Unusual Intracranial Stent Navigation through the Circle of Willis in a Patient with Recurrent Basilar Tip Aneurysm during Stent-Assisted Coiling

We describe a case of unusual Enterprise stent navigation through the Circle of Willis in a patient with a basilar tip aneurysm, left internal carotid artery (ICA) occlusion and previous right ICA stenting. Basilar tip aneurysms are known for their therapeutic challenges, especially when the posterior cerebral arteries (PCAs) are incorporated in the aneurysm neck. This becomes more technically demanding if the vertebral artery does not offer a route for stent navigation. We undertook stent-assisted coiling using the horizontal stenting of posterior cerebral arteries via both the posterior and anterior communicating artery navigation. This was necessary because the vertebral arteries were very tortuous, hence not suitable for stent navigation due to their small size and stenosis at their origin. Another compounding factor was the anatomy of the aneurysm neck in relation to the T-shaped origin of both P1 PCAs from the basilar artery. The right ICA was stented previously and the whole navigation was done through this stented artery as the opposite left ICA was occluded at the bifurcation. In addition, there was no visualized posterior communicating artery (PCOM) on the right side, so following navigation through the anterior communicating artery (ACOM) the left PCOM artery was catheterized to reach the PCAs. After horizontal placement of stent, coiling was performed for the residual aneurysm. The outcome of this intervention revealed successful placement of the Enterprise stent in bilateral posterior cerebral arteries covering the aneurysm. Further coiling of the basilar artery aneurysm was done with a good result. No complication was seen in the angiography suite or later in the course of action. Horizontal stent placement in wide-necked basilar aneurysms can be performed via the PCOM and ACOM arteries.

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STENT REMODELING TECHNIQUE FOR COILING OF RUPTURED WIDE-NECK CEREBRAL ANEURYSMS: CASE REPORT

Neurosurgery ◽

10.1227/01.neu.0000350984.86323.61 ◽

2009 ◽

Vol 65 (5) ◽

pp. E1007-E1008 ◽

Cited By ~ 10

Author(s):

Demetrius K. Lopes ◽

Kalani Wells

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Aneurysms ◽

Artery Aneurysm ◽

Anterior Communicating Artery ◽

Parent Vessel ◽

Aneurysm Neck ◽

Acute Subarachnoid Hemorrhage ◽

The Right ◽

Wide Neck ◽

Cordis Corporation

Abstract OBJECTIVE To describe a novel stent remodeling technique for the coiling of ruptured wide-neck cerebral aneurysms. CLINICAL PRESENTATION A 46-year-old man presented with acute subarachnoid hemorrhage (Hunt and Hess grade IV), intracerebral hemorrhage, and hydrocephalus. Cerebral angiography revealed a wide-neck small anterior communicating artery aneurysm. Conventional coiling was not successful because of coil instability and compromise of the dominant anterior cerebral artery. TECHNIQUE A 6-French shuttle sheath (Cook Medical, Indianapolis, IN) was advanced from a right femoral approach into the right common carotid artery. To protect the parent vessel during coiling without compromising blood flow, a Prowler Select Plus catheter (Cordis Corporation, Bridgewater, NJ) was navigated across the aneurysm neck. Subsequently, an Enterprise stent (22-mm length; Cordis Corporation) was partially deployed across the aneurysm's wide neck. It was very important to watch the distal markers of the stent and lock the stent delivery wire to the Prowler Select Plus with a hemostatic valve once the stent was halfway deployed. This maneuver was essential to prevent further deployment of the stent. The SL-10 microcatheter and Synchro 14 wire (Boston Scientific, Natick, MA) were carefully navigated to the aneurysm passing through the partially deployed stent. Coils were then delivered to the aneurysm using the stent as a scaffold. After coiling, the SL-10 microcatheter was removed and the stent was recaptured into the Prowler Select Plus catheter. During the recapture, there was initial resistance. This was easily overcome after deploying the stent a little more before resheathing. During the procedure, the patient received 2000 U of heparin after the first coil was detached in the aneurysm. CONCLUSION The stent remodeling technique is a novel endovascular technique that can be used to treat ruptured wide-neck aneurysms and maintain patency of parent vessels, avoiding the use of antiplatelet therapy in acute subarachnoid hemorrhage.

