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1.  Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage Associated with Bilateral Common Carotid Artery Occlusion 
Interventional Neuroradiology  2009;14(4):447-452.
Summary
Cases of aneurysm associated with the occlusion of both common carotid arteries are very rare. We present a case of ruptured aneurysms of the basilar bifurcation and posterior cerebral artery coexisting with bilateral common carotid artery occlusion, successfully treated by endovascular coil embolization with a double-balloon remodeling technique. Finally, we review the literature. A 62-year-old woman presented with severe headache; a computed tomography scan demonstrated subarachnoid hemorrhage. Angiography revealed that the bilateral common carotid arteries were occluded.
The muscle branches of the vertebral arteries had anastomosed to the bilateral external carotid arteries. Bilateral posterior communicating arteries had developed and supplied the bilateral internal carotid arteries. Two aneurysms (a saccular aneurysm of the P1 portion of the left posterior cerebral artery and a wide-necked aneurysm of the basilar bifurcation) were also observed. Endovascular embolization of the aneurysms was successfully performed using a double-balloon remodeling technique.
The patient made a full recovery after treatment, and the aneurysms remained obliterated 12 months after embolization. We believe that this is the first report of ruptured aneurysms associated with bilateral common carotid artery occlusion successfully treated by endovascular coiling. The double-balloon remodeling technique was useful for treatment of wide-necked basilar bifurcation aneurysm.
PMCID: PMC3313813  PMID: 20557745
bilateral common carotid artery occlusion, cerebral aneurysm, endovascular coiling, balloon neck remodeling
2.  Unusual Intracranial Stent Navigation through the Circle of Willis in a Patient with Recurrent Basilar Tip Aneurysm during Stent-Assisted Coiling 
Interventional Neuroradiology  2009;15(1):81-86.
Summary
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.
PMCID: PMC3306154  PMID: 20465934
Enterprise stent, navigation, circle of Willis
3.  Coil Embolization for Intracranial Aneurysms 
Executive Summary
Objective
To determine the effectiveness and cost-effectiveness of coil embolization compared with surgical clipping to treat intracranial aneurysms.
The Technology
Endovascular coil embolization is a percutaneous approach to treat an intracranial aneurysm from within the blood vessel without the need of a craniotomy. In this procedure, a microcatheter is inserted into the femoral artery near the groin and navigated to the site of the aneurysm. Small helical platinum coils are deployed through the microcatheter to fill the aneurysm, and prevent it from further expansion and rupture. Health Canada has approved numerous types of coils and coil delivery systems to treat intracranial aneurysms. The most favoured are controlled detachable coils. Coil embolization may be used with other adjunct endovascular devices such as stents and balloons.
Background
Intracranial Aneurysms
Intracranial aneurysms are the dilation or ballooning of part of a blood vessel in the brain. Intracranial aneurysms range in size from small (<12 mm in diameter) to large (12–25 mm), and to giant (>25 mm). There are 3 main types of aneurysms. Fusiform aneurysms involve the entire circumference of the artery; saccular aneurysms have outpouchings; and dissecting aneurysms have tears in the arterial wall. Berry aneurysms are saccular aneurysms with well-defined necks.
Intracranial aneurysms may occur in any blood vessel of the brain; however, they are most commonly found at the branch points of large arteries that form the circle of Willis at the base of the brain. In 85% to 95% of patients, they are found in the anterior circulation. Aneurysms in the posterior circulation are less frequent, and are more difficult to treat surgically due to inaccessibility.
Most intracranial aneurysms are small and asymptomatic. Large aneurysms may have a mass effect, causing compression on the brain and cranial nerves and neurological deficits. When an intracranial aneurysm ruptures and bleeds, resulting in a subarachnoid hemorrhage (SAH), the mortality rate can be 40% to 50%, with severe morbidity of 10% to 20%. The reported overall risk of rupture is 1.9% per year and is higher for women, cigarette smokers, and cocaine users, and in aneurysms that are symptomatic, greater than 10 mm in diameter, or located in the posterior circulation. If left untreated, there is a considerable risk of repeat hemorrhage in a ruptured aneurysm that results in increased mortality.
In Ontario, intracranial aneurysms occur in about 1% to 4% of the population, and the annual incidence of SAH is about 10 cases per 100,000 people. In 2004-2005, about 660 intracranial aneurysm repairs were performed in Ontario.
Treatment of Intracranial Aneurysms
Treatment of an unruptured aneurysm attempts to prevent the aneurysm from rupturing. The treatment of a ruptured intracranial aneurysm aims to prevent further hemorrhage. There are 3 approaches to treating an intracranial aneurysm.
Small, asymptomatic aneurysms less than 10 mm in diameter may be monitored without any intervention other than treatment for underlying risk factors such as hypertension.
Open surgical clipping, involves craniotomy, brain retraction, and placement of a silver clip across the neck of the aneurysm while a patient is under general anesthesia. This procedure is associated with surgical risks and neurological deficits.
Endovascular coil embolization, introduced in the 1990s, is the health technology under review.
Literature Review
Methods
The Medical Advisory Secretariat searched the International Health Technology Assessment (INAHTA) Database and the Cochrane Database of Systematic Reviews to identify relevant systematic reviews. OVID Medline, Medline In-Process and Other Non-Indexed Citations, and Embase were searched for English-language journal articles that reported primary data on the effectiveness or cost-effectiveness of treatments for intracranial aneurysms, obtained in a clinical setting or analyses of primary data maintained in registers or institutional databases. Internet searches of Medscape and manufacturers’ databases were conducted to identify product information and recent reports on trials that were unpublished but that were presented at international conferences. Four systematic reviews, 3 reports on 2 randomized controlled trials comparing coil embolization with surgical clipping of ruptured aneurysms, 30 observational studies, and 3 economic analysis reports were included in this review.
Results
Safety and Effectiveness
Coil embolization appears to be a safe procedure. Complications associated with coil embolization ranged from 8.6% to 18.6% with a median of about 10.6%. Observational studies showed that coil embolization is associated with lower complication rates than surgical clipping (permanent complication 3-7% versus 10.9%; overall 23% versus 46% respectively, p=0.009). Common complications of coil embolization are thrombo-embolic events (2.5%–14.5%), perforation of aneurysm (2.3%–4.7%), parent artery obstruction (2%–3%), collapsed coils (8%), coil malposition (14.6%), and coil migration (0.5%–3%).
Randomized controlled trials showed that for ruptured intracranial aneurysms with SAH, suitable for both coil embolization and surgical clipping (mostly saccular aneurysms <10 mm in diameter located in the anterior circulation) in people with good clinical condition:Coil embolization resulted in a statistically significant 23.9% relative risk reduction and 7% absolute risk reduction in the composite rate of death and dependency compared to surgical clipping (modified Rankin score 3–6) at 1-year.
