Delayed aneurysm rupture in a patient treated with flow redirection endoluminal device: A case report and literature review
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Japan.
Hiroki Sato, Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Japan.
DOI:10.25259/SNI_783_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Eisuke Tsukagoshi, Hiroki Sato, Shinya Kohyama. Delayed aneurysm rupture in a patient treated with flow redirection endoluminal device: A case report and literature review. 04-Nov-2022;13:506
How to cite this URL: Eisuke Tsukagoshi, Hiroki Sato, Shinya Kohyama. Delayed aneurysm rupture in a patient treated with flow redirection endoluminal device: A case report and literature review. 04-Nov-2022;13:506. Available from: https://surgicalneurologyint.com/surgicalint-articles/11979/
Background: Delayed aneurysm rupture after flow-redirection endoluminal device (FRED) implantation is rare. We report a case of internal carotid-cavernous fistula (CCF) caused by a delayed aneurysm rupture of the cavernous portion of the internal carotid artery (ICA) after FRED implantation.
Case Description: A 75-year-old woman had a gradually enlarging aneurysm at the C4 portion of the left ICA. We performed FRED implantation for the same. The FRED implantation procedure was smooth and the FRED expanded well and attached to the vessel wall. Five days after surgery, the patient developed a strong headache, hyperemia of the left eye, and disturbance of the left eye movement. Magnetic resonance imaging and angiography revealed a left CCF with cortical venous reflux. We performed transarterial aneurysmal and transvenous cavernous sinus embolization. Postoperatively, angiography showed no fistula and complete occlusion of the aneurysm; however, minor eye movement disorder persisted.
Conclusion: To prevent the development of delayed aneurysm rupture in patients treated with FRED, preoperative consideration of whether to add coil embolization is important, even if the aneurysm is located in the C4 portion of the ICA and there is no risk of subarachnoid hemorrhage, including the size of aneurysm. In this report, we have tried to alert surgeons regarding the risk of delayed aneurysm rupture due to FRED implantation.
Keywords: Carotid cavernous fistula, Delayed aneurysm, Flow-redirection endoluminal device, Internal carotid artery
Balloon- or stent-assisted coil embolization is a known endovascular treatment of wide-necked aneurysms. However, these treatments are limited by associated aneurysm recurrence rates.[
Written informed consent to publish this report was obtained from the patient before the submission process.
A 75-year-old woman (height: 148 cm, weight: 55 kg) was diagnosed with a gradually enlarging left internal carotid artery (ICA) aneurysm by magnetic resonance imaging (MRI). There were no neurological dysfunctions and no preexisting conditions. The aneurysm was a saccular aneurysm at the C4 portion of the ICA with a size of 9.4 mm × 9.1 mm, a neck of 8.0 mm, and a depth of 6.4 mm (aspect ratio of 0.8) [
(a) Magnetic resonance angiography showing an unruptured aneurysm at the cavernous portion of the left internal carotid artery. (b) 3D rotated angiography showing a saccular aneurysm at the C4 portion, with a size of 9.4 mm × 9.1 mm, a neck of 8.0 mm, and a depth of 6.9 mm (aspect ratio of 0.8). (c) Cone-beam computed tomography performed after the procedure shows a stent fitted well into the artery.
A 6Fr Axcelguide (Medikit, Tokyo, Japan) was placed at the left ICA. Headway 27 (Microvention-Terumo, California, USA) and CHIKAI 14 (ASAHI INTECC, Aichi, Japan) were inserted into SOFIASELECT (Microvention-Terumo, California, USA) and guided to the C1 portion of the ICA. We placed the FRED (5.0 mm × 26 mm) from the origin of the ophthalmic artery to the C5 portion of the ICA to cover the neck of the intracranial aneurysm. The FRED expanded well. Post-dilatation was not performed as cone-beam computed tomography showed that the stent fitted well into the artery [
(a) Left internal carotid arteriography before the procedure in the arterial phase. (b) Arterial phase after the procedure showing partial areas with no inflow of contrast that were present within the aneurysm. (c) Capillary phase before procedure showing no stagnation of blood flow within the aneurysm. (d) Capillary phase after the procedure showing stagnation within the aneurysm.
