Basilar Artery Aneurysm Research Articles

Stent-assisted coil embolization for blood blister-like aneurysm of upper basilar artery: a case report and literature review

Stent-assisted coil embolization for blood blister-like aneurysm of upper basilar artery: a case report and literature review

Endovascular Treatment Modalities for Basilar Artery Aneurysms

Endovascular Treatment Modalities for Basilar Artery Aneurysms

Our experience with the using of pCONUS2 implant for endovascular occlusion of cerebral bifurcation aneurysms

Objective ‒ to analyze the outcomes of endovascular treatment of aneurysms occluded by microcoils using pCONUS2 implants.Materials and methods. A retrospective analysis of treatment outcomes from January 2021 to March 2023 was conducted at the SO «Scientific-practical center of endovascular neuroradiology NAMS of Ukraine». Among 532 patients with cerebral aneurysms, 22 were treated with bifurcation implants pCONUS2 (Hydrophilic Polymer Coating (HPC)). The study group comprised 22 patients (11 females, 11 males, average age 53.01 years) with 26 aneurysms (3 patients had multiple aneurysms, one of which was excluded from use pCONUS2), including 9 (40.9 %) ruptured aneurysms. All of them were operated on during the acute period. Induction and controlled implantation of pCONUS2 were successfully performed in all patients. No technical problems have been registered that could make it difficult to navigate, start and detach the device. Results. Initial occlusion assessment using the modified Raymond-Roy classification (mRRC) showed total occlusion (mRRC 1) in 12 cases (54.5 %), near-complete occlusion (mRRC 2) in 6 cases (27.3 %), and residual filling (mRRC 3a and 3b) in 4 cases (18.2 %). Twenty-one patients were discharged or transferred for further treatment to the department of neurology with satisfactory treatment results (0–2 points on the modified Rankin Scale). One patient with a basilar artery aneurysm died from subarachnoid hemorrhage and severe vasospasm (6 points on the modified Rankin Scale). Angiographic follow-up was available for 9 patients, with stable occlusion in 7 cases and improvement from mRRC 3a to mRRC 1 in 2 cases.Conclusions. pCONUS bifurcation implants serve as an additional tool for treating wide-neck cerebral aneurysms, demonstrating high technical success rates and low complication and mortality rates.

Endoscopic endonasal transclival clipping of a cerebellar arteriovenous malformation feeding vessel and associated aneurysm; a 2D operative video

Positioned along the ventral surface of the pons, proximal superior cerebellar artery (SCA) aneurysms account for only 1.7% of all intracranial aneurysms [1]. Unlike more commonly encountered basilar artery aneurysms, patients often experience good outcomes when treated via endovascular coiling or surgical clipping [1,2]. These lesions frequently have a lateral projection and paucity of perforator arteries [2]. With further development of endoscopic endonasal techniques, access to this region is possible via a direct frontal exposure to the ventral brainstem, basilar artery and branching vessels. To date, there are only a limited number of reports describing an endoscopic endonasal transclival (EETC) approach for surgical clipping [3–5]. In this operative video, we detail the surgical clipping of a cerebellar arteriovenous malformation feeding vessel and an associated aneurysm using the EETC approach in a 59-year-old woman who presented with sudden onset of a severe headache. The feeding vessel and aneurysm’s midline location, just below the take-off of the SCA made it a good candidate for this surgery. Major steps included in this video include 1) transsphenoidal exposure of and subsequent drilling of the clivus, 2) dural opening into the pre-pontine cistern and dissection of the aneurysm, 3) clipping of the aneurysm, and 4) multi-layered closure of the skull base defect. Overall, the patient tolerated the procedure well and was found to have no residual filling of the aneurysm or the AVM feeding vessel at 2-year follow-up. EETC is a viable surgical option for the treatment of aneurysm located along the midline of the pre-pontine cistern.

