- Email: [email protected]
Endovascular Coil Embolization with Low-Profile Visualized Intraluminal Support Junior Stent for Ruptured Dissecting Aneurysm of Proximal Superior Cerebellar Artery—Case Report and Literature Review
Accepted Manuscript Endovascular coil embolization with LVIS Jr. stent for ruptured dissecting aneurysm of proximal superior cerebellar artery – a case report and literature review Shumpei Onishi, M.D., Shigeyuki Sakamoto, M.D., Ph.D., Takashi Sadatomo, M.D., Ph.D., Takeshi Hara, M.D., Junichiro Ochiai, M.D., Kiyoshi Yuki, M.D., Ph.D., Kaoru Kurisu, M.D., Ph.D. PII:
S1878-8750(18)32435-5
DOI:
https://doi.org/10.1016/j.wneu.2018.10.137
Reference:
WNEU 10581
To appear in:
World Neurosurgery
Received Date: 3 July 2018 Revised Date:
20 October 2018
Accepted Date: 22 October 2018
Please cite this article as: Onishi S, Sakamoto S, Sadatomo T, Hara T, Ochiai J, Yuki K, Kurisu K, Endovascular coil embolization with LVIS Jr. stent for ruptured dissecting aneurysm of proximal superior cerebellar artery – a case report and literature review, World Neurosurgery (2018), doi: https:// doi.org/10.1016/j.wneu.2018.10.137. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Onishi
ACCEPTED MANUSCRIPT
Title: Endovascular coil embolization with LVIS Jr. stent for ruptured dissecting aneurysm of proximal superior cerebellar artery – a case report and literature review
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Shumpei Onishi M.D.1,2*, Shigeyuki Sakamoto M.D., Ph.D.2, Takashi Sadatomo M.D., Ph.D.1, Takeshi Hara M.D.1, Junichiro Ochiai M.D.1, Kiyoshi Yuki M.D., Ph.D.1, Kaoru Kurisu M.D.,
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1
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Ph.D.2
Department of Neurosurgery, Higahsihiroshima Medical Center, 513 Jike, Saijo-cho,
Higashihiroshima-city, Hiroshima, 739-0041, Japan 2
Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima
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University, 1-2-3 Kasumi, Minami-ku, Hiroshima-city, Hiroshima, 734-8551, Japan Department of Neurosurgery, Higahsihiroshima Medical Center, Hiroshima, Japan
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*Corresponding author: Shumpei Onishi
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E-mail address: [email protected] Present Address:
Department of Neurosurgery, Higahsihiroshima Medical Center, 513 Jike, Saijo-cho, Higashihiroshima-city, Hiroshima, 739-0041, Japan Phone: +81-82-423-2176
1
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Abstract BACKGROUND: Superior cerebellar artery (SCA) aneurysm arising from the SCA itself is rare and
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treatment of this aneurysm is challenging because of the important anatomical structures, such as the
perforating arteries to the brainstem and the cranial nerves. We describe a successful coil
SC
embolization with LVIS Jr stent for the proximal SCA dissecting aneurysm.
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CLINICAL DESCRIPTION: A 50-year-old woman presenting right oculomotor nerve palsy and
subarachnoid hemorrhage. Cerebral angiography showed a dissecting wide neck aneurysm at
anterior pontomesencephalic segment of right SCA (diameter 1.0 mm). The patient was treated with
coiling assisted by LVIS Jr stent. Postoperative angiography demonstrated a complete embolized
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aneurysm and a parent artery preservation.
CONCLUSIONS: Endovascular treatment assisted with LVIS Jr stent for proximal SCA dissecting
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aneurysm arising from small parent artery was safely and effectively feasible.
2
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Background Superior cerebellar artery (SCA) aneurysm originating from the SCA itself is rare, reported
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incidence is 0.2% of all intracranial aneurysms.1 Distal SCA aneurysms are commonly treated with parent artery occlusion with coils or liquid materials.2,3 However, treatment of the proximal
SC
SCA aneurysm is challenging because of the important anatomical structures, such as the
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perforating arteries to the brainstem and the cranial nerves.4 Parent artery occlusion may lead to serious complications such as brainstem infarction. In this case, a dissecting SCA aneurysm was located on the proximal side of the SCA, anterior pontmesencephalic segment, from which important perforating arteries arise to the brainstem.5
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Low-profile Visualized Intraluminal Support Junior (LVIS Jr) is a self-expandable braided stent, which can be deployed at a small artery through a 0.017 inch microcatheter. Coil
EP
embolization assisted with LVIS Jr for an aneurysm arising from a small parent artery is
AC C
described as an effective way to reconstruct the parent artery6. We describe the successful coil embolization with LVIS Jr stent for proximal SCA dissecting aneurysm preserving a parent artery and perforating arteries.
