case report

A Large Ruptured Dissecting Internal Carotid Artery Aneurysm Treated by Flow Diverter and Coil Embolization: A Case Report and Literature Review

Kazumoto Suzuki1, Yumiko Mitome-Mishima1*, Kohsuke Teranishi1,  Akihide Kondo1, Hidenori Oishi1,2

1Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan

2Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Tokyo, Japan

*Corresponding author: Yumiko Mitome-Mishima, Department of Neurosurgery, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan

Received Date: 24 March, 2023

Accepted Date: 04 April, 2023

Published Date: 07 April, 2023

Citation: Suzuki K, Mitome-Mishima Y, Teranishi K, Kondo A, Oishi H (2023) A large ruptured dissecting internal carotid artery aneurysm treated by flow diverter and coil embolization: a case report and literature review. Int J Cerebrovasc Dis Stroke 6: 146. DOI: https://doi.org/10.29011/2688-8734.1000146

Abstract

Objective: We herein report a rare case of a ruptured internal carotid dissecting aneurysm treated with a flow diverter. Case Presentation: A 32-year-old man presented with a subarachnoid hemorrhage secondary to a ruptured internal carotid dissecting aneurysm.The aneurysm was treated by flow diverter (Pipeline embolization device) and coil embolization in the chronic phase. Rerupture occurred prior to the procedure, and a small amount of subarachnoid hemorrhage was observed after the procedure, but the modified Rankin scale score was unchanged from the onset of subarachnoid hemorrhage (modified Rankin scale score: 1). Eight-month follow-up digital subtraction angiography indicated O’Kelly–Marotta grade D and showed that the aneurysm was completely occluded. Four years have passed without recurrence. This management resulted in minimum hemorrhagic complications and no ischemic complications. Conclusion: Pipeline embolization device treatment in the chronic phase is valid to obtain good vascular reconstruction.

Introduction

Cerebral dissecting aneurysm, which may be asymptomatic, is a specific pathology that causes headache, cerebral infarction, and subarachnoid hemorrhage (SAH). SAH caused by dissecting aneurysms develops earlier than that caused by ruptured true saccular aneurysms and results in premature rebleeding, especially within 24 hours [1]. When SAH develops, radical surgery is generally required to prevent rebleeding, and treatments comprise open surgery and endovascular treatment. Both treatments require the selection of either vessel deconstruction or reconstruction. In open surgery, proximal ligation and trapping are performed for vessel deconstruction, and internal carotid artery (ICA)–external carotid artery bypass and a clip-wrap technique are performed for vessel reconstruction; however, this is highly invasive. In endovascular treatment, parent artery occlusion is performed for vessel deconstruction along with aneurysmal occlusion and stentassisted coil embolization. Flow diverters (FDs) have recently been used in vessel reconstruction. Together with a discussion of the literature, we herein report a case of Pipeline embolization device (PED) deployment for a ruptured ICA dissecting aneurysm treated in the chronic phase of SAH.

Case Presentation

A 32-year-old man experienced a sudden-onset headache. Four days after onset, he was admitted to a neighboring hospital with a diagnosis of SAH with right frontal lobe hemorrhage (Hunt & Kosnik classification grade 2, Fisher grade 4) (Figure 1A). The patient had no remarkable medical history, family history, or history of trauma. Digital subtraction angiography (DSA) showed irregular vascular dilatation and stenosis, predominantly in the anterior wall of the ICA, exhibiting the string-of-pearls sign from the paraclinoid portion of ICA to middle cerebral artery (M1 portion) (dilated part of C1–2 portion; longest diameter: 10.0 mm; shortest diameter: 7.6 mm) (Figure 1B–D). Based on these angiographic findings, rapid growth in a short period of time, young age, no risk factors for atherosclerosis, and no family history, the probability of a ruptured dissecting ICA aneurysm was considered. Because an occlusion test of the right ICA contraindicated therapeutic sacrifice of the parent artery, an alternative strategy using endovascular reconstruction with a PED was proposed in the chronic phase of SAH. Coil embolization was added to prevent delayed aneurysmal rupture. The patient was transferred to our institution for endovascular management. He presented with mild disturbance of consciousness (Glasgow coma scale score: E3V4M6), hand motion visual acuity, and incomplete oculomotor nerve palsy due to compression by the aneurysm. Because the risk of rerupture while waiting was judged to be high, antiplatelet therapy was scheduled to be performed immediately before the procedure. As expected, rerupture occurred prior to the procedure without neurological deterioration (Figure 1E). Therefore, the patient was treated with antiplatelet therapy (clopidogrel: 75 mg, followed by aspirin: 200 mg and clopidogrel: 150 mg). Platelet aggregation activity was assessed before the procedure using the VerifyNow test (Accumetrics, San Diego, CA, USA), with values of 200 P2Y12 reaction units (PRU) (inhibition 8%) [Prior to dual antiplatelet therapy (DAPT)] and 385 aspirin reaction units (ARU) 48 hours after starting DAPT.


