J Korean Neurosurg Soc.  2012 Apr;51(4):222-226. 10.3340/jkns.2012.51.4.222.

Waffle-Cone Technique Using Solitaire AB Stent

• Park HR
• Yoon SM
• Shim JJ
• Kim SH

• KMID: 2066915
• DOI: http://doi.org/10.3340/jkns.2012.51.4.222

Abstract

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.

Keyword

Wide-necked aneurysm; Waffle-cone technique; Solitaire AB stent

MeSH Terms

Aged, 80 and over
Aneurysm
Angiography
Brain
Brain Stem Infarctions
Catheters
Dizziness
Female
Headache
Humans
Middle Aged
Neck
Posterior Cerebral Artery
Stents
Subarachnoid Hemorrhage

Figure

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  Fig. 1 Case 1. Brain CT, CT angiograms (CTAs) and time of flight MR angiograms showing a basilar bifurcation giant aneurysm and a small anterior communicating artery (AComA) aneurysm. Brain CT (A) showing a subarachnoid hemorrhage in both Sylvian cisterns, the anterior interhemispheric fissure and right ambient cistern (Fisher grade III). A round, slightly hyperdense lesion depicted in the suprasellar cistern. CTAs (B and C) demonstrating a large basilar bifurcation aneurysm, which was considered ruptured, and an AComA small unruptured aneurysm. MR angiograms (D and E) clearly visualizing the inflow zone of a basilar bifurcation aneurysm from orifice to dome. The basal portion of aneurysm was not definitely visualized because of stagnant blood flow.

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  Fig. 2 Case 1. Preoperative, intraoperative and postoperative digital subtraction angiography. Preoperative AP (A) and lateral (B) vertebral angiograms showing a broad-necked giant basilar bifurcation aneurysm. Left posterior cerebral arteries (PCA) flow was visualized faintly, suggesting dominant flow from the posterior communicating artery. The orifices of both PCAs and superior cerebellar arteries (SCAs) were found to be incorporated in the giant aneurysm by 3-dimensional rotational angiography (3DRA) (C). A Solitaire intracranial stent (4×20 mm) is deployed into the aneurysmal sac distally, and into the distal basilar artery proximally in a 'waffle-cone' manner to protect the orifices of the right P1 and both SCAs (D). Partial obliteration of the giant basilar bifurcation aneurysm is achieved after 31 packing coils using the double catheter technique (E-H). Postoperative 3DRA demonstrating patent flow to both PCAs and SCAs (I).

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  Fig. 3 Case 2. Preoperative, intraoperative and postoperative digital subtraction angiography. Preoperative AP (A) and lateral (B) vertebral angiograms showing a broad-necked, large aneurysm of basilar bifurcation. Both P1s are incorporated in the aneurysm by 3-dimensional rotational angiography (C). A 4×20 mm Solitaire stent is deployed into the aneurysmal sac distally, and the distal basilar artery proximally in a waffle-cone manner to protect the orifices of both P1s and to support the coil mass (D). Near complete obliteration of the large basilar bifurcation aneurysm is achieved with 11 coils, while sparing flows of both PCAs (E and F). PCA : posterior cerebral artery.

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