Clinical Description A 50-year-old woman presenting a right-sided blepharoptosis and a mydriasis was referred to
3
Onishi
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our department. On examination, she also presented eye movement disorders suggesting a right oculomotor nerve palsy. Fluid-attenuated inversion recovery (FLAIR) magnetic resonance
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image (MRI) showed inter-peduncle hyperintensity legion suggesting subarachnoid hemorrhage (Figure 1). Cerebral angiography showed a dissecting aneurysm (the height was 1.69mm and
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the neck width was 3.45mm) at the anterior pontomesencephalic segment of the right SCA
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(Figure 2A), the diameter of parent artery, SCA, was 1.0 mm.
We planned endovascular stenting and coil embolization for the SCA aneurysm. Before the intervention, loading dose of aspirin (200mg/day) and clopidogrel (300mg/day) were administered.
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Endovascular procedure was performed under general anesthesia. During the procedure the patient received systemic heparinization to achieve an activated clotting time longer than 250 s.
EP
We inserted an 8 F guiding catheter with an inner diameter of 0.090 inches and a length of 90
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cm (Asahi FUBUKI®; Asahi Intecc Co., Ltd., Aichi, Japan ) in the V2 segment of the left vertebral artery through the right femoral artery. A Headway 17 microcatheter (Micro Vention, Inc., CA, USA) for a stent delivery through a TACTICS catheter with an inner diameter of 0.035 inches and a length of 120 cm (Technorat Corporation, Aichi, Japan) was navigated into the distal SCA. An Excelsior XT-17 microcatheter (Stryker, Fremont, CA, USA) for coil delivery was inserted into the aneurysm. A
4
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2.5×17 mm LVIS Jr stent (Micro Vention) was deployed along the anterior pontomesencephalic segment of the SCA. Subsequently the aneurysm was embolized from the Excelsior XT17
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microcatheter with jailing technique.
Complete obliteration was achieved without coil herniation into the SCA. (Figure 2B, C)
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Postoperative MRI diffusion weighted image (DWI) showed asymptomatic scattered
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hyperintensities at the right cerebellar hemisphere not at the brainstem. The patient was in good condition without complications nor new neurological deficit. Cerebral angiography 1 month later showed a completely embolized aneurysm and the parent artery preservation . (Figure 2D) Four months after the endovascular treatment, the levator function had almost recovered to the
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normal range. The eye movement function was gradually improving.
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Discussion
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SCA aneurysms originating from the SCA itself are rare, with reported incidence of 0.2% of all intracranial aneurysms.1 The SCA can be divided into four segments, 1) anterior pontomesencephalic
segment;
2)lateral
pontomesencephalic
segment;
3)
cerebellomesencephalic segment; 4) cortical segment.4 Proximal SCA aneurysms are rarer than distal SCA aneurysms. In this case, the SCA aneurysm was located at anterior pontomesencephalic segment which lies below the oculomotor nerve. The aneurysm was
5
Onishi
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suspected as the cause of oculomotor nerve palsy. And the direct perforating arteries to the brainstem arise from the segment.5 The characteristics of SCA aneurysms, presence of the
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important perforating arteries and the adjacent cranial nerves, make clipping of SCA aneurysm challenging surgery.7
SC
We searched “superior cerebellar artery aneurysm” on PubMed and found 23 case reports and 20 studies from 1996 to 2018 describing endovascular treatment for SCA aneurysm. Some of
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the studies contained basilar artery (BA) - SCA aneurysms8 and described SCA aneurysms without giving precise anatomical details. Excluding distal SCA aneurysms, BA-SCA aneurysms and ambiguous location aneurysms, only 3 cases of SCA aneurysms arising from
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proximal segment (anterior pontomesencephalic and proximal lateral pontomesencephalic segment) were found. They were treated by endovascular approach with coil embolization9,10 or
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only coronary stent deployment11. (Table 1) None of them were treated with coiling assisted by