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Anatomical variations of circle of Willis - a cadaveric study

International Surgery Journal ◽

10.18203/2349-2902.isj20171016 ◽

2017 ◽

Vol 4 (4) ◽

pp. 1249 ◽

Cited By ~ 1

Author(s):

Ramanuj Singh ◽

Ajay Babu Kannabathula ◽

Himadri Sunam ◽

Debajani Deka

Keyword(s):

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Anterior Part ◽

Cerebral Arteries ◽

Anatomical Variations ◽

Circle Of Willis ◽

Anterior Communicating Artery ◽

Surgical Interventions ◽

Collateral Channel ◽

The Right

Background: The circle of Willis (CW) is a vascular network formed at the base of skull in the interpeduncular fossa. Its anterior part is formed by the anterior cerebral artery, from either side. Anterior communicating artery connects the right and left anterior cerebral arteries. Posteriorly, the basilar artery divides into right and left posterior cerebral arteries and each join to ipsilateral internal carotid artery through a posterior communicating artery. Anterior communicating artery and posterior communicating arteries are important component of circle of Willis, acts as collateral channel to stabilize blood flow. In the present study, anatomical variations in the circle of Willis were noted.Methods: 75 apparently normal formalin fixed brain specimens were collected from human cadavers. 55 Normal anatomical pattern and 20 variations of circle of Willis were studied. The Circles of Willis arteries were then colored, photographed, numbered and the abnormalities, if any, were noted.Results: Twenty variations were noted. The most common variation observed is in the anterior communicating artery followed by some other variations like the Posterior communicating arteries, Anterior cerebral artery and posterior cerebral artery (PCA) was found in 20 specimens.Conclusions: Knowledge on of variations in the formation of Circle of Willis, all surgical interventions should be preceded by angiography. Awareness of these anatomical variations is important in the neurovascular procedures.

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Broad Neck Basilar Tip Aneurysm Treated by Neck Plastic Intra-Aneurysmal GDC Embolisation with Protective Balloon

Interventional Neuroradiology ◽

10.1177/159101999700300209 ◽

1997 ◽

Vol 3 (2) ◽

pp. 167-170 ◽

Cited By ~ 18

Author(s):

A. Takahashi ◽

M. Ezura ◽

T. Yoshimoto

Keyword(s):

Basilar Artery ◽

Balloon Catheter ◽

Artery Aneurysm ◽

Detachable Coil ◽

Guglielmi Detachable Coil ◽

Left Posterior ◽

Basilar Artery Aneurysm ◽

Basilar Tip Aneurysm ◽

Aneurysmal Neck ◽

The Stability

A 56-year-old male was found to have a basilar artery aneurysm by magnetic resonance imaging. Angiography demonstrated a broad neck basilar tip aneurysm. He refused surgical clipping but accepted intravascular embolisation. Introducing catheters were inserted into each of the bilateral vertebral arteries. A microcatheter was introduced into the aneurysm through one of the introducing catheters and a double lumen balloon catheter was introduced into the left posterior cerebral artery (PCA) through the other. The balloon was located from the left PCA to the basilar artery across the aneurysmal neck with the aid of a guidewire passed through the inner lumen of the balloon catheter. The balloon was inflated, and a Guglielmi detachable coil (GDC) was inserted until the platinum part was placed inside the aneurysm. The balloon was deflated to confirm the stability of the GDC, and then the GDC was electrically detached. This procedure was repeated until nine GDCs were successfully inserted. The aneurysm was tightly embolised despite its broad neck. Angiography comfirmed complete neck closure and stable preservation of the basilar artery and bilateral PCAs immediately, 1 week, 3 months, 6 months, and 12 months after embolisation without evidence of thrombo-embolic complications. Neck plastic intra-aneurysmal GDC embolisation using a protective balloon can be used to treat broad-neck aneurysms.

