Article Text
Abstract
Introduction One of the devices used for treatment of aneurysms is the Pipeline Embolization Device (PED, Medtronic, Irvine, CA, USA). Initially approved in 2011, it has shown good efficacy for treating a variety of aneurysms in both the anterior and posterior circulations, including complex and wide necked aneurysms. Among the rarely reported complications of endovascular treatment of cerebral aneurysms is delayed leukoencephalopathy. Generally these patients exhibit signs of demyelination, as evidenced by high signal changes in white matter areas, distal and remote from the coils or flow diverter. Some patients exhibit headaches or hemiparesis, headache, or are asymptomatic. Several hypotheses have been put forward regarding the etiology of this leukoencephalopathy after intervention. Some authors have suggested foreign body emboli, hypersensitivity reactions, such as to nickel or polymers used in catheters, as well as contrast induced encephalopathy. We present the cases of three consecutive patients who presented with vague neurological symptoms and were ultimately found to have demyelination and lab studies consistent with delayed leukoencephalopathy.
Methods Case series of three patients who underwent pipeline stenting and developed delayed leukoencephalopathy.
Results All three patients were women in the 6th and 7th decades of life with aneurysms of the anterior circulation. All underwent diagnostic angiography without issue. The first patient had the most severe presentation with hemipareis and an NIHSS of 3, MRI showed numerous enhancing lesions in the R cerebral hemisphere with internal cavitations concerning for infectious or demyelinating etiology. The second patient complained of generalized weakness and was admitted after MRA showed multiple sites of enhancement distal to the PED. The third patient complained of headache and eye pain, and MRI imaging showed multiple enhancing lesions with surrounding edema and microhemorrhage, most pronounced in the left external capsule. This was thought to be similar to the other cases of acute demyelination. All three patients were initially treated empirically with antibiotics, and were transitioned to pulse dose steroids with oral taper. The second and third patients in the series were treated with doxycycline as well. The aneurysms were successfully treated nonetheless. The patients remained on frequent surveillance MRI/MRA, and their presenting symptoms resolved before resolution of the lesions on imaging. 2 of the 3 patients are now completely at neurological baseline, and one of the patients is undergoing further workup for MS.
Conclusion Delayed Leukoencephalopathy is a known, rare complication of endovascular procedures. Patients may have a wide range of presentations. Treatment for this condition includes steroids, although there is no consensus on the dosing, timing, or duration of treatment. Additionally, the etiology remains unknown, although hypotheses exist regarding hypersensitivity reactions, foreign body reactions, or emboli stemming from the intervention. Further research is needed to better understand this process, as well as studies regarding optimal management and long term outcomes.
Disclosures Z. Sokol: None. J. Axelband: None. M. Oselkin: None.