The Neuroradiology Journal 20: 337-341, 2007

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Stenting and Coil Embolization of a Surgically Treated Residual Aneurysm of the Middle Cerebral Artery Bifurcation Associated with Coil Embolization of a Communicating Artery Aneurysm. A Case Report

M. LEONARDI, M. DALL’OLIO, A. STAFA, F. de SANTIS Neuroradiology Department, Bellaria Hospital; Bologna, Italy

Key words: brain aneurysms, intracranial stenting, interventional neuroradiology

SUMMARY – We describe the case of a 76-year-old man admitted to our hospital for mild subarachnoid haemorrhage detected by CT scan in an aneurysm of the left middle cerebral artery bifurcation treated surgically 29 years earlier and not completely occluded. Angiography disclosed a further aneurysm in the anterior communicating artery. During the same procedure we treated the residual aneurysm in the left middle cerebral artery bifurcation positioning a Neuroform3 stent (Boston) and embolization deploying two biologically active Cerecyte coils (Balt) for a total of 10 cm and excluding the communicating artery aneurysm from the circulation releasing two active Cerecyte coils for a total length of 30.9 cm. The procedure was well tolerated by the patient and did not give rise to neurological deficits.

Introduction The treatment alternatives for intracranial aneurysms are surgical clipping or endovascular embolization. The ISAT study reported positive outcomes for endovascular treatment being less invasive than surgery 1 with a lower mortality rate and fewer permanent invalidating neurological deficits. On the other hand, the study reported a higher percentage of incomplete aneurysm obliteration and post-treatment bleeding after embolization compared with clipping 2. Redo interventions on aneurysms already treated are problematic due to the presence of surgical clips or coils and the morphology of the revascularized portion of the aneurysm. In the past corrective intervention was usually surgical as coils could not be retained by the revascularized proximal portion of the an-

eurysm entailing a high risk of coil migration leading to thrombo-embolic complications. The advent of self-expanding intracranial stents and subsequent improvements to the latest devices have allowed not only the complete closure of coil embolized aneurysms but also corrective intervention for surgically treated lesions. In addition, the enhanced flexibility and navigability of new materials and the availability of extremely small stents has allowed the stenting of small distal arteries. We describe the case of a 76-year-old man with subarachnoid haemorrhage secondary to rupture of an aneurysm in the left middle cerebral artery bifurcation surgically treated but not completely occluded 29 years earlier, and a newly discovered aneurysm in the anterior communicating artery. Both lesions were treated by stenting and coil embolization during a single procedure. 337

Stenting and Coil Embolization of a Surgically Treated Residual Aneurysm of the Middle Cerebral Artery Bifurcation...

Figure 2 Anteroposterior view angiogram showing the small surgically treated aneurysm in the left middle cerebral artery associated with an artefact caused by the clip (arrow) and the anterior communicating artery aneurysm (arrowhead).







Figure 1 CT scan: small blood collections in the left Sylvian region and endoventricular bleeds with ventricular dilatation.





M. Leonardi

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Figure 3 3D reconstructed images. A) Anteroposterior view showing the two aneurysms (arrows) and the surgical clip (arrowhead). B) Oblique view showing the irregular shape of the anterior communicating artery aneurysm.

Case Report A 76-year-old man had undergone surgery at the age of 47 years for subarachnoid haemorrhage caused by rupture of an aneurysm in the 338

bifurcation of the left middle cerebral artery. The aneurysm was not completely excluded from the circulation with neck patency. At the time of observation the patient was receiving medical treatment for diabetes mellitus type 2, ar-

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The Neuroradiology Journal 20: 337-341, 2007

Figure 4 Unsubtracted anteroposterior view showing the proximal and distal positions of the stent and the surgical clip.