The advantage of coil embolization over surgical clipping varies widely with aneurysm location, but endovascular treatment seems beneficial for all sites.
There were less deaths in the first 7 years following coil embolization compared to surgical clipping (10.8% vs 13.7%). This survival benefit seemed to be consistent over time, and was statistically significant (log-rank p= 0.03).
Coil embolization is associated with less frequent MRI-detected superficial brain deficits and ischemic lesions at 1-year.
The 1- year rebleeding rate was 2.4% after coil embolization and 1% for surgical clipping. Confirmed rebleeding from the repaired aneurysm after the first year and up to year eight was low and not significantly different between coil embolization and surgical clipping (7 patients for coil embolization vs 2 patients for surgical clipping, log-rank p=0.22).
Observational studies showed that patients with SAH and good clinical grade had better 6-month outcomes and lower risk of symptomatic cerebral vasospasm after coil embolization compared to surgical clipping.
For unruptured intracranial aneurysms, there were no randomized controlled trials that compared coil embolization to surgical clipping. Large observational studies showed that:
The risk of rupture in unruptured aneurysms less than 10 mm in diameter is about 0.05% per year for patients with no pervious history of SAH from another aneurysm. The risk of rupture increases with history of SAH and as the diameter of the aneurysm reaches 10 mm or more.
Coil embolization reduced the composite rate of in hospital deaths and discharge to long-term or short-term care facilities compared to surgical clipping (Odds Ratio 2.2, 95% CI 1.6–3.1, p<0.001). The improvement in discharge disposition was highest in people older than 65 years.
In-hospital mortality rate following treatment of intracranial aneurysm ranged from 0.5% to 1.7% for coil embolization and from 2.1% to 3.5% for surgical clipping. The overall 1-year mortality rate was 3.1% for coil embolization and 2.3% for surgical clipping. One-year morbidity rate was 6.4% for coil embolization and 9.8% for surgical clipping. It is not clear whether these differences were statistically significant.
Coil embolization is associated with shorter hospital stay compared to surgical clipping.
For both ruptured and unruptured aneurysms, the outcome of coil embolization does not appear to be dependent on age, whereas surgical clipping has been shown to yield worse outcome for patients older than 64 years.
Angiographic Efficiency and Recurrences
The main drawback of coil embolization is its low angiographic efficiency. The percentage of complete aneurysm occlusion after coil embolization (27%–79%, median 55%) remains lower than that achieved with surgical clipping (82%–100%). However, about 90% of coiled aneurysms achieve near total occlusion or better. Incompletely coiled aneurysms have been shown to have higher aneurysm recurrence rates ranging from 7% to 39% for coil embolization compared to 2.9% for surgical clipping. Recurrence is defined as refilling of the neck, sac, or dome of a successfully treated aneurysm as shown on an angiogram. The long-term clinical significance of incomplete occlusion following coil embolization is unknown, but in one case series, 20% of patients had major recurrences, and 50% of these required further treatment.
Long-Term Outcomes
A large international randomized trial reported that the survival benefit from coil embolization was sustained for at least 7 years. The rebleeding rate between year 2 and year 8 following coil embolization was low and not significantly different from that of surgical clipping. However, high quality long-term angiographic evidence is lacking. Accordingly, there is uncertainty about long-term occlusion status, coil durability, and recurrence rates. While surgical clipping is associated with higher immediate procedural risks, its long-term effectiveness has been established.
Indications and Contraindications
Coil embolization offers treatment for people at increased risk for craniotomy, such as those over 65 years of age, with poor clinical status, or with comorbid conditions. The technology also makes it possible to treat surgical high-risk aneurysms.
Not all aneurysms are suitable for coil embolization. Suitability depends on the size, anatomy, and location of the aneurysm. Aneurysms more than 10 mm in diameter or with an aneurysm neck greater than or equal to 4 mm are less likely to achieve total occlusion. They are also more prone to aneurysm recurrences and to complications such as coil compaction or parent vessel occlusion. Aneurysms with a dome to neck ratio of less than 1 have been shown to have lower obliteration rates and poorer outcome following coil embolization. Furthermore, aneurysms in the middle cerebral artery bifurcation are less suitable for coil embolization. For some aneurysms, treatment may require the use of both coil embolization and surgical clipping or adjunctive technologies, such as stents and balloons, to obtain optimal results.
Diffusion
Information from 3 countries indicates that coil embolization is a rapidly diffusing technology. For example, it accounted for about 40% of aneurysm treatments in the United Kingdom.
In Ontario, coil embolization is an insured health service, with the same fee code and fee schedule as open surgical repair requiring craniotomy. Other costs associated with coil embolization are covered under hospitals’ global budgets. Utilization data showed that in 2004-2005, coil embolization accounted for about 38% (251 cases) of all intracranial aneurysm repairs in the province. With the 2005 publication of the positive long-term survival data from the International Subarachnoid Aneursym Trial, the pressure for diffusion will likely increase.
Economic Analysis
Recent economic studies show that treatment of unruptured intracranial aneurysms smaller than 10 mm in diameter in people with no previous history of SAH, either by coil embolization or surgical clipping, would not be effective or cost-effective. However, in patients with aneurysms that are greater than or equal to 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective.
In Ontario, the average device cost of coil embolization per case was estimated to be about $7,500 higher than surgical clipping. Assuming that the total number of intracranial aneurysm repairs in Ontario increases to 750 in the fiscal year of 2007, and assuming that up to 60% (450 cases) of these will be repaired by coil embolization, the difference in device costs for the 450 cases (including a 15% recurrence rate) would be approximately $3.8 million. This figure does not include capital costs (e.g. $3 million for an angiosuite), additional human resources required, or costs of follow-up. The increase in expenditures associated with coil embolization may be offset partially, by shorter operating room times and hospitalization stays for endovascular repair of unruptured aneurysms; however, the impact of these cost savings is probably not likely to be greater than 25% of the total outlay since the majority of cases involve ruptured aneurysms. Furthermore, the recent growth in aneurysm repair has predominantly been in the area of coil embolization presumably for patients for whom surgical clipping would not be advised; therefore, no offset of surgical clipping costs could be applied in such cases. For ruptured aneurysms, downstream cost savings from endovascular repair are likely to be minimal even though the savings for individual cases may be substantial due to lower perioperative complications for endovascular aneurysm repair.
