Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical Note
Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm Vijay Yanamadala a, Ning Lin b, Hekmat Zarzour b, Kai U. Frerichs b,c, Brian P. Walcott a,⇑, Ajith J. Thomas d, Ajit S. Puri e a
Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA Department of Neurosurgery, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA Department of Radiology, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA d Department of Neurosurgery, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA e Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA b c
a r t i c l e
i n f o
Article history: Received 19 August 2013 Accepted 29 November 2013 Available online xxxx Keywords: Aneurysm Endovascular coiling Pseudoaneurysm Subarachnoid hemorrhage
a b s t r a c t Acute intracranial pseudoaneurysms secondary to aneurysmal rupture are a rare entity with no clear evidence-based guidelines for treatment to our knowledge. There are numerous examples of successful treatment of pseudoaneurysms both surgically and endovascularly, the latter mainly within the anterior circulation. Risk of pseudoaneurysm rupture in the acute state during endovascular procedures with subsequent difficulty in controlling the bleeding without sacrificing the feeder artery has led to some reservation in using endovascular treatments more broadly. We report a rare case of a 52-year-old-woman who presented with acute subarachnoid hemorrhage and was found to have a ruptured 5 mm 8 mm bi-lobulated basilar apex aneurysm on CT angiography. Digital subtraction angiography demonstrated an associated anterior pseudoaneurysm that was formed secondary to the aneurysm rupture. The true aneurysm was successfully coiled with careful avoidance of the pseudoaneurysmal sac. Pseudoaneurysms are frequently identified for the first time during digital subtraction angiography. Recognizing their presence is essential for treatment planning. Acute pseudoaneurysms associated with true aneurysmal rupture can be safely and successfully treated by endovascular coiling of the true aneurysm. Care must be taken to avoid manipulation of the pseudoaneurysmal sac during the embolization. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Intracranial pseudoaneurysms are unusual and occur in less than 1% of patients with intracranial aneurysms [1,2]. The most common causes of pseudoaneurysm formation include blunt or penetrating head trauma, neoplasm, Marfan’s syndrome and other collagen vascular disorders, dissection, infection, vasculitis, and iatrogenic injury during surgery or endovascular procedures [3,4]. Rarely, rupture of a true cerebral aneurysm can lead to the development of a pseudoaneurysm [5–7]. These lesions are commonly referred to as ‘‘ghost aneurysms’’ due to their irregular angiographic appearance and changing shape [5]. Pseudoaneurysms are challenging to manage and are associated with high morbidity and mortality. Although open and endovascular treatments for intracranial pseudoaneurysms have both been reported, the optimal approach for management remains controversial. ⇑ Corresponding author. Tel.: +1 617 726 2000; fax: +1 617 643 4113. E-mail address: [email protected] (B.P. Walcott).
Herein, we present a rare case of a ruptured basilar artery aneurysm associated with an adjacent pseudoaneurysm, both of which were successfully treated with coil embolization. 2. Technical case report 2.1. Clinical features A 52-year-old woman with no past medical history presented with sudden onset of severe headache and subsequent loss of consciousness. She was brought to the emergency room intubated and obtunded. Her examination was notable for fixed non-reactive pupils at 1 mm bilaterally and extensor posturing in all four extremities. A non-contrast head CT scan demonstrated diffuse subarachnoid hemorrhage in the basal cisterns with intraventricular extension (Fig. 1A). CT angiogram demonstrated a 4–5 mm basilar apex aneurysm that extended into the suprasellar cistern, although the microanatomy of the aneurysm was not fully distinguishable. A right frontal external ventricular drain was
http://dx.doi.org/10.1016/j.jocn.2013.11.050 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yanamadala V et al. Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.11.050
2
V. Yanamadala et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Fig. 1. Preoperative non-contrast head CT scan (A) demonstrated diffuse subarachnoid hemorrhage, intraventricular hemorrhage, and hydrocephalus. Preoperative diagnostic cerebral angiogram in the anteroposterior (B) and lateral (C) views revealed a 5 mm 8 mm basilar apex aneurysm.
