Endovascular Treatment for Thrombosed Giant Fusiform Vertebral Artery Aneurysm: A Rare Case Report

Abstract

Giant fusiform aneurysm of the vertebral artery is not common and is usually associated with thrombosis due to swirling blood flow, and manifests as mass effect on the medullary region with slow progression of neurological sign and symptoms. Trapping and ligation combined with bypass surgery, endovascular surgery, and proximal occlusion and flow diverter placement have been described; however, the optimal treatment is still debatable. A 35-year-old female presented to us with complaints of mild occipital headache, moderate pain over the right side of the nape region, numbness, and tingling sensation transferring to the right upper shoulder for 1 month. Magnetic resonance imaging (MRI) of cervical spine and brain revealed normal cervical spine. Brain MRI and digital subtraction angiography were done that revealed an almost completely thrombosed giant fusiform aneurysm of the V4 segment of the vertebral artery. Patient underwent endovascular therapy with complete coils packing. Postoperative status went uneventful. She was discharged on the 7th day of procedure. Complete occlusion of thrombosed giant fusiform V4 segment vertebral artery aneurysm by endovascular therapy with coils embolization is safe and effective.

Keywords

thrombosed - giant fusiform aneurysm - vertebral artery - coils embolization - outcome

Introduction

Giant fusiform aneurysm of the vertebral artery (VA) is one of the rare vascular entities, describing 4 to 6% of all intracranial giant aneurysm.[1] [2] [3] [4] These fusiform aneurysms usually present with thrombosis because of turbulent blood flow and gradually become larger causing mass effect on the medulla oblongata resulting in poor prognosis. Open surgical clipping with decompression by aneurysmectomy could relieve mass effect earlier. Surgical therapy for such aneurysms is effective; however, it is challenging in consequence of their location on the medulla oblongata, wide necked, and intra-aneurysmal thrombosis.[2] [3] [5] [6] With advancement of techniques and tools, endovascular therapies (EVTs) have been well established for these aneurysm treatments at present date. Furthermore, EVT is usually applied for unruptured giant fusiform VA aneurysm and could not relieve from mass effect, which may result in continuous compression causing medulla oblongata infarction, leading to death.[7] Therefore, we report a case of almost completely thrombosed giant fusiform unruptured aneurysm of V4 segments of VA that was treated by EVT with complete occlusion of the aneurysm by coil packing.

Case Presentation

Case Presentation and Endovascular Technique

A 35-year-old young female without any relevant medical or traumatic history visited our hospital due to mild posterior headache, pain along with numbness, and tingling sensation over the right posterior neck and shoulder for 1 month, but severe right posterior neck pain for 1 day before admission. Magnetic resonance imaging (MRI) of cervical spine was done, which reveled normal cervical spine. Brain MRI was done for further investigation, which reported an almost complete thrombosed giant dolichoectatic right VA causing compression upon the adjacent medulla oblongata and inferior pons ([Fig. 1A] and [B]). Digital subtraction angiography (DSA) was also done for further evaluation of the vascular anatomy, which revealed an almost completely thrombosed giant fusiform aneurysm of the V4 segment of the right VA measuring 35.55 mm (length) × 7.16 mm (maximum diameter) × and 4.00 mm (minimum diameter) ([Fig. 1C]). Proximal part of the aneurysm of the VA was normal. Posterior inferior cerebellar artery (PICA) originated just proximal to the origin of the aneurysm. No any major branches or perforators were seen around the aneurysm. Patient did not have any other neurological symptoms except neck pain and numbness. On DSA, the anterior spinal artery, which has a potential risk of thrombus occlusion, was not seen ([Fig. 1G] and [L]).

Fig. 1 Axial and sagittal section of T2-weighted brain magnetic resonance imaging (MRI) showing almost complete thrombosed fusiform aneurysm of vertebral artery over the medullary region (A). Lateral view of the left vertebral artery injection (digital subtraction angiography [DSA]) and three-dimensional (3D) DSA showing almost completely thrombosed giant aneurysm of the V4 segment of the right vertebral artery measuring 35.55 mm (length) × 7.16 mm (maximum diameter) × 4.00 mm (minimum diameter) (B and C). Digital subtraction angiography (D) showing fusiform aneurysm with guiding catheter(yellow arrow), first microcatheter, SL-10 (blue arrow), and second microcatheter, Phenom-17 (red arrow). DSA (E) showing deployment of the first two coils and yellow arrow showing Sterling Monorail percutaneous transluminal angioplasty (PTA) balloon dilation catheter, 4F, 4.5 mm × 20 mm. DSA (F and G) showing complete occlusion of aneurysm with coils with patency of contralateral vertebrobasilar artery. Postoperative bone and brain window computed tomography (CT) of head showing complete embolized aneurysm without hemorrhage and infarction (H). Follow-up CT head at 1 month and brain MRI at 3 months showing normal brain, brainstem, and spinal cord without any infarction (I–L).

