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Flow-Diverter Stent for an Unruptured Aneurysm at the Junction of the Internal Carotid Artery and Persistent Primitive Trigeminal Artery: Case Report and Literature Review
Case Report
Flow-Diverter Stent for an Unruptured Aneurysm at the Junction of the Internal Carotid Artery and Persistent Primitive Trigeminal Artery: Case Report and Literature Review Hirotaka Sato, Koichi Haraguchi, Yashuhiro Takahashi, Shunya Ohtaki, Tadakazu Shimizu, Nobuyuki Matsuura, Kazumi Ogane, Takeo Ito
Key words Flow-diverter stent - Internal carotid artery - Persistent primitive trigeminal artery aneurysm - Selective coil embolization -
Abbreviations and Acronyms BA: Basilar artery CTA: Computed tomography angiography DSA: Digital subtraction angiography ICA: Internal carotid artery PPTA: Persistent primitive trigeminal artery Department of Neurosurgery, Hakodate Shintoshi Hospital, Hakodate, Japan To whom correspondence should be addressed: Hirotaka Sato, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 132:329-332. https://doi.org/10.1016/j.wneu.2019.08.199 Journal homepage: www.journals.elsevier.com/worldneurosurgery
- BACKGROUND:
Persistent primitive trigeminal artery (PPTA), which is a fetal carotid-basilar anastomosis, is the most common embryologic vascular remnant persisting in adults. Aneurysms can arise between the internal carotid artery (ICA) and PPTA. Here we present a case of ICA-PPTA aneurysm treated with a flow-diverter stent.
- CASE
DESCRIPTION: A 52-year-old woman had left abducens nerve palsy. Imaging detected a large left ICA-PPTA aneurysm, which we chose to treat with a flow-diverter stent after embolizing the PPTA with a coil. Although the abducens nerve palsy did not change, there were no signs of cerebral infarction, and no new symptoms appeared postoperatively. Blood flow in the aneurysm had disappeared on digital subtraction angiography after 6 months.
- CONCLUSIONS:
This is the first case report of ICA-PPTA aneurysm successfully treated with a flow-diverter stent. We could stop blood flow from the posterior circulation by embolizing the PPTA with a coil, allowing the use of a flow-diverter stent. This report can be used as a reference for the procedure in future work.
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
INTRODUCTION Persistent primitive trigeminal artery (PPTA), a fetal carotid-basilar anastomosis, is the most common embryologic vascular remnant persisting in adults.1 Aneurysms can arise between the internal carotid artery (ICA) and a PPTA.1-4 Recently, ICA aneurysms have been treated with a flow-diverter stent. Here we present the first report of a case of an ICA-PPTA aneurysm treated with a flowdiverter stent. This report could serve as a reference for the procedure in the future. CASE PRESENTATION A 52-year-old woman presented to another hospital with a complaint of double vison. Left abducens nerve palsy and a left ICA aneurysm were detected, and she was referred to our hospital. She had a family history of subarachnoid hemorrhage.
