the original lesion (straight arrow).

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    Illustration showing the Palmaz—Schatz intravascular stainless steel stent, which was used in the BA across the neck of the aneurysm. This stent measures 15 mm in length and can be expanded up to 4 mm in diameter.

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    Radiograph showing an exchange guidewire that was placed in the distal BA. The intravascular stent (arrows) was positioned from the inflow to the outflow of the BA aneurysm, allowing bridging and creation of an aneurysm neck; it was then expanded to 4 mm by means of a balloon.

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    Left: Vertebral angiogram obtained after stent placement demonstrating the stent lying across the ruptured fusiform BA aneurysm (arrows). Right: After GDC placement through the interstices of the stent, the follow-up arteriogram demonstrates occlusion of the dome and body of the aneurysm by the coils (curved arrows) and excellent blood flow through the distal BA and PCA.

References

1.

Berenstein ARansohoff JKupersmith Met al: Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries. Functional investigation and embolization. Surg Neurol 21:3121984Berenstein A Ransohoff J Kupersmith M et al: Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries. Functional investigation and embolization. Surg Neurol 21:3–12 1984

2.

Chyatte DFode NCSundt TM Jr: Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg 69:3263311988Chyatte D Fode NC Sundt TM Jr: Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg 69:326–331 1988

3.

Fox AJViñuela FPelz DMet al: Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms. J Neurosurg 66:40461987Fox AJ Viñuela F Pelz DM et al: Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms. J Neurosurg 66:40–46 1987

4.

Geremia GBakon MBrennecke Let al: Experimental arteriovenous fistulas: treatment with porous metallic stents. AJNR 16:196519731995Geremia G Bakon M Brennecke L et al: Experimental arteriovenous fistulas: treatment with porous metallic stents. AJNR 16:1965–1973 1995

5.

Geremia GBakon MBrennecke Let al: Experimental arteriovenous fistulas: treatment with silicone-covered metallic stents. AJNR 18:2712771997Geremia G Bakon M Brennecke L et al: Experimental arteriovenous fistulas: treatment with silicone-covered metallic stents. AJNR 18:271–277 1997

6.

Guglielmi GViñuela FDuckwiler Get al: Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 7:5155241992Guglielmi G Viñuela F Duckwiler G et al: Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 7:515–524 1992

7.

Higashida RTHalbach VVCahan LDet al: Detachable balloon embolization therapy of posterior circulation intracranial aneurysms. J Neurosurg 71:5125191989Higashida RT Halbach VV Cahan LD et al: Detachable balloon embolization therapy of posterior circulation intracranial aneurysms. J Neurosurg 71:512–519 1989

8.

Higashida RTHalbach VVCahan LDet al: Transluminal angioplasty for treatment of intracranial arterial vasospasm. J Neurosurg 71:6486531989Higashida RT Halbach VV Cahan LD et al: Transluminal angioplasty for treatment of intracranial arterial vasospasm. J Neurosurg 71:648–653 1989

9.

Higashida RTHalbach VVDowd CFet al: Endovascular surgical approach to intracranial vascular diseases. J Endovasc Surg 3:1461571996Higashida RT Halbach VV Dowd CF et al: Endovascular surgical approach to intracranial vascular diseases. J Endovasc Surg 3:146–157 1996

10.

Higashida RTHalbach VVDowd CFet al: Interventional neurovascular treatment for giant aneurysms of the posterior circulation. J Surg Cereb Stroke 21:4014061993Higashida RT Halbach VV Dowd CF et al: Interventional neurovascular treatment for giant aneurysms of the posterior circulation. J Surg Cereb Stroke 21:401–406 1993

11.

Higashida RTTsai FYHalbach VVet al: Transluminal angioplasty, thrombolysis, and stenting for extracranial and intracranial cerebral vascular disease. J Intervent Cardiol 9:2452551996Higashida RT Tsai FY Halbach VV et al: Transluminal angioplasty thrombolysis and stenting for extracranial and intracranial cerebral vascular disease. J Intervent Cardiol 9:245–255 1996

12.

Jane JAWinn HRRichardson AE: The natural history of intracranial aneurysms: rebleeding rates during the acute and long term period and implication for surgical management. Clin Neurosurg 24:1761841977Jane JA Winn HR Richardson AE: The natural history of intracranial aneurysms: rebleeding rates during the acute and long term period and implication for surgical management. Clin Neurosurg 24:176–184 1977

13.

