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Giant vertebral artery aneurysm in a child treated with endovascular parent artery occlusion and coil embolization.

Park HS, Nakagawa I, Wada T, Nakagawa H, Hironaka Y, Kichikawa K, Nakase H - Surg Neurol Int (2014)

Bottom Line: This was done to avoid a coil mass effect to the brainstem.Two additional coil embolization procedures were performed in response to recurrence.Staged endovascular strategy can be a safe and effective treatment option.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Nara Medical University, Nara, Japan.

ABSTRACT

Background: Intracranial giant vertebral artery aneurysms are extremely rare in the pediatric population and are associated with significant morbidity and mortality. The present report describes a case of a pediatric patient with giant vertebral artery aneurysm who presented with intracranial mass effect. This patient was successfully treated with endovascular parent artery occlusion and coil embolization.

Case description: A 7-year-old girl presented with tetraparesis, ataxia, dysphagia, and dysphonia. Cerebral angiography revealed intracranial giant aneurysm arising from the right vertebral artery. The patient underwent endovascular parent artery occlusion alone to facilitate aneurysmal thrombosis as an initial treatment. This was done to avoid a coil mass effect to the brainstem. However, incomplete thrombosis occurred in the vicinity of the vertebral artery union. Therefore, additional coil embolization for residual aneurysm was performed. Two additional coil embolization procedures were performed in response to recurrence. Mass effect and clinical symptoms gradually improved, and the patient had no associated morbidity or recurrence at 2 years after the last fourth coil embolization.

Conclusion: Intracranial giant vertebral artery aneurysms are rare and challenging in pediatric patients. Staged endovascular strategy can be a safe and effective treatment option.

No MeSH data available.


Related in: MedlinePlus

Left vertebral artery angiography 14 days after parent artery occlusion shows filling of the distal side of the residual aneurysm (a). Angiography reveals complete occlusion of the aneurysm after the third coil embolization (b). Second (before; c, after; d) and third (before; e, after; f) coil embolization demonstrates complete occlusion of the aneurysm
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Figure 3: Left vertebral artery angiography 14 days after parent artery occlusion shows filling of the distal side of the residual aneurysm (a). Angiography reveals complete occlusion of the aneurysm after the third coil embolization (b). Second (before; c, after; d) and third (before; e, after; f) coil embolization demonstrates complete occlusion of the aneurysm

