Therapy of a Large Vertebral Artery Aneurysm using
Stent and Coils
P. Lownie, David M. Pelz, Allan J. Fox
Background: Endovascular therapy is becoming an increasingly
popular treatment for cerebral aneurysms. Total angiographic
occlusion of small-necked aneurysms (<4 mm) can be obtained
in a high percentage of cases. The endovascular treatment of
wide-necked or fusiform aneurysms remains a challenge with complete
angiographic occlusion reported in <15% of cases. Case
Report: We describe the combined use of a flexible coronary
stent and platinum coils to treat a wide-necked aneurysm of
the distal left vertebral artery, in a patient with Grade IV
subarachnoid hemorrhage. Results: The procedure
was technically successful as the parent artery was protected
by the stent while coils were deposited in the aneurysm lumen.
Although angiographic aneurysm occlusion was incomplete, the
dome was packed with coils. No further hemorrhage has occurred.
Conclusion: Combined endovascular stent and coil
therapy is a promising technique for the treatment of wide-necked
Traitement endovasculaire d'un gros anévrisme de l'artère
vertébrale au moyen d'un stent et de serpentins. Introduction:
Le traitement endovasculaire de l'anévrisme cérébral
devient de plus en plus populaire. L'occlusion angiographique
totale des anévrismes à col étroit (4mm)
peut être réalisée dans une grande proportion
des cas. Le traitement endovasculaire des anévrismes
à col large ou des anévrismes fusiformes demeure
un défi, une occlusion angiographique complète
étant rapportée dans <15% des cas. Cas
clinique: Nous décrivons l'utilisation combinée
d'un stent coronarien flexible et de serpentins de platine pour
traiter un anévrisme à col large de la portion
distale de l'artère vertébrale gauche chez un
patient présentant une hémorragie sous-arachnoïdienne
de grade IV. Résultats: L'intervention
a été un succès technique, l'artère
mère étant protégée par le stent
alors que les serpentins étaient placés dans la
lumière de l'anévrisme. Bien que l'occlusion angiographique
de l'anévrisme était incomplète, le dôme
en était rempli de serpentins. Aucun saignement ne s'est
produit depuis l'intervention. Conclusion: L'utilisation
combinée d'un stent et de serpentins est une technique
prometteuse pour le traitement des anévrismes cérébraux
à col large.
J. Neurol. Sci. 2000; 27: 162-165
intracranial aneurysms are challenging lesions to treat.(1)
Surgical clipping may be difficult or impossible if a true neck
is not present. Endovascular therapy of these lesions has been
limited to proximal balloon occlusion if adequate collateral
circulation exists(2,3) and, more recently the "remodelling"
technique(4) which involves platinum coil deposition in the
aneurysm lumen with temporary balloon occlusion of the parent
vessel to prevent egress of the coils. In this case report,
we describe the treatment of a wide-necked aneurysm of the distal
left vertebral artery using a flexible coronary stent to bridge
the wide neck and allow safe placement of platinum coils through
the interstices of the stent to occlude the aneurysm lumen.
64-year-old male presented with a sudden severe headache three
weeks prior to admission. He was treated for presumed tension
headache but then experienced another severe headache with decreased
level of consciousness. A CT scan (Figure
1) showed a large acute subarachnoid and intraventricular
hemorrhage with hydrocephalus. He was intubated and sent to
our institution for further investigation and management.
admission to the intensive care unit, the patient was unconscious
with no spontaneous movements, eye opening or speech. He did
localize to moderately painful stimuli bilaterally and could
move all four limbs. His pupils were 2 mm and sluggishly reactive,
corneal reflexes were intact and plantar reflexes were downgoing.
He was assessed as Hunt and Hess Grade IV.
angiography demonstrated a large, wide-necked aneurysm of the
distal left vertebral artery (Figure
2). The neck measured at least 8-10 mm and the dome diameter
was approximately 1.2 cm. The left posterior inferior cerebellar
artery (PICA) originated more proximally from the vertebral
artery. The right vertebral artery was small and ended in the
right PICA. There was no spontaneous filling of the posterior
communicating arteries and compression views were not done.