Abstract 285: Intraventricular And Subarachnoid Hemorrhage Secondary To Arteriovenous Malformation, A Diagnostic Neurologic Manifestation Of Osler‐Weber‐Rendu Disease

Introduction Osler‐Weber‐Rendu disease, also known as hereditary hemorrhagic telangiectasia (HTT), is a developmental vascular disease characterized by multiple arteriovenous malformations (AVMs) due to genetic defects in endothelial angiogenesis pathways. HHT is a clinical diagnosis based on the fulfillment of the Curacao Diagnostic Criteria, including involvement of internal organs with AVMs, significant recurrent nosebleeds, telangiectasias, and family history of HHT. HHT has a prevalence of 1.5 to 2 people/10,000, although this is considered a falsely low representation due to missed diagnosis and variable penetrance. Autosomal dominantly inherited heterozygous mutations disrupt the TGF‐beta‐mediated pathways causing aberrant blood vessel development with fragility and AVM formation. There are two forms of HHT: (HHT1) has a higher incidence in women and typically involves pulmonary and cerebral arteriovenous malformations (AVM). Mutations in the endoglin gene are thought to be responsible for HTT1 and comprise approximately 61% of the cases. HTT2 is associated with a higher rate of liver AVMs, involves a mutation in Activin A Receptor‐Like Type 1 (ACVRL1), and is responsible for approximately 37% of cases. Other genetic mutations include SMAD4 and GDF2, which are transmitter and binding proteins and occur about 2% of the time. Methods Case report and review of literature Results Case:A 52‐year‐old woman with a large frontoparietal arteriovenous malformation originally found at the age of 17, with a history of frequent epistaxis, mucocutaneous telangiectasias and two children with epistaxis and telangiectasias. Her diagnosis of HHT was made at her third hjospitalization due to a non‐traumatic subarachnoid hemorrhage. A Chest CT angiography and a CT angiography of the intra and extracranial vasculature demonstrated an extensive right holohemispheric cerebral AVM, an unruptured 8‐mm basilar artery aneurysm, and multiple enlarged pulmonary arteries with narrow inlet and outlets concerning for pulmonary AVMs. A subsequent digital subtraction angiogram (DSA) of the brain confirmed the extensive holohemispheric AVM, unruptured basilar artery aneurism with subarachnoid hemorrhage originating from the AVM. On examination she had multiple lingual, and hard/soft palate telangiectasias and an extensive anterior pedal telangiectasia. Given the heavy cerebral AVM burden with multiple cerebral artery feeders, the AVM angiosclerosis and basilar artery aneurysm embolization were deferred. The patient proceeded under medical management alone with a plan for personal and familial genetic testing. Conclusion HHT is a rare cause of cerebral AVMs at high risk of spontaneous bleeding. Managing these AVMs can be a challenge, given the extent and location of these. However, diagnosis of HHT can inform prognosis and guide medical management due to improved prognosis for HHT‐related AVMs and aneurysms compared to non‐HHT AVMs.

Partially thrombosed giant basilar artery aneurysm with attenuated contrast enhancement of the intraluminal thrombus on vessel wall MRI after flow diversion treatment: illustrative case.

The effect of vessel wall magnetic resonance imaging (VW-MRI) enhancement in partially thrombosed aneurysms has previously indicated aneurysmal instability and a rupture risk. However, whether the contrast effect of the wall changes before or after flow diversion treatment is still under investigation. The authors report a case of a partially thrombosed basilar artery aneurysm that increased in size over a short period, worsened brainstem compression symptoms, and was treated with a flow diverter stent with good results. In this case, VW-MRI after surgery showed a reduced contrast effect on the intraluminal thrombus within the aneurysm. The aneurysm thrombosed and markedly regressed over the next 5 months, with remarkable improvement in the brainstem compression symptoms. This finding on VW-MRI may indicate an attenuation of neovascularization in the thrombus wall and be a sign of aneurysm stabilization.

Super-giant fusiform basilar artery aneurysm.

Intracranial aneurysms are focal pathological dilatation of the arteries with a prevalence of 3.2%. Mainly genetic disorders, family history, hypertension and smoking put patients at high risk of intracranial aneurysms formation. MR angiogram, CT angiogram or conventional angiography can detect aneurysms 5 mm or larger in size. Fusiform aneurysms are rare and mainly due to dissection or atherosclerosis. Majority of these are in the posterior circulation and represent 3-13% of all intracranial aneurysms. These may be presented as stroke, cranial nerve palsies, brainstem compression and SAH. A diameter greater than 10 mm is a risk factor for rupture and warrants early intervention.