Computed tomography angiography revealed a large aneurysm (dome, 15.8 mm; neck, 15.5 mm; height, 9.4 mm) in the cavernous segment of the left ICA, and a PPTA branched in the neck (Figure 1AeD). The PPTA was connected with the basilar artery (BA). We planned treatment with a flow-diverter stent. Unless cerebral blood flow from the PPTA is stopped, the success rate of treatment would be low even with a flowdiverter stent. Therefore, we performed a balloon occlusion test to determine whether the PPTA could be embolized. We performed this procedure given a previous report about penetrating branches from the PPTA to the brainstem.5 We considered the possibility of symptoms when the blood flow was stopped from the ICA. We placed an 8-F Optimo balloon catheter (Tokai Medical Products, Aichi, Japan) proximal to the aneurysm and a 4 15-mm HyperGlide catheter (Medtronic, Minneapolis, Minnesota, USA) distal to the aneurysm. Both
WORLD NEUROSURGERY 132: 329-332, DECEMBER 2019
balloon catheters were inflated, and the ICA was blocked proximal and distal to the aneurysm. We confirmed the appearance of neurological brainstem symptoms but could not recognize them. We concluded that the PPTA could be embolized. Under general anesthesia, a microcatheter was inserted in the PPTA. To reduce the risk for brain stem infarction, we selectively embolized the ICA side of the PPTA (Figure 2A and B). Because selective coiling was possible, we successfully blocked the connection between the aneurysm and PPTA (Figure 2C). The patient exhibited no new neurologic deficits or cerebral infarction postoperatively. She was discharged from the hospital with a plan for treatment with a flow-diverter stent 1 month later. The staged treatment was provided because of insurance issues. At 1 month after embolization of the PPTA, treatment with a flow-diverter stent
www.journals.elsevier.com/world-neurosurgery
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CASE REPORT HIROTAKA SATO ET AL.
FLOW-DIVERTER STENT FOR ANEURYSM
Figure 1. (A) Computed tomography angiography image showing a large aneurysm in the cavernous segment of the left internal carotid artery (ICA) and persistent primitive trigeminal artery (PPTA) branching from the neck. (B) The PPTA (arrow) and the basilar artery (BA; arrowhead). (C) The PPTA branching from the
was performed. We used a 6-Fr guiding sheath (Flexor Shuttle Select, 90 cm; Cook Medical, Bloomington, Indiana, USA) and placed a 5-Fr Navien catheter (Medtronic) in the ICA. We then placed a microcatheter (Marksman; Medtronic) distal to the aneurysm, from which a 4.75 16-mm Pipeline Flex catheter (Medtronic) was placed to cover the neck of the aneurysm. The eclipse sign was recognized on digital subtraction angiography (DSA) (Figure 3B) immediately after placement of the flow-diverter stent (Figure 3C). There were no signs of cerebral infarction postoperatively. Although the
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neck of the aneurysm (arrow). The PPTA is connected with the BA. The arrowhead indicates the ICA. (D) The aneurysm has a dome size of 15.8 mm, a neck size of 15.5 mm, and a height of 9. 2 mm.
patient’s abducens nerve palsy persisted, she was discharged without any new symptoms. We confirmed disappearance of the blood flow in the aneurysm on DSA after 6 months (Figure 3D). DISCUSSION The present case had 2 clinical issues. First, the likelihood of successful treatment with a flow-diverter stent was low, because the PPTA branched from the ICA-PPTA aneurysm. Cases of embolization of the ICA-PPTA aneurysm including the PPTA have been
reported.3,4 Therefore, the selective embolization of the PPTA in this case is noteworthy. Embolizing the PPTA made this case similar to that of a large cavernous aneurysm. Ishikawa et al.1 classified the treatment strategies for large or giant cavernous aneurysms associated with PPTA into 4 types. In type 4, a flow-diverter stent is used. Chen et al.2 reported a case of giant thrombosed PPTA aneurysm treated with a covered stent. However, in treatment type 4, the PPTA is not embolized. The success rate of treatment could increase by embolizing the PPTA, as was done in our
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.199
CASE REPORT HIROTAKA SATO ET AL.
FLOW-DIVERTER STENT FOR ANEURYSM
Figure 2. Digital subtraction angiography images after embolization of a persistent primitive trigeminal artery (PPTA). (A) The PPTA (arrow). (B)
case. Treatment types 1e3 involve stopping inflow from the PPTA, and thus
Selective embolization of the PPTA with a coil. (C) The PPTA is not drawn.
inflow from the PPTA should be stopped in treatment type 4.
Figure 3. Digital subtraction angiography (DSA) images of treatment with a flow-diverter stent (FDS). (A) DSA image before placement of the FDS. (B) The FDS in place (arrowhead). (C) Eclipse sign. (D) Absence of blood flow in the aneurysm at 6 months after stent placement.
