Stent-assisted coiling of fusiform middle cerebral artery aneurysm treatment
Treating fusiform aneurysms of the middle cerebral artery (MCA) presents significant challenges due to their complex anatomy and involvement of multiple arterial branches. Traditional endovascular coiling may be insufficient for these aneurysms, as the coils can prolapse into the parent vessel, leading to incomplete occlusion and an increased risk of rupture.
Stent-assisted coiling has emerged as a valuable technique for managing such complex aneurysms. In this approach, a stent is deployed across the aneurysm neck to provide structural support, preventing coil prolapse into the parent artery. This method enhances the stability of the coil mass within the aneurysm sac, promoting thrombosis and eventual aneurysm occlusion.
The procedure typically involves the following steps:
1. Access and Navigation: A catheter is introduced through the femoral artery and advanced to the MCA.
2. Stent Deployment: A stent is positioned across the aneurysm neck, covering the origin of the aneurysm and any involved side branches.
3. Coil Embolization: Detachable platinum coils are inserted into the aneurysm sac through the stent, filling the cavity and promoting clot formation.
4. Post-Procedure Assessment: Angiographic imaging is performed to evaluate aneurysm occlusion and patency of the parent artery.
This technique is safe and effective, providing durable aneurysm closure. However, higher complication rates and worse outcomes are associated with the treatment of ruptured aneurysms. Stent delivery before coil deployment reduces the risk of procedural complications.
In some cases, a staged approach may be employed, starting with the implantation of a braided stent to act as scaffolding for hemodynamically active, low-porosity flow diverters. This method aims to minimize the risk of thromboembolic complications by keeping the flow diverter’s distal and proximal ends away from critical bifurcations.
Given the complexity of fusiform MCA aneurysms, treatment decisions should be individualized, considering factors such as aneurysm size, location, and the patient's overall health. A multidisciplinary team approach, involving neurosurgeons and interventional neuroradiologists, is essential to determine the most appropriate treatment strategy.
Stent-assisted coiling for fusiform middle cerebral artery aneurysm treatment may be deployed to support the artery and help secure the coils for fusiform aneurysms. This technique is particularly useful when the aneurysm involves the neck of the artery or is located in a difficult-to-reach area.
The stent helps prevent coil migration and creates scaffolding to support the embolization process. It can also help reduce the risk of recanalization and improve the long-term success of the embolization.
Complex MCA aneurysms could be treated by stent-assisted coiling and showed a 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 1).
I15153
Case Report: Embolization of Right Middle Cerebral Artery Aneurysm in a 43-Year-Old Male with Favorable Outcome
Abstract:
This case report discusses stent-assisted coiling of fusiform middle cerebral artery aneurysm treatment of a right fusiform middle cerebral artery aneurysm in a 43-year-old male patient. The patient was admitted with an intraparenchymal hemorrhage secondary to a ruptured fusiform aneurysm. After a two-stage embolization procedure, the patient showed favorable clinical outcomes with minimal residual aneurysm neck on follow-up angiographic studies. The case highlights the importance of timely intervention and the role of endovascular techniques in treating complex aneurysms.
Introduction: Aneurysms of the middle cerebral artery (MCA) are relatively uncommon but can present with significant neurological consequences when ruptured. In this case, a 43-year-old male presented with an intraparenchymal hematoma secondary to a ruptured fusiform aneurysm of the MCA. A staged endovascular embolization approach was used to manage the aneurysm, resulting in a favorable clinical course.
Case Presentation:
No significant medical or surgical history. The patient has no history of diabetes mellitus (DM), hypertension (HTA), or dyslipidemia (DLP). He is a non-smoker and denies alcohol consumption.
- Presenting Complaint:
The patient was transferred from another hospital to our center after a ruptured fusiform aneurysm of the MCA. He presented with symptoms of an intraparenchymal hematoma in the right temporal lobe.
- Initial Examination:
On initial examination, the patient was conscious and oriented. He exhibited bradipsychia (slowness in thinking) and minimal paresis in the left facial muscles and left upper limb (muscle strength IV/V). The patient was eupneic with a saturation of 100% on oxygen therapy at 2L. The rest of the physical examination was unremarkable.
- Initial Diagnostic Imaging:
A CT scan confirmed the presence of an intraparenchymal hematoma in the right temporal lobe. Angiography revealed a fusiform aneurysm in the right MCA.
- Management:
The patient was admitted to the Intensive Care Unit (ICU). The initial treatment involved embolization of the larger part of the aneurysm using three coils. The smaller part of the aneurysm was scheduled for a second procedure.
The second procedure was performed and involved:
- Placement of a stent: A stent was deployed to cover the neck of the aneurysm.
- Embolization with coils: The aneurysmal sac was embolized using coils, and follow-up angiographic imaging showed a good result, with a minimal residual neck.
- Outcome:
Post-procedure, the patient remained stable after a favorable course in the ICU. Upon arrival at the ward, the patient was conscious, oriented, and stable, with no signs of long-tract dysfunction. He tolerated a regular diet and was able to walk independently.
Follow-up angiography confirmed adequate embolization of the aneurysm, with minimal residual neck. There were no complications during the embolization procedures.
Discussion:
Fusiform aneurysms, while less common than saccular aneurysms, are particularly challenging due to their irregular shape and difficulty in achieving complete occlusion. Endovascular treatment, particularly the use of coils and stent deployment, has become the gold standard for managing such aneurysms. This case demonstrates the effectiveness of a two-stage embolization approach for a fusiform MCA aneurysm, achieving both a technically successful result and a favorable clinical outcome.
The patient's recovery highlights the importance of early intervention and appropriate endovascular management. Moreover, the absence of major complications during the procedure, such as rebleeding or ischemic events, underlines the safety of this treatment modality in experienced hands.
Conclusion:
This case report demonstrates the successful management of a ruptured fusiform MCA aneurysm with endovascular embolization. The patient's clinical course was favorable, and follow-up imaging showed an adequate result with minimal residual aneurysmal neck. Endovascular techniques remain a valuable tool in the treatment of complex aneurysms, offering both a minimally invasive approach and a high success rate.
Keywords: Aneurysm, Endovascular embolization, Middle cerebral artery, Fusiform aneurysm, Coils, Stent, Neurosurgery.
Case reports
A case of a fusiform aneurysm of the proximal MCA, which was successfully treated using stent-assisted coil embolization. A 42-year-old man presented with repeated headaches and syncope. Five years earlier, a right MCA aneurysm had been treated by aneurismal wrapping. Magnetic resonance images (MRI) revealed a partially thrombosed proximal MCA aneurysm at the right perisylvian region. Digital subtraction angiography (DSA) revealed a multilobulated fusiform-shaped aneurysm. The patient underwent stent-assisted coil embolization under general anesthesia and symptoms resolved postoperatively. Three-month follow-up angiography revealed no recanalization of the aneurysm and indicated tolerable blood flow through the right MCA, as compared to the preoperative angiography. We suggest that in selected patients, stent-assisted coil embolization of proximal MCA fusiform aneurysms can be an effective treatment modality 2)