Successful endovascular treatment of a growing megadolichoectasic vertebrobasilar artery aneurysm by flow diversion using the “diverter-in-stent” technique

doi:10.1016/j.jocn.2011.07.011

Journal of Clinical Neuroscience

Volume 19, Issue 1, January 2012, Pages 166-170

https://doi.org/10.1016/j.jocn.2011.07.011 Get rights and content

Abstract

Giant dolichoectatic and fusiform aneurysms of the vertebrobasilar artery are among the most difficult and dangerous aneurysms to treat. Conservative management may be reasonable in asymptomatic elderly patients. Nevertheless, due to the frequent presence of mass effect on the brainstem and the risks of thromboembolic events and rupture, these aneurysms often demand treatment rather than observation. With the advancement of endovascular techniques some of these lesions have become treatable without the high morbidity and mortality rates associated with open surgical treatment. When dealing with giant, progressively enlarging symptomatic aneurysms, more limited therapeutic alternatives are available. The authors present a case of a growing megadolichoectatic vertebrobasilar artery aneurysm causing major disability due to increasing mass effect in a 51-year-old man. The aneurysm was treated with flow diversion by placing multiple telescoped stents and diverters (“diverter-in-stent” technique), achieving thrombosis of the aneurysm and reduction of the mass effect on the brainstem, with neurological improvement. The successful clinical and angiographic results observed in our case of giant dolichoectasic vertebrobasilar aneurysm contribute to the literature on giant aneurysms treated by means of flow diversion.

Section snippets

Patient presentation and neuroradiological examination

A 51-year-old man who was a heavy smoker with hypertension, hyperlipidemia, diabetes, morbid obesity, COPD, and a history of repetitive minor ischemic stroke presented with progressive neurological deterioration. He had been diagnosed with basilar artery dolichoectasia six years earlier, but was not considered to be a candidate for either surgical or endovascular intervention. There had been repeated hospital admissions for stepwise progressive lower cranial nerve and motor deterioration, and

Results

The patient tolerated the procedure well and was transferred to the neurosurgical intensive care unit for overnight observation. He recovered rapidly, returning to baseline status two hours after the procedure, and was extubated. After 12 h, he developed respiratory compromise, was reintubated, and assisted mechanically for 12 h.

Head CT two days showed no significant changes in mass effect. Mannitol, steroids, and low dose subcutaneous enoxiparin were started. Lower cranial nerve function

Discussion

We report successful endovascular treatment of a symptomatic megadolichoectatic basilar aneurysm by means of flow diversion, achieved with the placement of telescoped stents and a diverter (“diverter-in-stent” technique), followed by contralateral vertebral artery occlusion. Flow diversion was associated with transient clinical deterioration followed by consistent neurological improvement, secondary to aneurysm thrombosis and reduction of mass effect. Management of hydrocephalus with a VP shunt

Disclaimer

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Acknowledgement

The authors wish to thank Mrs. Shifra Fraifeld for her editorial assistance in the preparation of this manuscript.

