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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 64-67

Stent-assisted aneurysm coiling of a complex A1–A2 aneurysm: A technically demanding but useful procedure in complex intracranial aneurysms


1 Institute of Neurosciences, Sakra World Hospital, Bengaluru, Karnataka, India
2 Manipal Hospitals, Whitefield, Bengaluru, Karnataka, India

Date of Submission22-Jul-2020
Date of Acceptance28-Jul-2020
Date of Web Publication1-Oct-2020

Correspondence Address:
Dr. Sibhi Ganapathy
Manipal Hospitals, Whitefield, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_2_20

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  Abstract 


Intracranial aneurysms are a subject of controversy. Anterior circulation aneurysms are usually considered surgical territory, yet endovascular prowess can affect good results with minimal morbidity and comparable long-term results. We present a complex anterior cerebral artery aneurysm that would require either a bypass or a complex vessel reconstructive procedure. Instead, we proceeded to perform a stent-assisted coiling trapping the coils inside the aneurysm through a covered stent, thereby ensuring vascular continuity and complete aneurysm control. A brief review of the literature is also added to put this report in perspective.

Keywords: Anterior cerebral artery, fusiform aneurysm, intracranial aneurysm, stent-assisted coiling


How to cite this article:
Gopal S, Ganapathy S. Stent-assisted aneurysm coiling of a complex A1–A2 aneurysm: A technically demanding but useful procedure in complex intracranial aneurysms. J Cerebrovasc Sci 2020;8:64-7

How to cite this URL:
Gopal S, Ganapathy S. Stent-assisted aneurysm coiling of a complex A1–A2 aneurysm: A technically demanding but useful procedure in complex intracranial aneurysms. J Cerebrovasc Sci [serial online] 2020 [cited 2020 Nov 28];8:64-7. Available from: http://www.jcvs.com/text.asp?2020/8/1/64/296925




  Introduction Top


Ever since the publication of the International Subarachnoid Haemorrhage and Aneurysm trial (ISAT trial), there has been a debate about the appropriate modality for the treatment of intracranial aneurysms.[1] Further clarity was brought through Robert Spetzler and his Barrow Ruptured Aneurysm Trial (BRAT trial) series where anterior circulation aneurysm was considered better for surgical clipping, whereas posterior circulation aneurysm was considered endovascular territory.[1] Further reports by the UCAS Japan Investigators and other large randomised trials have proceeded conflicting reports leading to the need to individualise treatment with respect to the natural history of the aneurysm, locations, shape and modalities available in the centre in question as well as the expertise of the neurosurgeon/radiologist treating the patient in question.[1],[2] Thus, with such a complex issue not even close to a conclusion, we present our case of a complex A1–A2 aneurysm treated endovascularly with good results.


  Case Report Top


A 60-year-old male, a known hypertensive for many years, was seen in the emergency room with sudden onset of headache and severe neck pain. The ictus occurred 1 h before the admission. On examination, his blood pressure was 170/90; his Glasgow Coma Scale was 14 with no focal neurological deficits. He, however, had an episode of giddiness in January 2017 with no loss of consciousness. No headache or associated neck pain occurred then. It was decided to manage conservatively. At this presentation, however, magnetic resonance imaging and magnetic resonance angiogram of the brain were done. The imaging done showed ectasia of the right anterior cerebral artery with a small bleb which occupied the entire right A1–A2 junction engulfing the anterior communicating artery as well [Figure 1]. Computed tomography angiography three-dimensional recon along with a digital subtraction angiography study along with an Right Carotid Artery (RCA) study was done. This showed a larger fundus of the aneurysm. This coupled with the symptomatic presentation made us consider intervention over observation.
Figure 1: Showing the fusiform aneurysm occupying the A1-A2 junction encompassing the anterior communicating artery and its perforators

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The management options were varied. We had at our disposal facilities for both surgical and endovascular intervention. Surgical options ranged from clipping and bypass surgeries. Clipping options included proximal and distal clipping of the aneurysm, just proximal clipping and proximal and distal clipping along with clipping of the anterior communicating artery [Figure 2]. Bypass options included either an A3–A3 bypass or a superior temporal artery anterior communicating artery bypass (STA ACA) with trapping and clipping of the aneurysm [Figure 3] which would involve considerable sub frontal and inter hemispheric retraction which in a tense brain which would lead to more damage. Endovascular options ranged from simple coiling of the aneurysm sacrificing one ACA, stent-assisted coiling of the aneurysm, to flow diverter placement [Figure 4].
Figure 2: Showing the various surgical options possible for the aneurysm. The Options include proximal and distal clipping, proximal clipping alone and finally clipping of the aneurysm and the anterior communicating artery

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Figure 3: Bypass surgical options where the aneurysm is clipped as shown in figure 2 with either an A3-A3 side to side bypass or an augmentative Superficial temporal artery (STA) to Anterior cerebral artery (ACA) bypass.

