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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 4  |  Page : 449-450

Endovascular treatment of ruptured wide-necked basilar tip aneurysm with Y stenting and coiling in a case of bilateral internal carotid artery occlusion with moyamoya disease


Department of Neurointervention, King Edward Memorial Hospital, Pune, India

Date of Web Publication6-Sep-2012

Correspondence Address:
Lakshmi Sudha Prasanna Karanam
Department of Neurointervention, King Edward Memorial Hospital, Pune
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.100739

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How to cite this article:
Alurkar A, Karanam LS, Oak S, Dange N. Endovascular treatment of ruptured wide-necked basilar tip aneurysm with Y stenting and coiling in a case of bilateral internal carotid artery occlusion with moyamoya disease. Neurol India 2012;60:449-50

How to cite this URL:
Alurkar A, Karanam LS, Oak S, Dange N. Endovascular treatment of ruptured wide-necked basilar tip aneurysm with Y stenting and coiling in a case of bilateral internal carotid artery occlusion with moyamoya disease. Neurol India [serial online] 2012 [cited 2021 Oct 18];60:449-50. Available from: https://www.neurologyindia.com/text.asp?2012/60/4/449/100739


Sir,

Moyamoya disease (MMD) is a chronic occlusive vascular disorder, characterized by abnormal moyamoya vessels at the base of the skull, due to the termination of the internal carotid artery (ICA). The main blood supply to the brain relies on the collateral circulation. This report presents a case with bilateral ICA occlusion, due to moyamoya and a ruptured basilar tip aneurysm, treated successfully by the endovascular technique.

A 30-year-old male presented with a sudden onset of headache. A computed tomography (CT) scan [Figure 1]a showed diffuse subarachnoid hemorrhage (SAH). Digital subtraction angiography showed bilateral terminal ICA occlusion with moyamoya collaterals. The vertebral angiogram [Figure 1]b and c showed a wide-necked basilar tip aneurysm. Endovascular treatment was planned and because of the wide aneurysm in the neck, Y stenting was opted. The patient was preloaded with 300 mg clopidogrel and 300 mg aspirin on the evening prior to the procedure, with a repeat dose of clopidogrel 150 mg and aspirin 150 mg four hours prior to the procedure. The procedure was conducted under general anesthesia. Y stenting with two enterprise stents (Cordis Neurovascular, Miami, Florida, USA) was done for aneurysm neck remodeling, which was then densely packed with multiple detachable coils. The post-procedure angiogram [Figure 1]d showed complete exclusion of the aneurysm from the circulation, with good pial collaterals to the anterior circulation. There were no untoward effects during or after the procedure. At the clinical follow-up at one month, the neurological examination was normal. He was kept on clopidogrel 75 mg per day and ecospirin 150 mg per day for a period of one year and was advised to continue ecospirin 150 mg per day life-long. A control angiogram done after one year showed stable occlusion of the aneurysm with good collaterals [Figure 1]e and f.
Figure 1: CT scan showing diffuse subarachnoid hemmorhage (a), DSA showing the wide necked basilar tip aneurysm (arrows in b and c), Post procedure angiogram showing exclusion of the aneurysm (d) from the
circualtion. Control angiogram (e) showing stable occlusion and the good collaterals to the anterior circulation in te capillary phase (f)


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Moyamoya disease is commonly reported in the Japanese population. The female-to-male ratio is 1.8 : 1. [1] There are three types of aneurysms in MMD: Peripheral, dissecting, and true aneurysms in the circle of Willis. On account of the occlusive disease of anterior circulation, there is compromised flow dynamics across the circle of Willis, inducing an increased flow through the basilar and posterior cerebral arteries. The presence of the rupture suggests that hemodynamic stress is involved. Surgical approaches [2] in these cases are difficult because of the interference of the fragile collateral vessels, which cannot be sacrificed. The endovascular approach is considered a good alternative, as the aneurysm can be safely approached without affecting the moyamoya vessel. [3] Poor clinical course in patients with hemorrhagic MMD, accounting for high bleeding rates (28-35%) have been reported. [4] Hence, these aneurysms need to be managed aggressively. Recent studies have supported the use of an adequate and standard antiplatelet regimen in stent-assisted coiling, even in the setting of acute SAH. [5] A loading dose of clopidogrel provides a platelet inhibition of 55% in one hour and 80% in five hours. [6] Hence, we preferred the standard antiplatelet regimen, to prevent thromboembolic events.

 
 ╗ References Top

1.Nishimoto A. Moyamoya disease (author's transl). Neurol Med Chir (Tokyo) 1979;19:221-8.  Back to cited text no. 1
[PUBMED]    
2.Iwama T, Todaka T, Hashimoto N. Direct surgery formajor artery aneurysm associated with moyamoya disease. Clin Neurol Neurosurg 1997;99 Suppl 2:S191-3.  Back to cited text no. 2
[PUBMED]    
3.Nishio A, Hara M, Otsuka Y, Tsuruno T, Murata T. Endovascular treatment of posterior cerebral aneurysm associated with moyamoya disease. J Neuroradiol 2004;31:60-2.  Back to cited text no. 3
[PUBMED]    
4.Yoshida Y, Yoshimoto T, Shirane R, Sakurai Y. Clinical course, surgical management, and long-term outcome of moyamoya patients with rebleedingafter an episode of intracerebral hemorrhage: An extensive follow-up study. Stroke 1999;30:2272-6.  Back to cited text no. 4
[PUBMED]    
5.Lodi YM, Latorre JG, El-Zammar Z, Swarnkar A, Deshaies E, Fessler RD. Stent assisted coiling of the ruptured wide necked intracranial aneurysm. J Neurointerv Surg 2012;4:281-6.  Back to cited text no. 5
    
6.Moshfegh K, Redondo M, Julmy F, Wuillemin WA, Gebauer MU, Haeberli A, et al. Antiplatelet effects of clopidogrelcompared with aspirin after myocardial infarction: Enhanced inhibitory effects ofcombination therapy. J Am Coll Cardiol 2000;36:699-705.  Back to cited text no. 6
[PUBMED]    


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