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stents for the proximal segment of SCA aneurysm. Owing to the presence of perforators to the brain stem, preservation of the parent artery is a more important issue in treatment of the proximal SCA aneurysm than that of the distal SCA aneurysm. We also identified 7 cases of treatment for SCA aneurysms using stents; 2 cases of Neuroform stent12, 2 cases of Enterprise stent13, 1 case of Belocity (coronary stent) (Cordis) 11, 1 case of Leo Baby braided stent (Balt, Montmelo, France)
14
, 1 case of LVIS stent15 and the other case
6
Onishi
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without details8. In our case, we selected LVIS Jr stent delivery system which is a low-profile self-expanding,
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closed-cell, braided nitinol wires stent. It can be deployed in small intracranial arteries through a 0.017-in microcatheter and has advantages for the endovascular treatment of aneurysms with
SC
small parent arteries. The LVIS Jr stent is approved for wide-neck intracranial aneurysm. The
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pivotal US LVIS trial revealed the safety and effectiveness of coil embolization with LVIS stent for wide-necked cerebral aneurysm. In the study, the mean neck width was 4.2±1.4 mm and the aneurysms were treated with high occlusion rate and low recurrence rate.15 In our case, the wide neck aneurysm was completely embolized with LVIS Jr stent. In addition, the LVIS Jr stent is
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recommended for the parent artery from 2.0 to 3.5 mm.16 A previous study reported that coiling for ruptured and unruptured aneurysms arising from small arteries, mean parent arteries were 17
The stents can be safely deployed in parent artery less
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2.2 mm (range from 0.9 to 2.5 mm).
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than 2.0 mm, most of them were in the anterior circulation. In another report, posterior cerebellar artery (PICA) aneurysm case series described that coiling of aneurysm arising from PICA assisted with LVIS Jr was also safely feasible.6 In our case, the diameter of the parent artery (SCA) was 1.0 mm, the LVIS Jr stent was easily navigated and deployed preserving the parent artery. Braided stents (LVIS (Micro Vention, CA, USA) and LEO (Balt, Montmorency, France)) had
7
Onishi
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higher pore densities and metal coverage than laser cut stents (Neuroform (Stryker, MI, USA) and Enterprise (Codman, MA, USA)).18 Based on computational fluid dynamics modeling,
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self-expandable braided type stents provide higher metal coverage rate and dedicate to flow diverting effect than laser cut type stents.19 In this case, due to the characteristics of
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without infarction at territories of the perforating arteries.
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self-expandable braided stents, LVIS Jr may have dedicated to complete occlusion of aneurysms
Conclusion
We reported a case of proximal SCA dissecting aneurysm with endovascular treatment
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preserving the parent and perforating arteries. Coil embolization assisted with LVIS Jr in a small
1.
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References
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parent artery is safely and effectively feasible.
Locksley HB. SECTION V, PART I: Natural History of Subarachnoid Hemorrhage,
Intracranial Aneurysms and Arteriovenous Malformations. Journal of Neurosurgery.
1966;25:219-239.
2.
Lubicz B, Leclerc X, Gauvrit J-Y, Lejeune J-P, Pruvo J-P. Endovascular treatment of
peripheral cerebellar artery aneurysms. American Journal of Neuroradiology. 2003;24:1208-1213.
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3.
Leonardi M, Simonetti L, Andreoli A. Endovascular treatment of a distal aneurysm of the
superior cerebellar artery by intra-aneurysmal injection of glue. Interv Neuroradiol. 2001;7:343-348.
Hardy DG, Peace DA, Rhoton AL. Microsurgical anatomy of the superior cerebellar artery.
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4.
Neurosurgery. 1980;6:10-28.
Garcia-Gonzalez U, Cavalcanti DD, Agrawal A, Spetzler RF, Preul MC. Anatomical study
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5.
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on the “perforator-free zone”: reconsidering the proximal superior cerebellar artery and basilar artery
perforators. Neurosurgery. 2012;70(3):764–72–discussion771–2.
6.
Samaniego EA, Abdo G, Hanel RA, Lima A, Ortega-Gutierrez S, Dabus G. Endovascular
treatment of PICA aneurysms with a Low-profile Visualized Intraluminal Support (LVIS Jr) device.
7.
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J NeuroIntervent Surg. 2016;8:1030-1033.
Atalay B, Altinors N, Yilmaz C, Caner H, Ozger O. Fusiform aneurysm of the superior
Patra DP, Bir SC, Maiti TK, et al. Superior Cerebellar Artery Aneurysms, the “Sui Generis”
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8.