emergently placed for drainage of cerebrospinal fluid and control of intracranial hypertension. The patient was transferred to the neurointerventional suite for digital subtracted angiography (DSA) and embolization. 2.2. Angiographic features DSA demonstrated an irregular, bi-lobed aneurysm at the basilar apex, measuring 5 mm 8 mm (Fig. 1B, C). There was an elongated, contrast-opacified cavity located anterior-inferiorly to the basilar apex aneurysm and the basilar artery, which was best appreciated in the lateral views of the angiogram (Fig. 2). This lesion filled with contrast unevenly and in a delayed fashion, as shown in the early (Fig. 2A, E) and late (Fig. 2B, F) arterial phases of the angiogram. Contrast stasis and delayed contrast washout were also observed in the early (Fig. 2C, G) and late (Fig. 2D, H)
venous phases. These findings collectively suggested that a large pseudoaneurysm was present in the interpeduncular and prepontine cisterns, which had a narrow connection anteriorly to the true aneurysm sac at the basilar apex. No thrombus was visualized within the aneurysm or the pseudoaneurysm. The decision was made to proceed with coil occlusion of the true aneurysm dome without entering the pseudoaneurysm to minimize the risk of procedural re-rupture. 2.3. Endovascular embolization Under fluoroscopic supervision, a 6 French Neuron guide catheter (Penumbra, Alameda, CA, USA) was placed at the distal cervical segment of the left vertebral artery over an exchange-length Glidewire (Terumo, Somerset, NJ, USA). Using a magnified roadmap technique, a SL-10 microcatheter (Boston Scientific, Boston, MA,
Fig. 2. Different phases of the cerebral angiogram demonstrated a pseudoaneurysm associated with the ruptured basilar apex aneurysm. Early (A, E) and late (B, F) arterial phases in the anteroposterior (A, B) and lateral (E, F) views showed delayed and unequal filling of a large, irregular pseudoaneurysm anterior to the true basilar apex aneurysm. There was contrast stasis and delayed washout in the pseudoaneurysm in the early (C, G) and late (D, H) venous phases.
Please cite this article in press as: Yanamadala V et al. Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.11.050
V. Yanamadala et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
USA) was advanced over a Synchro II guidewire (Boston Scientific) to access the basilar apex aneurysm. Then, a Guglielmi detachable coil (GDC) 10/360 5 mm 10 cm coil (Boston Scientific) was placed in the aneurysm dome, followed by five more GDC coils. The cavity of the pseudoaneurysm was carefully avoided. Both the aneurysm and the pseudoaneurysm were still opacified after the first coil placement (Fig. 3A, D), however the pseudoaneurysm was gradually obliterated after additional coil placement (Fig. 3B, E). Post-embolization angiography (Fig. 3C, F) demonstrated no contrast filling within the aneurysm or the pseudoaneurysm. The patient tolerated the procedure without complications. She required placement of a percutaneous gastrostomy tube and a ventriculoperitoneal shunt during the hospitalization. She was discharged to a rehabilitation facility on hospital day 21. Subsequently, the patient continued to recover and was fully awake, oriented, and able to move all extremities at her first post-hospitalization visit. MRI of the brain 4 weeks after coil embolization demonstrated thrombosis of the pseudoaneurysm and no residual filling of the basilar apex aneurysm (Fig. 4).
