Introduction Surgical clipping of intracranial aneurysm can be complicated by clip encroachment of the parent artery. We present a case where symptomatic MCA stenosis occurring after clipping of a left carotid terminus aneurysm with reperfusion was restored using a Pipeline Embolization Device to buttress open the MCA.
Case report A 61-year-old African American underwent an orbito-zygomatic craniotomy of multiple aneurysms, including a 15 mm left carotid terminus aneurysm. After clip placement the left carotid terminus, ACA, and MCA origins were widely patent with a 2 mm dog ear remnant along the MCA (top figure) Abstract P-0015 figure 1. The anterior dome of the aneurysm was incised and showed no filling of the aneurysm. There was no vascular kinking or compromise of flow in the carotid terminus or MCA measured by intra-operative Doppler. Post-operatively the patient's neurological exam declined to somnolence, confusion and right-sided hemiparesis. CT/CTA/CTP demonstrated patency of the left carotid terminus and MCA, a small infarct in the left lentiform nuclei, and markedly increased mean transit time in the left MCA territory with preservation of the cerebral blood volume. Diagnostic angiography demonstrated a critical narrowing of the carotid terminus and MCA origin with delayed flow through the left MCA territory (bottom left figure) Abstract P-015 figure 1. There was no filling of the aneurysm, including the dog ear remnant noted at surgery. A 3.0×18 mm PED was advanced across the narrowing and deployed followed by intra-device angioplasty. Post PED and angioplasty angiography demonstrated improved caliber of the narrowed segment with markedly improved perfusion of the MCA territory (bottom right figure). The aneurysm remained completely occluded.
Discussion Arterial stenosis due to an aneurysm clip traditionally required surgical re-positioning of the aneurysm clip. Endovascular options are limited due to poor radial resistive forces of neurovascular nitinol stents. However, cobalt chromium has a higher specific modulus than nitinol that makes it an attractive high stiffness, low weight material. As such, Pipeline should have a steeper loading curve and corresponding radial resistive force, than nitinol stents. In addition, the static friction at the points of intersection of the braided tines may also provide additional resistance to deflection.
Conclusion Successful restoration of flow using Pipeline was achieved without complication.
Competing interests R Turner: Microvention, Codman. ev3, Penumbra, Mindframe. A Turk: None. I Chaudry: None. E Nyberg: None.
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