Selective Neck Occlusion of a Large Complex Aneurysm of the Middle Cerebral Artery Trifurcation with the UltraSoft Coil
Goetz Benndorfa,
Stefan Kroppenstedtb,
Adriana Campic and
Andreas Unterbergb
a Department of Radiology, Charité, Campus Virchow, Humboldt University of Berlin, Germany
b Department of Neurosurgery, Charité, Campus Virchow, Humboldt University of Berlin, Germany
c Department of Neuroradiology, Hospital San Raffaele, Milan, Italy
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FIG 1. Initial left internal carotid artery (ICA) arteriograms, anteroposterior (A) and lateral views (B and D).
A and B, Images show a large aneurysm originating from the MCA trifurcation with a short neck from the distal M1 segment (arrow in A). Two major branches arise from the dome of the aneurysm (arrowheads).
C, 3D image obtained at rotational angiography. The cone-shaped short and broad-based neck is better visualized than on the 2D-DSA images.
D, Lateral-oblique projection obtained during test occlusion. The tip of the microcatheter (arrowhead) cannot be advanced into the aneurysmal dome; it is wedged into the narrowed neck (arrow) that is directed anteriorly and cranially. This placement results in subtotal occlusion of the inflow zone and leads to immediate retrograde filling of the distal MCA territory (not shown).
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FIG 2. Postembolization arteriograms of the left ICA A, B, and D, lateral views; C, anteroposterior view.
A, Nonsubtracted image. A 2/6-cm UltraSoft coil is placed into the aneurysmal sac with the distal end serving as an anchor (right arrow). The proximal part (3 cm) is placed through the stenosis (left arrow) and then densely folded into the neck. It conforms well to the shape of the neck (arrowheads), with no protrusion into the M1 segment. Asterisk indicates stagnation of contrast material.
B and C, Placement of this single coil (arrows in B) results in the complete disappearance of the aneurysm. In C, the coil loops at the base of the neck and is superimposed onto the lumen of M1 (arrow), but does not actually protrude into it.
D, Late-phase image demonstrate how the involved MCA territory is filled in retrograde fashion by the leptomeningeal collaterals (arrowheads).
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FIG 3. Three-month follow-up arteriogram of the left ICA, anteroposterior (A and C) and lateral views (B and D).
A and B, Images show a patent MCA lumen without a residual neck (arrow) and without coil migration into the aneurysmal sac or protrusion into the parent artery.
C, Magnified view reveals that the coil mesh (arrow) is placed outside the M1-segment.
D, Nonsubtracted view shows an unchanged configuration of the initially placed coil and demonstrates stability of the packing.
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