Figure 1: Unenhanced axial CT scan and DSA (A–D) at onset in the previous hospital and (E–G) at the time of rerupture at our institution. (A) CT showed subarachnoid hemorrhage and intracranial hemorrhage in the right frontal lobe. A bleeding source was identified in the right ICA dissecting aneurysm on (B, C) DSA and (D) three-dimensional DSA. Three-dimensional DSA showed irregular vessel dilatation exhibiting the string-of-pearls sign from the ICA (C2 portion) to the middle cerebral artery (M1 portion). (E– G) On DSA, the ruptured dissecting ICA aneurysm appeared larger. CT, computed tomography; DSA, digital subtraction angiography; ICA, internal carotid artery.

Twenty-nine days after onset, aneurysmal treatment was performed under general anesthesia (without systematic heparinization) to prevent rebleeding. The ruptured dissecting ICA aneurysm had become larger (longest diameter: 26.1 mm; shortest diameter: 17.1 mm) (Figure 1F and G). A 6-Fr guiding sheath (Axcelguide STA, 6-Fr, 85 cm; Medikit, Tokyo, Japan) was inserted for PED placement via the right femoral artery approach, and a 5-Fr femoral artery long sheath and 5-Fr guiding catheter (5-Fr Envoy MPC, 90 cm; Cerenovus Spectra, Tokyo, Japan) were placed for coil embolization via the left femoral artery. First, an Excelsior SL-10 microcatheter (Stryker Neurovascular, Fremont, CA, USA) was coaxially inserted with the 6-Fr guiding sheath to guide the distal part of the PED to the aneurysm. The guidewire was extended using a Chikai extension wire (Asahi Intecc, Aichi, Japan), and the SL-10 was removed by the over-the-wire method. This was followed by insertion of a 5-Fr distal support catheter (Navien, 115 cm; Medtronic, Tokyo, Japan) and a microcatheter (Marksman, 150 cm; Medtronic), which were guided to the M1 segment for PED placement. An Excelsior SL-10 microcatheter was inserted into the aneurysm coaxially with an Envoy guide catheter (Codman Neurovascular, Wokingham, UK). A Pipeline Flex embolization device (3.5 × 35 mm) (Medtronic) was deployed from M1 to C4, and percutaneous angioplasty was performed with a TransForm SC 4.0- × 7.0-mm occlusion balloon catheter (Stryker Neurovascular) because of stent non-apposition. Finally, we added coiling via the SL-10 microcatheter to prevent delayed aneurysm rupture (Figure 2A–C). Immediately after the procedure, minor SAH was detected by flat-panel detector computed tomography; therefore, strict blood pressure control was performed for 2 days under sedation. After extubation, the patient was drowsy, but he improved rapidly. The 8-month follow-up DSA showed O’Kelly– Marotta grade D, and wall apposition with the PED was verified (Figure 2D, E). The irregular caliber of the parent vessel had been smoothly repaired, and four years have passed without recurrence. The modified Rankin scale score was unchanged compared with the preoperative score for hand motion visual acuity and incomplete oculomotor palsy. Clopidogrel was suspended 15 months after the procedure, while aspirin was continued.