Guidelines
The two Guidance documents issued by the National Institute of Clinical Excellence (UK) in 2005 support the use of coil embolization for both unruptured and ruptured (SAH) intracranial aneurysms, provided that procedures are in place for informed consent, audit, and clinical governance, and that the procedure is performed in specialist units with expertise in the endovascular treatment of intracranial aneurysms.
Conclusion
For people in good clinical condition following subarachnoid hemorrhage from an acute ruptured intracranial aneurysm suitable for either surgical clipping or endovascular repair, coil embolization results in improved independent survival in the first year and improved survival for up to seven years compared to surgical clipping. The rebleeding rate is low and not significantly different between the two procedures after the first year. However, there is uncertainty regarding the long-term occlusion status, durability of the stent graft, and long-term complications.
For people with unruptured aneurysms, level 4 evidence suggests that coil embolization may be associated with comparable or less mortality and morbidity, shorter hospital stay, and less need for discharge to short-term rehabilitation facilities. The greatest benefit was observed in people over 65 years of age. In these patients, the decision regarding treatment needs to be based on the assessment of the risk of rupture against the risk of the procedure, as well as the morphology of the aneurysm.
In people who require treatment for intracranial aneurysm, but for whom surgical clipping is too risky or not feasible, coil embolization provides survival benefits over surgical clipping, even though the outcomes may not be as favourable as in people in good clinical condition and with small aneurysms. The procedure may be considered under the following circumstances provided that the aneurysm is suitable for coil embolization:
Patients in poor/unstable clinical or neurological state
Patients at high risk for surgical repair (e.g. people>age 65 or with comorbidity), or
Aneurysm(s) with poor accessibility or visibility for surgical treatment due to their location (e.g. ophthalmic or basilar tip aneurysms)
Compared to small aneurysms with a narrow neck in the anterior circulation, large aneurysms (> 10 mm in diameter), aneurysms with a wide neck (>4mm in diameter), and aneurysms in the posterior circulation have lower occlusion rates and higher rate of hemorrhage when treated with coil embolization.
The extent of aneurysm obliteration after coil embolization remains lower than that achieved with surgical clipping. Aneurysm recurrences after successful coiling may require repeat treatment with endovascular or surgical procedures. Experts caution that long-term angiographic outcomes of coil embolization are unknown at this time. Informed consent for and long-term follow-up after coil embolization are recommended.
The decision to treat an intracranial aneurysm with surgical clipping or coil embolization needs to be made jointly by the neurosurgeon and neuro-intervention specialist, based on the clinical status of the patient, the size and morphology of the aneurysm, and the preference of the patient.
The performance of endovascular coil embolization should take place in centres with expertise in both neurosurgery and endovascular neuro-interventions, with adequate treatment volumes to maintain good outcomes. Distribution of the technology should also take into account that patients with SAH should be treated as soon as possible with minimal disruption.
PMCID: PMC3379525  PMID: 23074479
4.  Initial Experience with the New Double-lumen Scepter Balloon Catheter for Treatment of Wide-necked Aneurysms 
Korean Journal of Radiology  2013;14(5):832-840.
Objective
A new double-lumen balloon catheter was being developed for the treatment of cerebral aneurysms. The purpose of this study is to report our initial experience of a double-lumen balloon catheter for the treatment of wide-necked aneurysms.
Materials and Methods
Seventeen patients (mean age, 63 years; range, 45-80 years) with wide-necked, with or without a branch-incorporated aneurysms, (10 ruptured and 9 unruptured) were treated with balloon-assisted coil embolization using a double-lumen balloon catheter (Scepter C™ or Scepter XC™) for 7 months after being introduced to our country. Locations of the aneurysms were posterior communicating artery (n = 7), anterior communicating artery or A2 (n = 7), middle cerebral artery (MCA) bifurcation (n = 3), basilar artery tip (n = 1) and anterior choroidal artery (n = 1). The initial clinical and angiographic outcomes were retrospectively evaluated.
Results
Coil embolization was successfully completed in all 19 aneurysms, resulting in complete occlusions (n = 18) or residual neck (n = 1). In one procedure, a thrombus formation was detected at the neck portion of the ruptured MCA bifurcation aneurysm near to the end of the procedure. It was completely resolved with an intra-arterial infusion of Glycoprotein IIb/IIIa inhibitor (Tirofiban, 1.0 mg) without any clinical sequela. There were no treatment-related events in the remaining 18 aneurysms. At discharge, functional neurological state improved in 11 patients (10 patients with ruptured aneurysm and 1 with unruptured aneurysm presenting with mass symptoms) and 6 patients with unruptured aneurysms had no newly developed symptoms.
Conclusion
In this preliminary case series, the newly developed double-lumen Scepter balloon appears to be a safe and convenient device for coil embolization of wide-necked aneurysms.
doi:10.3348/kjr.2013.14.5.832
PMCID: PMC3772268  PMID: 24043982
Intracranial aneurysm; Coil embolization; Balloon
5.  Leo Stent for Endovascular Treatment of Broad-Necked and Fusiform Intracranial Aneurysms 
Interventional Neuroradiology  2007;13(3):255-269.
Summary
The advent of intracranial stents has widened the indications for endovascular treatment of broad-necked and fusiform aneurysms. Leo stent is a self-expandable, nitinol, braided stent dedicated to intracranial vessels. The aim of this study is to present our experience in endovascular treatment of broad-necked and fusiform intracranial aneurysms using self-expanding, nitinol Leo stents.
Between February 2004 and November 2006, 25 broad-necked and three fusiform aneurysms in 28 patients were treated using Leo stents in our centre. There were 18 patients who experienced acute subarachnoid haemorrhage due to aneurysm rupture, two patients who experienced SAH at least 12 months ago and in eight patients aneurysms were found incidentally. Aneurysms were located as follows: internal carotid artery15, basilar artery5, basilar tip3, posterior inferior cerebral artery2, M1/M2 segment1, A2 segment1 and vertebral artery1.
There were no difficulties with stent deployment and delivery. All patients after acute SAH (n=18) underwent stent implantation and coil embolization in one procedure. The remaining patients underwent coil embolization in a staged procedure. Immediate aneurysm occlusion of more than 95% was achieved in all patients who underwent stent placement and coil embolization in one procedure. There were three thromboembolic complications encountered in patients in an acute setting of SAH, preloaded only on acetylsalicylic acid. Use of abciximab led to patency within the stent and parent vessel. However, one of these patients presented rebleeding from the aneurysm during administration of abciximab and died.
Application of Leo stents in cases of broadnecked and fusiform intracranial aneurysms is safe and effective with a low complication rate.