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cerebellar artery: short review article. Acta Neurochir (Wien). 2007;149:291–294.
in Posterior Circulation: The Role of Microsurgery in the Endovascular Era. World Neurosurg.
2016;94:229-238.
9.
Chaloupka JC, Putman CM, Awad IA. Endovascular therapeutic approach to peripheral
aneurysms of the superior cerebellar artery. American Journal of Neuroradiology.
1996;17:1338-1342.
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10.
Gotoh H, Takahashi T, Shimizu H, Ezura M, Tominaga T. Dissection of the superior
cerebellar artery: a report of two cases and review of the literature. Journal of Clinical Neuroscience.
11.
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2004;11(2):196-199.
Zenteno M, Santos-Franco J, Aburto-Murrieta Y, et al. Superior cerebellar artery aneurysms
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treated using the sole stenting approach. Technical note. Journal of Neurosurgery.
12.
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2007;107:860-864.
Pandey AS, Koebbe C, Rosenwasser RH, Veznedaroglu E. Endovascular coil embolization
of ruptured and unruptured posterior circulation aneurysms: review of a 10-year experience.
Neurosurgery. 2007;60(4):626–36–discussion636–7.
Rho MH, Park HJ, Chung EC, et al. Various techniques of stent-assisted coil embolization of
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13.
wide-necked or fusiform artherosclerotic and dissecting unruptured vertebrobasilar artery aneurysms
Di Stefano G, Limbucci N, Cruccu G, Renieri L, Truini A, Mangiafico S. Trigeminal
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14.
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for reducing recanalization: mid-term results. Acta Neurochir (Wien). 2013;155(11):2009-2017.
Neuralgia Completely Relieved After Stent-Assisted Coiling of a Superior Cerebellar Artery
Aneurysm. World Neurosurg. 2017;101:812.e5-812.e9.
15.
Fiorella D, Boulos A, Turk AS, et al. J NeuroIntervent Surg Epub ahead of print: 8 October
2018. doi:10.1136/ neurintsurg-2018-014309
16.
Cho YD, Sohn C-H, Kang H-S, et al. Coil embolization of intracranial saccular aneurysms
10
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using the Low-profile Visualized Intraluminal Support (LVIS™) device. Neuroradiology.
2014;56:543-551.
Santillan A, Boddu S, Schwarz J, et al. LVIS Jr. stent for treatment of intracranial aneurysms
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17.
with parent vessel diameter of 2.5 mm or less. Interv Neuroradiol. 2018;24:246-253.
Cho S-H, Jo W-I, Jo Y-E, Yang KH, Park JC, Lee DH. Bench-top Comparison of Physical
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18.
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Properties of 4 Commercially-Available Self-Expanding Intracranial Stents. Neurointervention.
2017;12(1):31-39.
19.
Wang C, Tian Z, Liu J, et al. Flow diverter effect of LVIS stent on cerebral aneurysm
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2016;14:199.
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hemodynamics: a comparison with Enterprise stents and the Pipeline device. J Transl Med.
11
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Figure 1: Fluid-attenuated inversion recovery magnetic resonance image showed inter-peduncle hyperintensity suggesting subarachnoid hemorrhage.
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Figure 2: Left vertebral angiography showed a wide-necked aneurysm at anterior
pontomesencephalic segment of the superior cerebellar artery (A). Image acquired after
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deployment stent and coil embolization (B). Final angiography showed complete occlusion of
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the aneurysm and preservation of the parent artery (C). One month follow-up angiography showed persistent occlusion of the aneurysm with the parent artery preservation (D). The
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proximal and distal markers of the LVIS Jr stent is indicated with white arrows. (B, C, D)
12
ACCEPTED MANUSCRIPT Age/ Authors gender Chaloupka, et al. (1996)9
Clinical
Endovascular
manifestation
treatment
SAH
Site
SCA
Outcome
SCA occlusion
occlusion
MD
proximal 40M lat. pont. seg. 45M
ant. pont. seg.
SAH
SCA occlusion
occlusion
GR
Zenteno, et al. (2007)11
35M
ant. pont. seg.
SAH
Stent deployment
preservation
GR
Present case
50F
ant. pont. seg.
SAH
preservation
GR
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Gotoh, et al. (2004)10
stent assisted coiling
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lat. pont. seg., lateral pontomesencephalic segment; ant. pont. seg., anterior pontomesencephalic segment; SAH,
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subarachnoid hemorrhage; PAO, parent artery occlusion; MD, moderate disability; GR, good recovery.
