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Endovascular treatment of a basilar artery dissecting aneurysm

Tratamento endovascular de aneurisma dissecante da artéria basilar

Abstracts

Basilar artery (BA) dissecting aneurysms pose difficulties to treatment because both bleeding and thrombosis can happen in the same patient, clinical course is unpredictable and high morbidity is usual. We report the case of a 37-year-old woman with a BA aneurysm probably caused by arterial dissection, presenting embolic and hemorrhagic complications. The aneurysm was submitted to endovascular treatment with stenting and coil embolization. Clinical and radiological results were excellent and no complications were observed, suggesting that BA stenting and coil embolization may be a safe and effective treatment for this condition.

basilar artery dissection aneurysm; endovascular treatment; stenting; coil embolization


Aneurismas associados a dissecção da artéria basilar (AB) apresentam dificuldades terapêuticas, pois sangramentos e fenômenos trombóticos podem ocorrer no mesmo paciente, seu curso clínico é imprevisível e sua morbidade, alta. Relatamos o caso de uma paciente de 37 anos com aneurisma de artéria basilar provavelmente causado por dissecção arterial, apresentando-se com complicações hemorrágicas e embólicas. O aneurisma foi submetido a tratamento endovascular com colocação de "stent" e embolização com molas. Os resultados clínico e radiológico foram excelentes e nenhuma complicação foi observada, sugerindo que o tratamento dos aneurismas de AB dissecantes com colocação de "stent" e embolização com molas possa ser seguro e eficaz.

aneurismas associados a dissecção da artéria basilar; tratamento endovascular; embolização com molas; "stent"


SCIENTIFIC NOTES

Endovascular treatment of a basilar artery dissecting aneurysm

Tratamento endovascular de aneurisma dissecante da artéria basilar

Cristiane Borges PatrocloI; Paulo Puglia JrI, II; Claudia da Costa LeiteI, II; Fabio Iuji YamamotoI, II; Jovana Gobbi Marchesi CiríacoI; Milberto ScaffI, II; Adriana Bastos ConfortoI, II

Departments of Neurology and Radiology, Hospital das Clínicas, São Paulo University, São Paulo SP, Brazil

IMD

IIPhD

ABSTRACT

Basilar artery (BA) dissecting aneurysms pose difficulties to treatment because both bleeding and thrombosis can happen in the same patient, clinical course is unpredictable and high morbidity is usual. We report the case of a 37-year-old woman with a BA aneurysm probably caused by arterial dissection, presenting embolic and hemorrhagic complications. The aneurysm was submitted to endovascular treatment with stenting and coil embolization. Clinical and radiological results were excellent and no complications were observed, suggesting that BA stenting and coil embolization may be a safe and effective treatment for this condition.

Key words: basilar artery dissection aneurysm, endovascular treatment, stenting, coil embolization.

RESUMO

Aneurismas associados a dissecção da artéria basilar (AB) apresentam dificuldades terapêuticas, pois sangramentos e fenômenos trombóticos podem ocorrer no mesmo paciente, seu curso clínico é imprevisível e sua morbidade, alta. Relatamos o caso de uma paciente de 37 anos com aneurisma de artéria basilar provavelmente causado por dissecção arterial, apresentando-se com complicações hemorrágicas e embólicas. O aneurisma foi submetido a tratamento endovascular com colocação de "stent" e embolização com molas. Os resultados clínico e radiológico foram excelentes e nenhuma complicação foi observada, sugerindo que o tratamento dos aneurismas de AB dissecantes com colocação de "stent" e embolização com molas possa ser seguro e eficaz.

Palavras-chave: aneurismas associados a dissecção da artéria basilar, tratamento endovascular, embolização com molas, "stent".

Dissecting aneurysms represent up to 28% of aneurysmal abnormalities involving the intracranial vertebral artery (VA) and its branches. In contrast, basilar artery (BA) dissection seems to be rare1,2, presenting more frequently with brain stem ischemia and rarely with subarachnoid hemorrhage3-6. This lesion carries significant mortality and morbidity. Fatal rebleeding may occur in 19% of BA dissecting aneurysms that present with subarachnoid hemorrhage1,6. In addition, bleeding may complicate BA dissections presenting initially with brain ischemia. The risk is greater within the first 24 hours and rebleeding is less likely to occur after 2 weeks. In some cases, the lesion may even show spontaneous regression.

Because of their rarity, the management of BA dissecting aneurysms is controversial and challenging, as illustrated by the case we report, the patient give informed consent for publication this case report.

CASE

A 37-year-old woman reported a sudden sensation in the occipital region described in her words as a "dilating vein in the head" seven days before being admitted. The sensation lasted for a few hours and was followed by nausea and right homonymous hemianopsia. She had a history of migraine without aura since adolescence and her sister had a myocardium infarct at the age of 22.

