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• W2149202479 abstract "Editor: Despite recent advances in balloon- and stent-assisted coiling, the endovascular treatment of wide-neck (>4 mm) aneurysms, especially when they are large and incorporate adjacent arteries into their base, remains very difficult or impossible with current endovascular techniques. We describe a technique for reconstructing a terminal (T-shaped) bifurcation with use of a double stent in a patient with a recurrent basilar apex aneurysm. A 68-year-old man was treated for subarachnoid hemorrhage from a ruptured basilar-tip aneurysm in October 2002. The aneurysm was treated with use of detachable platinum coils and balloon neck protection with two balloons, one positioned in each posterior cerebral artery (PCA), on two occasions (October 2002 and May 2003). Six months after the second treatment, the patient experienced the sudden onset of a severe headache associated with a disconjugate gaze. No subarachnoid hemorrhage was detected on computed tomography. Angiography revealed that there had again been significant coil compaction with recanalization and an increase in size of the aneurysm. The extent of incorporation of the origin of the right PCA into the aneurysm base had increased. After discussion of the treatment alternatives in detail, a T-configured stent placement technique was thought to offer the best chance for additional treatment of this aneurysm. Because of their flexibility and open cell construction, Neuroform stents (Boston Scientific/Target Therapeutics, Natick, MA) were chosen for treatment; before treatment, we tested the technique with two Neuroform stents in vitro to see the configuration of the stents when placed in a crossing stent configuration (Figure). Informed consent was obtained from the patient before treatment. The patient was administered daily doses of clopidogrel 425 mg and aspirin 325 mg orally before the procedure. During the procedure, the patient underwent heparin infusion, with the activated clotting time maintained at 2.5–3 times baseline levels. Endovascular treatment was performed with the patient under general anesthesia with use of a bilateral common femoral artery approach. After initial arteriography, the first Neuroform stent (4 × 20 mm) was positioned and deployed in the right PCA so that it extended from the P2 segment of the PCA to the distal segment of the basilar artery. Next, a second Neuroform stent of the same size was delivered though an open cell of the first stent and was deployed from the P2 segment of the left PCA into the distal segment of the basilar trunk. The proximal part of the second stent was positioned so that it was within the lumen of the first stent (Figure, parts a,b). The aneurysm was then catheterized through the two stents with use of a microcatheter (Excelsior SL-10; Boston Scientific). No difficulty was experienced crossing through the bridging stents. The recanalized portion of the aneurysm was coiled with use of a series of 20 platinum coils (Micrus, Mountain View, CA). Dense packing of the aneurysm was intentionally avoided in an effort to avoid placing excess force on the stents. Posttreatment angiography revealed only a small residual neck (Figure, part c). The posttreatment course of the patient was uneventful and he was discharged home from the hospital 2 days after treatment. Two weeks after discharge, the patient was readmitted to the hospital because of a seizure and decreased level of consciousness. Magnetic resonance imaging of the brain revealed multiple bilateral acute cerebellar and brainstem infarcts. He had discontinued clopidogrel and aspirin several days before the onset of the change in his neurologic condition. After stabilization of his general status, the patient was transferred to a nursing home for long-term rehabilitation, with major residual neurologic deficits. He died a week after transfer to the nursing home. Outcome after coiling of ruptured basilar bifurcation aneurysms is superior to that achieved with surgical clipping (1Brilstra EH Rinkel GJ van der Graaf Y van Rooij WJ Algra A Treatment of intracranial aneurysms by embolization with coils: a systematic review.Stroke. 1999; 30: 470-476Crossref PubMed Scopus (392) Google Scholar, 2Lempert TE Malek AM Halbach VV et al.Endovascular treatment of ruptured posterior circulation cerebral aneurysms: clinical and angiographic outcomes.Stroke. 2000; 31: 100-110Crossref PubMed Scopus (122) Google Scholar). Because of the combination of the patient's age, the morphology of his aneurysm, the presence of a dense coil mass in the aneurysm, and the estimated mortality and severe morbidity, surgical clipping was not assessed as a first treatment choice. Likewise, because of the substantial risk of recurrent bleeding after incomplete coiling (especially in giant aneurysms) and the large size of this aneurysm, conservative therapy was excluded (3Eskridge JM Song JK Endovascular embolization of 150 basilar tip aneurysms with Guglielmi detachable coils: results of the Food and Drug Administration multicenter clinical trial.J Neurosurg. 1998; 89: 81-86Crossref PubMed Scopus (209) Google Scholar, 4Malisch TW Guglielmi G Vinuela F et al.Intracranial aneurysms treated with the Guglielmi detachable coil: midterm clinical results in a consecutive series of 100 patients [Published erratum appears in J Neurosurg 1998;88:359].J Neurosurg. 1997; 87: 176-183Crossref PubMed Scopus (307) Google Scholar). Recently, the self-expanding Neuroform stent was approved by the US Food and Drug Administration specifically for the treatment of wide-neck aneurysms. The wide cells of the deployed stent (2.0 –2.5 F) allow easy insertion of a microcatheter through the stent. Placement of a second Neuroform stent through the interstices of the first has been described previously by Broadbent et al (5Broadbent LP Moran CJ Cross III, DT Derdeyn CP Management of Neuroform stent dislodgement and misplacement.AJNR Am J Neuroradiol. 2003; 24: 1819-1822PubMed Google Scholar). We also checked the feasibility of the technique in vitro with two nonsterile Neuroform stent samples and observed the deployed stents in a T configuration (Figure, part d). The low radial force exerted by the stent was enough to keep the coils from protruding into the parent artery. Although some of the struts overlapped at the crossing points of two stents, this was not sufficient to alter flow significantly. Because of the risk of thromboembolic phenomena after stent implantation, we initiated and maintained antiplatelet therapy. Based on our previous experience with the Neuroform stent in treatment of aneurysms, we estimated the risk of thrombus formation as acceptable as long as antiplatelet therapy was maintained. Use of this technique in the cerebral vasculature may provide a valuable addition to the ability to treat difficult intracranial aneurysms. The degree to which the risk of thromboembolic phenomena is increased when crossing stents are used and the long-term outcome of patients treated with this technique remain to be determined." @default.
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• W2149202479 date "2004-09-01" @default.
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• W2149202479 title "Reconstruction of the Basilar Tip with T Stent Configuration for Treatment of a Wide-Neck Aneurysm" @default.
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