Wide-necked Basilar Tip Aneurysm Research Articles

Single centre experience of stent-assisted coiling of wide-necked basilar tip aneurysms.

To report clinical and radiological follow-up outcomes of stent-assisted coiling of wide-necked basilar tip aneurysms and to evaluate the safety and efficacy of this treatment choice. A retrospective review was carried out of 19 patients with wide-necked basilar tip aneurysms in our institution between 2010 and 2020. The rates of perioperative complication, morbidity, mortality, imaging follow-up and re-treatment were analysed. Our technical complication rate was 11% but did not result in treatment failure. The combined procedure related morbidity and mortality rate of the 19 patients who underwent stent assisted coiling was also 11%. 16 of 19 patients had undergone angiographic follow-up with a mean period of 32 months. 81% of patients with angiographic follow-up had a satisfactory occlusion (RROI or II) with 11% requiring re-treatment. Those requiring re-treatment were both treated with laser-cut stents; this is in contrast with no re-treatments required in the patients treated with braided stents. Our report provides acceptable outcomes in wide-necked basilar termination aneurysms which are very challenging to treat. Aneurysms treated with braided stents had better efficacy outcomes than those with laser-cut stents. Given the emergent and increasing utility of alternative endovascular techniques such as intrasaccular devices and flow diverters, real-world data are lacking on more conventional approaches such stent-assisted coiling, especially so in the posterior circulation. The associated relatively higher aneurysmal haemorrhagic risk in this location warrants further additional safety and efficacy data for this treatment approach, which this paper provides.

How I do it: neuromonitoring-guided clipping of high-riding basilar tip aneurysm.

Clipping of basilar tip aneurysms presents unique challenges due to the risk of perforator compromise and subsequent disabling stroke. Herein, we describe the correct trajectory of the clip applier to clip basilar tip aneurysms through an orbitozygomatic approach to prevent perforator injury and discuss management of intraoperative neuromonitoring changes. We anticipate that this video and illustration will aid surgeons as they treat complex wide-necked basilar tip aneurysms with microsurgical clipping.

Contrast-induced neurotoxicity presented as transient cortical blindness after stent-assisted coiling of a medium-sized unruptured basilar artery aneurysm: A case report and review of the literature

Background: Contrast-induced neurotoxicity is a rare event after endovascular diagnostic procedures or interventions and presents as transient neurological deficit. Herewith, we present a case of reversible complete cortical blindness after uneventful stent-assisted coiling of a medium-sized unruptured basilar artery aneurysm.Case Description: A 70-year-old woman with a medium-sized 10 mm/6 mm wide neck basilar tip aneurysm was planned for endovascular obliteration of the lesion. The procedure was done under general anesthesia. The contrast agent was iso-osmolar, nonionic. The aneurysm was coiled, and a stent was placed in the left posterior cerebral artery achieving sufficient aneurysm packing. No signs of vessel obliteration were observed during the procedure. On awakening of anesthesia, the patient reported complete visual loss. Ophthalmological examination was normal. The patient was brought back to the angio-suite but there were no signs of parent vessel compromise from the endovascular implants or distal vessel occlusion. An MRI of the brain was done showing no signs of brain ischemia, just mild brain edema in both occipital lobes. Given the results of the radiological studies and clinical presentation, the diagnosis of contrast-induced neurotoxicity was accepted. In 72 h, the patient had complete resolution of the visual loss and was discharged home with no additional neurological worsening.Conclusion: Contrast-induced neurotoxicity is a rare event that can occur after uneventful endovascular interventions of the brain vessels. Knowledge of this rare complication, after exclusion of all other possible reversible causes, is important for the treatment and prognosis of the patient.

Management of Wide-Necked Basilar tip Aneurysms.

While the frequency of direct surgery for basilar tip aneurysms is decreasing, the need for safe and effective surgical treatments for difficult-to-treat aneurysms, including large or wide-necked aneurysms, is likely to continue. In this chapter, our surgical approach for large wide-necked basilar tip aneurysms using the orbitozygomatic approach, the anterior temporal approach, and hybrid surgery are described.