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Abbreviations: Superior cerebellar artery (SCA) Low-profile Visualized Intraluminal Support Junior (LVIS Jr) Fluid-attenuated inversion recovery (FLAIR)
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Magnetic resonance image (MRI)
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basilar artery (BA)
S1878-8750(18)32435-5
DOI:
https://doi.org/10.1016/j.wneu.2018.10.137
Reference:
WNEU 10581
To appear in:
World Neurosurgery
Received Date: 3 July 2018 Revised Date:
20 October 2018
Accepted Date: 22 October 2018
Please cite this article as: Onishi S, Sakamoto S, Sadatomo T, Hara T, Ochiai J, Yuki K, Kurisu K, Endovascular coil embolization with LVIS Jr. stent for ruptured dissecting aneurysm of proximal superior cerebellar artery – a case report and literature review, World Neurosurgery (2018), doi: https:// doi.org/10.1016/j.wneu.2018.10.137. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Onishi
ACCEPTED MANUSCRIPT
Title: Endovascular coil embolization with LVIS Jr. stent for ruptured dissecting aneurysm of proximal superior cerebellar artery – a case report and literature review
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Shumpei Onishi M.D.1,2*, Shigeyuki Sakamoto M.D., Ph.D.2, Takashi Sadatomo M.D., Ph.D.1, Takeshi Hara M.D.1, Junichiro Ochiai M.D.1, Kiyoshi Yuki M.D., Ph.D.1, Kaoru Kurisu M.D.,
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1
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Ph.D.2
Department of Neurosurgery, Higahsihiroshima Medical Center, 513 Jike, Saijo-cho,
Higashihiroshima-city, Hiroshima, 739-0041, Japan 2
Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima
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University, 1-2-3 Kasumi, Minami-ku, Hiroshima-city, Hiroshima, 734-8551, Japan Department of Neurosurgery, Higahsihiroshima Medical Center, Hiroshima, Japan
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*Corresponding author: Shumpei Onishi
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E-mail address: [email protected] Present Address:
Department of Neurosurgery, Higahsihiroshima Medical Center, 513 Jike, Saijo-cho, Higashihiroshima-city, Hiroshima, 739-0041, Japan Phone: +81-82-423-2176
1
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Abstract BACKGROUND: Superior cerebellar artery (SCA) aneurysm arising from the SCA itself is rare and
RI PT
treatment of this aneurysm is challenging because of the important anatomical structures, such as the
perforating arteries to the brainstem and the cranial nerves. We describe a successful coil
SC
embolization with LVIS Jr stent for the proximal SCA dissecting aneurysm.
M AN U
CLINICAL DESCRIPTION: A 50-year-old woman presenting right oculomotor nerve palsy and
subarachnoid hemorrhage. Cerebral angiography showed a dissecting wide neck aneurysm at
anterior pontomesencephalic segment of right SCA (diameter 1.0 mm). The patient was treated with
coiling assisted by LVIS Jr stent. Postoperative angiography demonstrated a complete embolized
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aneurysm and a parent artery preservation.
CONCLUSIONS: Endovascular treatment assisted with LVIS Jr stent for proximal SCA dissecting
AC C
EP
aneurysm arising from small parent artery was safely and effectively feasible.
2
Onishi
ACCEPTED MANUSCRIPT
Background Superior cerebellar artery (SCA) aneurysm originating from the SCA itself is rare, reported
RI PT
incidence is 0.2% of all intracranial aneurysms.1 Distal SCA aneurysms are commonly treated with parent artery occlusion with coils or liquid materials.2,3 However, treatment of the proximal
SC
SCA aneurysm is challenging because of the important anatomical structures, such as the
M AN U
perforating arteries to the brainstem and the cranial nerves.4 Parent artery occlusion may lead to serious complications such as brainstem infarction. In this case, a dissecting SCA aneurysm was located on the proximal side of the SCA, anterior pontmesencephalic segment, from which important perforating arteries arise to the brainstem.5
TE D
Low-profile Visualized Intraluminal Support Junior (LVIS Jr) is a self-expandable braided stent, which can be deployed at a small artery through a 0.017 inch microcatheter. Coil
EP
embolization assisted with LVIS Jr for an aneurysm arising from a small parent artery is
AC C
described as an effective way to reconstruct the parent artery6. We describe the successful coil embolization with LVIS Jr stent for proximal SCA dissecting aneurysm preserving a parent artery and perforating arteries.
