- Department of Neurosurgery, University of Mississippi Medical Center, North State Street, Jackson, MI, USA
- Department of Radiology and Neurosurgery, University of Mississippi Medical Center, North State Street, Jackson, MI, USA
Ludwig D. Orozco
Department of Radiology and Neurosurgery, University of Mississippi Medical Center, North State Street, Jackson, MI, USA
DOI:10.4103/2152-7806.80349Copyright: © 2011 Orozco LD. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Orozco LD, Buciuc RF. Balloon-assisted coiling of the proximal lobule of a paraophthalmic aneurysm causing panhypopituitarism: Technical case report. Surg Neurol Int 30-Apr-2011;2:59
How to cite this URL: Orozco LD, Buciuc RF. Balloon-assisted coiling of the proximal lobule of a paraophthalmic aneurysm causing panhypopituitarism: Technical case report. Surg Neurol Int 30-Apr-2011;2:59. Available from: http://sni.wpengine.com/surgicalint_articles/balloon-assisted-coiling-of-the-proximal-lobule-of-a-paraophthalmic-aneurysm-causing-panhypopituitarism-technical-case-report/
Background:We describe an intra-aneurysmal balloon-assisted technique to limit the coil volume in a large bilobulated paraophthalmic aneurysm. Our intent was to reduce the mass effect and presenting symptoms of diabetes insipidus (DI) with hypopituitarism.
Case Description:A 32-year-old woman presented with symptoms of DI and her work-up demonstrated hypopituitarism and partial bitemporal visual field defects. Cerebral angiography revealed a large paraophthalmic aneurysm with two distinctive lobules, projecting toward the pituitary fossa. The patient declined craniotomy but consented for endovascular treatment. The plan was to limit the embolization to the proximal lobule only. Initially, we used a dual microcatheter technique with a microcatheter in each lobule. A framing coil in the distal lobule did not prevent coil migration from the proximal lobule. Instead, we elected to use a Hyperform balloon in the distal lobule and were able to successfully coil the proximal lobule only. Her 3-year follow-up angiogram revealed a completely occluded aneurysm. The patient experienced resolution of the DI and improvement of her visual fields. However, she remained in hypopituitarism.
Conclusion:Intra-aneurysmal balloon-assisted coiling of proximal aneurysmal lobules might be an alternative for the reduction of mass effect related to the coil mass. Careful follow-up is needed because subtotal occlusion carries a future risk of growth, recanalization and rupture. Unruptured intracranial carotid aneurysms can present with reversible DI and usually permanent pituitary disturbances.
Keywords: Aneurysm, balloon-assisted coiling, diabetes insipidus, hypopituitarism, mass effect
Controversy exists about the optimal treatment of intracranial aneurysms presenting with symptoms of mass effect. Total and subtotal endovascular occlusion results in improvement of mass effect and neural compression.[
It is well known that intrasellar and suprasellar aneurysms can present with hypopituitarism,[
We report the case of a patient with an unruptured bilobulated aneurysm of the paraophthalmic carotid artery, presenting with DI, hypopituitarism and partial visual field defects. The patient underwent balloon-assisted coiling limited to the proximal aneurysmal lobule in an attempt to reduce mass effect on the adjacent pituitary gland, hypothalamus and optic chiasm. The report includes the technical challenges encountered and a review of the literature for mass effect associated with coiling. We also discuss the hypothalamic and pituitary disturbances seen with intracranial aneurysms.
A 32-year-old woman presented with a 3-week history of persistent headaches, increased thirst, polyuria and blurred vision. Computed tomographic angiography (CTA) demonstrated a large suprasellar aneurysm [
Under general anesthesia, the patient was fully heparinized and a 6-French shuttle sheath (Cook, Bloomington, IN, USA) was placed in the cervical segment of the left internal carotid artery. Initially, and in order to prevent coil migration from the proximal lobule, two Prowler Select Plus microcatheters (Cordis Endovascular, Miami Lakes, FL, USA) were navigated into the distal and proximal aneurysmal lobules, respectively. Then, an undeployed GDC (Guglielmi Detachable Coil, Boston Scientific, Natick, MA, USA) was advanced in the distal lobule with the intent of tamponading the coils deployed in the proximal lobule.[
A Hyperform balloon (MicroTherapeutics, Inc., Irvine, CA, USA) was positioned inside the distal lobule, and a Prowler Select Plus catheter was navigated in the proximal one. The balloon was inflated to its maximum capacity and brought to the entrance of the distal lobule. Then, a GDC coil was advanced into the proximal lobule but not deployed. A follow-up imaging run demonstrated appropriate coil positioning, sparing the distal lobule [
Artist illustration of the intra-aneurysmal balloon-assisted coiling technique. (a) Inflated Hyperform balloon at the entrance of the larger distal aneurysmal lobule, limiting coiling to the proximal lobule. (b) A Hyperglide balloon is inflated across the aneurysm neck as the deflated intra-aneurysmal balloon is slowly removed to prevent coil mass disturbance (Artist: W. Kyle Cunningham, Medical Illustrator at the University of Mississippi Medical Center)
Finally, in order to withdraw the intra-aneurysmal balloon without disturbing the coil mass, a second balloon (Hyperglide, MicroTherapeutics, Inc., Irvine, CA, USA) was advanced and inflated across the aneurysm neck and the intra-aneurysmal balloon was slowly removed [
Post-procedural angiography demonstrated a stable coil mass and complete occlusion of the aneurysm.