3. Discussion In this technical note, we present the successful endovascular treatment of an acute basilar artery apex aneurysm with an associated pseudoaneurysm. In this patient, the clinical presentation of acute subarachnoid hemorrhage and subsequent angiographic findings suggest that the pseudoaneurysm formed secondary to the rupture of the true aneurysm, a rare cause of pseudoaneurysm formation [5]. Pre-operative recognition of the presence of a
3
pseudoaneurysm is essential for appropriate clinical decision making and for surgical planning. Multiple endovascular approaches have been reported to successfully obliterate an intracranial pseudoaneurysm [3,5–17], although the optimal treatment strategy remains controversial and likely needs to be determined on a patient-by-patient basis. Lempert et al. presented a series of 11 traumatic and iatrogenic anterior circulation pseudoaneurysms that were successfully treated endovascularly with coil embolization [16]. The authors reported only minor complications and concluded that pseudoaneurysms were best managed in the subacute period when the wall of the pseudoaneurysm had matured. Nomura et al. described eight patients with acute intracranial pseudoaneurysms who were treated either surgically or endovascularly, and reported a high intraprocedural re-rupture rate during endovascular embolization [7]. The authors suggested that endovascular surgeons should be particularly cautious to avoid advancing microinstruments into the area of pseudoaneurysm because of the fragile nature of the pseudoaneurysm wall in the acute phase. Recently, parent-artery reconstruction using Neuroform stents (Boston Scientific) [18] or covered stents [19–21] has been described, although such strategies have largely been applied to dissecting aneurysms of the vertebrobasilar junction or traumatic injury of the internal carotid artery. In addition, when parental artery sacrifice can be tolerated, liquid embolic material such as Onyx (ev3 Endovascular, Plymouth, MN, USA) [9,22] has also been reported to effectively occlude intracranial pseudoaneurysms. Intracranial pseudoaneurysm formation as a result of a ruptured true saccular aneurysm is extremely rare, and can be misdiagnosed as partially thrombosed cerebral aneurysm. Such
Fig. 3. Intra and post-coiling angiograms during the embolization procedure. After placement of the first coil, both the true aneurysm dome (asterisk) and the pseudoaneurysm (arrow) were still opacified in anteroposterior and lateral views (A, D). Additional coil deployment obliterated filling of the pseudoaneurysm (B, E). Postembolization angiogram demonstrated complete occlusion of the true aneurysm and no filling of the pseudoaneurysm (C, F).
Please cite this article in press as: Yanamadala V et al. Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.11.050
4
V. Yanamadala et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Fig. 4. MRI 1 month after coil embolization of the ruptured aneurysm. Non-contrast T1-weighted images in axial (A) and sagittal (B) views demonstrated thrombosis of the pseudoaneurysm (arrow).
lesions have been described as ‘‘ghost’’ aneurysms by Mori et al. due to the changing shape of contrast opacification on sequential radiographic images [5], and they are challenging to manage either surgically or endovascularly. Recognizing the presence of a pseudoaneurysm and identifying the connection between the true aneurysm and the pseudoaneurysm sac are essential for procedural planning. In our patient, the ruptured basilar apex aneurysm filled the pseudoaneurysm via a narrow connection anterior to the aneurysm dome (Fig. 2), and it was possible to place the microcatheter into the saccular aneurysm for coil embolization without disrupting the area of pseudoaneurysm. As the coil mass occluded the dome of the saccular aneurysm, the pseudoaneurysm sac no longer filled and eventually thrombosed. Careful analyses of the angioarchitecture of the aneurysm and avoiding the pseudoaneurysm sac during the endovascular intervention were both important factors to ensure patient safety and technical success in our patient. In summary, we present a rare case of acute pseudoaneurysm secondary to a ruptured basilar apex aneurysm that was successfully treated with coil embolization. Endovascular coiling may be used safely and effectively in selected cases of intracranial pseudoaneurysms, even in the acute phase.
