Delayed ischemic stroke due to stent marker band occlusion after stent-assisted coiling

Abstract

A middle-aged patient with an internal carotid-posterior communicating artery aneurysm and basilar artery tip aneurysm was treated by stent-assisted coiling. One ischemic infarction and two transient ischemic attacks occurred with the same symptoms (inability to walk unassisted and tendency to fall to the left) during the first 2 years post-treatment. The ischemic infarction was found in the right side of the pons, consistent with the vascular territory of the stent-containing vessel. The cause of the delayed ischemic stroke was investigated on DSA and cone beam CT, which revealed that the proximal end of the stent, one marker band, was just covering a small perforating artery of the basilar artery trunk. The present case suggests that marker band occlusion can induce delayed ischemic stroke. To prevent this complication, it is important to evaluate the perforating vessels preoperatively and carefully deploy a stent for the marker band to avoid occlusion of large perforating vessels. Post-treatment evaluation is also important because dual antiplatelet therapy will be required for a longer period if an artery is occluded by a marker band.

Keywords: aneurysm; platelets; stent; stroke.

Figure 1

(A and B) Three-dimensional rotational angiography, anteroposterior view and working angle view, showing the basilar tip aneurysm with low dome–neck ratio. (C) DSA, anteroposterior view, showing the basilar artery tip aneurysm before treatment. (D) DSA immediately after treatment showing complete occlusion of the basilar artery tip aneurysm.

Figure 2

Diffusion-weighted MRI showing that an ischemic stroke had occurred in the right side of the pons, consistent with the vascular territory of the stent-containing vessel.

Figure 3

(A) DSA 2 years after treatment showing complete occlusion of the basilar artery tip aneurysm and no thrombosis in the stent. Note the stent marker band (arrow) and small perforating vessel (arrowhead) from the basilar trunk. (B) Coronal view. Cone beam CT demonstrating adequate stent apposition to the vessel wall; the proximal end of the stent (arrow) is just covering a small perforating artery (arrowhead). (C) Axial view. At the proximal end of the stent, one marker band (arrow) was just covering a small perforating artery (arrowhead). (D) DSA after initial placement of the stent showing that the positional relationship between the marker band (arrow) and the small perforating vessel (arrowhead) has not been changed for 2 years compared with A.