CT demonstrated an ischemic infarction in the left occipital lobe. Cerebrospinal fluid was xantochromic and analysis revealed 1200 red cells. MRI showed the previous lesions and a left cerebellar infarction (Fig 1). MRA revealed a severe stenosis followed by dilatation in the middle portion of the basilar artery. Digital subtraction angiography (DSA), ten days after the ictus, showed a BA focal severe stensosis followed by dilatation and tight stenosis, suggesting a BA aneurysm caused by spontaneous dissection (Fig 2). Other slight stenoses were present in the middle and distal portions of the BA. The patient was submitted to endovascular treatment with BA stenting and aneurysm coil embolization without complications. During the procedure she received tirofiban, 0.6 mg intra-arterial bolus and 6.6 mg intravenous infusion for twelve hours. Afterwards, unfractioned heparin and clopidogrel 75 mg qd were given for seven days and then heparin was substituted by aspirin 100 mg qd. One month later, clopidogrel was discontinued and aspirin dose was increased to 300 mg qd.



The neurological examination remained was unchanged on discharge compared to patient admission. Two months later, no complications were observed. The NIH Stroke Score was 2 and the Modified Rankin score was 1. Six months later, DSA was repeated and showed the same good results. One a year after symptom onset, the the neurological examination is unchanged.

DISCUSSION

Three options should be considered when dealing with basilar artery aneurysms: conservative management, surgical treatment and endovascular intervention. The first one should be considered in patients with ischemic stroke without evidence of bleeding and without aneurysm formation. On the other hand, early intervention should be considered in patients with hemorrhage or aneurysms6. The three surgical options currently available are wrapping, proximal ligation and arterial reconstruction by direct surgical clipping. The efficacy of the first modality is unproven, and there are only anecdotal descriptions of the other techniques in treatment of BA lesions. The poverty of information about surgical procedures can be justified by the difficult or sometimes impossible access to the BA. Endovascular approach of BA dissection relayed in the past on occlusion of the parent vessel6-8. Subsequently, the development of appropriate stents for intracranial arteries led to good results, first in BA fusiform aneurysms unrelated to dissection9 and later, in BA dissections10,11. Endovascular treatment of intracranial dissection aneurysms has been previously described. However, there has been limited experience on successful treatment of BA dissections complicated by aneurysms with stenting and coil embolization12-16. Good outcomes were reported after this procedure in only three cases9,13.

In the presented case, excellent angiographic and clinical results have been obtained. Endovascular treatment was chosen because of its potential advantages. First, a stent redirects blood flow by disrupting inflow into the aneurysm from the parent vessel. This decreased inflow contributes to thrombosis of the aneurysm and also probably reduces the risk of the coils becoming compacted. Second, a stent supports coiling by "remodeling" the neck of an aneurysm and by preventing migration of coil loops from aneurysms, especially from wide neck aneurysms that otherwise could represent an obstacle to treatment. Finally, a stent also provides a matrix for endothelial growth. The luminal surface of the stent is covered by a layer of neointima and the segment from which the aneurysm arises is thereby remodeled1,17-20. The approach to posterior circulation arteries by endovascular devices is quite direct and now there are available new, autoexpansible stents designed for intracranial use.

However, some cautions must be taken into account. First, stents may induce intimal hyperplasia and especially in smaller branches this could lead to significant stenosis. Second, as stents are potentially thrombogenic, anticoagulation during the procedure and long-term antiplatelet prophylaxis may be necessary and could represent an additional risk in the setting of subarachnoid hemorrhage. To avoid this risk, aneurysm access with a catheter to provide coil deployment was guaranteed before placing the stent. Third, in theory occlusion of ostia of small perforating branches, especially along the basilar trunk, could be complicated with ischemic events, although this has not been common in animal models13,18.

In conclusion, BA dissecting aneurysms pose difficulties to treatment because both bleeding and thrombosis can happen in the same patient, clinical course is unpredictable and high morbidity is usual. No complications were observed in the presented case suggesting that BA stenting and coil embolization may be a safe and effective treatment for this condition.

Received 12 February 2007, received in final form 4 June 2007. Accepted 4 August 2007.

Dra. Cristiane Borges Patroclo - Department of Neurology / Hospital das Clínicas / São Paulo University - Avenida Dr. Enéas de Carvalho Aguiar 255 / 5084 - 05403-000 São Paulo SP - Brasil. E-mail: crispatroclo@yahoo.com.br

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Publication Dates

  • Publication in this collection
    06 Dec 2007
  • Date of issue
    Dec 2007

History

  • Accepted
    04 Aug 2007
  • Reviewed
    04 June 2007
  • Received
    12 Feb 2007
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