Usefulness of Y-shaped PulseRider-assisted coil embolization for basilar artery tip aneurysm with a misaligned axis: A case report

Abstract

Background: Endovascular treatment of wide-necked bifurcation aneurysms remains challenging. Although the advent of PulseRider and Web has expanded treatment options, aneurysms with a large deviation from the parent artery axis remains difficult to treat. We present the case of a wide-necked bifurcation aneurysm that was misaligned with the angle between the long axis of the parent artery and the aneurysm and was successfully treated with Y-shaped PulseRider-assisted coil embolization.

Case description: A 64-year-old woman presented with an unruptured basilar tip aneurysm. Cerebral angiography showed a wide-necked aneurysm measuring 8.1 mm × 6.1 mm, neck 5.7 mm. The aneurysm was strongly tilted to the right and posterior relative to the basilar artery, and the bilateral posterior cerebral artery (PCA) and superior cerebellar artery (SCA) diverged from the aneurysm body. PulseRider-assisted coil embolization was performed. A Y-shaped PulseRider was selected to be placed in a hybrid fashion with the right arch in the aneurysm and the left arch in the branch. Adequate coil embolization with preservation of the bilateral PCA and SCA was possible, and cerebral angiography immediately after the treatment showed slight dome filling. Cerebral angiography 6 months after the procedure showed that the embolic status had improved to complete occlusion.

Conclusion: For wide-neck bifurcation aneurysms with a misaligned axis, a Y-shaped PulseRider used in a hybrid fashion, in which the leaflet on the side with the tilted axis is placed in the aneurysm, allows the PulseRider to be deployed more closely to the aneurysm, thereby enabling good coil embolization.

Keywords: Coil embolization; PulseRider; Wide-neck bifurcation aneurysm.

Figure 1:

Cerebral angiography showing a wide-necked aneurysm measuring 8.1 mm × 6.1 mm; neck, 5.7 mm, at the BA tip. (a and b) The aneurysm is strongly tilted to the right and posterior relative to the BA, and the bilateral PCA and SCA diverge from the aneurysm body. BA: Basilar artery, PCA: Posterior cerebral artery, and SCA: Superior cerebellar artery.

Figure 2:

(a) A PulseRider (10Y/2.7–3.5) is deployed in a hybrid fashion with the right arch in the aneurysm and the left arch in the PCA as planned. (b) The aneurysm neck is covered by PulseRider, and the barrel view shows no deviation of the coil into the parent artery (arrowhead). (c) A cerebral angiography immediately after treatment showing slight dome filling, and bilateral PCA and SCA blood flow is normal. (d) A cerebral angiography 6 months after the treatment showing that the embolic status had improved to complete occlusion. PCA: Posterior cerebral artery and SCA: Superior cerebellar artery.

Figure 3:

(a) When the aneurysm is displaced to the left or right in relation to the axis of the parent artery, it is ideal to place the PulseRider in the extra-aneurysm position. (b) However, this is often difficult, and hybrid placement should also be considered. (c) The Y-shaped PulseRider can adhere more closely to the neck than the T-shaped PulseRider. (d) Cerebral angiography immediately after treatment shows no coil deviation in the parent artery in the barrel view (arrowhead).