[6]
[7]
[8] [9]
[10] [11]
[12]
[13]
[14]
[15]
Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
[16]
[17]
References [18] [1] Kassell NF, Torner JC, Haley Jr EC, et al. The international cooperative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 1990;73:18–36. [2] Kassell NF, Torner JC, Jane JA, et al. The international cooperative study on the timing of aneurysm surgery. Part 2: surgical results. J Neurosurg 1990;73:37–47. [3] Brzozowski K, Frankowska E, Piasecki P, et al. The use of routine imaging data in diagnosis of cerebral pseudoaneurysm prior to angiography. Eur J Radiol 2011;80:e401–9. [4] Walcott BP, Nahed BV, Kahle KT, et al. Cerebrovascular bypass and aneurysm trapping for the treatment of an A2-segment anterior cerebral artery pseudoaneurysm and herniation through a skull base defect following trauma. J Clin Neurosci 2012;19:149–51. [5] Mori K, Kasuga C, Nakao Y, et al. Intracranial pseudoaneurysm due to rupture of a saccular aneurysm mimicking a large partially thrombosed aneurysm
[19]
[20]
[21]
[22]
(‘‘ghost aneurysm’’): radiological findings and therapeutic implications in two cases. Neurosurg Rev 2004;27:289–93. Ide M, Kobayashi T, Tamano Y, et al. Pseudoaneurysm formation at the rupture site of a middle cerebral artery aneurysm–case report. Neurol Med Chir (Tokyo) 2003;43:443–6. Nomura M, Kida S, Uchiyama N, et al. Ruptured irregularly shaped aneurysms: pseudoaneurysm formation in a thrombus located at the rupture site. J Neurosurg 2000;93:998–1002. Binning MJ, Eskandari R, Couldwell WT. Direct surgical repair of carotid pseudoaneurysm in an infant. Childs Nerv Syst 2010;26:1151–3. Medel R, Crowley RW, Hamilton DK, et al. Endovascular obliteration of an intracranial pseudoaneurysm: the utility of onyx. J Neurosurg Pediatr 2009;4:445–8. Honda M, Nagamine T, Yamashiro K, et al. An intracranial pseudoaneurysm in the distal middle cerebral artery in a child. Pediatr Neurosurg 2008;44:426–9. Ding H, You C, Yin H. Nontraumatic and noninfectious pseudoaneurysms on the circle of Willis: 2 case reports and review of the literature. Surg Neurol 2008;69:414–7 [discussion 417]. Horiuchi T, Nakagawa F, Miyatake M, et al. Traumatic middle cerebral artery aneurysm: case report and review of the literature. Neurosurg Rev 2007;30:263–7 [discussion 267]. Dunn IF, Woodworth GF, Siddiqui AH, et al. Traumatic pericallosal artery aneurysm: a rare complication of transcallosal surgery. Case report. J Neurosurg 2007;106:153–7. Tanoue S, Kiyosue H, Matsumoto S, et al. Ruptured ‘‘blisterlike’’ aneurysm with a pseudoaneurysm formation requiring delayed intervention with endovascular coil embolization. Case report. J Neurosurg 2004;101:159–62. Pride Jr GL, Replogle RE, Rappard G, et al. Stent-coil treatment of a distal internal carotid artery dissecting pseudoaneurysm on a redundant loop by use of a flexible, dedicated nitinol intracranial stent. AJNR Am J Neuroradiol 2004;25:333–7. Lempert TE, Halbach VV, Higashida RT, et al. Endovascular treatment of pseudoaneurysms with electrolytically detachable coils. AJNR Am J Neuroradiol 1998;19:907–11. Kadyrov NA, Friedman JA, Nichols DA, et al. Endovascular treatment of an internal carotid artery pseudoaneurysm following transsphenoidal surgery. Case report. J Neurosurg 2002;96:624–7. Fiorella D, Albuquerque FC, Deshmukh VR, et al. Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms. Neurosurgery 2006;59:291–300 [discussion 291–300]. Yi AC, Palmer E, Luh GY, et al. Endovascular treatment of carotid and vertebral pseudoaneurysms with covered stents. AJNR Am J Neuroradiol 2008;29:983–7. Li MH, Li YD, Gao BL, et al. A new covered stent designed for intracranial vasculature: application in the management of pseudoaneurysms of the cranial internal carotid artery. AJNR Am J Neuroradiol 2007;28:1579–85. Fusonie GE, Edwards JD, Reed AB. Covered stent exclusion of blunt traumatic carotid artery pseudoaneurysm: case report and review of the literature. Ann Vasc Surg 2004;18:376–9. Eddleman CS, Surdell D, DiPatri Jr A, et al. Infectious intracranial aneurysms in the pediatric population: endovascular treatment with Onyx. Childs Nerv Syst 2008;24:909–15.