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Figure 4: Endovascular options including simple coiling, flow diverter placement and finally stent assisted coiling

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In comparison to the surgical options, the endovascular techniques presented a simple and elegant option, with less chance for complications and secondary and tertiary brain injury. There was less exposure to metal (due to subarachnoid haemorrhage [SAH]), less retraction, less dissection of a tense brain, yet a comprehensive solution to the problem present. The chosen endovascular strategy was a stent-assisted coiling keeping costs in mind along with efficacy. The only concern was the need for long-term usage of dual antiplatelets and tirofiban (GP2b3a antagonist).

The patient was assessed and shifted to the intensive care unit (ICU). The relatives were counselled and explained the procedure and the nature of the disease. An informed consent was taken and the required hardware was procured. The patient was placed under general anaesthetic on the cath lab gantry. Femoral access was obtained and initially, a 6f sheath was placed in situ. After reaching the carotid circulation in the brain, a sheath exchange was performed and a 7f long Raabe sheath was placed. A 6f Fargomax guiding catheter was placed just distal to the aneurysm.

Vasco 10 braided microcatheter was used in a coaxial manner in order to guide the coils separately through an Echelon 10 catheter [Figure 5]. A Leo baby stent (2.5 × 30) was deployed using the Fargomax and Vasco microcatheters across the aneurysm and coiling of the aneurysm was done through the jailed Echelon catheter (the advantage of the Leo baby was that it was a low-profile stent allowing it to gain access to vessels down to 0.2 mm in diameter, full visibility on fluoroscopy and most important of all resheathable up to 90% of its length. The stent also has round and short flayed ends to enhance grip to the vessel intima preventing migration. Barricade coils (3 in number) were placed into the aneurysm and tightly packed to induce thrombosis and further reduce the ingress of blood. Final runs were taken to ensure the stability of the system.
Figure 5: Showing passage of the microcatheter through the aneurysmal segment. Deployment of the stent and coiling of the aneurysm, shown sequentially

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The sheath was then exchanged to a smaller 6f sheath and left in situ overnight. The patient was extubated and shifted to the ICU for overnight observation. The next day after checking the ACT, the sheath was removed successfully. The patient was immobilised for 6 h, after which he was made to walk. He was discharged on the 3rd post-procedure day with minimal cognitive deficits such as memory impairment and confusion which gradually improved as well. He was put on dual antiplatelets and reviewed 2 weeks later. Complete improvement with the stability of the endovascular system confirmed by a check angiogram. He continues to do well without deficits or recurrence.


  Discussion Top


The genesis of intracranial aneurysms has been described as a play of environmental factors on structural and physiological deficiencies of the cerebral vasculature. Structural factors include the lack of medial gap in the vessel wall, repeated branching, especially at 90°, small diameter vasculature in a high pressure, high-flow vascular system and lack of vessel support in the subarachnoid space.[2],[3],[4] Patient factors include atherosclerosis, vessel dissection and association with other diseases such as von Recklinghausen's disease, fibromuscular dysplasia, systemic lupus erythematosus, Ehlers–Danlos disease and various collagen-associated vascular diseases.[4],[5]

Fusiform aneurysms present a unique disadvantage as they present not only a risk of rupture but also a risk to obstruction to the unimpeded flow of blood in the vessel.[4],[5],[6] The treatment of fusiform aneurysms should be based on the presence and type of symptoms, the lesion size and location and the risk of any accompanying intervention.[4],[5] Day et al. have suggested guidelines for the treatment of patients with dissecting aneurysms of the MCA. They recommend that most small and some large focal dilatations, especially those that are asymptomatic, should be treated conservatively unless serial neuroimaging assessment indicates significant enlargement over time.[4] However, the appearance of symptoms requires aggressive intervention. Lanzino et al. and Nikawa et al. also recommended conservative treatment in patients with dissecting aneurysms without neurological deterioration or recurrent SAH because of the possibility of spontaneous resolution of a dissecting aneurysm. Day et al. also recommend that patients with stenotic or occlusive lesions presenting with acute ischemic symptoms should be treated conservatively.[5] However, Kurino et al. reported a patient with a dissecting aneurysm in the MCA who presented with ischemic symptoms and who showed a poor outcome after conservative treatment. They recommended surgical revascularisation distal to the compromised artery.[6] Much of this discussion is based on the previously high collateral cost of managing fusiform aneurysms. However, the newer modalities such as endovascular flow diversion, covered stents and even surgical techniques such as bypasses have reduced the morbidity of such lesions, increasing the indications for intervention, thereby reducing morbidity and eventual mortality.