A review of the top 100 most influential articles on basilar artery aneurysms.

Basilar artery aneurysms account for approximately 5% of all intracranial aneurysms. This bibliometric analysis summarizes the most-cited articles on basilar artery aneurysms and highlights the contributing articles to today's evidence-based practice. In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until August 2022. The keyword "basilar artery aneurysm" or "basilar aneurysm" was used. Our results were arranged in descending order based on the article's citation count. The 100 most cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact Per Paper (SNIP), and Hirsch index. The keyword-based search showed that 699 articles were published between 1888 and 2022. The top 100 articles were published between 1961 and 2019. The top 100 most cited articles collected a total of 8869 citations with an average of 89 citations per paper. The rate of self-citations accounted for an average of 4.85% of the total number of citations. The bibliometric analysis provides a quantitative overview of how medical topics and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in basilar artery aneurysms by finding the top 100 most cited papers.

Acute loading dose of antiplanets before Stent-assisted repair of cerebral aneurysm associated with reduced ischemic events and good outcomes (P8-5.016)

<h3>Objective:</h3> Objective is to evaluate if loading doses of aspirin and clopidogrel (LDAC) reduces TEE without increased intracranial hemorrhage (IH) and improves outcomes in SARIA. <h3>Background:</h3> There are no universal antiplatelets regimens to prevent Thromboemboembolic event (TEE) in stent-assisted repair of intracranial aneurysms (SARIA). Antiplatelets effects are highest in first 4 hours. <h3>Design/Methods:</h3> Consecutive patients underwent SARIA with LDAC; aspirin 324 mg (4 baby aspirin) and clopidogrel 300 mg in 2 to 4 hours before procedure were enrolled from 2011 to 2022. Outcome was measured using modified Rankin Scale (mRS) score. <h3>Results:</h3> 112 patients with mean age of 53 ± 13 underwent SARIA (7 ruptured and 55 symptomatic). Aneurysms are; Right internal carotid artery (ICA) 27, left ICA 35, middle cerebral artery 25, basilar artery 19 and anterior communicating artery 6. There are no intra-operative ruptures. Small left subarachnoid hemorrhage developed on a right MCA aneurysm on day 3, which resolved spontaneously. Stent thrombosis in one; resolved with intraarterial integrilin with no stroke. Clinical TEE were observed in 2 cases (1.8%); first event was in a 42 years old woman with a giant right ICA giant aneurysm and achieved mRS 1. Second event was visual distortion and diplopia in a 66 years old woman with basilar artery aneurysm and achieved mRS1. Ruptured and symptomatic were repaired and no subarachnoid hemorrhages during follow-up. Immediate complete and near complete obliteration of aneurysm was observed in 72% and subtotal in 28%. There was no mortality or permanent disability in our series. 90 days mRankins 0 and 1 was observed in 98 (92.5%), mRS 2 in 7(6.6%) at baseline and mRS 3 in 2 (1.9%), which sustained in 12 months. <h3>Conclusions:</h3> LDAC in SARIA is associated with reduced TEE without increased IH and good outcome. LDAP may be an option in SARIA to prevent TEE. Further studies are required. <b>Disclosure:</b> Dr. Lodi has nothing to disclose.

Teaching NeuroImages: High-resolution MRI before and during a sentinel headache demonstrates aneurysm wall hemorrhage

A 3T brain MRI, performed in a 48-year-old woman presenting with progressive headaches, demonstrated a 20-mm unruptured saccular basilar artery aneurysm. High-resolution vessel-wall MRI showed a chronic mural thrombus and a circumferential aneurysm wall enhancement (figure), an imaging marker of aneurysm instability.1 Two days later, she had a transient thunderclap headache, considered the worst headache she had ever reported. Repeated 3T MRI demonstrated acute mural hemorrhage without subarachnoid hemorrhage. Sentinel headaches, reported in every fourth patient preceding aneurysm rupture,2 have been interpreted as reflecting a warning for subarachnoid leak or, alternatively, structural wall changes, such as stretching or acute mural hemorrhage.

Transpetrosal Routes to the Skull Base-Anterior and Posterior Transpetrosal Approaches.

