Advertisement

Basilar Artery Trunk Aneurysm: Unruptured Saccular Aneurysm of the Distal Basilar Artery Trunk at the Origin of the Left Superior Cerebellar Artery with Brainstem Compression, LEO Stent-Induced Flow Diversion of the Aneurysm with Resolution of the Mass Effect and No Perforator Occlusion, and Good Clinical Outcome with Midterm Follow-Up

  • Hegoda Levansri Dilrukshan MakalandaEmail author
  • Geoffrey Lie
  • Ken Wong
  • Pervinder Bhogal
Living reference work entry
  • 10 Downloads

Abstract

An 80-year-old female patient presented with a persistent occipital headache over the course of a year, with no clear cause. She had no focal neurological deficit on clinical examination. An MRI scan showed a large 19 mm unruptured saccular aneurysm of the distal basilar artery (BA) at the origin of the left superior cerebellar artery (SCA) with compression of the subjacent pons. DSA confirmed the presence of a thrombosed dissecting saccular aneurysm of the distal BA, with its neck incorporating the origin of the left SCA. In order to remodel the aneurysm, to reduce rupture risk, and to decrease mass effect, a flow diverting stent was inserted. To reduce the risk of basilar perforator and posterior circulation side-branch vessel occlusion, a higher-porosity LEO stent was placed rather than a lower-porosity flow diverting stent. Repeated MRI/MRA examinations at 3 and 12 months confirmed the successful treatment of the aneurysm, with a sustained reduction in size and mass effect. The current treatment considerations for aneurysms located within the basilar artery territory and reaching a balance between flow diversion and the risk of perforator infarction is the main topic of this chapter.

Keywords

Basilar artery Dissecting saccular aneurysm Endovascular treatment Flow diverting stents Perforator occlusion Neointimal endothelialization LEO stent Compression of the pons Risk of perforator infarction Clopidogrel Remodeling of the parent vessel Low porosity Increased porosity Neo-endothelialization Particle imaging velocimetry LEO baby Higher-porosity stents 