WORLD NEUROSURGERY 132: 329-332, DECEMBER 2019
Second, whether it is always possible to embolize PPTA is speculative. Salas et al.5 described an interesting classification of PTA variations: lateral petrosal and medial sphenoid. Lateral variation occurs when the PPTA is lateral to the abducens nerve and pierces the dura medial to the sensitive root of the trigeminal nerve. Medial sphenoid variation occurs when the PPTA courses medial to the abducens nerve and pierces the clival dura toward the BA. The lateral variation gives rise to perforating branches to the pons, and oculomotor nerve palsy, trigeminal neuralgia, and abducens nerve palsy might result from lateral PPTA.5,6 Because the present case was a lateral petrosal variation, brainstem infarction could not be ruled out. Therefore, embolization after confirming the presence of symptoms in the balloon occlusion test is important. Weon et al.7 reported that cases of vertebral artery hypoplasia and BA dependence on blood flow from a PPTA are at high risk for infarction. In the present case, the possibility of brain stem infarction might have been low, because the vertebral artery was not hypoplastic and the BA was not dependent on blood flow from the PPTA. In other words, the risk for infarction might not have been high. However, the balloon occlusion test could be important in cases of embolization of PPTA, even when the patient is at a low risk for brainstem infarction. In this operation, we wanted
www.journals.elsevier.com/world-neurosurgery
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CASE REPORT HIROTAKA SATO ET AL.
to embolize only the PPTA on the side of the ICA to minimize risk; therefore, the embolization was performed before stent placement because of the ease of access from the side of the ICA. We were able to treat ICA-PPTA aneurysm with a flow-diverter stent. However, the long-term outcomes of treating ICAPPTA aneurysms with a flow-diverter stent has not been reported. Similar cases should be studied and reported in the future. CONCLUSIONS This is the first case report of ICA-PPTA aneurysm successfully treated with a flow-diverter stent. Embolization of PPTA has been suggested to improve the success rate. Moreover, the complication rate can be lowered by paying attention to the anatomic features and performing the balloon occlusion test. This report can
332
www.SCIENCEDIRECT.com
FLOW-DIVERTER STENT FOR ANEURYSM
serve as a reference for this procedure in the future.
5. Salas E, Ziyal IM, Sekhar LN, Wright DC. Persistent trigeminal artery: an anatomic study. Neurosurgery. 1998;43:557-561 [discussion: 561-562].
REFERENCES
6. Kim MJ, Kim MS. Persistent primitive trigeminal artery: analysis of anatomical characteristics and clinical significances. Surg Radiol Anat. 2015;37: 69-74.
1. Ishikawa T, Yamaguchi K, Anami H, Sumi M, Ishikawa T, Kawamata T. Treatment of large or giant cavernous aneurysm associated with persistent trigeminal artery: case report and review of literature. World Neurosurg. 2017;108: 996.e11-996.e15. 2. Chen WH, Tsai TH, Shen SC, Shen CC, Tsuei YS. A case of giant thrombosed persistent primitive trigeminal artery aneurysm presenting with trigeminal neuralgia and successfully treated by a covered stent: case report and review of literature. Clin Neuroradiol. 2015;25:207-210. 3. Li MH, Li WB, Pan YP, Fang C, Wang W. Persistent primitive trigeminal artery associated with aneurysm: report of two cases and review of the literature. Acta Radiol. 2004;45:664-668. 4. Zhang CW, Xie XD, Yang ZG, et al. Giant cavernous aneurysm associated with a persistent trigeminal artery and persistent otic artery. Korean J Radiol. 2009;10:519-522.