The extended middle fossa approach with anterior petrosectomy, or anterior transpetrosal approach, is a highly effective and direct approach to difficult-to-access petroclival tumors and basilar artery aneurysms. This surgical approach exposes a significant window of the posterior fossa dura between the mandibular nerve, internal auditory canal, and petrous internal carotid artery, below the level of the petrous ridge, and provides an unobstructed view of the middle fossa floor to the upper half of the clivus and petrous apex, without requiring removal of the zygoma. The posterior transpetrosal approaches, including the perilabyrinthine, translabyrinthine, and transcochlear approaches, provide direct and wide exposure of the cerebellopontine angle and posterior petroclival region. The translabyrinthine approach is commonly used for the removal of acoustic neuromas and other lesions of the cerebellopontine angle. We provide a stepwise description of how we perform these approaches and how to combine and extend them in order to achieve transtentorial exposure.

LVIS-within-enterprise double-stent technique with coil embolization in the treatment of patients with acutely ruptured intracranial vertebrobasilar artery-dissecting aneurysms.

This study aimed to evaluate the feasibility of the low-profile visualized intraluminal support (LVIS)-within-enterprise double-stent technique for patients with acutely ruptured intracranial vertebrobasilar artery-dissecting aneurysms (ari-VBDAs). A total of 30 patients with ari-VBDAs who underwent reconstructive treatment using LVIS-within-enterprise double-stent technique with coil embolization between January 2014 and May 2022 were retrospectively enrolled. Patients' characteristics and clinical and imaging outcomes were reviewed. The functional outcomes were assessed using the modified Rankin scale (mRS). A total of 34 ari-VBDAs were identified, including seven (20.6%) basilar artery aneurysms and 27 (79.4%) vertebral artery aneurysms. All aneurysms were successfully treated in the acute phase. In total, six (20.0%) patients experienced in-hospital serious adverse events, including two deaths (6.7%). The median clinical follow-up time of the remaining 28 patients was 20.0 (IQR, 7.3-40.8) months. The incidences of dependency or death (mRS score of 3-6) at discharge and at the last follow-up were 16.7% and 14.3%, respectively. Aneurysm rebleeding occurred in one (3.3%) patient periprocedurally. In total, three (10.0%) patients had ischemic events, one of which occurred during the periprocedural period and two occurred during follow-up. A total of two patients (6.7%) underwent ventriculoperitoneal shunt. Imaging follow-up was available for 14 patients at the median of 12.0 (IQR, 7.0-12.3) months, with a complete occlusion rate of 93.3% (14/15). In total, one patient experienced parent artery occlusion, and no aneurysm was recanalized. LVIS-within-enterprise double-stent technique with coil embolization for the treatment of patients with ari-VBDAs could be performed with a good safety profile and high technical success rate. The rate of complete aneurysm occlusion during follow-up seemed to be satisfactory.

Biomimetic tissue phantoms for neurosurgical near-infrared fluorescence imaging.

Neurosurgical fluorescence imaging is a well-established clinical approach with a growing range of indications for use. However, this technology lacks effective phantom-based tools for development, performance testing, and clinician training. Our primary aim was to develop and evaluate 3D-printed phantoms capable of optically and morphologically simulating neurovasculature under fluorescence angiography. Volumetric digital maps of the circle of Willis with basilar and posterior communicator artery aneurysms, along with surrounding cerebral tissue, were generated. Phantoms were fabricated with a stereolithography printer using custom photopolymer composites, then visualized under white light and near-infrared fluorescence imaging. Feature sizes of printed components were found to be within 13% of digital models. Phantoms exhibited realistic optical properties and convincingly recapitulated fluorescence angiography scenes. Methods identified in this study can facilitate the development of realistic phantoms as powerful new tools for fluorescence imaging.

Abstract Number ‐ 132: Stent‐assisted repair of the intracranial aneurysms with loading dose of antiplanets and perioperative events.