References

  1. Augsburger L, Farhat M, Reymond P, Fonck E, Kulcsar Z, Stergiopulos N, Rüfenacht DA. Effect of flow diverter porosity on intraaneurysmal blood flow. Klin Neuroradiol. 2009;19(3):204–14.  https://doi.org/10.1007/s00062-009-9005-0.CrossRefPubMedGoogle Scholar
  2. Awad AJ, Mascitelli JR, Haroun RR, De Leacy RA, Fifi JT, Mocco J. Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion. Neurosurg Focus. 2017;42(6):E14.  https://doi.org/10.3171/2017.3.FOCUS1748.CrossRefPubMedGoogle Scholar
  3. Aydin K, Barburoglu M, Sencer S, Berdikhojayev M, Coskun B, Akpek S. Flow diversion with low-profile braided stents for the treatment of very small or uncoilable intracranial aneurysms at or distal to the circle of Willis. AJNR Am J Neuroradiol. 2017;38(11):2131–7.  https://doi.org/10.3174/ajnr.A5362.CrossRefPubMedGoogle Scholar
  4. Bhogal P, Ganslandt O, Bäzner H, Henkes H, Pérez MA. The fate of side branches covered by flow diverters-results from 140 patients. World Neurosurg. 2017;103:789–98.  https://doi.org/10.1016/j.wneu.2017.04.092.CrossRefPubMedGoogle Scholar
  5. Bouillot P, Brina O, Ouared R, Lovblad KO, Farhat M, Pereira VM. Particle imaging velocimetry evaluation of intracranial stents in sidewall aneurysm: hemodynamic transition related to the stent design. PLoS One. 2014;9(12):e113762.  https://doi.org/10.1371/journal.pone.0113762.CrossRefPubMedPubMedCentralGoogle Scholar
  6. Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke. 2013;44(2):442–7.  https://doi.org/10.1161/STROKEAHA.112.678151.CrossRefPubMedGoogle Scholar
  7. Cagnazzo F, Cappucci M, Dargazanli C, Lefevre PH, Gascou G, Riquelme C, Morganti R, Mazzotti V, Bonafe A, Costalat V. Flow-diversion effect of LEO stents: aneurysm occlusion and flow remodeling of covered side branches and perforators. AJNR Am J Neuroradiol. 2018;39(11):2057–63.  https://doi.org/10.3174/ajnr.A5803.CrossRefPubMedGoogle Scholar
  8. Cebral JR, Castro MA, Burgess JE, Pergolizzi RS, Sheridan MJ, Putman CM. Characterization of cerebral aneurysms for assessing risk of rupture by using patient-specific computational hemodynamics models. AJNR Am J Neuroradiol. 2005;26(10):2550–9.PubMedGoogle Scholar
  9. Fiorella D, Albuquerque FC, Deshmukh VR, Woo HH, Rasmussen PA, Masaryk TJ, McDougall CG. Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms. Neurosurgery. 2006;59(2):291–300; discussion 291-300.  https://doi.org/10.1227/01.NEU.0000223650.11954.6C.CrossRefPubMedGoogle Scholar
  10. Fischer S, Vajda Z, Aguilar Perez M, Schmid E, Hopf N, Bäzner H, Henkes H. Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology. 2012;54(4):369–82.  https://doi.org/10.1007/s00234-011-0948-x.CrossRefPubMedGoogle Scholar
  11. Kallmes DF, Ding YH, Dai D, Kadirvel R, Lewis DA, Cloft HJ. A new endoluminal, flow-disrupting device for treatment of saccular aneurysms. Stroke. 2007;38(8):2346–52.  https://doi.org/10.1161/STROKEAHA.106.479576.CrossRefPubMedGoogle Scholar
  12. Kulcsár Z, Ernemann U, Wetzel SG, Bock A, Goericke S, Panagiotopoulos V, Forsting M, Ruefenacht DA, Wanke I. High-profile flow diverter (silk) implantation in the basilar artery: efficacy in the treatment of aneurysms and the role of the perforators. Stroke. 2010;41(8):1690–6.  https://doi.org/10.1161/STROKEAHA.110.580308.CrossRefPubMedGoogle Scholar
  13. Lieber BB, Stancampiano AP, Wakhloo AK. Alteration of hemodynamics in aneurysm models by stenting: influence of stent porosity. Ann Biomed Eng. 1997;25(3):460–9.CrossRefGoogle Scholar
  14. Lopes DK, Jang DK, Cekirge S, Fiorella D, Hanel RA, Kallmes DF, Levy EI, Lylyk P. Morbidity and mortality in patients with posterior circulation aneurysms treated with the pipeline embolization device: a subgroup analysis of the international retrospective study of the pipeline embolization device. Neurosurgery. 2018;83(3):488–500.  https://doi.org/10.1093/neuros/nyx467.CrossRefPubMedGoogle Scholar
  15. Lylyk P, Ferrario A, Pasbón B, Miranda C, Doroszuk G. Buenos Aires experience with the Neuroform self-expanding stent for the treatment of intracranial aneurysms. J Neurosurg. 2005;102(2):235–41.  https://doi.org/10.3171/jns.2005.102.2.0235.CrossRefPubMedGoogle Scholar
  16. Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR, Berez AL, Tran Q, Nelson PK, Fiorella D. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery. 2009;64(4):632–42; discussion 642-3; quiz N6.  https://doi.org/10.1227/01.NEU.0000339109.98070.65.CrossRefPubMedGoogle Scholar