Clinical Description A 50-year-old woman presenting a right-sided blepharoptosis and a mydriasis was referred to
3
Onishi
ACCEPTED MANUSCRIPT
our department. On examination, she also presented eye movement disorders suggesting a right oculomotor nerve palsy. Fluid-attenuated inversion recovery (FLAIR) magnetic resonance
RI PT
image (MRI) showed inter-peduncle hyperintensity legion suggesting subarachnoid hemorrhage (Figure 1). Cerebral angiography showed a dissecting aneurysm (the height was 1.69mm and
SC
the neck width was 3.45mm) at the anterior pontomesencephalic segment of the right SCA
M AN U
(Figure 2A), the diameter of parent artery, SCA, was 1.0 mm.
We planned endovascular stenting and coil embolization for the SCA aneurysm. Before the intervention, loading dose of aspirin (200mg/day) and clopidogrel (300mg/day) were administered.
TE D
Endovascular procedure was performed under general anesthesia. During the procedure the patient received systemic heparinization to achieve an activated clotting time longer than 250 s.
EP
We inserted an 8 F guiding catheter with an inner diameter of 0.090 inches and a length of 90
AC C
cm (Asahi FUBUKI®; Asahi Intecc Co., Ltd., Aichi, Japan ) in the V2 segment of the left vertebral artery through the right femoral artery. A Headway 17 microcatheter (Micro Vention, Inc., CA, USA) for a stent delivery through a TACTICS catheter with an inner diameter of 0.035 inches and a length of 120 cm (Technorat Corporation, Aichi, Japan) was navigated into the distal SCA. An Excelsior XT-17 microcatheter (Stryker, Fremont, CA, USA) for coil delivery was inserted into the aneurysm. A
4
Onishi
ACCEPTED MANUSCRIPT
2.5×17 mm LVIS Jr stent (Micro Vention) was deployed along the anterior pontomesencephalic segment of the SCA. Subsequently the aneurysm was embolized from the Excelsior XT17
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microcatheter with jailing technique.
Complete obliteration was achieved without coil herniation into the SCA. (Figure 2B, C)
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Postoperative MRI diffusion weighted image (DWI) showed asymptomatic scattered
M AN U
hyperintensities at the right cerebellar hemisphere not at the brainstem. The patient was in good condition without complications nor new neurological deficit. Cerebral angiography 1 month later showed a completely embolized aneurysm and the parent artery preservation . (Figure 2D) Four months after the endovascular treatment, the levator function had almost recovered to the
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normal range. The eye movement function was gradually improving.
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Discussion
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SCA aneurysms originating from the SCA itself are rare, with reported incidence of 0.2% of all intracranial aneurysms.1 The SCA can be divided into four segments, 1) anterior pontomesencephalic
segment;
2)lateral
pontomesencephalic
segment;
3)
cerebellomesencephalic segment; 4) cortical segment.4 Proximal SCA aneurysms are rarer than distal SCA aneurysms. In this case, the SCA aneurysm was located at anterior pontomesencephalic segment which lies below the oculomotor nerve. The aneurysm was
5
Onishi
ACCEPTED MANUSCRIPT
suspected as the cause of oculomotor nerve palsy. And the direct perforating arteries to the brainstem arise from the segment.5 The characteristics of SCA aneurysms, presence of the
RI PT
important perforating arteries and the adjacent cranial nerves, make clipping of SCA aneurysm challenging surgery.7
SC
We searched “superior cerebellar artery aneurysm” on PubMed and found 23 case reports and 20 studies from 1996 to 2018 describing endovascular treatment for SCA aneurysm. Some of
M AN U
the studies contained basilar artery (BA) - SCA aneurysms8 and described SCA aneurysms without giving precise anatomical details. Excluding distal SCA aneurysms, BA-SCA aneurysms and ambiguous location aneurysms, only 3 cases of SCA aneurysms arising from
TE D
proximal segment (anterior pontomesencephalic and proximal lateral pontomesencephalic segment) were found. They were treated by endovascular approach with coil embolization9,10 or
EP
only coronary stent deployment11. (Table 1) None of them were treated with coiling assisted by
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stents for the proximal segment of SCA aneurysm. Owing to the presence of perforators to the brain stem, preservation of the parent artery is a more important issue in treatment of the proximal SCA aneurysm than that of the distal SCA aneurysm. We also identified 7 cases of treatment for SCA aneurysms using stents; 2 cases of Neuroform stent12, 2 cases of Enterprise stent13, 1 case of Belocity (coronary stent) (Cordis) 11, 1 case of Leo Baby braided stent (Balt, Montmelo, France)
