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Persistent aneurysm growth following pipeline embolization device assisted coiling of a fusiform vertebral artery aneurysm: a word of caution!

Kerolus M, Kasliwal MK, Lopes DK - Neurointervention (2015)

Bottom Line: Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents.Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety.However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH).

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Rush University Medical Center, Chicago, U.S.A.

ABSTRACT
The complex morphology of vertebrobasilar fusiform aneurysms makes them one of the most challenging lesions treated by neurointerventionists. Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents. Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety. However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH). We report a rare case of persistent aneurysmal growth after coiling and placement of the Pipeline Embolization Device (PED; ev3, Irvine, California, USA) for SAH from a fusiform vertebral artery aneurysm. As consequences of aneurysm rupture can be devastating especially in patients with a prior SAH, the clinical relevance of recognizing and understanding such patterns of failure cannot be overemphasized as highlighted in the present case.

No MeSH data available.


Related in: MedlinePlus

A. Axial computed tomography (CT) scan of the head showing presence of Fisher grade 3 SAH. B. Digital subtraction angiography (DSA) demonstrating right vertebral artery fusiform aneurysm with the PICA takeoff arising from the base of a focal dilatation from the fusiform aneurysm segment. C. Post embolization DSA showing deployment of a 3.75 × 18 mm PED completely covering the fusiform vertebral aneurysm along with Raymond class II occlusion of the focal dilatation arising from the fusiform aneurysm. D. Follow up angiogram at 6 months showing the presence of aneurysm regrowth and coil compaction (left panel) despite well deployed PED across the aneurysm (right panel). E. Anteroposterior (left panel) and lateral (middle and right panels) images from DSA performed 3 months after the second procedure showing remodeling of the right vertebral artery with no residual or recurrent aneurysm.
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Figure 1: A. Axial computed tomography (CT) scan of the head showing presence of Fisher grade 3 SAH. B. Digital subtraction angiography (DSA) demonstrating right vertebral artery fusiform aneurysm with the PICA takeoff arising from the base of a focal dilatation from the fusiform aneurysm segment. C. Post embolization DSA showing deployment of a 3.75 × 18 mm PED completely covering the fusiform vertebral aneurysm along with Raymond class II occlusion of the focal dilatation arising from the fusiform aneurysm. D. Follow up angiogram at 6 months showing the presence of aneurysm regrowth and coil compaction (left panel) despite well deployed PED across the aneurysm (right panel). E. Anteroposterior (left panel) and lateral (middle and right panels) images from DSA performed 3 months after the second procedure showing remodeling of the right vertebral artery with no residual or recurrent aneurysm.

Mentions: A 43-year-old male with a history of uncontrolled hypertension was admitted to our neuroscience intensive care unit form an outside institution with a diagnosis of a Hunt & Hess grade 4/Fisher grade 3 SAH (Fig. 1A). An EVD was placed on admission and a digital subtraction angiography (DSA) was performed which demonstrated presence of the right vertebral artery fusiform aneurysm with the posterior inferior cerebellar artery (PICA) arising from the base of a focal dilatation from the fusiform aneurysm segment (Fig. 1B). After consideration of all the treatment options, endovascular treatment was elected in view of poor grade SAH and patients' cardiopulmonary status. He underwent coil embolization along with placement of a PED across the aneurysm. A 6-French guide catheter was used to selectively catheterize the right vertebral artery. A microcatheter was subsequently placed into the vertebral artery with coiling of the focal dilatation arising off the aneurysm along with deployment of a 3.75×18 mm PED completely covering the fusiform vertebral aneurysm for vessel remodeling. A Raymond class II occlusion of the focal dilatation arising from the fusiform aneurysm was achieved (Fig. 1C). The patient was loaded with aspirin and clopidogrel during the procedure. The EVD was converted to a ventriculo-peritoneal shunt before the patient was discharged home in a good neurological condition. He was alert and oriented with no focal def icits at discharge except presence of right sided sixth cranial nerve palsy. Dual antiplatelet agents were prescribed for 6 months following the procedure. Routine follow up angiography done at 6 months as per our institutional protocol showed coil compaction and enlargement and regrowth of both the focal dilatation and the fusiform aneurysm without migration of the pipeline stent (Fig. 1D). Even though the patient was asymptomatic, considering significant enlargement of the aneurysm with a prior presentation with SAH, he was taken back to the neuro-interventional suite with placement of three overlapping PED's (3.5 mm×18×2 and 3.5×14 mm) to increase the overall coverage area and further reduce the shear stress which possibly caused the aneurysm to continue growing despite treatment with a single PED on presentation. The post procedure course was uneventful and he was discharged home with no new neurological deficits. A follow up angiography was performed at 3 months which showed no residual aneurysm (Fig. 1E) with no neurological deficits on clinical examination.