Mentions: A 7-year-old girl presented with a 1-month history of gait disturbance, dysarthria, dysphagia, and hoarseness and with a 1-day history of muscular weakness of the extremities. Neurological examination revealed oculomotor, trochlear, abducens, glossopharyngeal, vagus, and accessory nerve palsy and tetraparesis. Computerized tomography revealed a giant right VA aneurysm expanding at the vertebrobasilar junction (diameter, 40 mm) without calcification. Magnetic resonance (MR) imaging demonstrated a giant aneurysm without intraaneurysmal thrombosis that was compressing the brainstem [Figure 1]. Digital subtraction angiography (DSA) showed the aneurysm arising 2 cm distal to the posterior inferior cerebellar artery (PICA) orifice to vertebrobasilar junction, fetal-type left posterior communicating artery, and bilateral VAs of similar caliber [Figure 2a and b]. A 6-Fr guiding catheter (Shuttle; Cook Medical, Inc., Bloomington, IN) was inserted into the right femoral artery and guided into the right VA. An Excelsior 1018 microcatheter (Boston Scientific, Watertown, MA) and a balloon catheter (HyperForm 7mm; 7mm; Micro Therapeutics) were introduced into the parent artery (right VA) through each guiding catheter. Parent artery coil embolization distal to the PICA was performed under flow control by balloon inflation at V4 portion of right VA, and complete PAO with preservation of the right PICA patency was achieved by the end of the procedure [Figure 2c and d]. However, one-third of the aneurysm was not thrombosed [Figure 3a]. Coil embolization was subsequently performed 14 days after PAO after the patient presented with respiratory depression due to mass effect. A 6-Fr guiding catheter (Shuttle) was inserted into the right femoral artery and guided into the left VA. An Excelsior 1018 microcatheter (Boston Scientific) was introduced into the left VA through the guiding catheter. Thirteen bare platinum coils were introduced into the aneurysm through the microcatheter, and total occlusion was confirmed at the end of this procedure [Figure 3b]. However, 1.5 months after the first coil embolization, follow-up DSA showed recurrent dome filling at the distal side of the aneurysm because of sinking of the coils into the intraaneurysmal thrombus due to pulsation effect from the VA union [Figure 3c]. A second coil embolization procedure was then performed using the balloon (HyperForm 4mm; 7mm; Micro Therapeutics) remodeling technique for tight packing and avoiding coil protrusion to the union of VA. An Excelsior 1018 microcatheter (Boston Scientific) was introduced into the aneurysm and a balloon catheter (HyperForm 4 mm; 7 mm; Micro Therapeutics) was placed at the union of VA through the guiding catheter introduced into the left VA. Seventeen bioactive coils were introduced into the aneurysm. The aneurysm was totally occluded [Figure 3d], but reappearance of dome filling was noted 1 month after the second embolization [Figure 3e]. A third coil embolization procedure was performed, and eight bioactive coils were introduced into the aneurysm using the balloon-assist technique. Postembolization DSA confirmed total occlusion of the aneurysm [Figure 3f]. All procedures were performed with systemic heparinization to maintain the activated clotting time at levels above 2- to 3-fold the baseline value and oral aspirin (100 mg) was started after introducing guiding catheter through a gastric tube. Follow-up DSA at 1 month [Figure 4a] after the last fourth embolization did not show recurrence of the aneurysm aside from a small neck remnant. The patient's postoperative course was uneventful. Although no ischemic or edematous changes of the brainstem were depicted in the course of the treatment, mass effect to the brainstem gradually decreased, and her cranial nerve palsy completely resolved [Figure 4b]. No new neurological deficits developed, and the patient was able to resume her normal life. Two years later, follow-up MR angiography did not show any recurrence of aneurysm [Figure 4c].


Giant vertebral artery aneurysm in a child treated with endovascular parent artery occlusion and coil embolization.

Park HS, Nakagawa I, Wada T, Nakagawa H, Hironaka Y, Kichikawa K, Nakase H - Surg Neurol Int (2014)

Left vertebral artery angiography 14 days after parent artery occlusion shows filling of the distal side of the residual aneurysm (a). Angiography reveals complete occlusion of the aneurysm after the third coil embolization (b). Second (before; c, after; d) and third (before; e, after; f) coil embolization demonstrates complete occlusion of the aneurysm
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4109167&req=5