Introduction Introduction: Thromboemboembolic event (TEE) remains the mail perioperative challenge in addition to the potential intracranial hemorrhage (IH) in stent‐assisted repair of intracranial aneurysms (IA), and there are no standard antiplatelet strategies. Bases on the data, antiplatelets effects are more pronounce in first 4 hours after administration of antiplatelets. Objectives: To evaluate the effect of acute loading doses of aspirin and clopidogrel (LDAC) in TEE and hemorrhagic events associate with stent‐assisted repair of intracranial aneurysm. Additionally, to review the outcome of those patient who underwent stent‐assisted coiling using LDAC. Methods Consecutive patients underwent stent‐assisted repair of aneurysm using loading doses of aspirin 324 mg (4 baby aspirin) and clopidogrel 300 mg 2 to 4 hours before the procedure were enrolled from 2011 to 2022. Patients demographics including intra‐operative and post operative events were recorded. Outcome was measured using modified Rankin Scale (mRS) score. Results 96 patients (6 had baseline mRS 2) with mean age of 53 ± 13 underwent 98 stent‐assisted procedures including two Y‐stent neck reconstructions to treat 98 (6 ruptured and 41 symptomatic aneurysms) IA. Aneurysms are Right internal carotid artery (ICA) 25, left ICA 30, middle cerebral artery (MCA) 22, basilar artery 17 and anterior communicating artery 2.Stent deployment was achieved in all cases. Coil prolapsed and stretching occurred in one right ICA case, required deployment of additional 3 intracranial stents and one carotid artery stent with no clinical events. There was no intra‐operative rupture or IH. A small perioperative left hemispheric subarachnoid hemorrhage was observed on a right MCA aneurysm on day 3 after discharged, which resolved spontaneously without stopping antiplatelet. Intra‐operative stent thrombosis developed in one who had two aneurysms in right ICA with significant cerebrovascular risk factors; resolved with intraarterial integrilin followed by intravenous for infusion with no clinical consequences immediately and 12 months follow‐up; was resistant to clopidrogel and placed on ticagrelor.Post‐operative TEE were observed in 2 cases (2%); first event was observed on day 2 in a 42 years old woman with a giant right ICA giant aneurysm with NIHSS 6 and who recovered completely (NIHSS 0, mRS 1) in 90 days. The second event was visual distortion and diplopia (NIHSS 0) developed on day 2 in a 66 years old woman with basilar artery aneurysm. Her symptoms resolved completely and return to nursing job. All ruptured and symptomatic aneurysms were secure immediately and there are no subarachnoid hemorrhages during follow‐up. TEE was associated withperiorerative smoking. Immediate complete and near complete obliteration of aneurysm was observed in 66% and subtotal in 34%. There was no mortality or permanent disability in our series. 90 days mRankins 0 and 1 was observed in 96% and mRS 2 in 7% (baseline mRS) Conclusions Our study revealed that LDAC in stent‐assisted repair of IA is associated with a low TEE without added risk of IH with clinical good outcome. Our antiplatelets loading regimen may be an option in stent‐assisted repair of IA, especially when patients are unreliable and aneurysms are symptomatic. Further studies are required.

First-in-human trial of Stabilizer device in neuroendovascular therapy

ObjectivesFlow diverter or stent implantation to intracranial target lesion requires large inner diameter microcatheter navigation. The exchange method using stiff long wire is often necessary if it is difficult to navigate over the regular guidewire. However, this method has an intrinsic risk of vessel damage and may cause severe complications. We investigated the safety and efficacy of a new device, the Stabilizer device for navigation in a first-in-human clinical trial under the Certified Review Board agreement. Materials and methodsThe Stabilizer is a 320 cm length exchange wire with a stent for anchoring and is compatible with a 0.0165” microcatheter. The trial design is a prospective single-arm open-label registry. Inclusion criteria are elective flow diverter treatment or stent-assisted coiling, expected to be difficult to navigate a microcatheter with a regular micro guidewire, and obtained documented consent. The primary endpoint of the study was a hemorrhagic complication. ResultsFive patients were enrolled in this trial. The median age is 52 years, ranges from 41 to 70, and all patients were female. Three aneurysms were located on the internal carotid artery, one on the vertebral artery, and one on the basilar artery. Basilar artery aneurysm was treated by stent-assisted coiling and others were treated by flow diverter deployment. All cases successfully navigate microcatheter for the treatment by the trial method using Stabilizer device without any adverse event. ConclusionsThe results from this first-in-human consecutive five cases show the safety of the Stabilizer device in neuro-endovascular therapy for navigation of devices to the intracranial target lesion.