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Fusiform aneurysms
2018, Intracranial Aneurysms
Vertebrobasilar fusiform aneurysms, which represent some of the most daunting lesions treated by cerebrovascular surgeons, are defined by separate inflow and outflow ostia. These aneurysms typically present with brainstem ischemic stroke or compressive symptoms of the brainstem, cerebellum, or cranial nerves. In patients with ischemic stroke or compressive symptoms, the natural history includes steady progression of the aneurysm's presenting signs and symptoms. Although the most time-tested management for fusiform vertebrobasilar aneurysms presenting with compressive symptoms is flow reduction or flow reversal, this strategy relies largely on the presence of adequate collateralization through the posterior communicating arteries. Flow diversion has achieved mixed results, and its use is recommended for cases of compressive symptoms and poor collateralization through the posterior communicating arteries. Anticoagulation is considered the best management for patients with vertebrobasilar aneurysms that present with ischemic stroke and no compressive symptoms. Lastly, we propose an algorithm for symptomatic patients with fusiform vertebrobasilar aneurysms based on presentation.
Vertebrobasilar fusiform aneurysms
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Good outcomes (mRS 0–2) were seen 6 patients (60%), and 4 patients died (40%). Many other case reports of flow-diverting stents for fusiform posterior circulation aneurysms have been published, with good outcomes.35,74–76 However, the use of flow diverters in the posterior circulation should be approached with caution, because some physicians have noted high complication rates and poor long-term outcomes.77
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Recently, flow diverters have been found to offer valuable options in the management of other vascular lesions, including symptomatic chronic carotid occlusion. This opens new potential applications for these devices in the field of cerebrovascular disease.5 In vertebral artery dissections causing occlusion associated with a burden of extensive clots, we have found that the reduced porosity of the diverter mesh serves as an effective barrier to in-stent clot protrusion and distal embolization.
Flow diverters constitute a new generation of flexible self-expanding stent-like devices with a high metal-surface area coverage, specifically designed for the endovascular management of complex cerebral aneurysms. Recently, other potential applications for these devices in the field of occlusive cerebrovascular disease have been described. In vertebral artery dissections causing occlusion associated with a burden of extensive clots, we have found that the reduced porosity of the diverter mesh serves as an effective barrier to in-stent clot protrusion and distal embolization. We describe the novel use of a flow diverter for the management of an occlusive traumatic vertebral artery dissection. Diverter implantation allowed subsequent angioplasty.
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The better outcome might be related with choosing therapeutic strategy individually and timely retreatment. More recently, encouraging results of large or giant vertebrobasilar fusiform aneurysms treated by newly developed flow divert stents have been reported [20–22]. This therapy offer a promising treatment for fusiform, large, and giant aneurysms, though there were some limitations such as limited experiences in ruptured lesions and lack of long-term follow-up data [22].
Fusiform aneurysms of vertebrobasilar arteries pose great challenge to surgical and endovascular treatment, especially large and giant aneurysms. We retrospectively reviewed our experiences and results of endovascular treatments for a series of 10 consecutive patients with large and giant fusiform aneurysms. Eight patients underwent stents placement (5 patients) or stent-assisted coiling (3 patients), and 2 patients underwent proximal occlusion of the parent arteries. Retreatment was needed in 2 patients. With the exception of 1 patient who died of rebleeding after sole stenting, the remaining 9 patients had good outcome. Reconstructive strategies using stents is a useful alternative for large and giant fusiform aneurysms of the vertebrobasilar arteries.
Prospects and Dilemmas of Endovascular Treatment for Vertebrobasilar Dolichoectasia
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Failure of tandem flow diversion for intracranial aneurysms: Literature review and illustrative case
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Case ReportSuccessful endovascular treatment of a growing megadolichoectasic vertebrobasilar artery aneurysm by flow diversion using the “diverter-in-stent” technique

Abstract

Section snippets

Patient presentation and neuroradiological examination

Results

Discussion

Disclaimer

Acknowledgement

J Clin Neurosci

Surgical and endovascular management of symptomatic posterior circulation fusiform aneurysms

J Neurosurg

Transfacial transclival approach for midline posterior circulation aneurysms

Neurosurgery

Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients

J Neurosurg

Basilar trunk aneurysm surgically treated with anterior petrosectomy and external carotid artery-to-posterior cerebral artery bypass: technical note

Neurosurgery

Definitive reconstruction of circumferential, fusiform intracranial aneurysms with the pipeline embolization device

Neurosurgery

Surgical treatment of complex intracranial aneurysms

Neurosurgery

Efficacy and current limitations of intravascular stents for intracranial internal carotid, vertebral, and basilar artery aneurysms

J Neurosurg

Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience

Neurosurgery

Enlarging vertebrobasilar dolichoectasia with subarachnoid hemorrhage heralded by recurrent ischemia. Case illustration

J Neurosurg

Case Report
Successful endovascular treatment of a growing megadolichoectasic vertebrobasilar artery aneurysm by flow diversion using the “diverter-in-stent” technique