J Korean Neurosurg Soc.  2013 May;53(5):274-280. 10.3340/jkns.2013.53.5.274.

Various Techniques of Stent-Assisted Coil Embolization of Wide-Necked or Fusiform Middle Cerebral Artery Aneurysms : Initial and Mid-Term Results

• Won YS
• Rho MH
• Kim BM
• Park HJ
• Kwag HJ
• Chung EC

• KMID: 1426194
• DOI: http://doi.org/10.3340/jkns.2013.53.5.274

Abstract

OBJECTIVE
To evaluate the feasibility and clinical and angiographic outcomes of stent-assisted embolization for complex middle cerebral artery (MCA) aneurysms.
METHODS
The records of 23 consecutive patients with 24 MCA aneurysms, who underwent stent-assisted embolization of the aneurysm, were retrospectively evaluated.
RESULTS
Fifteen aneurysms were treated with one stent and 8 were treated using more than two stents (5 a stent-within-a-stent, 1 triple stents, and two Y-stent). Angiographically, complete or near complete occlusion was achieved in 15 aneurysms (65.2%), residual neck in five (21.7%), and residual aneurysm in three (13.1%). Five aneurysms demonstrated thrombosis within the stent during the procedure and hospitalization, and were resolved by intraarterial and intravenous Tirofiban injection. Symptomatic thromboembolic complications were developed in five patients and permanent deficits demonstrated in two patients with modified Rankin Scale 1 and 2, respectively. Treatment-related permanent morbidity and mortality rates were 8.3% and 0% with relatively high complication rate. Angiographic follow-up was available in 17 aneurysms at 6-31 months (mean, 13.2 months) and showed stable or improved in 15 (88.2%) and major and minor recurrence in one, respectively.
CONCLUSION
Complex MCA aneurysms could be treated by stent-assisted coiling and showed lower recanalization rate during mid-term follow-up by effective flow diversion due to various stent-assisted techniques. Our results warrant further study with a longer follow-up period in a larger sample.

Keyword

Coil embolization; Intracranial aneurysm; Middle cerebral artery; Stent

MeSH Terms

Aneurysm
Follow-Up Studies
Hospitalization
Humans
Intracranial Aneurysm
Middle Cerebral Artery
Neck
Recurrence
Retrospective Studies
Stents
Thrombosis
Tyrosine
Tyrosine

Figure

• 

  Fig. 1 A 59-year-old man with an unruptured left MCA bifurcation aneurysm with incorporation of the superior divisional branch. Left internal carotid three dimensional angiogram (A) on working projection shows incorporation of the superior divisional branch at the neck. Immediate control angiogram reveals complete embolization of the aneurysm with the stent-assisted technique (B). The patient showed mild motor aphasia five minutes later after final control angiogram and the superior divisional branch is completely occluded (C). After intra-arterial Tirofiban injection, the superior divisional branch is partially recanalized with remnant thrombus within the stent (D). Further infusion of Tirofiban does not solve the remnant thrombus. Left ICA angiogram reveals complete recanalization after insertion of another stent within the stent (E and F). MCA : middle cerebral artery, ICA : internal carotid artery.

• 

  Fig. 2 A 51-year-old man with a large unruptured aneurysm with very wide neck at the distal M1. Left ICA (A) and three dimensional angiogram (B) on working angle show a large aneurysm with a wide neck at the distal M1 of the MCA. Near complete occlusion of the aneurysm with a residual neck is achieved by a stent-within-a-stent technique (C). Six-month follow-up shows stable with a small residual neck (D). MCA : middle cerebral artery, ICA : internal carotid artery.

• 

  Fig. 3 A 56-year-old man with a recurrent ruptured aneurysm after surgical clipping 6 years prior. Brain CT shows a large hematoma in the right temporal lobe and a large amount of subarachnoid hemorrhage (A). Right ICA angiogram (B) and three dimensional reconstruction image (C) shows a fusiform aneurysm with lobulated contour, suggesting dissecting nature. Complete occlusion of the aneurysm was done by a stent-within-a-stent technique (D and E). Nine-month follow-up angiogram shows a major recurrence (F) and complete occlusion is observed on immediate control angiogram after coiling with a stent-assisted technique (G) and at 15 months (H). ICA : internal carotid artery.

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