T- configuration stent assisted coiling treatment of a complex wide-necked basilar tip aneurysm

The advancement of intracranial stent technology and techniques has extended the applications of endovascular coiling methods for complex intracranial aneurysms. Coiling of wide-necked and complex bifurcation aneurysms usually requires double stent implantation. Different configurations for double stent-assisted coil embolization have been described. The T-configuration stent-assisted coiling procedure was recently described as a feasible, effective, and relatively safe endovascular technique used to treat wide-necked complex bifurcation aneurysms. In this article, we present the successful management of a complex wide-neck basilar tip aneurysm using a slightly modified T-configuration stent-assisted coiling technique.

The Geometry of Y-Stent Configurations Used for Wide-Necked Aneurysm Treatment: Analyzing Double-Barrel Stents In Vitro Using Flat-Panel Computed Tomography

Stent-assisted coil embolization of wide-necked bifurcation aneurysms often employs a Y configuration stent. A similar stent configuration, termed kissing/double-barrel (KDB), is used often at the aortoiliac bifurcation. Studies of KDB stents in aortoiliac disease show that rates of thromboembolic complications vary with the cross-sectional geometry of the stent pair, a function of the radial crush resistive force of each stent. We assessed cross-sectional geometry of intracranial stent pairs in an invitro model of the basilar artery using flat-panel computed tomography. In a silicone model of a wide-necked basilar tip aneurysm, 6 simulated KDB stent deployment trials were performed using combinations of 5 stents (Enterprise 1, Enterprise 2, Neuroform Atlas, LVIS, LVIS Jr.). Flat-panel computed tomography reconstructions were used to assess cross-sectional stent geometry. Relative conformability, defined by ovalization and D-ratio, radial crush resistive force (predicted vs. actual), and radial mismatch fraction were compared by stent type (braided vs. laser-cut). Several distinct forms of cross-sectional stent geometry were observed. Braided stents had lower ovalization and D-ratio (P= 0.015) than laser-cut stents. The Neuroform Atlas/LVIS combination yielded the lowest radial mismatch fraction (19.7% vs. mean 44.3% ± 0.7%). Braided stents tended to have a deployed stent radius closer to the expected (nominal) diameter (i.e., higher relative crush resistive force) than laser-cut stents (measured vs. nominal diameter discrepancy+38.6% ± 21.1% vs. -10.7% ±16.1%, P= 0.14). In constant anatomy, cross-sectional geometry of the KDB stent configuration will vary depending on the design and structure of the stents employed.

Intentional Stent Herniation Technique Using Neuroform Atlas Stent System for Embolization of a Wide-Necked Basilar Tip Aneurysm.

Endovascular treatment for complex wide-necked basilar tip aneurysms is challenging. Multiple stenting may be an option to deal with such aneurysms; however, the risk of ischemic complications is reported to be relatively high. Here, we report a case of unruptured basilar tip aneurysm treated using the intentional stent herniation technique to preserve the aneurysmal neck branches. A 65-year-old woman presented with a growing unruptured basilar tip aneurysm associated with bilateral posterior cerebral arteries (PCAs) arising from the aneurysmal dome. We intentionally selected a large-sized Neuroform Atlas stent (Stryker, Kalamazoo, MI, USA) compared to the parent artery and deployed it along the right PCA to the basilar artery. The stent was herniated into the aneurysmal dome near the origin of the left PCA, resulting in the preservation of the left PCA. Successful coil embolization was achieved with acceptable obliteration. The intentional stent herniation technique may be an effective approach to treat complex wide-necked basilar tip aneurysms.