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Average dimensions of the vessels at the base of the brain and the embryological basis of its variations

National Journal of Clinical Anatomy ◽

10.1055/s-0039-3401724 ◽

2013 ◽

Vol 02 (04) ◽

pp. 180-189

Author(s):

Iqbal S.

Keyword(s):

Anterior Part ◽

Cerebral Arteries ◽

Cerebral Dominance ◽

Circle Of Willis ◽

Detailed Knowledge ◽

Differential Growth ◽

Ischemic Attack ◽

The Individual ◽

The Right ◽

The Brain

Abstract Background and aims: The cerebral circulation is constantly maintained by the anastomotic circle of Willis which is often anomalous in more than 50% of the normal adult brains. These anomalies increase the risk of the stroke and transient ischemic attack in older patients. Adequate blood flow through the circle of Willis is often necessary to prevent these ischemic infarctions. The anomalies of cerebral vessels are directly related to the differential growth of various parts of the brain. A detailed knowledge of the individual measurements of the cerebral arteries is useful to neurosurgeon in planning the shunt operations and in the choice of their patients. The present study is aimed to analyze the average dimensions of the vessels at the base of brain and an attempt to explain the common form of variations in terms of embryological development. Materials and methods: Fifty adult cadaveric brains were obtained from routine cadaveric dissections. The base of the brain with the circle of Willis was fixed in 10% formalin and preserved. The circle was analyzed for variations in the size, length and number of the component vessels and any asymmetry in the configuration. The dimensions of the vessels forming the circle were measured using graduated calipers. The observations were recorded and tabulated. Results: Asymmetry was observed in 10% to 36% of the circles in this study. Anomalies were more common in the posterior than in the anterior part of the circle. The posterior anomalies included hypoplastic vessels, absent vessels and embryonic derivation while anterior anomalies were predominantly of accessory vessels. Middle cerebral artery exhibited the least variations. In majority of the circles, left sided vessels were larger in diameter than the right. Conclusions: Variations are more common in the posterior than in the anterior part of the circle and on the right than on the left side of the brain. There was no correlation between the variations of circle of Willis of the right side and the left cerebral dominance. There seems to be no difference between races, concerning the anatomic variations of the brain circulation.

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Models of intracranial aneurysms for angiographic imaging modalities. A technical note

Medicina ◽

10.3390/medicina43070071 ◽

2007 ◽

Vol 43 (7) ◽

pp. 562 ◽

Cited By ~ 1

Author(s):

Edvardas Žurauskas ◽

Jurgita Ušinskienė ◽

Virginija Gaigalaitė ◽

Raphael Blanc ◽

Andrius Ušinskas ◽

...

Keyword(s):

Cerebral Arteries ◽

Artery Aneurysm ◽

Technical Note ◽

In Vitro Production ◽

Plastic Tube ◽

Technical Aspects ◽

Human Specimen ◽

Glass Tubes ◽

Basilar Tip Aneurysm

Objective. To delineate technical aspects of vascular models with intracranial aneurysm in vitro production, suitable for angiographic imaging. Material and methods. Wax (K2 exact, S-U-CERAMO-CAPS-WAX), Girtl’s mass, gelatin, and silicone (Silicone 10015 Den Braven, Elastosil 7683/25, Elite Double 32 Shore-A, Rema-Sil) were used for model production. Construction of models was based on T-shaped plastic tube connections and lost core techniques. Images of rotational angiography, glass tubes with aneurysm, and casts obtained in human specimen were used as samples of cerebral arteries. Results. Technical aspects of vascular models production were delineated in experience of eight silicone models produced. M1 was hand made with basilar tip aneurysm; M2 was obtained according to angiography images with internal carotid artery supraclinoid part bifurcation to anterior and middle cerebral artery aneurysm. BM1 and BM2 casts were made using glass tubes with lateral aneurysm, M3 – from T-shaped plastic tubes with lateral aneurysms. M4, M5, and M6 were formed using casts obtained in human specimen with basilar tip aneurysm. Conclusions. Silicone of two components is practical for casts of cerebral arteries in human specimen production. Gelatinous solution 50°C diluted 1:1 with water can be used for copies of arterial casts production. Wax materials are unsuitable for making casts in a human specimen.