7. Weon YC, Choi SH, Hwang JC, Shin SH, Kwon WJ, Kang BS. Classification of persistent primitive trigeminal artery (PPTA): a reconsideration based on MRA. Acta Radiol. 2011;52:1043-1051.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 31 July 2019; accepted 24 August 2019 Citation: World Neurosurg. (2019) 132:329-332. https://doi.org/10.1016/j.wneu.2019.08.199 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.199
Flow-Diverter Stent for an Unruptured Aneurysm at the Junction of the Internal Carotid Artery and Persistent Primitive Trigeminal Artery: Case Report and Literature Review Hirotaka Sato, Koichi Haraguchi, Yashuhiro Takahashi, Shunya Ohtaki, Tadakazu Shimizu, Nobuyuki Matsuura, Kazumi Ogane, Takeo Ito
Key words Flow-diverter stent - Internal carotid artery - Persistent primitive trigeminal artery aneurysm - Selective coil embolization -
Abbreviations and Acronyms BA: Basilar artery CTA: Computed tomography angiography DSA: Digital subtraction angiography ICA: Internal carotid artery PPTA: Persistent primitive trigeminal artery Department of Neurosurgery, Hakodate Shintoshi Hospital, Hakodate, Japan To whom correspondence should be addressed: Hirotaka Sato, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 132:329-332. https://doi.org/10.1016/j.wneu.2019.08.199 Journal homepage: www.journals.elsevier.com/worldneurosurgery
- BACKGROUND:
Persistent primitive trigeminal artery (PPTA), which is a fetal carotid-basilar anastomosis, is the most common embryologic vascular remnant persisting in adults. Aneurysms can arise between the internal carotid artery (ICA) and PPTA. Here we present a case of ICA-PPTA aneurysm treated with a flow-diverter stent.
- CASE
DESCRIPTION: A 52-year-old woman had left abducens nerve palsy. Imaging detected a large left ICA-PPTA aneurysm, which we chose to treat with a flow-diverter stent after embolizing the PPTA with a coil. Although the abducens nerve palsy did not change, there were no signs of cerebral infarction, and no new symptoms appeared postoperatively. Blood flow in the aneurysm had disappeared on digital subtraction angiography after 6 months.
- CONCLUSIONS:
This is the first case report of ICA-PPTA aneurysm successfully treated with a flow-diverter stent. We could stop blood flow from the posterior circulation by embolizing the PPTA with a coil, allowing the use of a flow-diverter stent. This report can be used as a reference for the procedure in future work.
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
INTRODUCTION Persistent primitive trigeminal artery (PPTA), a fetal carotid-basilar anastomosis, is the most common embryologic vascular remnant persisting in adults.1 Aneurysms can arise between the internal carotid artery (ICA) and a PPTA.1-4 Recently, ICA aneurysms have been treated with a flow-diverter stent. Here we present the first report of a case of an ICA-PPTA aneurysm treated with a flowdiverter stent. This report could serve as a reference for the procedure in the future. CASE PRESENTATION A 52-year-old woman presented to another hospital with a complaint of double vison. Left abducens nerve palsy and a left ICA aneurysm were detected, and she was referred to our hospital. She had a family history of subarachnoid hemorrhage.
Computed tomography angiography revealed a large aneurysm (dome, 15.8 mm; neck, 15.5 mm; height, 9.4 mm) in the cavernous segment of the left ICA, and a PPTA branched in the neck (Figure 1AeD). The PPTA was connected with the basilar artery (BA). We planned treatment with a flow-diverter stent. Unless cerebral blood flow from the PPTA is stopped, the success rate of treatment would be low even with a flowdiverter stent. Therefore, we performed a balloon occlusion test to determine whether the PPTA could be embolized. We performed this procedure given a previous report about penetrating branches from the PPTA to the brainstem.5 We considered the possibility of symptoms when the blood flow was stopped from the ICA. We placed an 8-F Optimo balloon catheter (Tokai Medical Products, Aichi, Japan) proximal to the aneurysm and a 4 15-mm HyperGlide catheter (Medtronic, Minneapolis, Minnesota, USA) distal to the aneurysm. Both
WORLD NEUROSURGERY 132: 329-332, DECEMBER 2019
balloon catheters were inflated, and the ICA was blocked proximal and distal to the aneurysm. We confirmed the appearance of neurological brainstem symptoms but could not recognize them. We concluded that the PPTA could be embolized. Under general anesthesia, a microcatheter was inserted in the PPTA. To reduce the risk for brain stem infarction, we selectively embolized the ICA side of the PPTA (Figure 2A and B). Because selective coiling was possible, we successfully blocked the connection between the aneurysm and PPTA (Figure 2C). The patient exhibited no new neurologic deficits or cerebral infarction postoperatively. She was discharged from the hospital with a plan for treatment with a flow-diverter stent 1 month later. The staged treatment was provided because of insurance issues. At 1 month after embolization of the PPTA, treatment with a flow-diverter stent
www.journals.elsevier.com/world-neurosurgery
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CASE REPORT HIROTAKA SATO ET AL.
