Ten-year follow-up of giant basilar aneurysm treated by sole stenting technique: a case report

Abstract

Introduction: The sole stenting technique has emerged as a new tool for the management of intracranial aneurysms. However, several concerns have emerged about the long-term behavior of intracranial stents, particularly their safety and efficacy.

Case presentation: We present the first case of an intracranial aneurysm intentionally treated with the sole stenting technique. After ten years of clinical and imaging follow-up, the lesion has healed and no intrastent stenosis is observed.Several issues concerning this technique are discussed. For instance, the modification of the angle and intra-aneurysmal thrombosis may account as positive effects; negative outcomes include in-stent thrombosis or stenosis.

Conclusions: This case report, involving a long clinical and imaging follow-up, provides an example of the effectiveness, safety, durability and simplicity of the sole stenting technique in the management of intracranial aneurysms.

Figure 1

Imaging of the aneurysm before (A), during the stenting (B-G) and in vascular rescue procedure (H-J). A) Preoperative angio-CT: Aneurysm of the basilar artery (hollow arrow) and evidence of wide neck (thin arrows). B) to G) First procedure. A balloon-expandable stent (arrowhead in B and thick arrow in C) is advanced on a microguidewire (thin arrows in B). Once the stent was deployed, it slid out of place towards the sac (thick arrows in D). The whole misplaced stent was gently pushed into the sac (thick arrow in E and F) using a balloon mounted on the same microguidewire (thin arrows in E). A second balloon-expandable stent (arrowhead in F) is placed over the entire length of this wide-necked aneurysm (hollow arrow in F). This second balloon-expandable stent is in a correct position within the parent vessel (dotted arrow in G), the first misplaced BES lies within the aneurysm (thick arrow in G) and a sluggish intraaneurysmal vortex motion is clearly shown (hollow arrow in G). Second procedure. Neurological impairment four hours later explained by in-stent thrombosis. An intravascular clot initially emerging from the thrombosing sac (hollow arrow in H) overflows into the basilar artery (dotted arrow in H). Both pharmacological and mechanical measures using a microguidewire (thin arrows in J) successfully recanalize the arterial tree distal to the aneurysm (J). Imaging follow-up. At one week, the T1 magnetic resonance imaging shows a residual stroke in the ventral portion of the cerebral peduncle (dotted arrow in K).

Figure 2

Imaging follow-up spanning ten years. A) Imaging at three months. Angio-CT reconstruction shows the first (thick arrow) and the second (dotted arrow) with a dog-ear residual sac (thin arrow). B) One year imaging. Digital Subtraction Angiography showing complete healing of the aneurysm (B). No in-stent stenosis. No recanalization. C) to F): Ten years imaging. Control Digital Subtraction Angiography runs (C and D) show no aneurysm and a patent stented vessel. The misplaced intra-aneurysmal extravascular stent is shown as well (thin arrow in D). Three-dimensional reconstruction (E and F) confirms these findings, with a nice visualization of both stents in dual reconstruction (dotted and thick arrows in E). No in-stent stenosis. No recanalization.