PMCID: PMC3345341  PMID: 20566117
endovascular, intracranial aneurysm, Leo, stent, fusiform
6.  Thromboembolic Complication Induced Stable Occlusion of a Ruptured Basilar Tip Aneurysm 
Interventional Neuroradiology  2010;16(1):83-88.
Summary
We describe a case of a ruptured basilar bifurcation aneurysm that thrombosed during preparation for endovascular therapy as a complication of diagnostic angiogaphy, and showed a favorable evolution during long-term follow-up.
Endogenous thrombosis of ruptured, non giant aneurysms is uncommon. The persistence of occlusion over time in such cases is not well established.
Two weeks after rupture, a 6 x 8 mm basilar bifurcation aneurysm was referred for endovascular treatment. During preparation for endovascular coil occlusion, without having any endovascular material at the level of the basilar artery, a complete thrombotic occlusion of the basilar bifurcation and aneurysm was observed. Given the good collateral circulation for both posterior cerebral arteries no thrombolysis was undertaken. The early follow-up of seven days, three and six months showed a complete recanalization of the basilar artery and remodeling of the basilar bifurcation. The 20 months imaging follow-up demonstrated a small aneurysm regrowth at the prevoius location that remained stable during the follow-up of seven years. Unchanged biological and hemodynamic characteristics. however, may pose an elevated risk of a new aneurysm formation over time, making long-term imaging follow-up, and in case of progression, aneurysm occlusion necessary for the patient.
PMCID: PMC3277964  PMID: 20377984
cerebral aneurysm, subarachnoid hemorrhage, spontaneous thrombosis, wessel wall remodeling, aneurysm regrowth
7.  Rupture of a Large Vertebral Artery Aneurysm Following Proximal Occlusion 
Interventional Neuroradiology  2005;11(1):51-58.
Summary
Proximal occlusion of the vertebral artery is regarded as a safe and effective method of treating aneurysms of the vertebral artery or the vertebrobasilar junction unsuitable for treatment by neck clipping. Complications known to develop after this procedure include ischemic lesions of the perforators and other areas. There are only a limited number of reports on early rupture of aneurysm following proximal occlusion of the vertebral artery for the treatment of unruptured aneurysm. We recently encountered a case of large aneurysm of the vertebral artery identified after detection of brainstem compression. This patient underwent proximal occlusion of the vertebral artery with a coil and developed a fatal rupture of the aneurysm ten days after proximal occlusion.
The patient was a 72-year-old woman who had complained of dysphagia and unsteadiness for several years. An approximately 20 mm diameter aneurysm was detected in her left vertebral artery. She underwent endovascular treatment, that is, her left vertebral artery was occluded with coils at a point proximal to the aneurysm. Her initial post-procedure course was uneventful. However, she suddenly developed right-side hemiparesis nine days after procedure. At that time, CT scan suggested sudden thrombosis of the aneurysm. Right vertebral angiography revealed a small part of the aneurysm. She was treated conservatively. Ten days after the procedure, she suffered massive subarachnoid haemorrhage.
Both the present case and past reports suggest that proximal occlusion of the vertebral artery is effective in treating relatively large aneurysms unsuitable for treatment by neck clipping or trapping. However, when the bifurcation of the posterior inferior cerebellar artery (PICA) is distal to the occluded point in cases where the PICA bifurcates from the aneurysm or the neck region, blood supply to the aneurysm may persist because anterograde blood flow to the PICA may be preserved. Therefore, clinicians must consider the possibility of aneurysm rupture after proximal occlusion in the following cases:
1) when the aneurysm is large or giant, but non-thrombosed;
2) when thrombosis occurs soon after the procedure;
3) when postoperative angiography shows partial filling of the aneurysm with contrast agent through the contralateral vertebral artery of basilar artery or the cervical muscle branches.
PMCID: PMC3403788  PMID: 20584435
large unruptured aneurysm, vertebral artery, proximal occlusion, subarachnoid haemorrhage
8.  Y-Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms 
Interventional Neuroradiology  2011;17(1):36-48.
Summary
This report evaluated the short and midterm results of the safety and effectiveness of the treatment technique with hybrid and non-hybrid Y-configured, dual stent-assisted coil embolization of wide-neck intracranial aneurysms, and reviewed the literature concerning this technique.
Nine patients, eight with unruptured and one with ruptured aneurysms were included in the study. Of aneurysms embolized with a hybrid (with two different stents) and non-hybrid (with two identical stents) technique, three were located in the anterior communicating artery, three at the tip and one at the distal site of basilar artery, and two in the middle cerebral artery. All aneurysms included the orifices of bifurcation vessels. All aneurysms were stented and embolized during the same session. While Neuroform and Enterprise stents were used in the hybrid technique, two Enterprise stents were used in the non-hybrid technique.
Dual Y-stent assisted coil embolization was performed successfully in eight of nine patients (88.9%), including five patients (55.6%) with hybrid and three patients (33.3%) with non-hybrid technique. No procedural complication, no mortality and no minor or major neurological complications were seen during the angiographic or clinical follow-up. When an attempt was made at passing the second stent through the first Enterprise stent, the stent protruded inside the aneurysm in one patient (11.1%).
Hybrid or non-hybrid dual Y-stent-assisted coil embolization in the treatment of ruptured or unruptured wide-neck and complex intracranial aneurysms is a safe and effective method from the viewpoint of short and midterm results.
PMCID: PMC3278021  PMID: 21561557
intracranial aneurysm, stent, therapeutic embolization
9.  Multimodal Treatment for Complex Intracranial Aneurysms: Clinical Research 
Objective
For patients with giant or dissecting aneurysm, multimodal treatment consisting extracranial-intracranial bypass surgery plus clip or coil for parent artery occlusion may be necessary. In this study, the safety and efficacy of multimodal treatment in 15 patients with complex aneurysms were evaluated retrospectively.
Methods
From January 1995 to June 2007, the authors treated 15 complex aneurysms that were unable to be clipped or coiled. Among them, nine patitents had unruptured aneurysms and 6 had ruptured aneurysms. Aneurysms were located in the internal cerebral artery (ICA) in 11 patients (4 in the dorsal wall, 4 in the terminal ICA, 1 in the paraclinoid, and 2 in the cavernous ICA), in the middle cerebral artery (MCA) in 2, and in the posterior circulation in two patients
Results
Fifteen patients with complex aneurysms were treated with bypass surgery previously. Thirteen patients were treated with external carotid middle cerebral artery (ECA-MCA) anastomosis, and one patient with superficial temporal to posterior cerebral artery (STA-PCA) and another patient with occipital artery to posterior inferior cerebellar artery (OA-PICA) anastomosis. Parent artery occlusion was then performed with a clip in 9 patients, with a coil in 4, with balloon plus coil in one patient. All 15 aneurysms were successfully treated with clip or coil combined with bypass surgery. Follow-up angiograms showed good patency of anastomotic site in 10 out of 11 patients, and perfusion study showed sufficient perfusion in 6 out of 9 patients.