There was no significant vasospasm and no other aneurysms were
identified. A ventricular drain was placed and the patient improved
over the next few days to Hunt and Hess Grade III. His level
of consciousness improved and he was intermittently moving his
arms and legs spontaneously and to command. He would open his
eyes to command yet he continued to only withdraw bilaterally
to painful stimuli. Due to the poor clinical grade, it was decided
to attempt endovascular treatment. This was performed five days
after the hemorrhage.
patient was placed under general anaesthetic in the neuroangiography
suite. A 9 French sheath was placed in the left femoral artery
using Seldinger technique. The left vertebral artery was then
selectively catheterized using a 9 French Shuttle introducing
catheter (Cook, Bloomington IN). A 0.014 guidewire was then
advanced through the introducing catheter into the vertebral,
basilar and left posterior cerebral arteries. An AVE coronary
artery stent (Medtronic, Mississauga ON), 5 mm diameter, 3 cm
length was then placed across the base of the aneurysm. Great
care was taken to ensure adequate stent purchase on either side
of the aneurysm base, and the stent was then deployed (Figure
two-tip marker Tracker 10 microcatheter (Target/Boston Scientific,
Fremont CA) was then advanced into the distal left vertebral
artery. The microcatheter was navigated through the interstices
of the stent into the aneurysm lumen (Figure
4). When satisfactory catheter position was achieved, seven
Guglielmi Detachable Coils (GDC) were deposited within the aneurysm
lumen (Figure 5).
There was some resistance during deposition of the last two
coils, and the last one detached prematurely during attempted
withdrawal. This was likely due to damage incurred at the coil
wire junction during introduction rather than by stent traction
during coil withdrawal. An attempt to retrieve this coil was
unsuccessful and it was left in situ, with the proximal end
in the aortic arch, and no coiling observed in the vertebral
artery. In our experience with damaged minicatheters and coils
left in the aorta, clinical complications have been rare.
postembolization angiogram showed continued filling of the aneurysm
with stasis of contrast in the dome (Figure 6). The patient
tolerated the procedure well and afterwards he was spontaneously
opening his eyes and following commands. He was maintained on
antiplatelet medication (Aspirin 350 mg once a day). His level
of consciousness gradually improved but his postoperative course
was complicated by the development of hydrocephalus, meningitis,
pneumonia, and a subdural hematoma after a fall. He had difficulties
with swallowing and an unusual hypophonia. Postoperative MRI
examinations showed no evidence for new infarction although
the brainstem was partially obscured by metal artefact. Postoperative
angiography was not performed due to the patient's medical complications,
but ultrasound showed continued patency of the left vertebral
artery. On discharge to his home hospital for rehabilitation
one month after the procedure, he was oriented to name and place,
following commands and moving all extremities but he did have
residual proximal limb weakness and hypophonia. The mechanism
of these deficits was uncertain but was thought to be related
to brainstem injury at the time of hemorrhage rather than by
perforator occlusion by the stent and coils.
coiling has become a popular alternative to surgery for the
treatment of cerebral aneurysms.(5,6) Complete angiographic
occlusion can be obtained in up to 85% of aneurysms with necks
<4 mm in diameter, but <15% in aneurysms with wider necks.7
in the coiling of large aneurysms occur at the base if the neck
is wider than the dome height.(7) It is very difficult to prevent
egress of coils into the parent artery in these situations,
with attendant risks of thrombus formation, distal emboli or
vessel occlusion. The "remodelling technique" has been described
by Moret et al(4) to address these problems. One or two nondetachable
balloon catheters are placed at the base of a wide-necked aneurysm.
A minicatheter is introduced into the aneurysm lumen for coil
deployment, and the balloon is temporarily inflated as the coils
approach the neck to prevent them from encroaching on the parent
vessel, and to mold them to the aneurysm contour. This technique
therefore involves multiple catheters and temporary vessel occlusion.
use of stents in the treatment of experimental aneurysms has
been demonstrated by several authors.(8,9) Stents and coils
were used in these reports to successfully treat fusiform aneurysms
in pigs. Covered stents have also been used to treat experimentally
created arteriovenous fistulae.(10) In humans, vein-covered
stents have been used to repair a traumatic cervical carotid
our case, surgical options were limited due to the very wide
neck of the posterior circulation aneurysm. Proximal balloon
occlusion of the left vertebral artery would have been hazardous
due to the small right vertebral artery which ended in PICA
and the uncertain status of the posterior communicating arteries.
our knowledge, this is the first use of a stent and platinum
coils to treat a wide-necked intracranial aneurysm in Canada.