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Figure 5 Final, post-embolization control angiograms.

terial hypertension and prostatic hypertrophy. The patient presented at the emergency room of another hospital on 17th March 2007 with a ten day history of spatiotemporal disorientation and worsening deambulation difficulties. A CT

scan sent electronically to the Neuroradiology Service at our hospital disclosed mild subarachnoid haemorrhage in the site of previous surgery with endoventricular collections and hydrocephalus (figure 1). The patient was trans339

Stenting and Coil Embolization of a Surgically Treated Residual Aneurysm of the Middle Cerebral Artery Bifurcation...

ferred to the neurosurgery ward at our hospital and underwent surgery to position an external ventricular shunt. Angiography disclosed a residual aneurysm in the left middle cerebral artery and another irregularly shaped aneurysm in the anterior communicating artery (figure 2, 3). Three days later the patient had endovascular treatment to occlude both aneurysms. The procedure was performed with the patient under general anaesthesia and total heparinization to obtain coagulation times between 250 and 350 seconds to which an i.v. bolus of 1g aspirin (Aspegic) was added. After positioning a 5F calibre guiding catheter (Envoy, Cordis), a Neuroform3 stent (2.5 mm×2 cm) (Boston) was deployed in the bifurcation of the left middle cerebral artery in front of the surgically treated residual aneurysm with its proximal tip in the horizontal portion of the middle cerebral artery and its distal tip in one of the branches (figure 4). The residual aneurysm was then microcatheterized (Excelsior 10, Boston) through the stent mesh where two biologically active coils (Cerecyte, Balt) were released for a total length of 10 cm. Later in the same procedure the anterior communicating artery aneurysm was also microcatheterized and another two active coils (Cerecyte, Balt) released for a total length of 30.9 cm. At the end of the procedure both aneurysms had been occluded from the circulation (figure 5) and the patient awoke without neurological deficits. The following drug management protocol was adopted: for 48h after the endovascular procedure enoxaparin (Clexane) 4×2 was associated with ticlopidine (Tiklid) 250×2, acetyl salicylic acid (Ascriptin) 0.3×1 and ranitidine (Zantac) 1×150 mg tab daily. Anti-aggregant therapy was administered at these doses for seven days after the procedure. Ticlopidine (Tiklid) was subsequently reduced to 250×1 and continued alongside the other drugs at the same doses for seven days. Ticlopidine (Tiklid) was then suspended and acetyl salicylic acid (Ascriptin) 0.3×1 and ranitidine (Zantac) 1 150 mg tab daily continued for six months. No premedication was given prior to Neuroform stent insertion. Haemochrome was measured on the tenth day of treatment to disclose possible low platelet levels. Discussion Rebleeding of a surgically treated aneurysm is rare, occurring in 1.21% of cases in the ISAT study and from 0 to 2.27% in other literature 340

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reports 2. Incomplete exclusion of surgically treated aneurysms from the circulation was 17.8% according to ISAT, but varied widely from 0 to 26.3% in other studies 2. Our patient had undergone surgical treatment for a left middle cerebral artery aneurysm 29 years earlier. Angiography disclosed another aneurysm in the anterior communicating artery. Although the patient’s symptoms had arisen several days before hospital admission, rebleeding of the surgically treated incompletely occluded aneurysm was suspected from the small subarachnoid bleed around the site of surgery. The residual aneurysm was small and was probably the neck of the surgically treated aneurysm showing a large communication with the middle cerebral artery. In these cases coil embolization of the aneurysmal sac carries a high risk of coil migration outside the aneurysm giving rise to thromboembolic complications. Hence we opted to position a stent across the front of the residual aneurysm and subsequently occlude the lesion with coils deployed through the stent mesh. The stent reduces the possibility of coil migration both during and after the embolization procedure. In addition, the stent offers wellknown therapeutic advantages confirmed by clinical studies and experimental models. The stent mesh serves as a matrix to aid endothelial growth and coil compaction, thereby reducing blood inflow within the aneurysmal sac and contributing to stasis and then thrombosis 3-8. In our patient the stent had to be released astride the aneurysm and hence the bifurcation of the middle cerebral artery, positioning its proximal tip in the horizontal stretch of the cerebral artery and its distal tip in one of the narrower branches. A recent study on eight patients described the placement of self-expanding Neuroform stents associated with the release of coils to treat wide-necked aneurysms in distal arteries with diameters

Stenting and coil embolization of a surgically treated residual aneurysm of the middle cerebral artery bifurcation associated with coil embolization of a communicating artery aneurysm. A case report.

We describe the case of a 76-year-old man admitted to our hospital for mild subarachnoid haemorrhage detected by CT scan in an aneurysm of the left mi...
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