Clinical Study
Stent-assisted coiling strategies for the treatment of wide-necked basilar artery bifurcation aneurysms

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Abstract

Stent-assisted coiling is now the preferred treatment option for wide-necked basilar artery bifurcation aneurysms (BABA). However, the optimal choice of specific treatment strategies is still not well documented. In this paper, based on the “two-neck” theory of BABA, we classified the stent-assisted coiling treatment of BABA into three types: unilateral stent-assisted coiling, unilateral stent plus contralateral microcatheter or microwire-assisted coiling, and bilateral stent-assisted coiling. We assessed the feasibility and effectiveness of different stent-assisted coiling strategies for the treatment of BABA. Twenty-three BABA patients treated with stent-assisted coiling between May 2003 and September 2012 were included. Of the 23 aneurysms, 16 were treated with unilateral stent-assisted coiling, two were treated with unilateral stent and microcatheter or microwire-assisted coiling, and five were treated with bilateral stent-assisted coiling. All 23 BABA were successfully embolized, with a technical success rate of 100%. According to the Raymond classification, the immediate procedural outcome was grade I in nine patients, grade II (neck residue) in four patients and grade III (body filling) in 10 patients. The rate of procedure-related complications was 4.3% (1/23), where intra-operative hemorrhage occurred during coiling due to rupture of the aneurysm. Of the 23 patients, 16 (69.6%) had angiographic follow-up. The mean follow-up duration was 13.5 months (range 1–46 months). Angiographic follow-up showed complete occlusion in 10 patients (62.5%), improvement in two patients (12.5%), stability in three patients (18.7%), and recanalization in one patient (6.25%). The various stent-assisted coiling strategies available at present are feasible and effective for the treatment of wide-necked BABA.

Introduction

Basilar artery bifurcation aneurysms (BABA) account for about 5% of all intracranial aneurysms. Clipping of these aneurysms is extremely challenging for neurosurgeons due to their deep location and complex anatomy. Thalamic perforator injury during surgery and intra-operative rupture often leads to severe clinical complications. Reported combined mortality and morbidity rates are as high as 26% in some microsurgery series of BABA [1]. Endovascular therapy has become the first choice for BABA treatment owing to its minimal invasiveness and relatively low procedure-related complication rate [2]. However, it is often difficult to use coils alone to treat BABA aneurysms, which frequently have wide necks or involve the origin of bilateral posterior cerebral arteries, and sometimes even the initial segment of the superior cerebellar artery.

Since the first use of the intracranial Neuroform stent (Boston Scientific, Fremont, CA, USA) in 2002, various stent-assisted coiling techniques have been widely applied to the treatment of wide-necked intracranial aneurysms [3]. Stent-assisted coiling can prevent coils from protruding into the parent artery, reconstruct the parent artery, and promote endothelial cells to cover the aneurysm neck. In addition, stents change the local hemodynamic status, thus facilitating thrombosis within the aneurysm to achieve the goal of treatment. To date, there have been few systematic evaluations of the treatment of BABA with stent-assisted coiling. We retrospectively reviewed the clinical data of 23 BABA patients who were treated with stent-assisted coiling at our hospital between May 2003 and September 2012. We aimed to evaluate the feasibility and effectiveness of stent placement for this kind of aneurysm using different stenting strategies. In addition, the selection of stenting strategy, technique details and clinical outcomes were analyzed.

Section snippets

Patient population

Twenty-three BABA patients who received stent-assisted coiling at our hospital between May 2003 and September 2012 were included in this study. There were 11 men and 12 women with a mean age of 51.2 ± standard deviation of 15.6 years (range 22–71). Of the 23 aneurysms, six were unruptured. Of the 17 patients with ruptured BABA, 10 were admitted because of acute subarachnoid hemorrhage (<28 days). According to the Hunt-Hess classification, five patients had grade I subarachnoid hemorrhage, two had

Immediate post-operative results

Successful stent placement was achieved in all patients, resulting in a technical success rate of 100%. A total of 28 stents were implanted into the parent arteries, including 19 Enterprise stents (Cordis), six Neuroform stents, two BX stents (Cordis), and one Solitaire stent (ev3 Endovascular, Irvine, CA, USA), with Enterprise and Neuroform stents most frequently used, accounting for 67.9% and 21.4% respectively. According to the Raymond classification [5], the immediate post-procedural

Discussion

The basilar bifurcation region is deeply located with abundant branches. The necks of aneurysms occurring in this region often involve the bilateral posterior cerebral arteries or even the superior cerebellar artery, including the initial segment of these arteries a part of the aneurysm. Although the course of such an aneurysm is continuous with that of the basilar artery and it is straightforward for a microcatheter to enter the aneurysm, coverage of the aneurysm neck and preservation of the

Conclusion

Stent-assisted coiling for the treatment of BABA is feasible and effective. With the advancement of stenting techniques, improved therapeutic outcomes can be expected. But as the number of patients reported in this study is small, a long term follow-up study with a larger cohort of patients is needed in future research.

Conflicts of interest/disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

Acknowledgements

This work was supported by National Natural Science Foundation of China (Grant No. 81000494) and Shanghai Science & Technology Committee (Grant No. 10441901902).

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