Dual microcatheter technique for the treatment of a ruptured wide neck basilar tip aneurysm

Endovascular treatment is a safe and efficient therapy for intracranial aneurysms with lower complication and mortality rates compared to surgical clipping. Wide-neck aneurysms still represent a challenge to complete and safe aneurysm occlusion in spite of techniques such as stent-assisted or balloon-assisted coiling, developed in order to achieve better occlusion rates. These techniques themselves may lead to further complications, so alternative methods such as the dual microcatheter technique were developed. This technique assumes that, via two microcatheters inserted into an aneurysm, simultaneous deployment of two coils achieves a stable coil frame without the use of adjunctive devices. The aim of this paper is to present a successfully treated basilar tip wide-neck aneurysm treated with the dual microcatheter technique.Case report. A 46-year-old male patient with acute onset of severe headache presented in the emergency room with altered state of consciousness. Non-enhanced CT scan showed subarachnoid and intraventricular haemorrhage. CT angiography revealed a wide-neck basilar tip aneurysm. Digital subtraction angiography confirmed the presence of an aneurysm with a wide, 4.9 mm neck.Dual microcatheter technique was chosen as the first treatment option, while a hypercompliant balloon was kept as backup. Two microcatheters were placed inside de aneurysm and two coils were introduced in order to form a stable framing coil mass that served as a support for further coils deployed in an alternately manner through each microcatheter. No procedural complication occurred, and the patient’s evolution was uneventful with no neurological deficits at discharge.Conclusion. The dual microcatheter technique is a safe and effective therapeutic option for wide-neck ruptured or unruptured intracranial aneurysms. Periprocedural complication rates are similar to simple coiling or balloon-assisted coiling, but lower than for stent-assisted coiling.

Use of the PulseRider Device in the Treatment of Ruptured Intracranial Aneurysms: A Case Series

Wide-necked intracranial aneurysms present unique treatment challenges in the setting of subarachnoid hemorrhage. New generations of endoluminal devices (stents) have expanded our ability to treat complex aneurysms. The PulseRider Aneurysm Neck Reconstruction Device (PulseRider [Cerenovus, Irvine, California, USA]) is new to the U.S. market after receiving Food and Drug Administration approval in June 2017. Official recommendation for use of the PulseRider is with dual antiplatelet therapy (DAPT). Its design has been hypothesized to carry a lower risk of thromboembolic complications in the circumstance that DAPT needs to be discontinued. Between March and June 2018, we treated 4 cases of ruptured wide-necked basilar tip aneurysms at the University of Colorado Hospital, Aurora, Colorado, with PulseRider-assisted coil embolization. Imaging and chart reviews were performed retrospectively on each of these patients. All 4 aneurysms were successfully treated with PulseRider-assisted coil embolization. There were no periprocedural hemorrhages and no postprocedural reruptures. Two patients developed nonocclusive thrombi in the posterior cerebral arteries at the time of coiling, which was resolved with intra-arterial glycoprotein IIb/IIIa receptor antagonists. Two patients developed external ventricular drain-associated hemorrhages, only one of which developed after the administration of DAPT. All patients were eventually discharged to home. The PulseRider device represents a novel design for stent-assisted coil embolization. We report a small but promising series of its successful use in the acute treatment of wide-necked, ruptured basilar artery aneurysms. Additional experience is needed to determine if this device has a place in our armamentarium for treatment of ruptured aneurysms.

Hemodynamic Alterations for Various Stent Configurations in Idealized Wide-neck Basilar Tip Aneurysm

Stent-assisted coiling technology is widely used in the treatment of intracranial aneurysms. However, differences among various stent configurations have not been fully characterized. This study investigates the hemodynamic effects for various stent configurations. Computational fluid dynamics simulations were performed on an idealized wide-neck basilar tip aneurysm model, which was constructed from digital subtraction angiography images with a virtual stenting technique. The orifice of the aneurysm was tilted toward the left posterior cerebral artery (PCA). The right half-Y configuration caused only a small change in the overall intra-aneurysmal flow pattern compared with the pattern produced without a stent. Percentage of hemodynamic changes were all compared to the untreated aneurysm. The values of wall shear stress (WSS) and flow velocity showed reductions of 16.36 and 3.22 %, respectively. Although the Y configuration showed relatively obvious decreases of 56.27 and 33.55 % in WSS and flow velocity, respetively, the left half-Y configuration, which is usually deployed as the first stent clinically, produced a more obvious flow reduction than those of the right half-Y and Y configurations. Consistent decreases in the velocity and WSS were observed. WSS and flow velocity showed reductions of 58.39 and 41.76 %, respectively. The cross-bar configuration showed the highest WSS and flow velocity reductions (58.42 and 46.49 %, respectively). The right half-Y configuration had relative more impacts on the WSS of the right PCoA than the left half-Y configuration. For the Y and cross-bar configurations, the WSS of the right PCA obviously decreased. The overall pressure change was less than 1 % for the various configurations, with the Y configuration having the highest pressure increase (0.728 %). Simulation results demonstrate obvious differences among the various stent configurations in a wide-neck basilar tip aneurysm.