EVT was performed under general anesthesia using a monoplane DSA machine (Siemens, Germany). Bilateral femoral artery accesses were performed with 6F femoral sheath, and 5,000 IU heparin was given from right femoral sheath. Activated clotting time (ACT) was measured for the evaluation of anticoagulation. ACT value (> 250 seconds) was aimed to double the baseline ACT value after heparin injection. Note that 6F distal access guiding catheter, Envoy (Cerenovus, Johnson & Johnson), was navigated in few centimeters proximal to the PICA through 0.035 inch gliding wire (Terumo; Cook Medical). A diluted concentration of 1,000 IU heparin/1,000 mL normal saline was administered slowly through both guiding sheaths (Envoy) continuously throughout the procedure. Similarly, 10 mL nimodipine/1,000 mL normal saline was administered slowly with microcatheter (Excelsior SL-10; Stryker Neurovascular, United States) throughout the procedure. Envoy (Cerenovus, Johnson & Johnson) was navigated in the left VA to observe patency of posterior circulation, which was kept till complete occlusion of the aneurysm. Sterling Monorail percutaneous transluminal angioplasty (PTA) balloon dilation catheter, 4F, 4.5 mm × 20 mm (Boston), was advanced across the vertebrobasilar junction through left Envoy to prevent distal migration of coils and thrombus till the first two coils were deployed. Microcatheter (Excelsior SL-10) was advanced near the distal part of the aneurysm and the second microcatheter Phenom 17 (Medtronic, Irvine, California, United States) was advanced toward the proximity of the aneurysm through a 0.014 inch microwire (Synchro 2 soft; Stryker Neurovascular, United States; [Fig. 1D]). Then, the microwire was removed and Target 360 supersoft 10 mm × 30 cm sized coil (Stryker Neurovascular) was deployed through the first microcatheter (SL-10) and then Axium Prime Extra Soft 10 mm × 40 cm sized coil (EV3 Neurovascular, Medtronic) was advanced through Phenom 17, but was not deployed till third coil, Axium Prime Extra Soft, 25 mm × 50 cm (EV3 Neurovascular) was advanced through SL 10. Axium Prime Extra Soft 22 mm × 50 cm deployment was done by SL 10. Afterwards, SL-10 was advanced in the right PICA for supporting coil packing as well as for preventing from the prolapse of coils into the PICA. Then, Axium Prime Extra Soft 10 mm × 30 cm and 8 mm × 30 cm and Target 360 super soft 8 mm × 20 cm were deployed one by one through the microcatheter, Phenom -17, and PTA balloon ([Fig. 1E], yellow arrow) where complete coil embolization was seen ([Fig. 1F] and [G]). Postoperative period went uneventful ([Fig. 1H]). She was discharged well on tablet aspirin 75 mg/day. Patient was counseled to follow-up at 1, 3, 6, and 12 months following discharge from hospital. Angiographic evaluation was decided to be obtained at 6 months after the procedure until the patient had any neurological compromise. She visited the hospital with improvement in her symptoms without any new symptoms at the first and second follow-up period. So we advised only computed tomography head at the first follow-up period and brain MRI was done at the second follow-up period ([Fig. 1I–L]).

Discussion

Giant fusiform aneurysm of the V4 segment of the VA with thrombosis is rarely reported among giant intracranial aneurysm.[8] The major causative factor of vertebral aneurysm such as trauma, arteriosclerosis, vasculitis, as well as connective tissue disorder have been reported in previous literatures.[9] [10] In our report, the patient had no history of trauma, medical illness, and serological abnormalities, which is consistent with the report of other study.[11] Thrombosed fusiform aneurysm of the VA expand gradually into giant aneurysm resulting in compressive mass effect on the medulla oblongata.[5] The precise mechanism for growth of VA aneurysm is unclear, even though intra-aneurysmal thrombosis, repeated hemorrhage and remodeling of the wall of aneurysm,[12] and obvious vasa vasorum development on the occluded parent artery[4] have been explained in previous literature.

