Neurointervention.  2022 Nov;17(3):133-142. 10.5469/neuroint.2022.00311.

Physiologic Flow Diversion Coiling Technique for Wide-Necked Aneurysms with an Asymmetric Bidirectional Flow at the Aneurysm Neck

Affiliations
  • 1Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
  • 2Department of Neurointervention, GangNam St. Peter’s Hospital, Seoul, Korea

Abstract

Purpose
Wide-necked aneurysms in the circle of Willis (CoW) are prone to recur due to reciprocal bidirectional flow. We present a novel concept of coil embolization to prevent recurrence that uses physiologic flow diversion at the CoW.
Materials and Methods
We enrolled 14 patients (15 aneurysms) who underwent aneurysm coiling for wide-necked aneurysms with asymmetric bidirectional inflow into the aneurysm. Four patients had recurrent aneurysms after coiling. The concept of physiologic flow diversion included obliterating antegrade flow into the aneurysm sac as well as opposite CoW flow by performing compact coil packing with intentional protrusion out of the aneurysm neck to the communicating part.
Results
Fifteen aneurysms, including 4 recurrent aneurysms, in an anterior communicating artery (n=7), posterior communicating artery (n=5), and tip of the basilar artery (n=3) were treated with coil embolization (n=10) and stent-assisted coiling (n=5). All aneurysms had a wide neck, and the mean largest diameter was 9.0 mm. The mean packing density was 45.1%. Twelve aneurysms were completely occluded, and 3 aneurysms had tiny residual neck remnants. There was neither a neurological event nor recurrence during the mean 12.5 months of follow-up.
Conclusion
Wide-necked aneurysms at the CoW tend to recur. As a strategy to prevent a recurrence, physiologic flow diversion can be an option in treating wide-necked aneurysms in the CoW.

Keyword

Circle of Willis; Intracranial aneurysm; Magnetic resonance angiography; Treatment outcome

Figure

  • Fig. 1. An adult patient (patient 6) with a giant thrombosed anterior communicating artery (ACoA) aneurysm is referred due to repeated recurrence despite 3 embolizations. Magnetic resonance angiography (MRA) on arrival (A) and 3-dimensional rotational angiography (B) show a thrombosed sac (asterisk) in (A) and recurrent aneurysmal sac (asterisk) in (B) involving both sides of the anterior cerebral artery (ACA) A2 opening. MRA 1-day post-procedure (C) shows complete embolization of the aneurysm sac. Note a compensatory enlargement of the right ACA A1 (thick arrow) in (C) compared with the previous ACA A1 (thin arrow) in (A). Concept diagram of the procedure (D–F). A stent is deployed in the left ACA A1–2 segment to cover the wide aneurysm neck extending toward the left ACA A2 segment. The coils are densely packed to fill the neck, and a slight protrusion toward the ACoA is intentionally allowed. The diameter of the right ACA A1 segment increases to compensate for the diminished ACoA flow from the left ACA (thin and thick arrows in [D–F]).

  • Fig. 2. An adolescent patient (patient 9) presents with a giant aneurysm at the tip of the basilar artery (basilar tip) involving the left posterior cerebral artery (PCA) P1. Initial computed tomography angiography (A) shows a giant aneurysm sac (asterisk) that displaces the PCA arising from the aneurysm (arrow). Note that the left posterior communicating artery (PCoA) is invisible on (A) and on magnetic resonance angiography (MRA) (B) 1 day after coil embolization via the basilar artery. The 2-month follow-up MRA (C) reveals enlargement of the left PCoA and filling of a recurrent aneurysm sac (arrow) from the PCA without filling from the basilar artery suggesting back door opening after front door closure. Additional coiling (arrow) via the enlarged PCoA (D) shows the disappearance of the recurrent neck filling of the aneurysm (arrow in E) on MRA on the next day (E). The 2-year follow-up MRA (F) shows no recurrence of the aneurysm and remodeling of the left PCA (arrow), that is, physiologic flow diversion through the circle of Willis, which has a preventive effect on aneurysm recurrence at the basilar artery tip (front door).

  • Fig. 3. A wide-necked aneurysm (patient 5) at the anterior communicating artery (ACoA) origin of the right anterior cerebral artery (ACA). (A) Pre-embolization and (B) post-embolization magnetic resonance angiography after coil embolization with a guidewire protection technique with sufficient coiling of the neck into the ACoA. Note obliteration of the aneurysm and enlargement of the left ACA A1 after coiling as a sign of physiologic flow diversion (arrow) in (B).

  • Fig. 4. A wide-necked aneurysm (patient 13) at the posterior communicating artery (PCoA) origin of the right internal carotid artery. (A) Pre-embolization and (B) post-embolization magnetic resonance angiography after stent-assisted coil embolization with sufficient coiling of the neck into PCoA. Note obliteration of the aneurysm sac and enlargement of the right PCoA after coiling as a sign of physiologic flow diversion (arrow) in (B).


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