Another important factor leading to the findings of the ISAT and BRAT trials was the abundance of fusiform aneurysms in the posterior circulation.[7],[8],[9] Here, with vessel continuity and flow being critical to survival, endovascular therapy appeared to offer a significant advantage over surgery. The long-term ISAT review published in 2019 suggested no long-term difference as suggested by the BRAT and UCAS trial, thereby lessening the advantages of surgery in fusiform aneurysms.[8],[9] Hence, an overall improvement is expected with sufficient skill exercised in endovascular therapy, rather than surgery.[10],[11] If there are contraindications to long-term anticoagulant therapy or long-term antiplatelet therapy, then surgery may be considered. Options discussed above depend upon the dominant nature of the anterior cerebral circulation as enunciated by McAllister and Sengupta.[12] Non-dominant vessels may be either just ligated or the entire fusiform ectatic segment may be clipped relying upon the dominant ACA to service both the pericallosal arteries. If this is not possible, then vessel refashioning using clips or grafts along with bypasses may be used. Distal vessel augmentative bypasses have been shown to have good results. The technical knowhow and expertise, however, is considerable making it not frequently used.[11],[12]


  Conclusion Top


No fixed protocol exists for complex aneurysms. Individualisation of treatment keeping aneurysm structure, available facilities as well as surgeon expertise with patient characteristics leads to optimal results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nikawa S, Yamada J, Sumi Y, Yamakawa H. Dissecting aneurysm of the middle cerebral artery manifesting as subarachnoid haemorrhage and haemorrhagic infarctions. Case report. Neurol Med Chir (Tokyo) 2002;42:62-6.  Back to cited text no. 1
    
2.
Kurino M, Yoshioka S, Ushio Y. Spontaneous dissecting aneurysms of anterior and middle cerebral artery associated with brain infarction: A case report and review of the literature. Surg Neurol 2002;57:428-36.  Back to cited text no. 2
    
3.
Lanzino G, Kaptain G, Kallmes DF, Dix JE, Kassell NF. Intracranial dissecting aneurysm causing subarachnoid hemorrhage: The role of computerized tomographic angiography and magnetic resonance angiography. Surg Neurol 1997;48:477-81.  Back to cited text no. 3
    
4.
Day AL, Gaposchkin CG, Yu CJ, Rivet DJ, Dacey RG. Jr. Spontaneous fusiform middle cerebral artery aneurysms: Characteristics and a proposed mechanism of formation. J Neurosurg 2003;99:228-40.  Back to cited text no. 4
    
5.
Nakajima M, Fuse I, Tsuji K, Nozaki K. Anterior cerebral artery dissecting aneurysm presenting with subarachnoid haemorrhage. A case report and review of literature. Surg Cerebral Stoke 2009;37:128-34.  Back to cited text no. 5
    
6.
Kimura T, Nishimura K, Fukaya S, Morita A. Fusiform aneurysm of the anterior communicating artery treated by vascular reconstruction: Case report. Neurosurgery 2010;66:E1025-6.  Back to cited text no. 6
    
7.
Mantatzis M, Kizilkilic O, Albayram S, Kocer N, Islak C. Endovascular treatment of aneurysms associated with fenestrated A1 segment of anterior cerebral artery: Report of two cases. J Neuroimaging 2011;21:165-9.  Back to cited text no. 7
    
8.
Ion G, Chiriac A, Dobrin N, Poeata I. Ruptured fusiform aneurysm of the proximal anterior cerebral artery in young patient: Case report. Romanian Neurosurgery. 2015 Sep 15:286-90.  Back to cited text no. 8
    
9.
Seung WB, Kim JW, Park YS. Stent-assisted coil trapping in a manual internal carotid artery compression test for the treatment of a fusiform dissecting aneurysm. J Korean Neurosurg Soc 2012;51:296-300.  Back to cited text no. 9
    
10.
Alurkar A, Karanam LS, Nayak S, Oak S. Endovascular Treatment of A1 Aneurysms: A Series of Five Cases with a Brief Literature Review. Neuroradiol J 2012;25:533-40.  Back to cited text no. 10
    
11.
Tollard E, Niemtschik L, Darsaut TE, Guilbert F, Roy D, Raymond J, et al. Endovascular parent artery occlusion for the treatment of wide-neck A1 segment aneurysms: A single-center experience. AJNR Am J Neuroradiol 2011;32:174-8.  Back to cited text no. 11
    
12.
Wang HW, Xue Z, Ma YD, Sun ZH, Wu C. The special considerations in the surgical management of proximal anterior cerebral artery aneurysms. World Neurosurg 2019;127:e761-7.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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