Figure 3: Left vertebral artery angiography 14 days after parent artery occlusion shows filling of the distal side of the residual aneurysm (a). Angiography reveals complete occlusion of the aneurysm after the third coil embolization (b). Second (before; c, after; d) and third (before; e, after; f) coil embolization demonstrates complete occlusion of the aneurysm
Mentions: A 7-year-old girl presented with a 1-month history of gait disturbance, dysarthria, dysphagia, and hoarseness and with a 1-day history of muscular weakness of the extremities. Neurological examination revealed oculomotor, trochlear, abducens, glossopharyngeal, vagus, and accessory nerve palsy and tetraparesis. Computerized tomography revealed a giant right VA aneurysm expanding at the vertebrobasilar junction (diameter, 40 mm) without calcification. Magnetic resonance (MR) imaging demonstrated a giant aneurysm without intraaneurysmal thrombosis that was compressing the brainstem [Figure 1]. Digital subtraction angiography (DSA) showed the aneurysm arising 2 cm distal to the posterior inferior cerebellar artery (PICA) orifice to vertebrobasilar junction, fetal-type left posterior communicating artery, and bilateral VAs of similar caliber [Figure 2a and b]. A 6-Fr guiding catheter (Shuttle; Cook Medical, Inc., Bloomington, IN) was inserted into the right femoral artery and guided into the right VA. An Excelsior 1018 microcatheter (Boston Scientific, Watertown, MA) and a balloon catheter (HyperForm 7mm; 7mm; Micro Therapeutics) were introduced into the parent artery (right VA) through each guiding catheter. Parent artery coil embolization distal to the PICA was performed under flow control by balloon inflation at V4 portion of right VA, and complete PAO with preservation of the right PICA patency was achieved by the end of the procedure [Figure 2c and d]. However, one-third of the aneurysm was not thrombosed [Figure 3a]. Coil embolization was subsequently performed 14 days after PAO after the patient presented with respiratory depression due to mass effect. A 6-Fr guiding catheter (Shuttle) was inserted into the right femoral artery and guided into the left VA. An Excelsior 1018 microcatheter (Boston Scientific) was introduced into the left VA through the guiding catheter. Thirteen bare platinum coils were introduced into the aneurysm through the microcatheter, and total occlusion was confirmed at the end of this procedure [Figure 3b]. However, 1.5 months after the first coil embolization, follow-up DSA showed recurrent dome filling at the distal side of the aneurysm because of sinking of the coils into the intraaneurysmal thrombus due to pulsation effect from the VA union [Figure 3c]. A second coil embolization procedure was then performed using the balloon (HyperForm 4mm; 7mm; Micro Therapeutics) remodeling technique for tight packing and avoiding coil protrusion to the union of VA. An Excelsior 1018 microcatheter (Boston Scientific) was introduced into the aneurysm and a balloon catheter (HyperForm 4 mm; 7 mm; Micro Therapeutics) was placed at the union of VA through the guiding catheter introduced into the left VA. Seventeen bioactive coils were introduced into the aneurysm. The aneurysm was totally occluded [Figure 3d], but reappearance of dome filling was noted 1 month after the second embolization [Figure 3e]. A third coil embolization procedure was performed, and eight bioactive coils were introduced into the aneurysm using the balloon-assist technique. Postembolization DSA confirmed total occlusion of the aneurysm [Figure 3f]. All procedures were performed with systemic heparinization to maintain the activated clotting time at levels above 2- to 3-fold the baseline value and oral aspirin (100 mg) was started after introducing guiding catheter through a gastric tube. Follow-up DSA at 1 month [Figure 4a] after the last fourth embolization did not show recurrence of the aneurysm aside from a small neck remnant. The patient's postoperative course was uneventful. Although no ischemic or edematous changes of the brainstem were depicted in the course of the treatment, mass effect to the brainstem gradually decreased, and her cranial nerve palsy completely resolved [Figure 4b]. No new neurological deficits developed, and the patient was able to resume her normal life. Two years later, follow-up MR angiography did not show any recurrence of aneurysm [Figure 4c].

Bottom Line: This was done to avoid a coil mass effect to the brainstem.Two additional coil embolization procedures were performed in response to recurrence.Staged endovascular strategy can be a safe and effective treatment option.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Nara Medical University, Nara, Japan.

ABSTRACT

Background: Intracranial giant vertebral artery aneurysms are extremely rare in the pediatric population and are associated with significant morbidity and mortality. The present report describes a case of a pediatric patient with giant vertebral artery aneurysm who presented with intracranial mass effect. This patient was successfully treated with endovascular parent artery occlusion and coil embolization.

Case description: A 7-year-old girl presented with tetraparesis, ataxia, dysphagia, and dysphonia. Cerebral angiography revealed intracranial giant aneurysm arising from the right vertebral artery. The patient underwent endovascular parent artery occlusion alone to facilitate aneurysmal thrombosis as an initial treatment. This was done to avoid a coil mass effect to the brainstem. However, incomplete thrombosis occurred in the vicinity of the vertebral artery union. Therefore, additional coil embolization for residual aneurysm was performed. Two additional coil embolization procedures were performed in response to recurrence. Mass effect and clinical symptoms gradually improved, and the patient had no associated morbidity or recurrence at 2 years after the last fourth coil embolization.

Conclusion: Intracranial giant vertebral artery aneurysms are rare and challenging in pediatric patients. Staged endovascular strategy can be a safe and effective treatment option.

No MeSH data available.


Related in: MedlinePlus