Persistent aneurysm growth following pipeline embolization device assisted coiling of a fusiform vertebral artery aneurysm: a word of caution!

Kerolus M, Kasliwal MK, Lopes DK - Neurointervention (2015)

A. Axial computed tomography (CT) scan of the head showing presence of Fisher grade 3 SAH. B. Digital subtraction angiography (DSA) demonstrating right vertebral artery fusiform aneurysm with the PICA takeoff arising from the base of a focal dilatation from the fusiform aneurysm segment. C. Post embolization DSA showing deployment of a 3.75 × 18 mm PED completely covering the fusiform vertebral aneurysm along with Raymond class II occlusion of the focal dilatation arising from the fusiform aneurysm. D. Follow up angiogram at 6 months showing the presence of aneurysm regrowth and coil compaction (left panel) despite well deployed PED across the aneurysm (right panel). E. Anteroposterior (left panel) and lateral (middle and right panels) images from DSA performed 3 months after the second procedure showing remodeling of the right vertebral artery with no residual or recurrent aneurysm.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4355643&req=5

Figure 1: A. Axial computed tomography (CT) scan of the head showing presence of Fisher grade 3 SAH. B. Digital subtraction angiography (DSA) demonstrating right vertebral artery fusiform aneurysm with the PICA takeoff arising from the base of a focal dilatation from the fusiform aneurysm segment. C. Post embolization DSA showing deployment of a 3.75 × 18 mm PED completely covering the fusiform vertebral aneurysm along with Raymond class II occlusion of the focal dilatation arising from the fusiform aneurysm. D. Follow up angiogram at 6 months showing the presence of aneurysm regrowth and coil compaction (left panel) despite well deployed PED across the aneurysm (right panel). E. Anteroposterior (left panel) and lateral (middle and right panels) images from DSA performed 3 months after the second procedure showing remodeling of the right vertebral artery with no residual or recurrent aneurysm.
Mentions: A 43-year-old male with a history of uncontrolled hypertension was admitted to our neuroscience intensive care unit form an outside institution with a diagnosis of a Hunt & Hess grade 4/Fisher grade 3 SAH (Fig. 1A). An EVD was placed on admission and a digital subtraction angiography (DSA) was performed which demonstrated presence of the right vertebral artery fusiform aneurysm with the posterior inferior cerebellar artery (PICA) arising from the base of a focal dilatation from the fusiform aneurysm segment (Fig. 1B). After consideration of all the treatment options, endovascular treatment was elected in view of poor grade SAH and patients' cardiopulmonary status. He underwent coil embolization along with placement of a PED across the aneurysm. A 6-French guide catheter was used to selectively catheterize the right vertebral artery. A microcatheter was subsequently placed into the vertebral artery with coiling of the focal dilatation arising off the aneurysm along with deployment of a 3.75×18 mm PED completely covering the fusiform vertebral aneurysm for vessel remodeling. A Raymond class II occlusion of the focal dilatation arising from the fusiform aneurysm was achieved (Fig. 1C). The patient was loaded with aspirin and clopidogrel during the procedure. The EVD was converted to a ventriculo-peritoneal shunt before the patient was discharged home in a good neurological condition. He was alert and oriented with no focal def icits at discharge except presence of right sided sixth cranial nerve palsy. Dual antiplatelet agents were prescribed for 6 months following the procedure. Routine follow up angiography done at 6 months as per our institutional protocol showed coil compaction and enlargement and regrowth of both the focal dilatation and the fusiform aneurysm without migration of the pipeline stent (Fig. 1D). Even though the patient was asymptomatic, considering significant enlargement of the aneurysm with a prior presentation with SAH, he was taken back to the neuro-interventional suite with placement of three overlapping PED's (3.5 mm×18×2 and 3.5×14 mm) to increase the overall coverage area and further reduce the shear stress which possibly caused the aneurysm to continue growing despite treatment with a single PED on presentation. The post procedure course was uneventful and he was discharged home with no new neurological deficits. A follow up angiography was performed at 3 months which showed no residual aneurysm (Fig. 1E) with no neurological deficits on clinical examination.

Bottom Line: Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents.Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety.However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH).

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Rush University Medical Center, Chicago, U.S.A.

ABSTRACT
The complex morphology of vertebrobasilar fusiform aneurysms makes them one of the most challenging lesions treated by neurointerventionists. Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents. Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety. However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH). We report a rare case of persistent aneurysmal growth after coiling and placement of the Pipeline Embolization Device (PED; ev3, Irvine, California, USA) for SAH from a fusiform vertebral artery aneurysm. As consequences of aneurysm rupture can be devastating especially in patients with a prior SAH, the clinical relevance of recognizing and understanding such patterns of failure cannot be overemphasized as highlighted in the present case.

No MeSH data available.


Related in: MedlinePlus