The patient was discharged 5 days later. Over the following weeks, she had progressive resolution of polyuric episodes. Three years after treatment, her angiogram revealed a stable coil mass and persistent aneurysmal obliteration [
Panhypopituitarism and intracranial aneurysms
Intrasellar and suprasellar aneurysms represent an uncommon cause of hypopituitarism, accounting for only 0.17% of the cases.[
When DI results from clipping ruptured anterior cerebral or anterior communicating artery aneurysms, it is caused by vasospasm-related ischemia of the anterior portions of the hypothalamus.[
In a majority of cases, the DI usually resolves or improves within 3 weeks. DI can be seen in three different patterns: transient with normalization 12–36 hours after onset, prolonged with most returning to normal or near normal at 1 year, and the least frequent triphasic response.[
Technical aspects and mass effect considerations
In a recent report, Fiorella et al. described a double balloon technique to coil a large superior cerebellar artery (SCA) aneurysm. They used an intra-aneurysmal Hyperform balloon to preserve the origin of the SCA at the aneurysm neck. A second balloon (Hyperglide) was used to protect the parent basilar artery and trap the smaller intra-aneurysmal balloon during coiling.[
Our patient's bilobulated aneurysm had a smaller proximal lobule. It was reasonable to obliterate the aneurysm and at the same time decrease its mass effect/coil volume by limiting coiling to the proximal lobule. The previously described double catheter technique[
We do not recommend having a second deflated balloon within the parent vessel during coil embolization, as it would be a third instrument raising the possibility of thromboembolic events or vascular damage. Nonetheless, it is advised to have a second balloon ready to deploy on the instrument table, in the event of an intraoperative rupture.
Currently available is the Ascent balloon catheter (Micrus endovascular, San Jose, CA, USA), which can also function as a microcatheter/delivery system. If this catheter were available at the time of our reported technique, it would have functioned as the proximal lobule microcatheter and parent vessel balloon. This would have simplified our method to two micro-instruments instead of three, with the added benefit of having a balloon to secure the aneurysmal neck if needed.
Cranial nerve dysfunction, obstructive hydrocephalus, brainstem, and visual pathway compression constitute the more prevalent symptoms of mass effect related to intracranial aneurysms.[
Balloon-assisted remodeling of the coil mass is a technique available in the treatment of geometrically complex aneurysms. The primary goal of any method of treating intracranial aneurysms is to prevent aneurysm rupture. Considerations of mass effect response are secondary to considerations of the safety, efficacy, and durability of aneurysm obliteration. Whether there is greater reduction of mass effect with a lesser coil mass and distal dome deflation requires further investigation. Careful follow-up is needed because subtotal occlusion carries a future risk of growth, recanalization and rupture.[
The authors report a novel and creative strategy to coil only the proximal lobule of an unruptured bilobed aneurysm that was causing symptoms from mass effect, in an effort to spare the added coil mass necessary to coil the aneurysm in its entirety. A hyperform balloon was introduced and inflated in the distal lobule with the microcatheter positioned in the proximal lobule to deliver the coil mass exclusively in the proximal lobule. Once the proximal lobule was adequately coiled, the balloon in the distal lobule was deflated. Prior to removing the deflated balloon across the coil mass, a second balloon was introduced for parent vessel protection and inflated across the aneurysm neck to help buttress it as it is being pulled out so as not to drag the coils out into the parent vessel.
With more favorable anatomy, unassisted coiling of a larger proximal lobule should protect the distal lobule if complete aneurysm exclusion from the circulation is achieved. Balloon inflation in the distal lobule could be dangerous, particularly in the ruptured aneurysm setting. As the authors acknowledge, this is a highly technically demanding strategy that does not have widespread indications but can be kept in our “bag of tricks” for those rare yet extremely challenging cases. This interesting case reminds us that we must continue to become adept and creative at incorporating all adjunctive devices including balloons and stents, alone or in combination, to continue to expand treatment options toward challenging aneurysms. For this, the authors are to be congratulated.
We would like to thank Mrs. Renea Hays, Department of Radiology, for her help in the preparation of the images.
- Department of Neurological Surgery, Cerebrovascular Center, Cleveland Clinic, Cleveland OH, S40, 9500 Euclid Ave, Cleveland OH 44195. E-mail:
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