Flow Diverter Therapy of a Giant Fusiform Vertebrobasilar Junction Aneurysm in a Child: Case Report

A vertebrobasilar junction aneurysm successfully treated with a combination of surgical clipping and flow diverter placement based on the results of computational fluid dynamics analysis: illustrative case

BACKGROUND

The treatment of vertebrobasilar junction (VBJ) aneurysms is challenging. Although flow diverters (FDs) are a possible treatment option, geometrical conditions hinder intervention. VBJ aneurysms possess dual inflow vessels from the bilateral vertebral arteries (VAs), one of which is ideally occluded prior to FD treatment. However, it remains unclear which VA should be occluded.

OBSERVATIONS

A 75-year-old male with a growing VBJ complex aneurysm exhibiting invagination toward the brainstem and causing perifocal edema required intervention. Preoperative computational fluid dynamics (CFD) analysis demonstrated that left VA occlusion would result in more stagnant flow and less impingement of flow than right VA occlusion. According to the simulated strategy, surgical clipping of the left VA just proximal to the aneurysm was performed, followed by FD placement from the basilar artery trunk to the right VA. The patient demonstrated tolerance of the VA occlusion, and follow-up computed tomography angiography at 18 months after FD treatment confirmed the disappearance of the aneurysm.

LESSONS

Preoperative flow dynamics simulations using CFD analysis can reveal an optimal treatment strategy involving a hybrid surgery that combines FD placement and direct surgical occlusion for a VBJ complex aneurysm.

A Patient with a Large Aneurysm Complicated by Stenosis of the Internal Carotid Artery Distal to the Aneurysm in Whom Treatment Using a Pipeline Flex Was Performed

Objective

We report a case of in-stent stenosis as a complication at 6 months after the deployment of Pipeline Flex. This case necessitated retreatment for parent artery occlusion.

Case Presentation

A 55-year-old woman with right-side visual disorder was referred to our hospital for the deployment of Pipeline Flex. Cerebral digital subtraction angiography (DSA) demonstrated a large right-side paraclinoid aneurysm in combination with severe internal carotid artery (ICA) stenosis just beyond the aneurysm. We deployed Pipeline Flex under general anesthesia. After deployment, we performed angioplasty through the Pipeline. Six months after deployment, this patient exhibited exacerbation of visual disorder. Follow-up DSA revealed in-stent stenosis at 6 months after the deployment of Pipeline Flex. Therefore, we performed parent artery occlusion. Right-side visual disorder was improved in this patient.

Conclusion

If Pipeline is deployed for patients with ICA stenosis just beyond an aneurysm, we need to be aware of in-stent stenosis after deployment.