Endovascular treatment of wide-neck intracranial bifurcation aneurysms with 'Y'-configuration, double Neuroform® stents-assisted coiling technique: Experience in a single center

Abstract

Background Intracranial wide-neck aneurysms at the arterial bifurcations, especially in the aneurysms where the bifurcating branches emanate directly from the base of the aneurysm, have been particularly difficult on which to perform endovascular treatment. The 'Y'-configuration, double stent-assisted coil embolization is an option for the treatment of these difficult aneurysms, allowing the closure of the aneurysm, preserving the parent arteries. Material and methods In a nine-year period, 546 intracranial aneurysms in 493 patients were treated at our center by endovascular approach. We have reviewed the medical records and arteriographies from November 2007 to January 2017 of 45 patients who were treated using 'Y'-configuration double Neuroform® stent-assisted coil embolization. Results All patients were successfully treated. The location of the aneurysms were: middle cerebral artery (MCA) 20 (44.4%), anterior communicating artery (AComA) 17 (37.7%), basilar four (8.9%), internal carotid artery (ICA) bifurcation three (6.6%) and posterior communicating artery (PComA) one (2.2%). The mRS at hospital discharge was: mRS 0: 42 (93.3%), mRS 1: 1 (2.2%), mRS 2: 1 (2.2%) and mRS 5: 1 (2.2%). The Modified Raymond-Roy Occlusion Classification, in the control at six months, was: Class I: 41 (91.1%), Class II: 2 (4.4%), Class IIIa: 1 (2.2%) and Class IIIb: 1 (2.2%). Forty-four (97.8%) patients had a good outcome (mRS < 2) at six months. One (2.2%) patient had a poor outcome (mRS > 2) at six months that was due to sequelae of SAH. There was no mortality at six months. Conclusions This technique is safe and effective for the endovascular treatment of difficult wide-neck bifurcation aneurysms, allowing the stable closure of the aneurysm, preserving the parent arteries.

Keywords: Intracranial aneurysm; Neuroform; bifurcation aneurysm; coils; intracranial stent; ‘Y’ stenting; ‘Y’-configuration stenting.

Figure 1.

Middle cerebral artery bifurcation wide-neck aneurysm diagnosed by subarachnoid hemorrhage (a). Initially, the aneurysm was embolized with coils with the balloon remodeling technique. The control angiography at six months showed an aneurysmal remnant (b). It was decided to treat the aneurysm with ‘Y’-configuration, double Neuroform® stent-assisted coil embolization. A complete packaging of the aneurysm was obtained with Microsphere® microcoils and Target® detachable coils, preserving the afferent and efferent arteries (c). One-year follow-up angiographic study showed complete closure of the aneurysm and remodeling of the arteries (d).

Figure 2.

Aneurysm of the middle cerebral artery that had been clipped in another hospital several years ago (1999), and in the angiographic study by a new subarachnoid hemorrhage, due to rupture of another aneurysm, a repermeabilization of this aneurysm was appreciated (a). It was decided to treat the aneurysm with ‘Y’-configuration, double Neuroform® stent-assisted coil embolization. A complete packaging of the aneurysm was obtained with Microsphere® microcoils and Target® detachable coils preserving the afferent and efferents arteries ((b), (c), (d)). In images (b) and (c), we appreciate the surgical clip and the Neuroform® stents in a configuration in ‘Y’, which keep the coils inside the aneurysmal sac, keeping the afferent and efferent arteries patent. It is important to mention that in (b), (c) and (d), other embolized aneurysms can be seen, one with only coils (left posterior communicating artery) and another with coils assisted with one stent (anterior communicating artery).

Figure 3.

Basilar tip bifurcation wide-neck aneurysm (a). The first Neuroform® stent was deployed. Through the interstices of the first stent, a second Neuroform® stent was then deployed with half of the stent in the left posterior cerebral artery and the other half within the lumen of the previously placed stent in a ‘Y’-configuration, thereby recreating an aneurysm neck and enabling safe coil delivery while preserving the parent vessels. With an Excelsior SL-10® microcatheter the aneurysm is catheterized through the interstices of the two stents (b). Microcatheter was subsequently used to deliver the following bare platinum coils (Microsphere® microcoils and Target® detachable coils), until a complete packaging of the aneurysm (c) was achieved. One-year follow-up angiographic study showing complete closure of the aneurysm (d).