14
, 1 case of LVIS stent15 and the other case
6
Onishi
ACCEPTED MANUSCRIPT
without details8. In our case, we selected LVIS Jr stent delivery system which is a low-profile self-expanding,
RI PT
closed-cell, braided nitinol wires stent. It can be deployed in small intracranial arteries through a 0.017-in microcatheter and has advantages for the endovascular treatment of aneurysms with
SC
small parent arteries. The LVIS Jr stent is approved for wide-neck intracranial aneurysm. The
M AN U
pivotal US LVIS trial revealed the safety and effectiveness of coil embolization with LVIS stent for wide-necked cerebral aneurysm. In the study, the mean neck width was 4.2±1.4 mm and the aneurysms were treated with high occlusion rate and low recurrence rate.15 In our case, the wide neck aneurysm was completely embolized with LVIS Jr stent. In addition, the LVIS Jr stent is
TE D
recommended for the parent artery from 2.0 to 3.5 mm.16 A previous study reported that coiling for ruptured and unruptured aneurysms arising from small arteries, mean parent arteries were 17
The stents can be safely deployed in parent artery less
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2.2 mm (range from 0.9 to 2.5 mm).
AC C
than 2.0 mm, most of them were in the anterior circulation. In another report, posterior cerebellar artery (PICA) aneurysm case series described that coiling of aneurysm arising from PICA assisted with LVIS Jr was also safely feasible.6 In our case, the diameter of the parent artery (SCA) was 1.0 mm, the LVIS Jr stent was easily navigated and deployed preserving the parent artery. Braided stents (LVIS (Micro Vention, CA, USA) and LEO (Balt, Montmorency, France)) had
7
Onishi
ACCEPTED MANUSCRIPT
higher pore densities and metal coverage than laser cut stents (Neuroform (Stryker, MI, USA) and Enterprise (Codman, MA, USA)).18 Based on computational fluid dynamics modeling,
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self-expandable braided type stents provide higher metal coverage rate and dedicate to flow diverting effect than laser cut type stents.19 In this case, due to the characteristics of
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without infarction at territories of the perforating arteries.
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self-expandable braided stents, LVIS Jr may have dedicated to complete occlusion of aneurysms
Conclusion
We reported a case of proximal SCA dissecting aneurysm with endovascular treatment
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preserving the parent and perforating arteries. Coil embolization assisted with LVIS Jr in a small
1.
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References
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Figure 1: Fluid-attenuated inversion recovery magnetic resonance image showed inter-peduncle hyperintensity suggesting subarachnoid hemorrhage.
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Figure 2: Left vertebral angiography showed a wide-necked aneurysm at anterior
pontomesencephalic segment of the superior cerebellar artery (A). Image acquired after
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deployment stent and coil embolization (B). Final angiography showed complete occlusion of
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the aneurysm and preservation of the parent artery (C). One month follow-up angiography showed persistent occlusion of the aneurysm with the parent artery preservation (D). The
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proximal and distal markers of the LVIS Jr stent is indicated with white arrows. (B, C, D)
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Clinical
Endovascular
manifestation
treatment
SAH
Site
SCA
Outcome
SCA occlusion
occlusion
MD
proximal 40M lat. pont. seg. 45M
ant. pont. seg.
SAH
SCA occlusion
occlusion
GR
Zenteno, et al. (2007)11
35M
ant. pont. seg.
SAH
Stent deployment
preservation
GR
Present case
50F
ant. pont. seg.
SAH
preservation
GR
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Gotoh, et al. (2004)10
stent assisted coiling
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lat. pont. seg., lateral pontomesencephalic segment; ant. pont. seg., anterior pontomesencephalic segment; SAH,
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subarachnoid hemorrhage; PAO, parent artery occlusion; MD, moderate disability; GR, good recovery.
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Abbreviations: Superior cerebellar artery (SCA) Low-profile Visualized Intraluminal Support Junior (LVIS Jr) Fluid-attenuated inversion recovery (FLAIR)
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Magnetic resonance image (MRI)
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basilar artery (BA)