- Department of Neurosurgery Nara Medical University, Kashihara, Nara, Japan.
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan.
Ichiro Nakagawa, Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan.
DOI:10.25259/SNI_511_2021Copyright: © 2021 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, tweak, 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: Takaaki Mitsui1, Ichiro Nakagawa1, Masashi Kotsugi1, HunSoo Park1, Shohei Yokoyama1, Kaoru Myouchin2, Hiroyuki Nakase1. Remarkable shrinkage of a thrombosed giant aneurysm by stent-assisted jam-packed coil embolization. 06-Jul-2021;12:328
How to cite this URL: Takaaki Mitsui1, Ichiro Nakagawa1, Masashi Kotsugi1, HunSoo Park1, Shohei Yokoyama1, Kaoru Myouchin2, Hiroyuki Nakase1. Remarkable shrinkage of a thrombosed giant aneurysm by stent-assisted jam-packed coil embolization. 06-Jul-2021;12:328. Available from: https://surgicalneurologyint.com/surgicalint-articles/10950/
Background: Large and giant aneurysms are known to involve intra-aneurysmal thrombosis and present a poor prognosis because of compression of the surrounding brain tissue with enlargement of the aneurysm. These aneurysms are difficult to cure by endovascular treatment due to involvement of the vasa vasorum in their pathology. We report this technical note to describe stent-assisted jam-packed coil embolization for the treatment of a giant thrombosed aneurysm.
Case Description: A 62-year-old man presented with right homonymous hemianopsia, and magnetic resonance imaging (MRI) showed a giant thrombosed aneurysm with poor wall contrast enhancement, which indicates little involvement of the vasa vasorum, at the terminal part of the left internal carotid artery. To block blood flow into the aneurysmal dome, stent-assisted “jam-packed” coil embolization was performed. For this, a braided stent was shortened to enhance metal coverage ratio and tight aneurysmal coil packing was performed using a hydrogel coil. Our technique resulted in complete obliteration of the aneurysm, and MRI performed 1 year later showed remarkable shrinkage of the aneurysm dome.
Conclusion: Stent-assisted jam-packed coil embolization technique might be effective in shrinking the dome of giant thrombosed aneurysms with poor wall contrast enhancement.
Keywords: Jam-packed embolization, Thrombosed aneurysm, Vasa vasorum, Wall enhancement
Giant intracranial aneurysms are rare, heterogeneous lesions with complex vascular anatomy.[
History and examination
A 62-year-old man with a history of hypertension and dyslipidemia became aware of visual field impairment and right upper limb weakness. 5 months later, he underwent a check-up at the hospital ophthalmology clinic, where he was diagnosed with right homonymous hemianopsia. Computed tomography (CT) showed an intracranial mass lesion, for which he was referred to the neurosurgical department of the same hospital. At that time, he had symptoms of the right homonymous hemianopsia and weakness of the right upper limb (manual motor test: 4/5).
CT imaging revealed a multilobular heterogeneous density mass with a diameter of 38 mm × 33 mm × 23 mm, which compressed the ipsilateral basal ganglia. CT angiography showed unremarkable enhancement of the mass lesion. Head magnetic resonance (MR) T1-weighted imaging showed a heterogenous mixed intensity mass buried in the left basal ganglia, and compression of the optic nerve on the contralateral side. MR T2-weighted images showed findings suggestive of partial aneurysm wall hemorrhage, with no remarkable perifocal edema in the vicinity of the dome. Contrast-enhanced MR imaging (MRI) demonstrated poor contrast enhancement of the aneurysm wall which indicates little involvement of the vasa vasorum [
In such cases, the treatment strategy of direct surgical decompression of the aneurysm can be expected to immediately improve the symptoms caused by the mass effect. However, the procedure is associated with difficulty in securing the perforators in the vicinity of the aneurysm. Hence, we decided to perform stent-assisted “jam-packed” coil embolization with the purpose of interrupting the blood supply to the dome as soon as possible.
Aspirin (100 mg/day) and clopidogrel (75 mg/day) were administered a week before the procedure. An 8-Fr long sheath was placed in the right femoral artery under general anesthesia with motor evoked potential (MEP) monitoring. Heparinization was performed to maintain the activated clotting time at over 300 s. An 8-Fr guide catheter and 6-Fr distal access catheter were introduced into the left ICA, along with microcatheters for stenting (Headway 21, Terumo, Tokyo, Japan) and coil embolization (SL-10, Stryker, US). An LVIS stent (3.5 mm × 17 mm; Terumo, Tokyo, Japan) was deployed from the MCA proximal to the ICA with 25% shortening to enhance metal coverage ratio. using the push technique [
Outcome and follow-up
Postoperative diffusion-weighted imaging showed no new ischemic lesions and no new neurological symptoms. In addition, his preexisting symptoms were alleviated and he was subsequently discharged. 3 months after the treatment, his symptoms had completely recovered and DSA showed complete obliteration of the aneurysm and stent endothelialization. MRI performed 13 months after the treatment demonstrated remarkable shrinkage of the aneurysm [
Reportedly, 67% of enlarged thrombosed aneurysms present with serious neurological symptoms,[
The mechanisms of thrombosed giant cerebral aneurysm growth have been speculated in the previous literature. Ollikainen et al. pathologically reported the involvement of vasa vasorum,[
Flow diverter treatment for large and giant aneurysms has been previously reported, and a meta-analysis proved a high rate of aneurysm occlusion with the treatment.[
Stent-assisted jam-packed coil embolization technique might be effective for shrinking the dome of giant thrombosed aneurysms to immediately blocks blood flow into the aneurysm.
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