After the intervention, in addition to continuing oral aspirin 100 mg and clopidogrel 75 mg, argatroban 60 mg was administered over 24 h. There were no obvious findings of neurological deficits. The patient was discharged 3 days after the surgery. However, 2 days after discharge, the patient came back to our hospital with a strong headache. Conjunctival hyperemia of the left eye as well as left oculomotor nerve and trochlear nerve palsy was noted. MRI showed the occurrence of a left internal carotid-cavernous fistula (CCF;
(a) Magnetic resonance angiography showing left internal carotid-cavernous fistula. (b) Left carotid angiography showing reflux into the superior ophthalmic vein and superficial middle cerebral vein. (c) Left carotid angiography after the procedure shows little flow to the cavernous and inferior petrosal sinuses and no cortical reflux. Therefore, we decided to complete the transvenous embolization.
First, transarterial coil embolization of the ruptured aneurysm was attempted with the transcell technique. A 6Fr Axcelguide (Medikit Tokyo, Japan) was placed at the left ICA. We tried to advance the CHIKAI 14 and Headway Duo (Microvention-Terumo, California, USA) into the aneurysm through the stent mesh using a 4.2Fr FUBUKI (ASAHI INTECC, Aichi, Japan) as an intermediate catheter, which was pushed strongly against the stent. However, the Headway Duo was never advanced through the stent mesh along the CHIKAI 14, which easily went into the aneurysm. Thereafter, the CHIKAI 10 and Marathon (Medtronic, California, USA) were advanced into the aneurysm through the stent mesh after several attempts. Because only iED coils (Kaneka Medics, Kanagawa, Japan) smaller than 4 mm in size were able to pass through the Marathon, the aneurysm was not packed completely due to compartment formation, and the shunt flow was not stopped. Therefore, additional embolization with 50% n-butyl-2-cyanoacrylate was performed. However, the CCF appeared to persist on the left ICA angiography. For this reason, transvenous embolization was performed. A 7-Fr Guider (Stryker, Michigan, USA) was placed to the left inferior petrosal sinus. Headway Duo and a 45° pre-shaped Excelsior SL-10 (Stryker, Michigan, USA) were placed through the cavernous sinus and the SOV, respectively. Coil embolization of the SOV and cavernous sinus was performed. Although the shunt remained after the procedure, cortical venous reflux disappeared [
After the intervention, the patient continued to take aspirin 100 mg and clopidogrel 75 mg. The conjunctival hyperemia and trochlear nerve palsy improved, although the oculomotor nerve palsy persisted. A head MRI showed the disappearance of shunt flow. The patient was discharged 12 days after the intervention with slight left oculomotor nerve palsy (modified Rankin Scale 1); however, the symptoms improved 6 months after the intervention. The angiogram showed complete occlusion of the aneurysm and CCF, and 1 year after the surgery, only a slight eye movement disorder remained. The cerebral angiograms showed no lesion recurrence.
We reported a case of delayed aneurysm rupture that occurred after FRED placement despite the aneurysm having a low risk of delayed rupture. We attempted to alert the surgeons to the risk of delayed aneurysm rupture with FRED implantation to avoid a worse prognosis resulting from rupture. The FRED, which has been in use since 2012, has been reported to be effective and safe.[
According to our literature review, six cases of delayed rupture of aneurysms caused by the placement of a FRED have been reported.[
Regarding the Silk FD with single-layer braided design, the risk factors for delayed aneurysm rupture include large or giant aneurysms, symptomatic aneurysms, aspect ratio >1.6, and jet blood flow in the aneurysm.[
Some causes of delayed aneurysm rupture after FD implantation have been reported to be due to increased pressure in the aneurysm due to rapid thrombosis,[
For the prevention of delayed aneurysm rupture, there is no definite consensus on whether FD placement should be combined with coil embolization of the aneurysm or additional FD placement. With regard to additional coil embolization, Kulcsar et al.[
The patient developed oculomotor palsy after sinus-packing. Zhang et al.[
We reported a case of delayed aneurysm rupture that occurred after FRED implantation to alert surgeons about the possibility of this complication. The number of cases of FRED implantation is expected to increase in the future due to its ease of use and extended indications. However, even if FRED implantation is safer and the rupture rate of its aneurysm is lower than other options, delayed aneurysm rupture might still occur, as shown in this case. Careful follow-up, such as platelet aggregation evaluation and preoperative consideration on whether to add coil embolization, may help to prevent the development of delayed aneurysm rupture for patients treated with a FRED. However, it should be noted that the main limitation of this study is that only a single case was reported, and thus a mechanism could not be determined; therefore, further studies with more cases are needed.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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