Guglielmi detachable coil embolization for ruptured lower-midbasilar trunk aneurysms--a report of five cases

Direct V3 Vertebral Artery Access for Embolization of Partially Thrombosed Fusiform Basilar Trunk Aneurysm: Technical Case Instruction

BACKGROUND AND IMPORTANCE

Fusiform vertebrobasilar aneurysms carry significant morbidity. Endovascular strategies are preferred; however, unsafe or unfeasible access can call for innovative strategies.

CLINICAL PRESENTATION

An octogenarian patient with an enlarging fusiform proximal basilar artery aneurysm causing a sixth nerve palsy was found to have multiple anatomic features that precluded a transradial or transfemoral endovascular approach. She was thus treated with direct microsurgical access of the V3 segment of the vertebral artery for subsequent coil embolization and flow diversion.

CONCLUSION

This case introduces a novel combined microsurgical and endovascular strategy for treating a complex partially thrombosed fusiform basilar artery aneurysm. This approach should be reserved only for patients where conventional endovascular access is dangerous or unfeasible.

Roadmap Guided Direct Percutaneous Vertebral Artery Puncture for Mechanical Thrombectomy of Acute Basilar Artery Occlusion: A Technical Case Report and Review of the Literature

Access techniques for mechanical thrombectomy normally include percutaneous puncture of the common femoral or, more recently, the radial artery. Although target vessel catheterization may frequently not be devoid of difficulties via both routes, the vast majority of mechanical thrombectomy (MT) cases can be successfully managed. However, in a significant minority of cases, a stable target vessel access cannot be reached resulting in futile recanalization procedures and detrimental outcomes for the patients. As such, in analogy to direct carotid puncture for anterior circulation MT, direct vertebral artery (VA) puncture (DVP) is a direct cervical approach, which can constitute the only feasible access to the posterior circulation in highly selected cases. So far, due to the rarity of DVP, only anecdotal evidence from isolated case reports is available and this approach raises concerns with regard to safety issues, feasibility, and technical realization. We present a case in which bail-out access to the posterior circulation was successfully obtained through a roadmap-guided lateral direct puncture of the V2 segment of the cervical VA and give an overview of technical nuances of published DVP approaches for posterior circulation MT.

Saccular or dissecting aneurysms involving the basilar trunk: Endovascular treatment and clinical outcome

Objectives: Basilar artery trunk aneurysms (BTAs) are a rare pathology and difficult to treat. We present our experience regarding angiographic results and clinical outcomes for 16 BTAs treated by reconstructive endovascular treatment (EVT) using stent or balloon. Methods: Between January 2003 and December 2014, 15 patients (mean age, 58.6 years; 11 males) with 16 BTAs were enrolled. Clinical manifestation, outcomes and procedural complications were evaluated retrospectively, and follow-up angiography was performed 12 and 24 months after procedure. Results: Subarachnoid hemorrhage (SAH) developed in seven aneurysms and nine were found incidentally. In one case, SAH followed by acute infarction on pons. The location of the aneurysms was the pure basilar artery (BA) trunk in 13 and the junction of the BA and the superior cerebellar artery in 3. Reconstructive EVT was technically successful in 15 aneurysms (93.8%) and failed in one due to the difficulty of vascular access. Stent/balloon-assisted coiling was performed in 13 aneurysms and sole stent therapy in two aneurysms. One patient had periprocedural complication of acute in-stent thrombosis. All treated patients had no symptoms with the usual activities except three patients, who died from myocardial infarction, aneurysmal rebleeding, and cerebellar infarction. Angiographic follow-up was performed in nine aneurysms; three aneurysms were recanalized (33.3%) and six aneurysms had no interval change (66.7%). There was no significant event during the follow-up period (mean, 23.5 months). Conclusion: In the treatment of BTAs, reconstructive EVT may provide a feasible and safe option to microsurgery.

Anatomical features of the vertebral artery for transbrachial direct cannulation of a guiding catheter to perform coil embolization of cerebral aneurysms in the posterior cerebral circulation

BACKGROUND

Transbrachial approach is an alternative technique for coil embolization of posterior circulation aneurysms. The purpose of our study was to investigate the anatomical features of the vertebral artery (VA) for transbrachial direct VA cannulation of a guiding catheter (GC) to perform coil embolization of posterior circulation aneurysms.

