Clinical StudyStent-assisted coiling strategies for the treatment of wide-necked basilar artery bifurcation aneurysms
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.
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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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These authors have contributed equally to the manuscript.