Our patient had symptoms including mild occipital headache, severe right posterior neck pain, numbness, and tingling sensation over the right shoulder, which may be compression of the brainstem or abnormal pulsation of giant thrombosed aneurysm. Similarly, the following symptoms such as headache, dizziness, dysarthria, diplopia, dysmetria, hearing loss, neck pain, dysphasia, gait disturbance, hemi- or tetraparesis, or paraparesis have been found associated with giant fusiform VA aneurysm.[8] [13] [14] [15] Thrombosed VA aneurysms widen gradually and may rupture, which can be fatal for the patient, therefore earlier treatment strategies should be thought. Thrombosed giant aneurysm is one of the troublesome vascular diseases, and these can be managed by thrombectomy with clip reconstruction or bypass with parent artery occlusion other than traditional clipping alone.[4] [15] Surgical treatment is effective for instant relief from mass effect; however, it is challenging because of the location of the aneurysm near the brainstem and vascular tortuosity, and for these reasons good experience, knowledge, and skills of skull base surgery should be necessitated.[16] EVT, internal trapping with coils, and flow diverter stenting for such thrombosed large or giant fusiform VA aneurysms are the established choice of treatment methods; however, these EVTs are associated with higher rate of ischemic complications, morbidity, and mortality compared to anterior circulation aneurysm.[4] [7] [17] Occlusion of the ipsilateral VA may lead to ischemic changes of 8% if blood flow in the contralateral VA is inadequate.[18] Therefore, reconstruction procedure is adopted if VA on the aneurysm side does bear ischemic changes.[19] In our patient, deconstruction method was contemplated to be sustainable because the aneurysm of the V4 segment of VA was almost completely thrombosis with no major neurological symptoms except neck pain and numbness and blood flow to both PICA from both ipsilateral VA.

Our patient had an almost completely thrombosed giant fusiform unruptured aneurysm of V4 segments of VA who was treated by EVT with complete coil packing of the aneurysm. We performed double microcatheter technique. We first deployed coils in more distal part of the aneurysm and coil packing was done one by one from distal to proximal. Envoy (Cerenovus, Johnson & Johnson) was navigated in the left VA to observe patency of posterior circulation during embolization. Sterling Monorail PTA balloon dilation catheter, 4F, 4.5 mm × 20 mm (Boston), was advanced to the left, Envoy, across the junction of the vertebrobasilar artery to prevent migration of coils and thrombus distally. EVT with trapping for the management of thrombosed large or giant VA aneurysm may be effective for aneurysm at the nonbranching site.[4] [8] Similarly, Masahiro et al.[8] described the management of thrombosed large fusiform VA aneurysm by short segment internal trapping using N-butyl-2-cyanoacrylate and platinum coils. Furthermore, internal trapping for short distance with few coils alone might cause incomplete aneurysm occlusion when distance between aneurysm and perforator or branching vessels such as PICA is extremely short, which might be associated with medulla oblongata infarction.[8] [20] [21] But, if a large number of coils are placed in fusiform aneurysm to complete trapping it may get worse by mass effect.[8] In this report, we described a complete occlusion of aneurysm with double microcatheter technique along with support of PTA balloon maintaining patency of contralateral VA and PICA and no neurological deficit and infarction was reported after the procedure in our patient. However, the treatment by endovascular therapy for thrombosed large or giant VA aneurysm is not only the treatment strategy (destructcive or constructcive) with device (stent, coils or flow diverter), but also long term occlusion. Even with internal/external trapping, aneurysm may change and regrow in the long term, so we can say that the aneurysms have been cured after observation for several years or more. Therefore, this report has some limitations like it is retrospective, a case report, and short-term follow-up period. Therefore, long-term clinical and radiological outcomes are required to assess the effectiveness of this present report.

Conclusion

Giant fusiform aneurysm of the V4 segment of the VA associated with almost completely thrombosed may mimic symptoms of cervical radiculopathy. Complete occlusion of almost completely thrombosed giant fusiform V4 segment VA aneurysm by EVT with coil embolization is safe and effective. To validate this report more investigations and analysis of further cases and observation of long-term follow-up data are required.

Conflict of Interest

None declared.

Authors' Contributions

M.K. conceived and designed study, collected data, and wrote and drafted the manuscript. G.R. was responsible for editing and providing technical feedback with design and analyses.

Ethical Approval

This is a retrospective study so informed consent was taken from the institute and all involved participants included in this study.

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Publikationsverlauf

Artikel online veröffentlicht:
10. März 2025