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Abstract
Introduction Giant vertebrobasilar aneurysms may present with subarachnoid bleeding, ischemic manifestations and compressive symptoms. Their management remains challenging with a high morbidity and mortality. Inspire of successful endovascular treatment, acute postinterventional exacerbation of the compressive symptoms remains a relevant, potentially lethal complication
Case Description 59-year old male patient presented with a two-month history of headache, vertigo and dysarthria, which increased in intensity over the past two weeks. NIHSS 2, modified Rankin scale (mRS): 3. Initial MRI showed giant basilar artery aneurysm with brainstem compression and minimal edema. Maximal dimensions: 27 x 33 x 30 mm, neck: 17 mm (figure 1). Treatment plan: Flowdiverter and coiling
Oblique reconstruction showing aneurysm and neck measurements as well as the in-and outflow arterial segments
To minimize effect of postinterventional edema and brainstem compression a prophylactic external ventricular drain was applied. Prophylactic Fortecortin therapy was initiated on treatment day. Decompressive craniectomy was reserved for clinical deterioration. Technical challenges included dominant vertebral artery with elongation and kinking and difficult catheterization of distal basilar artery segment
Treatment over 2 sessions. Initially failed transfemoral approach, followed by a successful transradial approach. Platelet suppression using Glycoprotien IIb/IIIa inhibitor. Catheterization of distal artery segment was achieved using a large s-shaped microguidewire configuration (figures 2-3). Application of Flowdiverter (4.5*40 mm) and coiling in jailing technique. Follow-up MRI examination showed minimal progress of brainstem edema and compression and post interventional cerebellar microemboli. Patient discharged 28 days later with no new symptoms (NIHSS 1, mRS: 2).
Showing large S shaped curve of the microguidewire
Roadmap image in working projection showing successful catheterization of the outflow arterial segment of the aneurysm
Results Treatment of giant vetebrobasilar aneurysms is challenging. Treatment within an interdisciplinary team and adequate prophylactic measures could avoid potential complications.