Korean Journal of Cerebrovascular Surgery 2009;11(4):201-203.
Published online December 1, 2009.
A Complicated Case of Endovascular Stent Assisted Coil Embolization of an Aneurysm.
Huh, Hoon , Song, Kwan Young , Kim, Jung Hee , Kong, Min Ho , Kang, Dong Soo , Kim, Young Jun
1Department of Neurosurgery, Seoul Medical Center, Seoul, Koera. nssky@lycos.co.kr
2Department of Neurosurgery, College of Medicine, Dankook University, Cheonan, Korea.
Abstract
Endovascular coiling is one of the recent methods for treating cerebral aneurysm and this method is considered to be an alternative method for treating aneurysms. Yet there are several disadvantages of endovascular coiling. As is well known, a wide-necked aneurysm is not completely treated with endovascular coiling. Infarction of the parent artery due to coil compaction, recanalization and embolization is a significant problem of endovascular coiling for a wide-necked aneurysm. Wide-necked aneurysms have been recently treated with stent assisted coil embolization. Stent-assisted coil embolization results in a higher rate of complication. In this case report, we present a case with complication after stent-assisted endovascular coiling. We concluded that precise, cautious procedures are needed when performing complicated stent assisted endovascular coiling to prevent thromboembolic complications.
Key Words: Aneurysm, Coil, Stent, Complication

Introduction

The endovascular embolization is used widely as a treatment method of cerebral aneurysm rupture. But wide-necked aneurysm, dissecting aneurysm and fusiform aneurysm are difficult to treat with a method of coil embolization.1)2)5) Because a coil is tend to emerge from aneurysm into the parent artery.1)7) For this reason, wide-necked aneurysms and dissecting aneurysms are not considered amenable to treat with coil embolization.2)7) Recently, with a use of flexible intravascular stents, alternative method of treatment approach is possible in the field of endovascular treatment of intracranial wide-necked aneurysm.2)5)7) But the rate of complications of stent assisted endovascular treatment are increased as same manner. So, we report a case of complications after the endovascular coiling treatment with stent.

 

 

Case Report

 

46-years-old female was presented with severe headache and drowsy mentality. Computed tomography showed a subarachnoid hemorrhage with blood clot in prepontine cistern (Fig. 1-A).

The patient at presentation was evaluated as grade III of the Hunt and Hess grading scale. Computed tomography angiogram showed dissecting aneurysm of a vertebral artery, measured approximately 3¡¿4 mm in its size (Fig. 1-B,C).

And digital subtraction angiography showed a dissecting aneurysm of right vertebral artery (Fig. 1-D,E).

Subsequently, we inserted 25mm sized stent from left vertebral artery to basilar artery. After the placement of Neuroform stents (Boston Scientific /Target Therapeutics, Inc., Natick, MA), the aneurysm was embolized with GDC coil (Fig. 1-F).

Postoperative management was proceeded in the intensive care unit and the patient was administered oral aspirin (100mg/day) and plavix (75mg/day).

24 hours after the endovascular procedure, the patient was presented with a sudden visual disturbances. And a following diffusion-weighted MR image showed a cerebral infarction on visual cortex bilaterally (Fig. 1-G).

The patient was managed with Nimodipine and antiplatelet agent. And Ôtriple HÕ therapy and systemic heparinization were also proceeded accordingly. patientsÕ mental status was not changed after the infarction and symptoms of increased intracranial pressure were not presented either. Angiography was not done because patient did not wanted evaluation of cerebral infarction. Patient discharged with more improved visual acuity on post operative day 28th.

 

Discussion

Recently, stent assisted endovascular coiling provides more secure protection of the parent vessel. And these methods are useful in complete packing with lower risk of rupture, coil migration, or parent artery obstruction.1)3)4)5)6) In addition, the stent potentially provides a physical matrix for endothelial growth and allows appropriate remodeling of the parent vessel along the aneurysm neck.7) The stent assisted coiling is a useful method for the treatment of aneurysms unable to be treated with surgical methods or traditional endovascular treatment strategies.2) This method represents a viable treatment option for a selection of patients with wide-necked aneurysms and would be used more frequently in the new era of endovascular management of wide-necked cerebral aneurysms.4)7) But, procedures in this method are more complicated. And the rate of flow olbiterations in this method could be higher than that of simple endovascular embolization. Flow obliteration is presented by two reasons. First, mechanical obstruction by coil is the one of the reason. In this situation, operator should make coil loop not to be bulged out into parent artery. Balloon assisted neck plasty or using stent is useful in the broad neck aeurysm. And the point is that procedures must be done not too much packing near the origin of incorporated perforator at the neck portion. Another reason of flow obliteration is occlusion by clot or thrombus. Operators have to do the coiling procedure with careful manipulation of microcatheter and microguidewire not to injure the vessel wall and atheroma. Preventing and Treating vasospasm is also included in coiling strategies. If need, proper systemic heparinization and continuous heparin flushing fluid through the microcatheter and guiding catheter during the whole procedure is very important.

In our case, visual disturbances would be induced by thromboembolic event. It could be assumed by the fact that post-infarction radiologic findings were not different from postoperative radiologic findings. And symptoms of visual disturbances were improved after the systemic heparinization and antiplatelet agent therapy.

 

Conclusion

While proceeding multistaged stent assisted coiling which is more complicated than simple coiling in the procedures, meticulous procedure skills are needed. In addition, not only oral antiplatelet agents, but also postoperative heparinization might be considered in the case of the guiding catheter and microcatheter procedures are difficult to reach the targeted aneurysm.

Therefore, proceeding the complicated stent assisted coiling, operators should manage the procedure more cautiously in order to prevent thromboembolic complications.

 

 

References

 

1)              David Wells-Roth, Alessandra Biondi, Vallabh Janardhan, Kyle Chapple, Y.Pierre Gobin, Howard A.Riina: Endovascular procedures for treating wide-necked aneurysms. Neurosurg Focus 18(2):E7,2005

 

2)              Edward Greenberg, Jeffrey M.Katz, Vallabh Janardhan, Vallabh Janardhan, Howard Riina, Y.Pierre Gobin: Treatment of a giant vertebrobasilar artery aneurysm using stent grafts. J.Neurosurg 107:165-8,2007

 

3)              Jung-Ho Ko, Young-Joon Kim, Joon-Sung Cho, Keun-Tae Cho, Bong-Jin Park, Maeng-Ki Cho: The analysis of procedural complications of endovascular aneurysm coiling with GDC . J Korean Neurosurg Soc 36:394-9,2004

 

4)              Nathaniel P.Brooks, Aquilla S.Truk, David B.Niemann, Beverly Aagaard-Kienitz, Kari Pulfer, Thomas Cook: Frequency of thromboembolic events associated with endovascular aneurysm threatment : retrospective case series. J Neurosurg 108:1095-100,2008

 

5)              Pascal Jabbour, Christopher Koebbe, Erol Venznedaroglu, Ronald P.Benitez, Robert Rosenwasser: Stent-assisted coil placement for unruptured cerebral aneurysms. Neurosurg Focus 17(5):E10,2004

 

6)              Ricardo J. Komotar, J Mocco, David A.Wilson, E. Sander Connolly Jr, Sean D. Lavine, Philip M. Meyers: Current endovascular treatment options for intracranial carotid artery atherosclerosis. Neurosurg Focus 18(1):E5,2005

 

7)              Sepher Sani, Kirk W.Jobe, Demetrius K.Lopes: Treatment of wide-necked cerebral aneurysms with the Neuroform2 Treo stent. Neurosurg Focus 18(2):E4,200


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