  17. Marinković SV, Gibo H. The surgical anatomy of the perforating branches of the basilar artery. Neurosurgery. 1993;33(1):80–7.PubMedGoogle Scholar
  18. Mazur MD, Kilburg C, Wang V, Taussky P. Pipeline embolization device for the treatment of vertebral artery aneurysms: the fate of covered branch vessels. J Neurointerv Surg. 2016;8(10):1041–7.  https://doi.org/10.1136/neurintsurg-2015-012040.CrossRefPubMedGoogle Scholar
  19. Natarajan SK, Lin N, Sonig A, Rai AT, Carpenter JS, Levy EI, Siddiqui AH. The safety of pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center. J Neurosurg. 2016;125(1):111–9.  https://doi.org/10.3171/2015.6.JNS1565.CrossRefPubMedGoogle Scholar
  20. Phillips TJ, Wenderoth JD, Phatouros CC, Rice H, Singh TP, Devilliers L, Wycoco V, Meckel S, McAuliffe W. Safety of the pipeline embolization device in treatment of posterior circulation aneurysms. AJNR Am J Neuroradiol. 2012;33(7):1225–31.  https://doi.org/10.3174/ajnr.A3166.CrossRefPubMedGoogle Scholar
  21. Pumar JM, Arias-Rivas S, Rodríguez-Yáñez M, Blanco M, Ageitos M, Vazquez-Herrero F, Castiñeira-Mourenza JA, Masso A. Using Leo plus stent as flow diverter and endoluminal remodeling in endovascular treatment of intracranial fusiform aneurysms. J Neurointerv Surg. 2013;5(Suppl 3):iii22–7.  https://doi.org/10.1136/neurintsurg-2013-010661.CrossRefPubMedGoogle Scholar
  22. Rice BJ, Peerless SJ, Drake CG. Surgical treatment of unruptured aneurysms of the posterior circulation. J Neurosurg. 1990;73(2):165–73.  https://doi.org/10.3171/jns.1990.73.2.0165.CrossRefPubMedGoogle Scholar
  23. Saatci I, Yavuz K, Ozer C, Geyik S, Cekirge HS. Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol. 2012;33(8):1436–46.  https://doi.org/10.3174/ajnr.A3246.CrossRefPubMedGoogle Scholar
  24. Sadasivan C, Cesar L, Seong J, Rakian A, Hao Q, Tio FO, Wakhloo AK, Lieber BB. An original flow diversion device for the treatment of intracranial aneurysms: evaluation in the rabbit elastase-induced model. Stroke. 2009;40(3):952–8.  https://doi.org/10.1161/STROKEAHA.108.533760.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Szikora I, Berentei Z, Kulcsar Z, Marosfoi M, Vajda ZS, Lee W, Berez A, Nelson PK. Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol. 2010;31(6):1139–47.  https://doi.org/10.3174/ajnr.A2023.CrossRefPubMedGoogle Scholar
  26. Tateshima S, Tanishita K, Hakata Y, Tanoue SY, Viñuela F. Alteration of intraaneurysmal hemodynamics by placement of a self-expandable stent. Laboratory investigation. J Neurosurg. 2009;111(1):22–7.  https://doi.org/10.3171/2009.2.JNS081324.CrossRefPubMedGoogle Scholar
  27. van Rooij WJ, Sluzewski M. Perforator infarction after placement of a pipeline flow-diverting stent for an unruptured A1 aneurysm. AJNR Am J Neuroradiol. 2010;31(4):E43-4.  https://doi.org/10.3174/ajnr.A2034.CrossRefPubMedGoogle Scholar
  28. Wakhloo AK, Mandell J, Gounis MJ, Brooks C, Linfante I, Winer J, Weaver JP. Stent-assisted reconstructive endovascular repair of cranial fusiform atherosclerotic and dissecting aneurysms: long-term clinical and angiographic follow-up. Stroke. 2008;39(12):3288–96.  https://doi.org/10.1161/STROKEAHA.107.512996.CrossRefPubMedGoogle Scholar
  29. Wang C, Tian Z, Liu J, Jing L, Paliwal N, Wang S, Zhang Y, Xiang J, Siddiqui AH, Meng H, Yang X. Flow diverter effect of LVIS stent on cerebral aneurysm hemodynamics: a comparison with Enterprise stents and the pipeline device. J Transl Med. 2016;14(1):199.  https://doi.org/10.1186/s12967-016-0959-9.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Zenteno MA, Santos-Franco JA, Freitas-Modenesi JM, Gómez C, Murillo-Bonilla L, Aburto-Murrieta Y, Díaz-Romero R, Nathal E, Gómez-Llata S, Lee A. Use of the sole stenting technique for the management of aneurysms in the posterior circulation in a prospective series of 20 patients. J Neurosurg. 2008;108(6):1104–18.  https://doi.org/10.3171/JNS/2008/108/6/1104.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Hegoda Levansri Dilrukshan Makalanda
    • 1
    Email author
  • Geoffrey Lie
    • 1
  • Ken Wong
    • 1
  • Pervinder Bhogal
    • 1
  1. 1.Department of Interventional NeuroradiologyThe Royal London HospitalLondonUK

Personalised recommendations