Conclusion
These findings indicate that for patients with complex aneurysms, clip or coil for parent vessel occlusion with additive bypass surgery can successfully exclude the aneurysm from the neurovascular circulatory system.
doi:10.3340/jkns.2008.44.5.314
PMCID: PMC2612569  PMID: 19119468
Aneurysm; Clip; Coil; Bypass
10.  Ruptured Giant Basilar Artery Aneurysm in a Comatose Adolescent: Successful Obliteration Using Intraoperative SSEP, BAER, and MEP Monitoring 
Interventional Neuroradiology  2006;12(3):237-244.
Summary
Giant basilar aneurysms are infrequently seen in children. We present the endovascular management of an adolescent who presented comatose with pinpoint pupils due to a ruptured giant basilar trunk aneurysm. A noncontrast head CT disclosed a large prepontine lesion with brainstem hemorrhage. Catheter angiography showed a 4.5 cm irregular, fusiform basilar trunk aneurysm. With SSEP, BAER, and MEP monitoring, the patient underwent bilateral temporary vertebral artery occlusion, followed by GDC embolization of the aneurysm. Postprocedure internal carotid angiograms showed adequate blood supply to the basilar apex via patent posterior communicating arteries. On postprocedure day two, the patient was following commands.
The remainder of his hospital course was uneventful. Postoperative angiograms showed no residual filling of the aneurysm. At 12 months the patient was neurologically intact and at baseline function as an honor student and follow-up angiogram showed persistent occlusion of the aneurysm from the circulation. Successful endovascular treatment has been considered a less invasive and safer alternative to surgical management of some complex vascular lesions. While most reports on reversing basilar artery flow have been carried out in awake patients with neurological examinations, this is not possible in a patient presenting in a comatose state. This report suggests that SSEPs, BAERs and MEP may be of use in such patients in safely carrying out basilar artery occlusion.
PMCID: PMC3354541  PMID: 20569577
giant basilar aneurysm, aneurysm coiling, SSEP, BAER, MEP
11.  Sequential sidelong balloon remodeling technique in coil embolization of a wide-necked basilar tip aneurysm 
The use of balloon remodeling technique for coil embolization has developed into a safe alternative to stent assisted coil embolization for wide-necked aneurysms. Dual antiplatelet therapy when a stent is placed for assistance in the treatment of ruptured aneurysms is of concern. There are cases in which a single balloon seems insufficient to protect from coil herniation, like when two vessels are in the proximity of the side of the aneurysm neck. Techniques using two balloons for remodeling have been described; however, dual vascular access may be required. A case is presented in which a ruptured basilar tip wide-necked aneurysm was treated with a single balloon, using a sequential sidelong balloon remodeling technique. Complete embolization of the aneurysm was achieved maintaining patency of bilateral posterior cerebral arteries.
PMCID: PMC3694000  PMID: 23826436
12.  Ruptured peripheral aneurysms in a collateral pathway associated with stenosis of a major cerebral artery: Report of two cases 
Background
While hemodynamic stress can result in aneurysm formation, it rarely contributes to the development of peripheral aneurysms in collateral pathways. We report two patients with ruptured distal aneurysms in a collateral pathway associated with stenosis of a major cerebral artery.
Case Description
A 67-year-old man presented with intracerebral hemorrhage in the right frontal lobe. Digital subtraction angiography (DSA) revealed severe stenosis of the right middle cerebral artery and two aneurysms in the collateral pathway of the right anterior cerebral artery. The ruptured aneurysm was trapped and resected; histologically, it was a true saccular aneurysm. The unruptured aneurysm was clipped and the patient was discharged without additional neurological deficits. The second patient was a 73-year-old woman with subarachnoid hemorrhage. DSA revealed three arterial dilations. On the 7th day of hospitalization, one of the aneurysms in a posterior inferior cerebellar artery–anterior inferior cerebellar artery anastomosis that functioned as a collateral pathway in the presence of severe basilar artery stenosis was found to be enlarged. It was treated by selective aneurysmal coil embolization with parent artery preservation. Her postoperative course was uneventful and she was discharged without any neurological deficits.
Conclusion
We document the successful treatment of two patients with ruptured aneurysms in the peripheral portion of a collateral pathway. We discuss the histology of peripheral aneurysms and present a review of the literature.
doi:10.4103/2152-7806.82247
PMCID: PMC3130464  PMID: 21748034
Coil embolization; collateral pathway; histology; peripheral aneurysm; posterior inferior cerebellar artery–anterior inferior cerebellar artery anastomosis; true aneurysm
13.  Size and Location of Ruptured Intracranial Aneurysms 
Objective
The aim of study was to review our patient population to determine whether there is a critical aneurysm size at which the incidence of rupture increases and whether there is a correlation between aneurysm size and location.
Methods
We reviewed charts and radiological findings (computed tomography (CT) scans, angiograms, CT angiography, magnetic resonance angiography) for all patients operated on for intracranial aneurysms in our hospital between September 2002 and May 2004. Of the 336 aneurysms that were reviewed, measurements were obtained from angiograms for 239 ruptured aneurysms by a neuroradiologist at the time of diagnosis in our hospital.
Results
There were 115 male and 221 female patients assessed in this study. The locations of aneurysms were the middle cerebral artery (MCA, 61), anterior communicating artery (ACoA, 66), posterior communicating artery (PCoA, 52), the top of the basilar artery (15), internal carotid artery (ICA) including the cavernous portion (13), anterior choroidal artery (AChA, 7), A1 segment of the anterior cerebral artery (3), A2 segment of the anterior cerebral artery (11), posterior inferior cerebellar artery (PICA, 8), superior cerebellar artery (SCA, 2), P2 segment of the posterior cerebral artery (1), and the vertebral artery (2). The mean diameter of aneurysms was 5.47±2.536 mm in anterior cerebral artery (ACA), 6.84±3.941 mm in ICA, 7.09±3.652 mm in MCA and 6.21±3.697 mm in vertebrobasilar artery. The ACA aneurysms were smaller than the MCA aneurysms. Aneurysms less than 6 mm in diameter included 37 (60.65%) in patients with aneurysms in the MCA, 43 (65.15%) in patients with aneurysms in the ACoA and 29 (55.76%) in patients with aneurysms in the PCoA.