FLOW-DIVERTER STENT FOR ANEURYSM
Figure 1. (A) Computed tomography angiography image showing a large aneurysm in the cavernous segment of the left internal carotid artery (ICA) and persistent primitive trigeminal artery (PPTA) branching from the neck. (B) The PPTA (arrow) and the basilar artery (BA; arrowhead). (C) The PPTA branching from the
was performed. We used a 6-Fr guiding sheath (Flexor Shuttle Select, 90 cm; Cook Medical, Bloomington, Indiana, USA) and placed a 5-Fr Navien catheter (Medtronic) in the ICA. We then placed a microcatheter (Marksman; Medtronic) distal to the aneurysm, from which a 4.75 16-mm Pipeline Flex catheter (Medtronic) was placed to cover the neck of the aneurysm. The eclipse sign was recognized on digital subtraction angiography (DSA) (Figure 3B) immediately after placement of the flow-diverter stent (Figure 3C). There were no signs of cerebral infarction postoperatively. Although the
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neck of the aneurysm (arrow). The PPTA is connected with the BA. The arrowhead indicates the ICA. (D) The aneurysm has a dome size of 15.8 mm, a neck size of 15.5 mm, and a height of 9. 2 mm.
patient’s abducens nerve palsy persisted, she was discharged without any new symptoms. We confirmed disappearance of the blood flow in the aneurysm on DSA after 6 months (Figure 3D). DISCUSSION The present case had 2 clinical issues. First, the likelihood of successful treatment with a flow-diverter stent was low, because the PPTA branched from the ICA-PPTA aneurysm. Cases of embolization of the ICA-PPTA aneurysm including the PPTA have been
reported.3,4 Therefore, the selective embolization of the PPTA in this case is noteworthy. Embolizing the PPTA made this case similar to that of a large cavernous aneurysm. Ishikawa et al.1 classified the treatment strategies for large or giant cavernous aneurysms associated with PPTA into 4 types. In type 4, a flow-diverter stent is used. Chen et al.2 reported a case of giant thrombosed PPTA aneurysm treated with a covered stent. However, in treatment type 4, the PPTA is not embolized. The success rate of treatment could increase by embolizing the PPTA, as was done in our
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.199
CASE REPORT HIROTAKA SATO ET AL.
FLOW-DIVERTER STENT FOR ANEURYSM
Figure 2. Digital subtraction angiography images after embolization of a persistent primitive trigeminal artery (PPTA). (A) The PPTA (arrow). (B)
case. Treatment types 1e3 involve stopping inflow from the PPTA, and thus
Selective embolization of the PPTA with a coil. (C) The PPTA is not drawn.
inflow from the PPTA should be stopped in treatment type 4.
Figure 3. Digital subtraction angiography (DSA) images of treatment with a flow-diverter stent (FDS). (A) DSA image before placement of the FDS. (B) The FDS in place (arrowhead). (C) Eclipse sign. (D) Absence of blood flow in the aneurysm at 6 months after stent placement.