Treatment of wide-necked basilar tip aneurysm not amenable to Y-stenting using the PulseRider device

Endovascular treatment of broad-necked bifurcation aneurysms remains challenging. Stent-assisted coiling has been successful but requires catheterization of the branches off the parent vessel. We present the case of a patient...

Y-configuration double-stent-assisted coiling using two closed-cell stents for wide-neck basilar tip aneurysms.

This study aimed to evaluate clinical and angiographic outcomes of Y-configuration double-stent-assisted (Y-stent) coiling using two closed-cell stents for wide-necked basilar tip aneurysm (BTA). A total of 25 patients underwent Y-stent coiling using two closed-cell stents as a first-time treatment in 18 (3 ruptured) BTAs, retreatment in 2 BTAs and as a third treatment in 5 wide-necked BTAs. Clinical and angiographic outcomes were evaluated retrospectively. Treatment-related complications were three (12.0 %) thromboembolic infarctions due to two acute in-stent thromboses and one embolism. Twenty-two (88 %) patients had favorable outcomes (modified Rankin scale score [mRS], 0-2) during the follow-up period (mean, 30 months; range, 6-54 months). Two patients died: one from initial subarachnoid hemorrhage and the other from intracerebral hemorrhage due to underlying Moyamoya disease. Post-treatment angiograms showed complete occlusion in nine aneurysms, residual neck in 11 aneurysms and residual sac in five aneurysms. Follow-up angiograms were available at least once between 5 to 34 months (mean, 16 months) in 21 patients. Nineteen patients showed improved or stable states (complete occlusion, n = 17; residual neck, n = 2). Major recurrences occurred in two BTAs (9.5 %). Those two major recurrent aneurysms had been large-sized aneurysms at the initial coiling procedure. Both showed not only coil compaction but also progressive growth to giant-sized aneurysms and intra-aneurysmal thrombus formation at the Y-stent coiling as a third-time treatment. Y-stent coiling using two closed-cell stents is a safe and durable treatment option for wide-necked BTA, but may have limited efficacy for large/giant sized and thrombosed aneurysms.

Very late stent thrombosis following the placement of a crossing Y-stent with dual closed-cell stents for the coiling of a wide-necked aneurysm

The crossing Y-stent technique is a viable option for coiling of wide-necked bifurcation aneurysms. However, little is known about the long-term impact of this technique. Very late (>1 year) stent...

Treatment of Wide-Neck Basilar Tip Aneurysms Using the Web II Device

Endovascular treatment has assumed a major role in the management of intracranial aneurysms. Although current techniques have proven extremely effective in the embolization of a large number of intracranial aneurysms, wide-necked basilar tip aneurysms represent a subset that continues to pose technical challenges in treatment. This study reports our experience with WEB II, a new embolization device employed in four patients with this type of aneurysm.