Conclusion
Ruptured aneurysms in the ACA were smaller than those in the MCA. The most prevalent aneurysm size was 3-6 mm in the MCA (55.73%), 3-6 mm in the ACoA (57.57%) and 4-6 mm in the PCoA (42.30%). The more prevalent size of the aneurysm to treat may differ in accordance with the location of the aneurysm.
doi:10.3340/jkns.2009.45.1.11
PMCID: PMC2640825  PMID: 19242565
Size; Location; Aneurysm; Ruptured
14.  A Clinical Analysis of Twelve Cases of Ruptured Cerebral De Novo Aneurysms 
Yonsei Medical Journal  2007;48(1):30-34.
Formation of cerebral de novo aneurysms (CDNA) is rare, and the pathogenesis remains obscure. In this study, we investigated the factors that contribute to the formation of CDNA and suggest guidelines for following patients treated for cerebral aneurysms. We retrospectively reviewed 2,887 patients treated for intracranial aneurysm at our institute from January of 1976 to December of 2005. Of those patients, 12 were readmitted due to recurrent rupture of CDNA, which was demonstrated by cerebral angiography. We assessed clinical characteristics, such as gender, size and site of rupture, past history, and the time to CDNA rupture. Of the 12 patients, 11 were female and 1 was male, with a mean age at rupture of the first aneurysm of 44.7 years (range: 30-69 years). The mean time between the first episode of subarachnoid hemorrhage (SAH) and the second was 8.9 years (range: 1.0-16.7 years). The most common site of ruptured CDNA was the internal carotid artery (5 patients, 41.7%), followed by basilar artery bifurcation (3 patients, 25.0%). In the remaining 4 patients, rupture occurred in the anterior communicating, middle cerebral, anterior cerebral (A1), or posterior cerebral (P1) arteries. In 5 cases (41.7%), the CDNA occurred contralateral to the initial aneurysm. Eleven patients (91.7%) had a past history of arterial hypertension. There was no history of habitual smoking or alcohol abuse in any of the patients. Eight patients underwent clipping for CDNA and three patients were treated with coiling. One patient who had multiple aneurysms was treated with clipping following intra-aneurysmal coiling. Assessment according to the Glasgow Outcome Scale (GOS) of the patients after the treatment was good in 10 cases (83.3%) and fair in 2 cases (16.7%). Although formation of CDNA after successful treatment of initial aneurysm is rare, several factors may contribute to recurrence. In our study, female patients with a history of arterial hypertension were at higher risk for ruptured CDNA. We recommend follow-up imaging studies every five years after treatment of the initial aneurysm, especially in women and those with a history of arterial hypertension.
doi:10.3349/ymj.2007.48.1.30
PMCID: PMC2627997  PMID: 17326242
Cerebral de novo aneurysm; ruptured cerebral aneurysm
15.  Y-Stenting Endovascular Treatment for Ruptured Intracranial Aneurysms : A Single-Institution Experience in Korea 
Objective
Stent-assisted coiling on intracranial aneurysm has been considered as an effective technique and has made the complex aneurysms amenable to coiling. To achieve reconstruction of intracranial vessels with preservation of parent artery the use of stents has the greatest potential for assisted coiling. We report the results of our experiences in ruptured wide-necked intracranial aneurysms using Y-stent coiling.
Methods
From October 2003 to October 2011, 12 patients (3 men, 9 women; mean age, 62.6) harboring 12 complex ruptured aneurysms (3 middle cerebral artery, 9 basilar tip) were treated by Y-stent coiling by using self-expandable intracranial stents. Procedural complications, clinical outcome, and initial and midterm angiographic results were evaluated. The definition of broad-necked aneurysm is neck diameter over than 4 mm or an aneurysm with a neck diameter smaller than 4 mm in which the dome/neck ratio was less than 2.
Results
In all patients, the aneurysm was successfully occluded with no apparent procedure-related complication. There was no evidence of thromboembolic complication, arterial dissection and spasm during procedure. Follow-up studies showed stable and complete occlusion of the aneurysm in all patients with no neurologic deficits.
Conclusion
The present study did show that the Y-stent coiling seemed to facilitate endovascular treatment of ruptured wide-necked intracranial aneurysms. More clinical data with longer follow-up are needed to establish the role of Y-stent coiling in ruptured aneurysms.
doi:10.3340/jkns.2012.52.3.187
PMCID: PMC3483317  PMID: 23115659
Intervention; Stent; Subarachnoid hemorrhage
16.  Coil Embolization for Ruptured Cerebral Aneurysms of 2×3 mm Diameter 
Interventional Neuroradiology  2006;12(Suppl 1):97-100.
Summary
Small ruptured cerebral aneurysms, such as those of 2×3 mm diameter, are considered to be difficult to embolize by detachable coils because of the risk of procedural perforation of the aneurysms. We have treated these small aneurysms and report the techniques and pitfalls of these embolizations. Twenty-four patients with ruptured cerebral aneurysms of 2×3 mm diameter were intended for treatment by coil embolization. Before coil embolization, three-dimensional digital subtraction angiography was performed, and the simulation of the volume embolization ratio (VER) was performed in all patients, except for the first basilar artery aneurysm patient. The tip of the microcatheter was steam-shaped several times and was placed on the neck of the aneurysm. A balloon neck remodeling technique was used for two aneurysms. GDC 10 softs and soft SRs were used for the first ten aneurysms, and Ultrasofts were used for the last eleven aneurysms. Out of twenty-four aneurysm embolizations, we aborted the procedure in three cases, because of a failure in catheterization; we performed clipping surgery for these cases. For the first case of a basilar tip aneurysm, the aneurysm was perforated, due to the use of too long a coil and the insertion of the tip of the microcatheter into the aneurysmal dome. Minor infarction occurred in one patient.
The mean VER was 33.9%, and two aneurysms recanalized, and out of these one needed a second embolization. Six months postoperatively, 81% of patients had made in a good recovery or had a moderate disability. We recommend the following techniques to embolize aneurysms of 2×3 mm diameter: the tip of the microcatheter should be stabilized on the aneurysmal neck by steam shaping of the micro-catheter, GDC 10 soft and Ultrasoft should be selected for use, and the simulation of the VER should be performed before embolization to select coils of a suitable length.