Juvela S: Rebleeding from ruptured intracranial aneurysms. Surg Neurol 32:3233261989Juvela S: Rebleeding from ruptured intracranial aneurysms. Surg Neurol 32:323–326 1989

14.

Kassell NFTorner JC: Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery 13:4794811983Kassell NF Torner JC: Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery 13:479–481 1983

15.

Liermann DStrecker EPPeters J: The Strecker stent: indications and results in iliac and femoropopliteal arteries. Cardiovasc Intervent Radiol 15:2983051992Liermann D Strecker EP Peters J: The Strecker stent: indications and results in iliac and femoropopliteal arteries. Cardiovasc Intervent Radiol 15:298–305 1992

16.

Ljunggren BBrandt LSaveland Het al: Management of ruptured intracranial aneurysms: a review. Br J Neurosurg 1:9321987Ljunggren B Brandt L Saveland H et al: Management of ruptured intracranial aneurysms: a review. Br J Neurosurg 1:9–32 1987

17.

Massoud TFTurjman FJi Cet al: Endovascular treatment of fusiform aneurysms with stents and coils: technical feasibility in a swine model. AJNR 16:195319631995Massoud TF Turjman F Ji C et al: Endovascular treatment of fusiform aneurysms with stents and coils: technical feasibility in a swine model. AJNR 16:1953–1963 1995

18.

McDougall CGHalbach VVDowd CFet al: Endovascular treatment of basilar tip aneurysms using electrolytically detachable coils. J Neurosurg 84:3933991996McDougall CG Halbach VV Dowd CF et al: Endovascular treatment of basilar tip aneurysms using electrolytically detachable coils. J Neurosurg 84:393–399 1996

19.

Palmaz JC: Intravascular stenting: from basic research to clinical application. Cardiovasc Intervent Radiol 15:2792841992Palmaz JC: Intravascular stenting: from basic research to clinical application. Cardiovasc Intervent Radiol 15:279–284 1992

20.

Rosenørn JEskesen VSchmidt Ket al: The risk of rebleeding from ruptured intracranial aneurysms. J Neurosurg 67:3293321987Rosenørn J Eskesen V Schmidt K et al: The risk of rebleeding from ruptured intracranial aneurysms. J Neurosurg 67:329–332 1987

21.

Sundt TM Jr: Cerebral vasospasm following subarachnoid hemorrhage: evolution, management and relationship to timing of surgery. Clin Neurosurg 24:2282391977Sundt TM Jr: Cerebral vasospasm following subarachnoid hemorrhage: evolution management and relationship to timing of surgery. Clin Neurosurg 24:228–239 1977

22.

Szikora IGuterman LRWells KMet al: Combined use of stents and coils to treat experimental wide-necked carotid aneurysms: preliminary results. AJNR 15:109111021994Szikora I Guterman LR Wells KM et al: Combined use of stents and coils to treat experimental wide-necked carotid aneurysms: preliminary results. AJNR 15:1091–1102 1994

23.

Teitelbaum GPHalbach VVLarsen DWet al: Treatment of massive posterior epistaxis by detachable coil embolization of a cavernous internal carotid artery aneurysm. Neuroradiology 37:3343361995Teitelbaum GP Halbach VV Larsen DW et al: Treatment of massive posterior epistaxis by detachable coil embolization of a cavernous internal carotid artery aneurysm. Neuroradiology 37:334–336 1995

24.

Tettenborn DDycka J: Prevention and treatment of delayed ischemic dysfunction in patients with aneurysmal subarachnoid hemorrhage. Stroke 21 (Suppl 4):85891990Tettenborn D Dycka J: Prevention and treatment of delayed ischemic dysfunction in patients with aneurysmal subarachnoid hemorrhage. Stroke 21 (Suppl 4):85–89 1990

25.

Viñuela FDuckwiler GMawad M: Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients. J Neurosurg 86:4754821997Viñuela F Duckwiler G Mawad M: Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients. J Neurosurg 86:475–482 1997

26.

Wakhloo AKTio FOLieber BBet al: Self-expanding nitinol stents in canine vertebral arteries: hemodynamics and tissue response. AJNR 16:104310511995Wakhloo AK Tio FO Lieber BB et al: Self-expanding nitinol stents in canine vertebral arteries: hemodynamics and tissue response. AJNR 16:1043–1051 1995

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