Various techniques of stent-assisted coil embolization of wide-necked or fusiform artherosclerotic and dissecting unruptured vertebrobasilar artery aneurysms for reducing recanalization: mid-term results

Coil embolization of wide-necked or fusiform vertebrobasilar aneurysms is challenging and tends to involve frequent recanalization. The aim of our study was to evaluate complications and mid-term outcomes of complex vertebrobasilar artery aneurysms after stent-assisted coiling with various techniques. We retrospectively evaluated 28 cases of unruptured vertebrobasilar aneurysm treated by stent-assisted coiling. Forty-four of the 45 stents placed in 28 patients were deployed at the desired location (97.8 %). Single stent-assisted coiling was performed in 14 aneurysms, a stent-within-a-stent (SWS) technique was used in 12 aneurysms, and Y-stent-assisted coiling was employed in four basilar tip aneurysms. Two basilar tip aneurysms treated by single stent-assisted coiling recurred and were retreated by SWS and Y-stent-assisted coiling. Complete embolization was achieved in 19 aneurysms (67.8 %), and remnant neck persisted in eight aneurysms (28.6 %) and remnant aneurysm was noted in one aneurysm (3.6 %). Permanent neurologic deficit (Modified Rankin Scale 1 and 4) was noted in two patients (7.1 %). Angiographic follow-up (mean follow-up period: 20.8 months) was performed in 20 patients. Major recanalization occurred in two basilar tip aneurysms (10 %) and minor compaction was noted in one superior cerebellar artery aneurysm. The remaining 17 aneurysms were stable or improved (85 %). Complex vertebrobasilar aneurysm embolization with stent-assisted techniques was effective and feasible as a method for reducing recanalization during midterm angiographic follow-up. Large and wide-necked basilar tip aneurysms showed frequent major recanalization, and compact packing with single or Y-stent-assisted coiling is needed to prevent recanalization even if coiling will be done without stenting.

Y stenting assisted coiling using a new low profile visible intraluminal support device for wide necked basilar tip aneurysms: a technical report

Many endovascular techniques have been described in recent years for the management of wide necked aneurysms. The Y stent assisted technique has been generally used for coil embolization of wide...

Treatment of basilar tip aneurysms with horizontal PCA to PCA stent-assisted coiling: case series

Backgroun and objectiveCoiling of wide-necked basilar tip aneurysms is technically challenging and is often assisted by the placement of a stent. Stent placement in an anterograde fashion either with a...

Influence of stent configuration on cerebral aneurysm fluid dynamics

Embolic coiling is the most popular endovascular treatment available for cerebral aneurysms. Nevertheless, the embolic coiling of wide-neck aneurysms is challenging and, in many cases, ineffective. Use of highly porous stents to support coiling of wide-neck aneurysms has become a common procedure in recent years. Several studies have also demonstrated that high porosity stents alone can significantly alter aneurysmal hemodynamics, but differences among different stent configurations have not been fully characterized. As a result, it is usually unclear which stent configuration is optimal for treatment. In this paper, we present a flow study that elucidates the influence of stent configuration on cerebral aneurysm fluid dynamics in an idealized wide-neck basilar tip aneurysm model. Aneurysmal fluid dynamics for three different stent configurations (half-Y, Y and, cross-bar) were first quantified using particle image velocimetry and then compared. Computational fluid dynamics (CFD) simulations were also conducted for selected stent configurations to facilitate validation and provide more detailed characterizations of the fluid dynamics promoted by different stent configurations. In vitro results showed that the Y stent configuration reduced cross-neck flow most significantly, while the cross-bar configuration reduced velocity magnitudes within the aneurysmal sac most significantly. The half-Y configuration led to increased velocity magnitudes within the aneurysmal sac at high parent-vessel flow rates. Experimental results were in strong agreement with CFD simulations. Simulated results indicated that differences in fluid dynamic performance among the different stent configurations can be attributed primarily to protruding struts within the bifurcation region.

Endovascular treatment of ruptured wide-necked basilar tip aneurysm with Y stenting and coiling in a case of bilateral internal carotid artery occlusion with moyamoya disease

Endovascular treatment of ruptured wide-necked basilar tip aneurysm with Y stenting and coiling in a case of bilateral internal carotid artery occlusion with moyamoya disease

E-007 Y-Stenting for the treatment of basilar apex aneurysms

IntroductionDespite advances in surgical and endovascular treatment of intracranial aneurysms, the management of wide necked basilar tip aneurysms poses substantial treatment challenges. Y stenting, in which one stent is deployed...