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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 4  |  Page : 425-426

Reconstructive endovascular treatment of fusiform basilar aneurysm with SILK flow diverter


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

Date of Submission05-May-2013
Date of Decision06-May-2013
Date of Acceptance24-Jul-2013
Date of Web Publication4-Sep-2013

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


DOI: 10.4103/0028-3886.117589

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How to cite this article:
Alurkar A, Prasanna Karanam LS, Modh S, Sorte S. Reconstructive endovascular treatment of fusiform basilar aneurysm with SILK flow diverter. Neurol India 2013;61:425-6

How to cite this URL:
Alurkar A, Prasanna Karanam LS, Modh S, Sorte S. Reconstructive endovascular treatment of fusiform basilar aneurysm with SILK flow diverter. Neurol India [serial online] 2013 [cited 2021 Jan 24];61:425-6. Available from: https://www.neurologyindia.com/text.asp?2013/61/4/425/117589


Sir,

Fusiform aneurysms of intracranial circulation are rare and more difficult to treat than saccular aneurysms. [1] These aneurysms have a poor natural history with an 80% mortality in five years in untreated patients. [2] We present a case of a 42-year-old man with fusiform basilar aneurysm treated successfully with a reconstructive endovascular technique with a combination of intracranial stents and flow diverter placement.

A 42-year-old man with no significant past medical history presented with vague headaches. Magnetic resonance imaging (MRI) revealed a partially thrombosed fusiform aneurysm in the basilar artery [Figure 1]. Digital subtraction angiography showed a fusiform aneurysm of the basilar trunk filling on bilateral vertebral angiograms [Figure 2]. There was no support from the posterior communicating arteries from the anterior circulation. Because of the unfavorable geometry of the aneurysm involving the basilar trunk, we opted to do reconstructive treatment with Leo Plus stents and SILK flow diverters. Platelet aggregation test was done to rule out clopidogrel resistance and the patient was subsequently placed on Ecosprin 150 mg and clopidogrel 75 mg for a period of one week prior to the intervention. He was also placed on prophylactic steroid drugs (prednisolone 30 mg once daily) which was continued till two weeks post procedure. Two Leo Plus stents (Balt Extrusion) were placed initially across the aneurysm to act as scaffolds to prevent shortening of the SILK flow diverter (Balt Extrusion), which was then placed inside the Leo Plus stents via the same delivery microcatheter (Vasco 21; Balt Extrusion) to facilitate the flow diversion away from the aneurysm. Postprocedure angiogram showed reduced flow to the aneurysm [Figure 3]. On extubation, the patient did not have any neurological deficits; however, six hours later, he presented with dysarthria and mild weakness of left upper limb. Computed tomography (CT) scan of the brain done was negative for bleed and the patient gradually improved over the next 24 hours. He was discharged on the seventh postoperative day. At one-month clinical follow-up, his neurological examination was normal. Repeat angiogram showed complete exclusion of the basilar aneurysm with good flow in the reconstructed vessel [Figure 4].
Figure 1: Postcontrast T1 magnetic resonance (MR) image (a) and time‑of‑flight MR angiogram (b) showing the partially thrombosed fusiform midbasilar aneurysm

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Figure 2: Digital subtraction angiogram showing the fusiform basilar trunk aneurysm filling on bilateral vertebral angiograms (a and b)

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Figure 3: Right vertebral angiogram after the placement of two telescopic Leo Plus stents (a); immediate angiogram after placement of the SILK flow diverter in the Leo Plus stents showing the reduced flow to the aneurysm (b); fluoroscopic image showing the meshwork of telescopic Leo Plus stents with SILK flow diverter

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Figure 4: Control angiogram showing complete exclusion of the aneurysm (a) and fluoroscopic image showing the intact flow diverter system (b)

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Flow diverters have a higher metal coverage and lower porosity which helps in redirecting the blood flow away from the aneurysm and provides a scaffold for the neointimal growth and healing of the vessel wall. [3],[4] There are a few reports in the literature describing the use of flow diverters in fusiform vertebrobasilar aneurysms. [4],[5] Serious complications are reported in the literature with this therapy. In a report of seven patients treated with flow diverters, a favorable outcome was seen only in two patients. [4]

In our present case, the patient had transient deficit probably due to perforator infarct from which he recovered eventually, and thus the aneurysm was successfully treated with the flow diverter technique.

The complication rate of the reconstructive treatment in the reported series is high in symptomatic patients, whereas outcomes in patients with incidental aneurysms are more favorable. More rigorous studies with large series are required to study the efficacy of this option in fusiform basilar aneurysms.

 
  References Top

1.Mohr JP, Choi D, Grotta J, Wolf P. Stroke: Pathophysiology, diagnosis, and management. 4 th ed. Philadelphia: Churchill Livingstone; 2004. p. 1318.  Back to cited text no. 1
    
2.Steinberg GK, Drake CG, Peerless SJ. Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients. J Neurosurg 1993;79:161-73.  Back to cited text no. 2
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3.Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR, et al. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: The Buenos Aires experience. Neurosurgery 2009;64:632-43.  Back to cited text no. 3
[PUBMED]    
4.Siddiqui AH, Abla AA, Kan P, Dumont TM, Jahshan S, Britz GW, et al. Panacea or problem: Flow divertersin the treatment of symptomatic large or giant fusiform vertebrobasilaraneurysms. J Neurosurg 2012;116:1258-66.  Back to cited text no. 4
    
5.Van Oel LI, van Rooij WJ, Sluzewski M, Beute GN, Lohle PN, Peluso JP. Reconstructive endovascular treatment of fusiform and dissecting basilar trunk aneurysms with flow diverters, stents, and coils. AJNR Am J Neuroradiol 2013;34:589-95.  Back to cited text no. 5
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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