Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy

Abstract

Dilating HIV vasculopathy can be a cause of ischemic and hemorrhagic stroke in patients with HIV. Although first identified in children, this condition is increasingly being recognized in adults and has a dismal natural history under medical or expectant management. Vessel wall invasion by varicella zoster virus, HIV or Mycobacterium avium intracellulare complex (MAI) has been postulated as a possible etiology. We present a case of an adult patient with HIV and chronic disseminated MAI infection who presented with ischemic stroke and three fusiform cerebral aneurysms that were successfully treated with the pipeline embolization device (PED). Flow diversion may be a viable treatment option for patients presenting with this serious neurovascular condition when aneurysm location precludes parent vessel sacrifice or surgical bypass. In addition, platelet function testing with VerifyNow may be valuable in selecting the appropriate P2Y12 receptor antagonist to be used in order to prevent PED thrombosis, since some of the antiretroviral drugs may inhibit clopidogrel or prasugrel metabolism.

Figure 1

(A) Axial diffusion-weighted image showing acute infarctions in the left caudate head and posterior limb of the left internal capsule. (B) Frontal left internal carotid artery (ICA) angiogram showing fusiform dilation of the supraclinoid segment of the left ICA. (C) Frontal left vertebral angiogram showing fusiform dilation of the P1 segments of the posterior cerebral arteries bilaterally. (D) Volume-rendered three-dimensional reconstruction of a contrast-enhanced MRI of the brain performed 6 months prior to presentation showing a normal appearance of the circle of Willis.

Figure 2

(A) Frontal fluoroscopic image prior to pipeline embolization device (PED) deployment showing the bilateral PED inside the Marksman microcatheters. (B) Frontal fluoroscopic image showing the bilateral PEDs partially deployed into each P1 segment of the posterior cerebral arteries (PCA). (C) Frontal fluoroscopic image showing the fully deployed PEDs extending from each P1 segment of the PCAs to the distal basilar artery in a ‘kissing’ overlapping fashion. (D) Sagittal Dyna-CT angiogram reconstruction showing the ‘kissing’ overlapping PEDs in the distal basilar artery. (E) Final frontal left vertebral angiogram showing patency of the PEDs and distal cerebral vasculature with reduced flow to the left P1 segment PCA aneurysm.

Figure 3

(A) Frontal left internal carotid artery (ICA) angiogram 6 months after treatment showing complete remodeling of the left supraclinoid ICA aneurysm along the pipeline embolization device (PED) with patency of the left anterior choroidal artery and distal cerebral vasculature. (B) Lateral left ICA angiogram 6 months after treatment showing complete remodeling of the left supraclinoid ICA aneurysm along the PED with patency of the left anterior choroidal artery and distal cerebral vasculature.

Figure 4

(A) Frontal left vertebral angiogram 6 months after treatment showing complete remodeling of the bilateral P1 segment posterior cerebral artery (PCA) aneurysms along the pipeline embolization device (PED) with patency of the distal cerebral vasculature. There has also been vascular remodeling at the top of the basilar artery along the two ‘kissing’ PEDs. (B) Lateral left vertebral angiogram 6 months after treatment showing complete remodeling of the bilateral P1 segment PCA aneurysms along the PED with patency of the distal cerebral vasculature. There has also been vascular remodeling at the top of the basilar artery along the two ‘kissing’ PEDs. (C). Anteroposterior view of a volume-rendered three-dimensional reconstruction from a rotational catheter angiogram showing vascular remodeling at the top of the basilar artery along the two ‘kissing’ PEDs with four separate vascular channels providing blood flow to the bilateral superior cerebellar arteries (SCA) and PCAs. (D). Posteroanterior view of a volume-rendered three-dimensional reconstruction from a rotational catheter angiogram showing vascular remodeling at the top of the basilar artery along the two ‘kissing’ PEDs with four separate vascular channels providing blood flow to the bilateral SCAs and PCAs.