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Modified Orbitozygomatic Craniotomy for a Previously Coiled Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa018 ◽

2020 ◽

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Video Recording ◽

Artery Aneurysm ◽

Mass Effect ◽

Optic Chiasm ◽

Anterior Communicating Artery ◽

Aneurysm Neck ◽

Institutional Review Board Approval ◽

Institutional Review ◽

Clip Occlusion

Abstract Clip occlusion of previously coiled aneurysms poses unique technical challenges. The coil mass can complicate aneurysm neck access and clip tine approximation. This patient had a previously ruptured anterior communicating artery (ACOM) aneurysm that had been treated with coil embolization. On follow-up evaluation, the patient was found to have a recurrence of the aneurysm, which prompted an orbitozygomatic craniotomy for clip occlusion. The approach provided a favorable view of the aneurysm neck with the coil mass protruding outside the aneurysm dome. Indocyanine green fluoroscopy was used to assist with ideal permanent clip placement along the aneurysm neck. The segment of coils present outside the aneurysm neck was removed to reduce mass effect on the optic chiasm. Postoperative imaging demonstrated aneurysm obliteration. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Giant pericallosal artery aneurysm – Literature review and report of a rare case

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1626013 ◽

2013 ◽

Vol 32 (03) ◽

pp. 195-199

Author(s):

José Fernando Guedes Corrêa ◽

Ari Boulanger Sucussel Junior ◽

Rogério Martins Pires Amorim ◽

Lucas Santos Loiola ◽

Maristella Reis ◽

...

Keyword(s):

Surgical Treatment ◽

Cerebral Arteries ◽

Clinical Status ◽

Artery Aneurysm ◽

Mass Effect ◽

Imaging Studies ◽

Falx Cerebri ◽

Aneurysm Neck ◽

Pericallosal Artery ◽

Medial Surfaces

AbstractGiant pericallosal artery aneurysms are extremely rare. Aneurismatic lesions involving this artery are usually small, tend to early bleeding and might be associated with other lesions. Differential diagnosis of giant aneurysms are not easy and includes tumoral, infectious and vascular mass effect lesions. We report a case of a giant and partially thrombosed left pericallosal artery aneurysm. A 58-year-old man, presented with progressive headaches, seizures and speech alterations initially misdiagnosed as a falx cerebri meningioma. As clinical status continue to worsen, magnetic resonance imaging and digital cerebral angiography were performed and a vascular etiology was considered. The patient was then referred to our hospital for surgical treatment. The peculiarity of this case concerns the difficulty of surgical treatment once the surgeon was not able to obtain control of the afferent artery and the aneurysm neck could not be visualized. Also, the aneurysm adhered to the medial surfaces of the frontal lobes and covered the anterior cerebral arteries. Treatment by means of microsurgical thrombectomy, clipping and resection of the lesion was successfully performed. Microsurgical treatment may provide good results when carefully planned with the help of imaging studies of the lesion. It is essential to keep in mind that flexible approach is of great importance when dealing with giant aneurysmatic lesions of pericallosal artery due to its variety of intraoperative presentation.

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Orbitozygomatic Craniotomy for Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz303 ◽

2019 ◽

Vol 18 (1) ◽

pp. E5-E6

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Video Recording ◽

Artery Aneurysm ◽

Anterior Communicating Artery ◽

Parent Artery ◽

Aneurysm Neck ◽

Anterior Communicating Artery Aneurysm ◽

Institutional Review Board Approval ◽

Institutional Review ◽

Vessel Patency ◽

Aneurysmal Neck

Abstract Giant intracranial aneurysms pose a significant surgical challenge because of the associated difficulty in achieving adequate visualization of the parent artery and aneurysm neck. This patient had an incidentally identified giant anterior communicating artery aneurysm. An orbitozygomatic craniotomy was performed for aneurysm exposure and aneurysmal neck dissection. Aneurysm dome opening and thrombectomy was performed to debulk the aneurysmal mass, which facilitated subsequent aneurysmal neck visualization. Sequential utilization of temporary clips of the bilateral A1 and bilateral A2 vessels reduced hemorrhage during thrombectomy. Multiple permanent clips were applied along the dissected aneurysm neck to permit occlusion. A small fracture of the aneurysm neck was identified, and cotton was applied with subsequent tamponade utilizing a fenestrated clip to maintain hemostasis. Indocyanine green fluoroscopy was used to verify parent and distant vessel patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Transcirculation balloon-assisted stent-supported coil embolization of a basilar tip aneurysm