Abstract Number ‐ 83: First WEB case. Direct vertebral artery access for basilar tip artery aneurysm

Introduction being able to think of different accesses does not change the possibilities with each patient Methods case report Results Patient with subarachnoid hemorrhage in the posterior fossa. A tomography is performed that confirms the hemorrhage and a vascular lesion that is visualized at the top of the basilar artery. For the procedure, radial and femoral access was performed without achieving stable access to the basilar artery. Therefore, after multiple attempts, we consider that the best option is direct V2 left vertebral puncture. Access was achieved by vertebral puncture to the aneurysm and occlusion was performed on the top of the basilar artery. Tomographic controls were performed without complications. Patient then presented severe pulmonary compromise that required intubation and prolonged stay in the ICU. Control is performed after a month with adequate occlusion of the aneurysmal lesion. Conclusions it’s nothing new just follow what nelson hopkins says: If You Want to Learn New Things, Read Old Books: Cutdown Techniques Are Well Described in the Old Literature

New insights into cerebellar dysfunction in patients with delusional disorder: A systematic review

IntroductionThe cerebellum has been implicated in cognitive, affective and motor functions, including emotion regulation, executive control and sensorimotor processing. In schizophrenia, cerebellar dysfunction has been associated with treatment resistance and clinical features. However, few studies have been focused on delusional disorder (DD).ObjectivesOur main purpose was to review the evidence available on cerebellum abnormalities and dysfunctions in patients with DD.MethodsA systematic review was conducted through PubMed, Scopus and ClinicalTrials.gov (inception-June 2022) according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) directives. The following search terms were used: cerebellum OR cerebellar AND (“delusional disorder” AND paranoia). Reference lists from included studies were hand-checked to find other potential relevant papers.ResultsSix studies were included from a total of 119 retrieved records (PubMed: 52, Scopus: 66, ClinicalTrials.gov: 1). Study 1:Patients with DD somatic type (n=14) presented a decreased gray matter volume in cerebellar lobules compared to healthy controls (HC) (n=32, left lobule VIIIa) and non-somatic DD (n=18, lobule V). Cerebellar volumes did not seem to differ between HC and non-somatic DD. Study 2:Abnormalities of voluntary saccadic eye movements, linking frontal and cerebellar functions, were found in DD patients (n=34) compared to HC (n=40). Study 3: Abnormal smooth pursuit eye movements in DD (n=15) compared with HC (n=40) and similar to schizophrenia (n=40). Case reports (n=3): DD associated with Dandy-Walker variant (partial vermian hypoplasia), unruptured intracerebral aneurysm of basilar artery, and megacisterna magna.ConclusionsCerebellar deficits in patients with DD has been reported, particularly in those presenting somatic delusional contents.Disclosure of InterestNone Declared

Abstract Number ‐ 137: Delayed aneurysmal rupture of a giant fusiform vertebrobasilar aneurysm after flow‐diversion embolization with adjunctive coiling

Introduction Vertebrobasilar aneurysms carry a high risk of operative morbidity and high mortality risk with rupture. Treatment with flow diversion embolization has gained popularity. While adjunctive coiling may lower the risk of delayed aneurysm rupture (DAR), DAR can occur during stent endothelialization. describe a case of DAR following flow diversion with adjunctive coil embolization of a giant vertebrobasilar aneurysm and review the literature to further characterize this phenomenon. Methods PubMed was queried using search terms: “delayed,” “aneurysm,” “rupture,” “flow diverter,” “flow diversion,” and “flow diverting stent” yielding 220 results. There were 47 studies describing 89 patients with DAR after flow diversion. Results A forty‐five‐year‐old male presented with posterior fossa compression symptoms secondary to a 30‐mm fusiform basilar artery aneurysm, which grew during short‐interval follow‐up to 35 mm. The patient consented to endovascular embolization. Tri‐axial catheter access system was used to deploy seven telescoping flow diverters from the basilar tip to the intradural left vertebral artery, and nine coils were subsequently deployed in the aneurysm dome. The right vertebral artery was coil embolized. The procedure was uncomplicated and the patient was continued on dual‐antiplatelet therapy. Four weeks later, the patient became unresponsive with absent brainstem reflexes, workup revealed diffuse subarachnoid hemorrhage with intraventricular hemorrhage. Digital subtraction angiography demonstrated contrast extravasation at the aneurysm neck. He succumbed to his neurological injury two days later. Out of 89 patients with DAR after flow diversion, only 3 occurred in fusiform basilar aneurysms treated with adjunctive coil embolization. Only one case, a 37.1‐mm aneurysm treated with 3 flow diverters with adjunctive embolization, occurred at greater than 30 days post‐intervention. Conclusions This case highlights the need to better characterize the role of adjunctive coiling with flow diversion for large or giant aneurysms, and to better understand risk factors related to delayed aneurysm rupture.

