American Journal of Neuroradiology 26:198-200, January 2005
© 2005 American Society of Neuroradiology
Letter
Desperate Appliance
David M. Pelza,b,c,
Stephen P. Lowniea,
Max Kolea and
David Ramsayd
a Department of Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada
b Department of Diagnostic Radiology, University of Western Ontario, London, Ontario, Canada
c Department of Nuclear Medicine, University of Western Ontario, London, Ontario, Canada
d Department of Pathology (Neuropathology), University of Western Ontario, London, Ontario, Canada
We read with interest the recent case report by Michael Chow and the Cleveland Clinic group regarding treatment of a wide-necked basilar bifurcation aneurysm by using the Y-configuration double-stent technique (1). This report and others (2) show the enormous potential of flexible intracranial stents for therapy of complex cerebral aneurysms. As stated by the authors, however, limitations of the technique exist (3), and more will be discovered. We relate one such cautionary tale.
A 62-year-old woman was referred to our institution for treatment of a large, wide-necked basilar bifurcation aneurysm (Fig 1). Both P1 segments of the posterior cerebral arteries were incorporated in the neck. Our knowledge of the Cleveland experience and the anticipated difficulties with conventional endovascular therapies for aneurysms in this location led us to proceed with the double-stent assisted coiling approach.
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FIG 1. Right vertebral arteriogram (anteroposterior [AP]), shows a wide-necked basilar bifurcation aneurysm.
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This was achieved by using two 3.5 x 20 mm Neuroform (Boston Scientific, Natick, MA) stents and 386 cm of GDC (Boston Scientific) coils in a fashion similar to the method described by Chow et al (Figs 2). The procedure was performed under general anesthesia and full heparinization, with the standard pretreatment for Neuroform cases including aspirin and clopidigrel. There was near-complete obliteration of the aneurysm with preservation of both posterior cerebral arteries and no evidence of perforation, vessel dissection, or flow-limiting stenosis. The patient awoke from anesthesia with no focal neurologic deficit; however, approximately 6 hours later, she became progressively obtunded with left-sided weakness. A CT head scan showed a midbrain and upper pontine parenchymal hemorrhage (Fig 3), and cerebral angiography showed no change from the postprocedural study. The patient had a limited neurologic recovery but eventually succumbed to chronic hydrocephalus and pneumonia.
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FIG 2. Postoperative arteriograms.
A, Right vertebral arteriogram (AP), obtained after treatment with stents and coils, shows near complete obliteration of the aneurysm.
B, Unsubtracted image obtained from the postoperative arteriogram shows the radiopaque markers at the ends of the stents (arrowheads).
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FIG 3. CT head scan obtained 6 hours after treatment shows the pontine component of the acute brain stem hemorrhage (arrow).
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A subsequent review of the procedure showed considerable stretching of the right posterior cerebral artery during guidewire placement and positioning of the first Neuroform stent. There were no other technical problems encountered during the procedure. The postmortem neuropathologic examination showed no bleeding from the aneurysm (Fig 4) and no gross obstruction of pontine perforating vessels by the stents. There was a large right midbrain hemorrhage (Fig 5), with smaller hemorrhages in the right thalamus and right cerebellar hemisphere.
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FIG 4. Postmortem dissection of the circle of Willis, showing the coils inside an intact basilar bifurcation aneurysm (arrow). The stents are visible through the basilar and posterior cerebral arteries (arrowheads).
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Unusual foreign body granulomas were also seen microscopically (Fig 6) associated with the hemorrhages, possibly due to microembolism from the hardware. Although the cause of the midbrain hemorrhage is unknown, it may be due to stretching of perforating vessels, infarction, and bleeding related to anticoagulation.
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FIG 6. Microscopic section through the midbrain hemorrhage shows unusual intravascular foreign body granulomas (arrowheads) (H&E, x8).
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Despite an excellent angiographic result, this tragic clinicaloutcome demonstrates the risks inherent in novel, aggressive interventional strategies. This, however, should come as no surprise. As William Shakespeare noted long ago,
Diseases desperate grown
By desperate appliance are reliev’d
Or not at all (4)
References
- Chow MM, Woo HH, Masaryk TJ, Rasmussen PA. A novel endovascular treatment of a wide-necked basilar apex aneurysm by using a Y-configuration, double-stent technique. AJNR Am J Neuroradiol 2004;25:509–512[Abstract/Free Full Text]
- Fiorella D, Albuquerque FC, Han P, McDougall CG. Preliminary experience using the Neuroform stent for the treatment of cerebral aneurysms. Neurosurgery 2004;54:6–16[Medline]
- Broadbent LP, Moran CJ, Cross DT 3rd, Derdeyn CP. Management of Neuroform stent dislodgement and misplacement. AJNR Am J Neuroradiol 2003;24:1819–1822[Abstract/Free Full Text]
- Shakespeare W. Hamlet. In: The tragedies of Shakespeare. New York: The Modern Library. 2:IV, iii, 9