Neurosurgical FOCUS ◽

10.3171/2014.v2.focus14182 ◽

2014 ◽

Vol 37 (v1supplement) ◽

pp. 1

Author(s):

Vijay Agarwal ◽

Ali Zomorodi ◽

Cameron Mcdougal ◽

Ranjith Babu ◽

Adam Back ◽

...

Keyword(s):

Vertebral Artery ◽

Basilar Artery ◽

Coil Embolization ◽

Posterior Communicating Artery ◽

Link Type ◽

Left Posterior ◽

Basilar Tip Aneurysm ◽

The Right

We present the case of a balloon-assisted, stent-supported coil embolization of a basilar tip aneurysm. Initially, a balloon extending from the basilar artery into the right PCA was placed.3 However, even with a more proximal purchase, coils were found to impinge on the left PCA. Subsequently, a transcirculation approach was performed, where the left posterior communicating artery was utilized as a conduit for balloon support and the coils were embolized from the ipsilateral vertebral artery.1 However, after this transcirculation approach was completed, there was a coil tail extruding from the aneurysm. The balloon was then removed over an exchange wire and a horizontal stent advanced, spanning the entire neck of the aneurysm, eliminating the extruded coil.2The video can be found here: http://youtu.be/bMbtZoPnYvo.

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“Double-Barrel” Stent Reconstruction of a Symptomatic Fusiform Basilar Artery Aneurysm: Case Report

Neurosurgery ◽

10.1227/neu.0b013e318211f982 ◽

2011 ◽

Vol 68 (5) ◽

pp. E1491-E1496 ◽

Cited By ~ 9

Author(s):

Mark Bain ◽

Muhammad Shazam Hussain ◽

Alejandro Spiotta ◽

Vivekananda Gonugunta ◽

Shaye Moskowitz ◽

...

Keyword(s):

Basilar Artery ◽

Cerebral Arteries ◽

Artery Aneurysm ◽

High Rate ◽

Neurologic Recovery ◽

Aneurysmal Dilation ◽

Basilar Artery Aneurysm ◽

Flow Through ◽

Aneurysm Thrombosis ◽

Near Occlusion

Abstract BACKGROUND AND IMPORTANCE: Giant fusiform aneurysms of the basilar artery are associated with a high rate of morbidity and mortality. Treatment of these lesions can be difficult, especially when there are poor anatomic collaterals such as posterior communicating arteries. These lesions often have no acceptable treatment. The authors present a case of a patient with a symptomatic, fusiform basilar artery aneurysm successfully treated with a side-by-side (double-barrel), telescoping stent construct. CLINICAL PRESENTATION: A 56-year-old man presented with chief concerns of dysarthria and left-sided hemiparesis. MRI and conventional catheter-based angiography revealed a dolichoectatic basilar artery with 3 large fusiform aneurysms throughout its length. Flow through the patient's aneurysm was successfully reduced with a side-by-side stent construct and coiling of the proximal aneurysm dilation. The patient experienced stabilization of his ischemic events and neurologic recovery. A total of 6 Neurform-2 4.5 × 30-mm stents were navigated and positioned from the proximal posterior cerebral arteries to the distal vertebral arteries in a side-by-side (double-barrel), telescoping manner. These were deployed simultaneously by 2 operators to oppose the stent struts as well as the arterial wall. Next, the proximal aneurysmal dilation was coiled to near occlusion. Successful flow redirection and aneurysm thrombosis was observed. CONCLUSION: A novel, endovascular stenting technique for successfully treating symptomatic, giant basilar artery aneurysms is presented. This patient at 4 months was living independently with no further neurologic events or decline.

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