PMCID: PMC3387975  PMID: 20569610
subarachnoid haemorrhage, cerebral aneurysm, endovascular surgery
17.  Endovascular Treatment of Bilateral Carotid Artery Occlusion with Concurrent Basilar Apex Aneurysm: A Case Report and Literature Review 
We report a case of successful endovascular treatment of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. An elderly female patient with subarachnoid hemorrhage (SAH) onset was admitted to the hospital. Computed tomography (CT) and digital subtraction angiography (DSA) confirmed the presence of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. Brain blood supply was provided by the bilateral vertebral artery through the basilar artery. We treated the aneurysm with the endovascular approach by embolizing the aneurysm with three coils. The patient recovered well after surgery and showed no recanalization of the aneurysm on a one-year follow-up DSA. We also reviewed six similar cases found with a PUBMED database search (1980-2010), including those with bilateral common carotid artery occlusion. In conclusion, by using the endovascular approach, bilateral carotid artery occlusion with concurrent basilar apex aneurysm was efficiently treated.
PMCID: PMC3074092  PMID: 21487570
carotid artery occlusion; basilar apex aneurysm; endovascular treatment
18.  Endovascular Coil Embolization After Clipping: Endovascular Treatment of Incompletely Clipped or Recurred Cerebral Aneurysms 
Objective
The presence of a cerebral aneurysm remnant after surgical clipping is associated with a risk of regrowth or rupture. For these recurred aneurysms, coil embolization can be considered as a treatment option. We retrospectively reviewed cases of ruptured or regrown aneurysms after clipping treated by endovascular coil embolization.
Materials and Methods
We conducted a retrospective review of patients with ruptured or recurred aneurysm after clipping, who underwent coil embolization between January 1995 and December 2013. We evaluated clinical information and the outcomes of these cases.
Results
Eight patients were treated by endovascular coil embolization after surgical clipping. Six aneurysms were located in the anterior communicating artery, one in the posterior communicating artery, and one in the middle cerebral artery bifurcation. All patients were initially treated by surgical clipping because of a ruptured aneurysm. Aneurysm recurrence at the initial clipping site was detected in all cases. The median interval from initial to second presentation was 42 months. In four patients, aneurysms were detected before rupture and the four remaining patients presented with recurrent subarachnoid hemorrhage. All patients were treated by coil embolization and showed successful occlusion of aneurysms without complications.
Conclusion
Endovascular coil embolization can be a safe and successful treatment option for recurred aneurysms after clipping.
doi:10.7461/jcen.2014.16.3.262
PMCID: PMC4205253  PMID: 25340029
Intracranial aneurysm; Recurrence; Coil embolization; Clipping
19.  Endovascular Treatment of Berry Intracranial Aneurysms Using a New Detachable Coil System 
Interventional Neuroradiology  2001;7(2):93-102.
Summary
We aimed to assess and to demonstrate the efficiency of a new mechanical system in the endovascular treatment of berry intracranial aneurysms.
From September 1999 to October 2000, 38 patients with 40 aneurysms experienced selective embolization using Detach Coils (DCS® - Cook). They were 12 men and 26 women, aged 26 to 77 years, mean age 53.4. The clinical status of patients was graded by Hunt and Hess scale: Stage 0:8 - stage 1:3 - Stage II: 11 - Stage III: 11 - Stage TV: 2 - Stage V: 3. The localization of aneurysms was as follows: internal carotid artery: 11; sylvian artery: 10; anterior communicating artery: 5; anterior cerebral artery Al-A2: 5; intra-cavernous carotid artery: 1; basilar trunk: 5; PICA: 2; posterior cerebral artery: 1. The size of the aneurysms ranged from 2 to 40 mm. For embolization of aneurysms, we utilized 242 coils (mean number 6.05). The shape and size of coils varied as follows: longest J 6.25 - shortest 14-3 - longest S 10-20 - shortest S 2-2.
The mean time of procedure was 43 minutes (max 180 minutes - min 7 minutes). We did not have any technical complications during the procedure and no immediate rebleeding occurred. Initial follow-up of the patients showed angiographic full occlusion.
Detach Coils appear to be a very precise, reliable and rapid system, with high stability during coil detachment (in very small or very giant aneurysms) in the embolization of intracranial aneurysms, with an interesting aspect concerning the low cost of this new mechanical device.
PMCID: PMC3621540  PMID: 20663333
aneurysm, subarachnoid hemorrhagen, endovascular treatment
20.  Glue Embolization of Ruptured Anterior Thalamoperforating Artery Aneurysm in Patient with Both Internal Carotid Arteries Occlusion 
Thalamoperforating artery aneurysms are rarely reported in the literature. We report an extremely rare case of ruptured distal anterior thalamoperforating artery aneurysm which was treated by endovascular obliteration in a patient with occlusion of both the internal carotid arteries (ICAs) : A 72-year-old woman presented with severe headache and loss of consciousness. Initial level of consciousness at the time of admission was drowsy and the Glasgow Coma Scale score was 14. Brain computed tomography (CT) scan was performed which revealed intracerebral hemorrhage in right basal ganglia, subarachnoid hemorrhage, and intraventricular hemorrhage. The location of the aneurysm was identified as within the globus pallidus on CT angiogram. Conventional cerebral angiogram demonstrated occlusion of both the ICAs just distal to the fetal type of posterior communicating artery and the aneurysm was arising from right anterior thalamoperforating artery (ATPA). A microcatheter was navigated into ATPA and the ATPA proximal to aneurysm was embolized with 20% glue. Post-procedural ICA angiogram demonstrated no contrast filling of the aneurysm sac. The patient was discharged without any neurologic deficit. Endovascular treatment of ATPA aneurysm is probably a more feasible and safe treatment modality than surgical clipping because of the deep seated location of aneurysm and the possibility of brain retraction injury during surgical operation.
doi:10.3340/jkns.2011.49.5.287
PMCID: PMC3115150  PMID: 21716902
Anterior thalamoperforating artery; Aneurysm; Glue embolization
21.  The sutureless excimer laser assisted non-occlusive anastomosis (SELANA); a feasibility study in a pressurized cadaver model 
Acta Neurochirurgica  2010;152(9):1603-1609.
Objective
To compare intracranial feasibility of the conventional Excimer laser assisted non-occlusive anastomosis (ELANA) with the new experimental sutureless ELANA (SELANA).
Methods
Four pressurized human cadaver heads were bilaterally trepanated, using a combined pterional/pretemporal/transcavernous approach. In each head, seven ELANA anastomoses and seven contralateral SELANA anastomoses were constructed on (1) the proximal PCA/basilar artery (P1 segment/basilar artery; BA), (2) the distal posterior cerebral artery (PCA, P2 segment), (3) the supraclinoidal internal carotid artery (ICA), (4) the ICA bifurcation, (5) the proximal anterior cerebral artery (ACA, A1 segment), (6) the proximal middle cerebral artery (MCA, M1 segment), and (7) the distal MCA (M2 segment).