Higashida et al(12) have reported the use of this technique
to treat an acutely ruptured fusiform aneurysm of the basilar
artery with a subtotal angiographic occlusion and a good clinical
result. They used an articulated Palmaz-Schatz coronary stent
(Johnson and Johnson, Warren NJ) and GDC coils. In our case,
we chose a more flexible coronary artery stent which easily
traversed the curves of the vertebral artery and permitted passage
of a Tracker 10 minicatheter through the interstices for GDC
coil deployment. It was also hoped that the interstices of the
stent would permit continued perfusion of distal vertebral artery
et al(13) have recently reported on their series of eight patients
treated with a combined stent and coil approach. In this group,
which included both anterior and posterior circulation aneurysms,
they observed over 90% thrombosis of all lesions and no periprocedure
the angiographic occlusion was initially incomplete, it was
hoped that further thrombosis would occur on follow-up angiograms
which may be performed in the future. There has been no further
hemorrhage at four months follow-up and the patient continues
to improve slowly in rehabilitation.
use of stents for cerebral aneurysm treatment may be limited
by the proximity of small perforating vessels to the neck of
the aneurysm which may be compromised by the stent. The added
thrombogenic potential of stents and the possible development
of neointimal hyperplasia with parent vessel stenosis may be
further limitations of this treatment. There is a theoretical
risk of coil damage during passage through the interstices of
the stent, resulting in difficulties with placement and detachment.
and coils offer unique opportunities to treat difficult intracerebral
aneurysms. Technologies are evolving rapidly and a possible
future modification includes the use of covered stents to occlude
the wide necks of large aneurysms. The endovascular treatment
of fusiform aneurysms without defined necks remains problematic.
CG, Peerless SJ, Hernesniemi JA. Surgery of Vertebrobasilar
Aneurysms, New York: Springer, 1996.
AJ, Vinuela F, Pelz DM, et al. Use of detachable balloons
for proximal artery occlusion in the treatment of unclippable
cerebral aneurysms. J Neurosurg 1987;66:40-46.
RT, Halbach VV, Dowd CF, et al. Interventional neurovascular
treatment for giant aneurysms of the posterior circulation.
J Surg Cereb Stroke 1993;21:401-406.
J, Cognard C, Weill A, Castaings L, Rey A. The "Remodelling
Technique" in the treatment of wide-necked intracranial
aneurysms. Intervent Neuroradiol 1997;3:21-35.
F, Duckwiler G, Mawad M. Guglielmi detachable coil embolization
of acute intracranial aneurysm: perioperative and clinical
outcome in 403 patients. J Neurosurg 1997;86:475-482
C,Weill A, Castaings L, Rey A, Moret J. Intracranial berry
aneurysms: angiographic and clinical results after endovascular
treatment. Radiology 1998;206:499-510.
AF, Guglielmi G, Vinuela F, Duckwiler GR. Endovascular
occlusion of intracranial aneurysms with electrically
detachable coils: correlation of aneurysm neck size and
treatment results. Am J Neuroradiol 1994;15:815-820.
TF, Turjman F, Ji C et al. Endovascular treatment of fusiform
aneurysms with stents and coils: technical feasibility
in a swine model. Am J Neuroradiol 1995;16:1953-1963.
I, Guterman LR, Wells KM, et al. Combined use of stents
and coils to treat experimental wide-necked carotid aneurysms:
preliminary results. Am J Neuroradiol 1994;15:1091-1102.
G, Bakon M, Brennecke L, et al. Experimental arteriovenous
fistulas: treatment with silicone-covered metallic stents.
Am J Neuroradiol 1997;18:271-277.
TR, Butler C, Taylor D, Morris C, Zwimpfer T. Autologous
vein-covered stent repair of a cervical internal carotid
artery pseudoaneurysm: technical case report. Neurosurgery
RT, Smith W, Gress D, et al. Intravascular stent and endovascular
coil placement for a ruptured fusiform aneurysm of the
basilar artery. J Neurosurg 1997;87:944-949.
G, Wahkloo AK, Fessler RD, et al. Efficacy and current
limitations of intravascular stents for intracranial internal
carotid, vertebral, and basilar artery aneurysms. J Neurosurg
the Department of Diagnostic Radiology; and the Department
of Clinical Neurological Sciences, The University of
Western, London, Ontario, Canada.
September 17, 1999. Accepted in final form December
requests to: David M. Pelz, Department of Diagnostic
Radiology, London Health Sciences Centre, 339 Windermere
Road, London, Ontario N6A 5A5 Canada.
J. Neurol. Sci. 2000; 27: 162-165