Innovation in endovascular treatment of top basilar aneurysms - Ep.1/4

Endovascular occlusion is the treatment of choice for basilar tip aneurysm. However, the anatomy of the basilar tip and the frequently broadbased setup of basilar tip aneurysm may make treatment challenging.

Diverse strategies has been created to empower secure and successful endovascular treatment of bifurcation aneurysms counting balloon and stent assistance, neck-bridging devices and intrasaccular devices. However, all of these methods need some delicated steps, making the strategy complex and lead to device and/or procedure-related complications.

A scientific review of 235 cases showed recanalization rate of coil, stent, and Y stent as 38.9%, 19.2% and 8.3% respectively.

Here in this session, experts are debating scientifically about the several type of treatment and their efficacy, safety, reproducibility and durability.

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First interesting case:

A 52 years old male smoker, without medical history, he is having aura without headache. On CT brain there is 7.5x7 mm basilar tip saccular aneurysm.

In such challenging location, what are the treatment available?

Treatment options according to showed up simulation was as follow:

1- Y stenting.

But the important question here is which PCA to stent first? 

The more difficult one is to be tented first.

another important question is, are you going to jail the catheter?

Yes.

Tips and tricks for Y stent:

If the aneurysm is big enough, use 2 closed cell stent e.g. EVO stent for better flow diversion. When its a small aneurysm like this one, use open cell stent and another closed cell stent.

2- Intrasaccular device like web or contour which were tested on simulation.

3- The discussion was shifted to the hospital online and the expert said that he is using open cell stent (2 Pegasus hbc) or braided stent.

4- An innovated treatment was discussed which is a device called Eclip that has anchor part and aneurysm cover leaf-like part.

So, what is the technique for deployment of such device? 

Push the anchor part into the easy accessible branch for anchoring and then cover the neck of aneurysm by the leaf-like part, then deploy in the opposite branch.

Sizing: there is 4 sizing for non-flow diverting type and only one size for the flow diverting type.

How to select the suitable size? 

We select the size according to the neck size.

Procedural safety of this device: Is almost the same as other devices but there is no thromboembolic event beyond the procedure and that is probably by nontubular nature of the device and better wall apposition, this is under study and its expected to get final evaluation in one year.

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Another interesting but more complicated case:

A 75 year old female, smoker with history of hypertension and family history of sister died of ruptured intracranial aneurysm. On CT brain she has ruptured basilar tip aneurysm which is 17x14x15mm, she got ventriculomegaly and it was controlled with VP shunt, she don’t have PCOMs. Her GCS is 9.

In such challenging case, what are the treatment available?

Treatment options according to the scientific debate as follow:

1- Intrasaccular contour device: it could treat the aneurysm but its not enough, (its too big aneurysm for a web, so no web consideration)

2- Two flow diverters from PCAs to basilar and then aneurysm coiling.

3- Two eclipse ballon to protect SCAs and PCAs and stablize the procedure, then embolize the aneurysm with coils.

How to go around such big aneurysm without looping into it? 

By an innovative technology called Deflectable guide-wire which is a wire that can be torque from distance without needing to shape the wire tip, that help to choose branches easily.

4- Two flow diverter silk vista baby stent and coiling.

Is there any tips and tricks for this way of treatment? 

Yes , (1) if a vessel is 4mm you need two 3mm stent to fill it because two 2 mm stents will leave space around in the vessel, (2) both proximal end of stents must be at the same level to prevent over-expansion of one stent and fish-mouth of the other stent.

This kind of treatment will have higher level of thrombosis event so the patient should get higher dose of antiplateletes, which will increase risk of intracranial bleeding.

The aneurysm was treated with coiling and it showed recanalization in 6 months follow up (which is expected in these aggressive large aneurysm)