Results
In total, 26 of 28 ELANA anastomoses (93%) and 22 of 28 SELANA anastomoses (79%) could be completed. Two ELANA anastomoses on the BA could not be finished because of limited space. Six SELANA anastomoses could not be attached because the applicator did not facilitate an angulated anastomosis spot. Of the remaining anastomoses, more ELANA (eight) than SELANA (two) anastomoses could not be realized without manipulation of surrounding structures. The SELANA anastomoses were completed significantly faster than the ELANA, mean difference ranging from 11 min on the M2 to 107 min on the P1/BA.
Conclusion
This comparative study shows potential advantages of the SELANA anastomosis over the ELANA anastomosis because during application, it causes less manipulation of surrounding structures while it is faster and easier. Further preclinical research should be performed in order to improve SELANA feasibility on angulated anastomosis spots and to assess long-term SELANA patency and endothelialization.
doi:10.1007/s00701-010-0717-3
PMCID: PMC2927684  PMID: 20589401
Cerebral revascularization; Bypass; ELANA
22.  Coil Embolization of Intracranial Aneurysm in Polyarteritis Nodosa 
Interventional Neuroradiology  2013;19(2):203-208.
Summary
Polyarteritis nodosa (PAN) is a rare multisystem disease characterized by systemic necrotizing arteritis of small and medium size arteries. The skin, joints, kidneys, gastrointestinal tract and peripheral nerves are most commonly involved. Although aneurysms are commonly seen in the visceral vessels, intracranial aneurysms are rare with 15 reported cases. The intracranial aneurysms are usually multiple and located in supra- as well as infra-tentorial compartments. Most of the cases presented with subarachnoid or parenchymal hemorrhage. The aneurysms were usually small, although large cavernous aneurysms were reported in one case. Treatment guidelines are not clear regarding the management of these cases. Most patients were treated conservatively by medical management with surgical excision performed in only two cases and coiling done in one patient with cavernous aneurysms. Repeat hemorrhages or re-bleed in spite of medical treatment have also been reported.
We describe the case of a 22-year-old woman, a known case of PAN who presented with subarachnoid hemorrhage. Cerebral angiogram showed a ruptured right middle cerebral artery bifurcation aneurysm along with unruptured left middle cerebral, right posterior communicating and left posterior inferior cerebellar artery aneurysms. Her previous abdominal angiogram had revealed multiple aneurysms in visceral arteries. Successful coil embolization of the ruptured right MCA bifurcation aneurysm was performed with preservation of the parent vessel. The patient made a complete recovery and was placed on medical treatment for PAN. Follow-up MR angiography at three months revealed stable occlusion of the embolized aneurysm with no change in the unruptured aneurysms.
Although rare, PAN can be associated with intracranial aneurysms which can cause subarachnoid or parenchymal hemorrhage. Selected cases can be treated safely by coil embolization.
PMCID: PMC3670059  PMID: 23693044
polyarteritis nodosa, aneurysm, embolization
23.  Waffle-Cone Technique Using Solitaire AB Stent 
The waffle-cone technique is a modified stent application technique, which involves protrusion of the distal portion of a stent into an aneurysm fundus to provide neck support for subsequent coiling. The authors report two cases of wide necked basilar bifurcation aneurysms, which were not amenable to stent assisted coiling, that were treated using the waffle-cone technique with a Solitaire AB stent. A 58-year-old woman presented with severe headache. Brain CT showed subarachnoid hemorrhage and angiography demonstrated a ruptured giant basilar bifurcation aneurysm with broad neck, which was treated with a Solitaire AB stent and coils using the waffle-cone technique. The second case involved an 81-year-old man, who presented with dizziness caused by brain stem infarction. Angiography also demonstrated a large basilar bifurcation unruptured aneurysm with broad neck. Solitaire AB stent deployment using the waffle-cone technique, followed by coiling resulted in near complete obliteration of aneurysm. The waffle-cone technique with a Solitaire AB stent can be a useful alternative to conventional stent application when it is difficult to catheterize bilateral posterior cerebral arteries in patients with a wide-necked basilar bifurcation aneurysm.
doi:10.3340/jkns.2012.51.4.222
PMCID: PMC3377880  PMID: 22737303
Wide-necked aneurysm; Waffle-cone technique; Solitaire AB stent
24.  Basilar Artery Aneurysm at a Persistent Trigeminal Artery Junction 
Interventional Neuroradiology  2011;17(3):343-346.
Summary
The trigeminal artery is an anastomosis between the embryonic precursors of the vertebrobasilar and carotid systems, and may persist into adult life. The association of the persistent primitive trigeminal artery (PTA) with cerebral aneurysm is well documented in the literature and, in general, aneurysms are located in the anterior circulation. We describe a patient who presented with a panencephalic Fisher III subarachnoid hemorrhage due to rupture of an intracranial aneurysm. Digital arteriography showed a saccular aneurysm in the middle third of the basilar artery, adjacent to the junction with a persistent trigeminal artery. She was submitted to endovascular treatment with embolization of the basilar artery aneurysm with coils. Aneurysms at the PTA junction with the basilar artery are rare. This paper describes a case of PTA associated with an aneurysm in the basilar artery at PTA junction and briefly reviews the literature.
PMCID: PMC3396038  PMID: 22005697
trigeminal artery, basilar artery, aneurysm, subarachnoid hemorrhage
25.  Successful treatment of a ruptured aneurysm at the vertebral artery-posterior inferior cerebellar artery junction and simultaneous treatment of the stenotic vertebral artery with a single flow-diverting stent: a case report 
Introduction
This is the first report on the simultaneous successful treatment of a large ruptured saccular aneurysm and stenotic parent artery with a single flow-diverting stent.
Case presentation
We report the case of a 68-year-old Caucasian man with occlusion of the right vertebral artery and a ruptured aneurysm at the junction of the left posterior inferior cerebellar artery-left vertebral artery that was successfully treated by the deployment of a single flow-diverting stent in the stenotic left vertebral artery. Stent deployment was complicated by thrombotic occlusion of the basilar artery, which was successfully reopened. The patient recovered completely, and follow-up angiography at 4 months and 1 year showed patent vertebral artery with gradual shrinkage of the aneurysm.
Conclusions
This report contributes to the literature on treatment of large ruptured aneurysms localized in stenotic arteries and in areas of the endocranium where a mass of embolic material in the aneurysm (coils) might compromise the circulation in the parent blood vessel or compress vital brain structures.
doi:10.1186/1752-1947-8-172
PMCID: PMC4096498  PMID: 24886040
Cerebral aneurysm; Flow-diverting stent; Parent artery; Rupture; Stenosis

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