Please cite this article in press as: Yanamadala V et al. Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.11.050
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical Note
Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm Vijay Yanamadala a, Ning Lin b, Hekmat Zarzour b, Kai U. Frerichs b,c, Brian P. Walcott a,⇑, Ajith J. Thomas d, Ajit S. Puri e a
Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA Department of Neurosurgery, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA Department of Radiology, Brigham and Women’s Hospital & Harvard Medical School, Boston, MA, USA d Department of Neurosurgery, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA e Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA b c
a r t i c l e
i n f o
Article history: Received 19 August 2013 Accepted 29 November 2013 Available online xxxx Keywords: Aneurysm Endovascular coiling Pseudoaneurysm Subarachnoid hemorrhage
a b s t r a c t Acute intracranial pseudoaneurysms secondary to aneurysmal rupture are a rare entity with no clear evidence-based guidelines for treatment to our knowledge. There are numerous examples of successful treatment of pseudoaneurysms both surgically and endovascularly, the latter mainly within the anterior circulation. Risk of pseudoaneurysm rupture in the acute state during endovascular procedures with subsequent difficulty in controlling the bleeding without sacrificing the feeder artery has led to some reservation in using endovascular treatments more broadly. We report a rare case of a 52-year-old-woman who presented with acute subarachnoid hemorrhage and was found to have a ruptured 5 mm 8 mm bi-lobulated basilar apex aneurysm on CT angiography. Digital subtraction angiography demonstrated an associated anterior pseudoaneurysm that was formed secondary to the aneurysm rupture. The true aneurysm was successfully coiled with careful avoidance of the pseudoaneurysmal sac. Pseudoaneurysms are frequently identified for the first time during digital subtraction angiography. Recognizing their presence is essential for treatment planning. Acute pseudoaneurysms associated with true aneurysmal rupture can be safely and successfully treated by endovascular coiling of the true aneurysm. Care must be taken to avoid manipulation of the pseudoaneurysmal sac during the embolization. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Intracranial pseudoaneurysms are unusual and occur in less than 1% of patients with intracranial aneurysms [1,2]. The most common causes of pseudoaneurysm formation include blunt or penetrating head trauma, neoplasm, Marfan’s syndrome and other collagen vascular disorders, dissection, infection, vasculitis, and iatrogenic injury during surgery or endovascular procedures [3,4]. Rarely, rupture of a true cerebral aneurysm can lead to the development of a pseudoaneurysm [5–7]. These lesions are commonly referred to as ‘‘ghost aneurysms’’ due to their irregular angiographic appearance and changing shape [5]. Pseudoaneurysms are challenging to manage and are associated with high morbidity and mortality. Although open and endovascular treatments for intracranial pseudoaneurysms have both been reported, the optimal approach for management remains controversial. ⇑ Corresponding author. Tel.: +1 617 726 2000; fax: +1 617 643 4113. E-mail address: [email protected] (B.P. Walcott).
Herein, we present a rare case of a ruptured basilar artery aneurysm associated with an adjacent pseudoaneurysm, both of which were successfully treated with coil embolization. 2. Technical case report 2.1. Clinical features A 52-year-old woman with no past medical history presented with sudden onset of severe headache and subsequent loss of consciousness. She was brought to the emergency room intubated and obtunded. Her examination was notable for fixed non-reactive pupils at 1 mm bilaterally and extensor posturing in all four extremities. A non-contrast head CT scan demonstrated diffuse subarachnoid hemorrhage in the basal cisterns with intraventricular extension (Fig. 1A). CT angiogram demonstrated a 4–5 mm basilar apex aneurysm that extended into the suprasellar cistern, although the microanatomy of the aneurysm was not fully distinguishable. A right frontal external ventricular drain was
http://dx.doi.org/10.1016/j.jocn.2013.11.050 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yanamadala V et al. Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.11.050
2
V. Yanamadala et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Fig. 1. Preoperative non-contrast head CT scan (A) demonstrated diffuse subarachnoid hemorrhage, intraventricular hemorrhage, and hydrocephalus. Preoperative diagnostic cerebral angiogram in the anteroposterior (B) and lateral (C) views revealed a 5 mm 8 mm basilar apex aneurysm.