METHODS

Included in retrospective analysis were patients who underwent transbrachial coil embolization of cerebral aneurysms in the posterior cerebral circulation by direct VA cannulation of a GC from 2007 to 2013. Investigated were patient characteristics, preoperative sizes of aneurysms, aneurysms location, the angle formed by the target VA and the subclavian artery (AVS), and the VA diameter at the level of the fourth cervical vertebral body (VAD) in the side of the transbrachial access route.

RESULTS

Thirty-one patients with 32 aneurysms met our criteria. The locations of aneurysms were the VA (n = 16), basilar artery (BA) tip (n = 10), BA trunk (n = 3), BA superior cerebellar artery (n = 1), BA anterior inferior cerebellar artery (n = 1), and VA posterior inferior cerebellar artery (n = 1). The right brachial artery was punctured in 27 cases with 28 aneurysms as transbrachial direct cannulation of a GC, and left was in 4 cases with 4 aneurysms. The average AVS, ranging from 45° to 95°, was 77°, and the average VAD, ranging from 3.18 to 4.45 mm, was 3.97 mm.

CONCLUSION

For transbrachial direct cannulation of a GC, it seems required that the AVS is about 45° or more and the VAD is about 3.18 mm or more.

Initial experience of a novel sheath guide for transbrachial coil embolization of cerebral aneurysms in the anterior cerebral circulation

BACKGROUND

The transfemoral approach is a common technique for coil embolization of cerebral aneurysms in the anterior cerebral circulation. However, it is difficult to advance a guiding catheter into the carotid artery via the femoral route in patients with a tortuous aortic arch, an unfavorable supra-aortic takeoff, aortic diseases, or occlusion of the femoral artery.

OBJECTIVE

To report our initial experiences of coil embolization of cerebral aneurysms in the anterior cerebral circulation with a novel sheath guide for transbrachial carotid cannulation.

METHODS

A sheath guide designed specifically for transbrachial carotid cannulation was developed; transbrachial coil embolization for cerebral aneurysms began in May 2011. Included for analysis were patients who underwent transbrachial coil embolization for cerebral aneurysms in the anterior cerebral circulation from May 2011 to January 2012. Adjuvant techniques, angiographic results, procedural success, and periprocedural complications were investigated.

RESULTS

Ten patients underwent transbrachial coil embolization of cerebral aneurysms in the anterior cerebral circulation. All procedures were successful using the brachial route. No periprocedural complications occurred. Patients were permitted to get seated immediately after coil embolization even during hemostasis.

CONCLUSION

The sheath guide specifically designed for transbrachial carotid cannulation was useful for coil embolization of cerebral aneurysms in the anterior cerebral circulation.

Multiple non-branching dissecting aneurysms of the mid-basilar trunk presenting with sequential subarachnoid hemorrhages

OBJECTIVE

We describe a rare case of a patient with subarachnoid hemorrhage (SAH) due to a ventral dissecting mid-basilar aneurysm that was treated surgically. One week after surgery, the patient experienced sudden deterioration due to a new SAH caused by the development of a new aneurysm of the basilar trunk distinct from the previously clipped aneurysm.

CASE DESCRIPTION

A 54-year-old woman with acute subarachnoid hemorrhage was found to have a small, broad-based aneurysm arising from the ventral aspect of the mid-basilar artery. This complicated lesion was treated with a microsurgical clipping via a translabyrinthine pre-sigmoidal sub-temporal approach. One week postoperatively, the patient suffered a new SAH and was found to have developed a distinct basilar artery aneurysm. The patient was returned to the Operating Room for microsurgical clipping via the previous craniotomy. After surgery, the patient made a slow, but steady, recovery. She underwent repeated angiographic imaging, demonstrating a stable appearance. Two years post surgery, the patient had returned to work and had no obvious neurological deficit, with the exception of unilateral iatrogenic hearing loss.

CONCLUSION

We describe a rare case of multiple aneurysms originating in relation to a mid-basilar dissection, resulting in multiple episodes of SAH. These are difficult and dangerous lesions that can be treated with open microsurgical reconstruction or possibly via an endovascular approach. The intricate location of the lesions poses a particular challenge to neurosurgeons attempting to directly treat mid-basilar lesions.