Abstract Number ‐ 204: Robotics in Neuro‐Endovascular Field: Back to the Future

Introduction For more than three decades, robotic assisted surgery has been proposed, studied and put into action clinically. Likewise, it was cleared by the Food and Drug Administration for percutaneous coronary intervention in 2012 (K120834) and peripheral vascular intervention including carotid intervention in 2018 (K173288), but has not yet received clearance for intracranial neurovascular intervention in the USA. Recently, several pilot clinical studies assessed robotically performed neurointerventions. Methods We performed comprehensive electronic search till July 2022 on PubMed/Medline to retrieve all relevant studies and data were extracted for baseline characteristics, design, procedure type, safety and feasibility outcomes for qualitative synthesis. Results Our results yielded nine single center studies in UK, USA and China performed since 2015. The performed procedures included diagnostic cerebral angiography (36 patients), caroti aartery stenting (37 patients), unspecified robotic assisted intracranial intervention (18 patients) and stent‐assisted coil embolization of a basilar artery aneurysm (one case). The used robotic systems included Corpath GRX (5 studies), Magellan (2 studies), RobEnt (one study) and VIR‐2 (one study). The robotic assisted neurointervention was successful clinically without complications across all studies and for all procedures. The learning curve sounded promising but there were limitations in the design of systems for completing all steps robotically. Conclusions Robotics assisted procedures appear to be feasible and safe in neuro‐intevention field. Advantages include high accuracy, stability, safety, simplicity, versatility, monitoring, endothelial protection, and potential for remote access for procedures such as mechanical thrombectomy for acute ischemic stroke. However, there are many challenges including cost, manual steps, lack of manual resistance feeling, irrationality in the spatial arrangement of the robotic system and operating table. Additionally, most of the included studies were retrospective with small sample size and short term follow up and more well‐designed comparative prospective studies are needed to confirm these results.

Giant dissecting aneurysm of basilar artery in a child - treated by flow reversal: A case report.

Although intracranial aneurysms are rare in the paediatric population, the proportion of those involving posterior circulation is higher than that of adults (approximately 25% vs. 8%, respectively). Moreover, posterior circulation aneurysms in kids tend to be larger in size, many of them being giant dissecting types, and treatment of them is often challenging. Treatment of giant dissecting aneurysms, especially involving the Basilar artery is difficult due to strategic location and haemodynamic factors. Use of reconstructive techniques viz. flow-diverters and braided stents is difficult in children because of the lack of standard protocol for use of antiplatelet therapy and the need for prolonged use of the same. Continuous growth of parent vessel is also suggested as a pitfall for the use of a flow diverter/ braided stent which has a fixed caliber. Carefully planned endovascular parent or feeder branch artery occlusion (FAO) is a time-tested method to achieve flow reversal or favourable flow modifications in an arterial segment harbouring dissecting aneurysm. Here, in this case report, we describe a case of a ruptured distal giant basilar artery dissecting aneurysm in a 10-year-old boy treated with flow diversion by FAO. The dominant left vertebral artery was occluded, thereby diverting flow from the right vertebral artery towards the left posterior inferior cerebellar artery and decreasing flow through the aneurysm. On 1-year follow-up, the patient was asymptomatic and on check angiography, there was complete involution of the aneurysm with increased flow through bilateral posterior communicating arteries to distal posterior circulation which proved our hypothesis correct.