Coil Embolization with Subsequent Subacute Flow Diversion Before Hospital Discharge as a Treatment Paradigm for Ruptured Aneurysms

Acute Coiling With Delayed Flow Diversion for Posterior Communicating Segment Internal Carotid Artery Aneurysms: A Multicenter Case Series

BACKGROUND AND OBJECTIVES

In ruptured posterior communicating artery (PcomA) aneurysms, the protection of the aneurysm dome alone with initial subtotal coiling decreases the risk of rerupture in the acute setting but does not provide durable/definitive long-term protection against delayed rupture. Delayed flow diverter (FD) placement can be a potential alternative to definitively secure these aneurysms without increasing the risk of complications and PComA occlusion. We analyzed PComA aneurysms treated with a planned delayed FD after primary coiling and assess radiographic and clinical outcomes.

METHODS

We performed a retrospective study of prospectively collected data for intracranial aneurysms treated with planned FD at 2 institutions from 2013 to 2022. PComA aneurysms that underwent primary coiling and delayed FD placement were included for analysis.

RESULTS

There were 29 PComA aneurysms identified that were included in the analysis. Patients were mostly female (79.3%), with a median age of 60 years. The mean aneurysm maximum diameter was 7.2 mm ± (5.3). Immediate Raymond-Roy occlusion grade after primary coiling was I in 48.3%, II in 41.4%, and III in 10.3% of aneurysms. The median time from initial coiling to planned delayed FD placement was 6.3 months (3.2-18.6). A total of 21 (72.4%) aneurysms underwent follow-up radiological imaging. Complete and near-complete occlusion status was achieved in 76.2% of the evaluated aneurysms. There were no retreatments and no evidence of delayed aneurysm rupture. One case (3.5%) presented thromboembolic complications and 1 (3.5%) intracranial hemorrhagic complication after FD placement, which was associated with mortality. Most patients (90.5%) had a modified Rankin scale of ≤2 on the last follow-up.

CONCLUSION

Primary coiling with planned staged FD placement is effective for treating ruptured PComA aneurysms with high occlusion rates and low complications.

Ruptured thrombosed vertebral artery dissecting aneurysm treated with staged flow diverter after prediction of the rupture point by vessel wall MRI

The safety and feasibility of using staged flow diverter (FD) for ruptured cerebral aneurysms, in which coil embolization is performed in the acute phase and FD is deployed in the subacute phase, has recently been reported. This strategy requires assuming the rupture point and performing coil embolization. Although vessel wall magnetic resonance imaging (VW-MRI) has been reported to be useful in predicting the rupture point of aneurysms, its use with staged FD has not yet been reported. We report the first case of staged FD with preoperative contrast-enhanced VW-MRI to predict the rupture point for partially thrombosed vertebral artery dissecting large aneurysm involving posterior inferior cerebellar artery (PICA) origin. This approach achieved a very good outcome, not only completely occluding the aneurysm, but also reconstructing the parent artery while maintaining the patency of the PICA.

Dual-Lumen Balloon-Assisted Coiling and Staged Flow Diversion for Ruptured Wide-Necked Posterior Communicating Artery Aneurysm: Two-Dimensional Operative Video

Endovascular treatment of acutely ruptured wide-necked aneurysms presents well-known challenges because of the desire to avoid intracranial stenting with attendant dual antiplatelet therapy requirements. Balloon-assisted coiling (BAC) has been well described for this purpose, most commonly using a 2-microcatheter technique, with a balloon microcatheter protecting the aneurysm neck and a coiling microcatheter used to embolize the aneurysm.^1,2 However, the availability of advanced double-lumen balloon microcatheters with coiling markers allows for the use of a single-microcatheter technique in select instances.³ We present the case of a patient presenting with a ruptured wide-necked posterior communicating artery aneurysm with a large posterior communicating artery arising from the neck. The aneurysm dome had sufficient height to allow BAC using a single balloon microcatheter, which was used to protect the posterior communicating artery at the neck and deploy coils in the aneurysm dome. The aneurysm was intentionally subtotally coiled and the patient was retreated with a flow-diverting stent later during the same hospitalization (Video 1). Partial coiling followed by later flow diversion is a pragmatic strategy in wide-necked ruptured aneurysms,⁴ and use of a single balloon microcatheter for BAC can be useful in certain situations.