Transbrachial Stent-Assisted Coil Embolization of Right Posterior Inferior Cerebellar Artery Aneurysm: Technical Case Report

OBJECTIVE AND IMPORTANCE

We describe a case of stent-assisted coil embolization of a wide neck right posterior inferior cerebellar artery (PICA) aneurysm via a transbrachial artery approach.

CLINICAL PRESENTATION

A 73-year-old woman with a past medical history of hypertension, hyperlipidemia, colon cancer, and osteoporosis presented with a throbbing occipital area headache. Magnetic resonance angiography revealed a wide neck right PICA aneurysm. She presented for a planned endovascular stent-assisted coil embolization.

TECHNIQUE

The initial transfemoral approach was complicated by persistent guide catheter instability due to marked tortuosity of the right vertebral artery (VA). The left VA could not be accessed due to left subclavian occlusion with steal syndrome. Neuroform-2 (Boston Scientific; Natick, MA) stent-assisted Matrix (Boston Scientific; Natick, MA) coil embolization was successfully performed through a 6-French guide catheter using a transbrachial approach.

CONCLUSION

Current advances in technology produce neuroendovascular devices that are smaller with increased flexibility, allowing nonfemoral vascular access to the cerebral circulation via alternate arterial routes. This patient case demonstrates transbrachial access is a viable approach for endovascular aneurysm coil embolization, with or without stent assistance, in cases with an unstable guide catheter due to tortuous vessels or abnormal anatomy when femoral access is complicated or contraindicated.

Time-of-flight magnetic resonance angiography in the follow-up of intracranial aneurysms treated with Guglielmi detachable coils

The purpose of this study was to evaluate time-of-flight magnetic resonance angiography (MRA) in the follow-up of intracranial aneurysms treated with Guglielmi detachable coils (GDCs). From January 1998 to January 2002 27 MRA and intra-arterial digital subtraction angiography (IADSA) examinations were analyzed for residual aneurysms and arterial patency following GDC placement. A total number of 33 intracranial aneurysms was analyzed, including 18 located in the posterior circulation. The MRA analysis was based on source images in combination with maximum intensity projections. The IADSA was used as the reference standard. Two aneurysms were excluded from evaluation, because of susceptibility artefacts from other aneurysms, which were clipped. Sensitivity and positive predictive values of MRA in revealing residual aneurysms were, respectively, 89% and 80%. Specificity in ruling out remnant necks and residual flow around coils was, respectively, 91% and 97%, with a negative predictive value of, respectively, 95% and 100%. Specificity and negative predictive value of MRA for arterial occlusion were, respectively, 87% and 100% for the parent arteries and, respectively, 85% and 100% for the adjacent arteries. MRA is a reliable diagnostic tool in the follow-up of GDC treatment, and it may replace IADSA in excluding residual flow around coils and aneurysmal necks and in ruling out arterial occlusion.

Endovascular treatment of giant p1/p2 aneurysm by direct puncture of the vertebral artery. Case report

SUMMARY

Vascular access is usually achieved through a femoral arterial puncture using a modified Seldinger technique. However, selective catheterization of the great cerebral vessels by femoral approach fails completely when the vessel is tortuous or atheromatous. In case of posterior vascular circulation aneurysms, transbrachial approach or direct puncture of the vertebral artery (VA) is an alternative. The aneurysms of the posterior cerebral artery (PCA) are reported to be rare. Due to unfavorable anatomic location, the PCA aneurysms are difficult to reach during surgical procedure. Endovascular embolization is at present considered to be more effective and safer treatment of the PCA aneurysms arising from different segments, offering a viable alternative to the surgical approach. We report the case of the giant left PCA aneurysm, located at the junction of P1/P2 segments, successfully treated by parent artery occlusion achieved after the direct puncture of the right VA which was used because both VAs were tortuous, irregular and their ostia were not accessible by femoral approach. According to different authors, parent artery occlusion appears to be safe in the treatment of P2 segment aneurysms, whatever the location of the occlusion. In our case we decided to perform this kind of treatment believing it was the only possible one.