WORLD NEUROSURGERY 132: 329-332, DECEMBER 2019
Second, whether it is always possible to embolize PPTA is speculative. Salas et al.5 described an interesting classification of PTA variations: lateral petrosal and medial sphenoid. Lateral variation occurs when the PPTA is lateral to the abducens nerve and pierces the dura medial to the sensitive root of the trigeminal nerve. Medial sphenoid variation occurs when the PPTA courses medial to the abducens nerve and pierces the clival dura toward the BA. The lateral variation gives rise to perforating branches to the pons, and oculomotor nerve palsy, trigeminal neuralgia, and abducens nerve palsy might result from lateral PPTA.5,6 Because the present case was a lateral petrosal variation, brainstem infarction could not be ruled out. Therefore, embolization after confirming the presence of symptoms in the balloon occlusion test is important. Weon et al.7 reported that cases of vertebral artery hypoplasia and BA dependence on blood flow from a PPTA are at high risk for infarction. In the present case, the possibility of brain stem infarction might have been low, because the vertebral artery was not hypoplastic and the BA was not dependent on blood flow from the PPTA. In other words, the risk for infarction might not have been high. However, the balloon occlusion test could be important in cases of embolization of PPTA, even when the patient is at a low risk for brainstem infarction. In this operation, we wanted
www.journals.elsevier.com/world-neurosurgery
331
CASE REPORT HIROTAKA SATO ET AL.
to embolize only the PPTA on the side of the ICA to minimize risk; therefore, the embolization was performed before stent placement because of the ease of access from the side of the ICA. We were able to treat ICA-PPTA aneurysm with a flow-diverter stent. However, the long-term outcomes of treating ICAPPTA aneurysms with a flow-diverter stent has not been reported. Similar cases should be studied and reported in the future. CONCLUSIONS This is the first case report of ICA-PPTA aneurysm successfully treated with a flow-diverter stent. Embolization of PPTA has been suggested to improve the success rate. Moreover, the complication rate can be lowered by paying attention to the anatomic features and performing the balloon occlusion test. This report can
332
www.SCIENCEDIRECT.com
FLOW-DIVERTER STENT FOR ANEURYSM
serve as a reference for this procedure in the future.
5. Salas E, Ziyal IM, Sekhar LN, Wright DC. Persistent trigeminal artery: an anatomic study. Neurosurgery. 1998;43:557-561 [discussion: 561-562].
REFERENCES
6. Kim MJ, Kim MS. Persistent primitive trigeminal artery: analysis of anatomical characteristics and clinical significances. Surg Radiol Anat. 2015;37: 69-74.
1. Ishikawa T, Yamaguchi K, Anami H, Sumi M, Ishikawa T, Kawamata T. Treatment of large or giant cavernous aneurysm associated with persistent trigeminal artery: case report and review of literature. World Neurosurg. 2017;108: 996.e11-996.e15. 2. Chen WH, Tsai TH, Shen SC, Shen CC, Tsuei YS. A case of giant thrombosed persistent primitive trigeminal artery aneurysm presenting with trigeminal neuralgia and successfully treated by a covered stent: case report and review of literature. Clin Neuroradiol. 2015;25:207-210. 3. Li MH, Li WB, Pan YP, Fang C, Wang W. Persistent primitive trigeminal artery associated with aneurysm: report of two cases and review of the literature. Acta Radiol. 2004;45:664-668. 4. Zhang CW, Xie XD, Yang ZG, et al. Giant cavernous aneurysm associated with a persistent trigeminal artery and persistent otic artery. Korean J Radiol. 2009;10:519-522.
7. Weon YC, Choi SH, Hwang JC, Shin SH, Kwon WJ, Kang BS. Classification of persistent primitive trigeminal artery (PPTA): a reconsideration based on MRA. Acta Radiol. 2011;52:1043-1051.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 31 July 2019; accepted 24 August 2019 Citation: World Neurosurg. (2019) 132:329-332. https://doi.org/10.1016/j.wneu.2019.08.199 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.199