emergently placed for drainage of cerebrospinal fluid and control of intracranial hypertension. The patient was transferred to the neurointerventional suite for digital subtracted angiography (DSA) and embolization. 2.2. Angiographic features DSA demonstrated an irregular, bi-lobed aneurysm at the basilar apex, measuring 5 mm 8 mm (Fig. 1B, C). There was an elongated, contrast-opacified cavity located anterior-inferiorly to the basilar apex aneurysm and the basilar artery, which was best appreciated in the lateral views of the angiogram (Fig. 2). This lesion filled with contrast unevenly and in a delayed fashion, as shown in the early (Fig. 2A, E) and late (Fig. 2B, F) arterial phases of the angiogram. Contrast stasis and delayed contrast washout were also observed in the early (Fig. 2C, G) and late (Fig. 2D, H)
venous phases. These findings collectively suggested that a large pseudoaneurysm was present in the interpeduncular and prepontine cisterns, which had a narrow connection anteriorly to the true aneurysm sac at the basilar apex. No thrombus was visualized within the aneurysm or the pseudoaneurysm. The decision was made to proceed with coil occlusion of the true aneurysm dome without entering the pseudoaneurysm to minimize the risk of procedural re-rupture. 2.3. Endovascular embolization Under fluoroscopic supervision, a 6 French Neuron guide catheter (Penumbra, Alameda, CA, USA) was placed at the distal cervical segment of the left vertebral artery over an exchange-length Glidewire (Terumo, Somerset, NJ, USA). Using a magnified roadmap technique, a SL-10 microcatheter (Boston Scientific, Boston, MA,
Fig. 2. Different phases of the cerebral angiogram demonstrated a pseudoaneurysm associated with the ruptured basilar apex aneurysm. Early (A, E) and late (B, F) arterial phases in the anteroposterior (A, B) and lateral (E, F) views showed delayed and unequal filling of a large, irregular pseudoaneurysm anterior to the true basilar apex aneurysm. There was contrast stasis and delayed washout in the pseudoaneurysm in the early (C, G) and late (D, H) venous phases.
Please cite this article in press as: Yanamadala V et al. Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.11.050
V. Yanamadala et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
USA) was advanced over a Synchro II guidewire (Boston Scientific) to access the basilar apex aneurysm. Then, a Guglielmi detachable coil (GDC) 10/360 5 mm 10 cm coil (Boston Scientific) was placed in the aneurysm dome, followed by five more GDC coils. The cavity of the pseudoaneurysm was carefully avoided. Both the aneurysm and the pseudoaneurysm were still opacified after the first coil placement (Fig. 3A, D), however the pseudoaneurysm was gradually obliterated after additional coil placement (Fig. 3B, E). Post-embolization angiography (Fig. 3C, F) demonstrated no contrast filling within the aneurysm or the pseudoaneurysm. The patient tolerated the procedure without complications. She required placement of a percutaneous gastrostomy tube and a ventriculoperitoneal shunt during the hospitalization. She was discharged to a rehabilitation facility on hospital day 21. Subsequently, the patient continued to recover and was fully awake, oriented, and able to move all extremities at her first post-hospitalization visit. MRI of the brain 4 weeks after coil embolization demonstrated thrombosis of the pseudoaneurysm and no residual filling of the basilar apex aneurysm (Fig. 4).
