The patient is an otherwise healthy, 69 year-old man with hypercholesterolemia who presented to a neurologist with a mild memory disturbance.
MRI and MRA of the Brain were performed and revealed a large (10mm) wide-neck surpaclinoid carotid artery aneurysm which was confirmed with 3D DSA angiography (Figure 1). He was otherwise without complaint and neurologically intact.
Given the size of the aneurysm and the patient's otherwise good health and interest to have the aneurysm repaired to avert rupture, a decision was made to proceed with endovascular treatment.
The aneurysm appeared on the CTA to have a dysmorphic bilobed appearance with a very wide-neck and it was deemed to be a poor candidate for primary coiling alone. A decision was made to proceed with stent-assisted coiling. He was pre-medicated with ASA and Plavix for one week and under general anesthesia. A conventional cerebral angiogram was performed.
Appropriate measurements of the parent carotid vessel were obtained and these were used to choose a cordis enterprise stent that was navigate and deployed across the face of the aneurysm (Figure 2A). This allowed a microcatheter to be introduced through the opening in the stent and into the aneurysm (Figure 2B), where multiple coils were deployed to achieve aneurysmal thrombosis and protection (Figure 3). The patient was discharged home from the hospital the next day uneventfully.
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Figure 1: Left ICA 3-D DSA demonstrates wide neck clinoid segment aneurysm |
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Figure 2: A) Enterprise Stent (arrows) and First Coil Placed |
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Figure 2. B) Final DSA demonstrates stasis and progressive thrombosis of aneurysm sac (circle)
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Figure 3: Final Post 3-D DSA angiogram demonstrates successful stent coil embolization of wide-neck clinoid aneurysm |
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KEY LEARNING POINTS:
- Treatment of unruptured intracranial aneurysm is undertaken to prevent aneurysmal rupture and subarachnoid hemorrhage in select patients. Calculations of which patients to treat based on: age and health of patient, size of the aneurysm, aneurysm morphology and ease of treatment and patient interest to assume the risks of the procedure in exchange for decreasing the risk of aneurysm rupture in the future (Footnote 1, 2).
- Once a decision is made to proceed with treatment, the options of the endovascular repair or cranitotomy and clipping need to be weighed. At age 73 and harboring a large aneurysm, endovascular repair is a good option. Given the wide-neck morphology of the aneurysm, either flow diversion or stent-coiling (as performed here) are the best options (Footnote 2).
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REFERENCES:
- Wiebers, D. O., Whisnant, J. P., Huston, J., 3rd, Meissner, I., Brown, R. D., Jr, Piepgras, D. G., Forbes, G. S., Thielen, K., Nichols, D., O'Fallon, W. M., Peacock, J., Jaeger, L., Kassell, N. F., Kongable-Beckman, G. L., Torner, J. C., & International Study of Unruptured Intracranial Aneurysms Investigators (2003). Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet (London, England), 362(9378), 103–110.
- Brisman, J. L., Song, J. K., & Newell, D. W. (2006). Cerebral aneurysms. The New England journal of medicine, 355(9), 928–939.
- Molyneux, A. J., Birks, J., Clarke, A., Sneade, M., & Kerr, R. S. (2015). The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). Lancet (London, England), 385(9969), 691–697.
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AUTHORS
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