3. Discussion In this technical note, we present the successful endovascular treatment of an acute basilar artery apex aneurysm with an associated pseudoaneurysm. In this patient, the clinical presentation of acute subarachnoid hemorrhage and subsequent angiographic findings suggest that the pseudoaneurysm formed secondary to the rupture of the true aneurysm, a rare cause of pseudoaneurysm formation [5]. Pre-operative recognition of the presence of a
3
pseudoaneurysm is essential for appropriate clinical decision making and for surgical planning. Multiple endovascular approaches have been reported to successfully obliterate an intracranial pseudoaneurysm [3,5–17], although the optimal treatment strategy remains controversial and likely needs to be determined on a patient-by-patient basis. Lempert et al. presented a series of 11 traumatic and iatrogenic anterior circulation pseudoaneurysms that were successfully treated endovascularly with coil embolization [16]. The authors reported only minor complications and concluded that pseudoaneurysms were best managed in the subacute period when the wall of the pseudoaneurysm had matured. Nomura et al. described eight patients with acute intracranial pseudoaneurysms who were treated either surgically or endovascularly, and reported a high intraprocedural re-rupture rate during endovascular embolization [7]. The authors suggested that endovascular surgeons should be particularly cautious to avoid advancing microinstruments into the area of pseudoaneurysm because of the fragile nature of the pseudoaneurysm wall in the acute phase. Recently, parent-artery reconstruction using Neuroform stents (Boston Scientific) [18] or covered stents [19–21] has been described, although such strategies have largely been applied to dissecting aneurysms of the vertebrobasilar junction or traumatic injury of the internal carotid artery. In addition, when parental artery sacrifice can be tolerated, liquid embolic material such as Onyx (ev3 Endovascular, Plymouth, MN, USA) [9,22] has also been reported to effectively occlude intracranial pseudoaneurysms. Intracranial pseudoaneurysm formation as a result of a ruptured true saccular aneurysm is extremely rare, and can be misdiagnosed as partially thrombosed cerebral aneurysm. Such
Fig. 3. Intra and post-coiling angiograms during the embolization procedure. After placement of the first coil, both the true aneurysm dome (asterisk) and the pseudoaneurysm (arrow) were still opacified in anteroposterior and lateral views (A, D). Additional coil deployment obliterated filling of the pseudoaneurysm (B, E). Postembolization angiogram demonstrated complete occlusion of the true aneurysm and no filling of the pseudoaneurysm (C, F).
Please cite this article in press as: Yanamadala V et al. Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.11.050
4
V. Yanamadala et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Fig. 4. MRI 1 month after coil embolization of the ruptured aneurysm. Non-contrast T1-weighted images in axial (A) and sagittal (B) views demonstrated thrombosis of the pseudoaneurysm (arrow).
lesions have been described as ‘‘ghost’’ aneurysms by Mori et al. due to the changing shape of contrast opacification on sequential radiographic images [5], and they are challenging to manage either surgically or endovascularly. Recognizing the presence of a pseudoaneurysm and identifying the connection between the true aneurysm and the pseudoaneurysm sac are essential for procedural planning. In our patient, the ruptured basilar apex aneurysm filled the pseudoaneurysm via a narrow connection anterior to the aneurysm dome (Fig. 2), and it was possible to place the microcatheter into the saccular aneurysm for coil embolization without disrupting the area of pseudoaneurysm. As the coil mass occluded the dome of the saccular aneurysm, the pseudoaneurysm sac no longer filled and eventually thrombosed. Careful analyses of the angioarchitecture of the aneurysm and avoiding the pseudoaneurysm sac during the endovascular intervention were both important factors to ensure patient safety and technical success in our patient. In summary, we present a rare case of acute pseudoaneurysm secondary to a ruptured basilar apex aneurysm that was successfully treated with coil embolization. Endovascular coiling may be used safely and effectively in selected cases of intracranial pseudoaneurysms, even in the acute phase.
[6]
[7]
[8] [9]
[10] [11]
[12]
[13]
[14]
[15]
Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
[16]
[17]
References [18] [1] Kassell NF, Torner JC, Haley Jr EC, et al. The international cooperative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 1990;73:18–36. [2] Kassell NF, Torner JC, Jane JA, et al. The international cooperative study on the timing of aneurysm surgery. Part 2: surgical results. J Neurosurg 1990;73:37–47. [3] Brzozowski K, Frankowska E, Piasecki P, et al. The use of routine imaging data in diagnosis of cerebral pseudoaneurysm prior to angiography. Eur J Radiol 2011;80:e401–9. [4] Walcott BP, Nahed BV, Kahle KT, et al. Cerebrovascular bypass and aneurysm trapping for the treatment of an A2-segment anterior cerebral artery pseudoaneurysm and herniation through a skull base defect following trauma. J Clin Neurosci 2012;19:149–51. [5] Mori K, Kasuga C, Nakao Y, et al. Intracranial pseudoaneurysm due to rupture of a saccular aneurysm mimicking a large partially thrombosed aneurysm
[19]
[20]
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[22]
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Please cite this article in press as: Yanamadala V et al. Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.11.050
