Giant vertebral aneurysm: A case report detailing successful treatment with combined stenting and surgery

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1 SNI: Neurovsculr OPEN ACCESS For entire Editoril Bord visit : Editor: Kzuhiro Hongo, M.D., Shinsui University, Mtsomoto, Jpn Cse Report Gint verterl neurysm: A cse report detiling successful tretment with comined stenting nd surgery Griele Cpo, Mri C. Vescovi, Giovnni Tonito, Benedetto Petrli 1, Vldimir Gvrilovic 1, Mirn Skrp Deprtment of Neurosurgery, 1 Neurordiology, Aziend Snitri Universitri Integrt di Udine, Udine, Itly E mil: *Griele Cpo griele.cpo@gmil.com; Mri C. Vescovi mricterin.vescovi@gmil.com; Giovnni Tonito giovnni.tonito@liero.it; Benedetto Petrli petrli.enedetto@suiud.snit.fvg.it; Vldimir Gvrilovic - vldimir.gvrilovic@suiud.snit.fvg.it; Mirn Skrp skrp@suiud.snit.fvg.it *Corresponding uthor Received: 04 My 17 Accepted: 10 Octoer 17 Pulished: 16 Jnury 18 Astrct Bckground: Gint neurysms (>25 mm) rising from the verterl rtery (VA) often present with slow progression of symptoms nd signs ecuse of grdul rinstem nd crnil nerve compression. The underlying pthophysiology is not well understood, nd tretment, wherever possile, is tilored to ech singulr cse. Endovsculr mngement does not usully solve the prolem of mss compression, wheres surgicl tretment involves severl complictions. Cse Description: A 58 yer old womn presented with continuously growing gint right VA neurysm, prtilly thromosed, even fter endovsculr tretment (plcement of two diversion flow stents). Opertive prtil neurysmectomy nd intropertive plcement of n endovsculr lloon llowed removl from circultion without significnt leeding with good neurologicl outcome. Conclusions: The vriility of VA thromosed gint neurysms implies customized therpeutic strtegy. Comined endovsculr techniques nd surgicl clipping llow sfe nd successful trpping nd neurysmectomy. This cse highlights the enefits of treting similr pthologies with comintion of oth techniques. Access this rticle online Wesite: DOI: /sni.sni_170_17 Quick Response Code: Key Words: Endovsculr tretment, fenestrted clip, flow diverter, gint neurysm, neurovsculr surgery, temporry lloon occlusion, verterl rtery INTRODUCTION Intrcrnil neurysms (IAs) with dimeter of >25 mm rising from the verterl rtery (VA) re rre, representing 4 6% of ll intrcrnil gint neurysms. [14] They re often ssocited with thromosis ecuse of swirling lood flow nd usully present s mss lesions with slow progressive growth, cusing symptoms nd signs due to compression of the djcent rinstem. The underlying pthophysiology is not well understood yet, lthough vs vsorum seems to ply crucil role in the growth mechnism. [6,14] The ntomicl nd vsculriztion vriility implies d hoc tilored indiction nd tretment. Endovsculr coiling nd stenting, which re considered to e the tretments of choice, present high rte of lte complictions minly ecuse they do not solve the prolem of rin This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution NonCommercil ShreAlike 3.0 License, which llows others to remix, twek, nd uild upon the work non commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com How to cite this rticle: Cpo G, Vescovi MC, Tonito G, Petrli B, Gvrilovic V, Skrp M. Gint verterl neurysm: A cse report detiling successful tretment with comined stenting nd surgery. Surg Neurol Int 2018;9: Surgicl Neurology Interntionl Pulished y Wolters Kluwer - Medknow

2 Surgicl Neurology Interntionl 2018, 9:6 compression. Surgicl procedures with the removl of the neurysm from the circultion prove most effective; however, surgicl mngement is still prticulrly difficult due to prolems presented y their loction, lrge neck, clcifiction, or thromosis. CASE DESCRIPTION History A 58 yer old womn presented in nother institution with complints of hedche, dizziness, ilterl rm presthesi, nd visul disturnce. Her neurologicl exmintion showed ducens nerve plsy. A computerized tomogrphy scn (ngio CT), nd lter cererl ngiogrphy, displyed gint prtilly thromosed right VA (V4) dissecting neurysm [Figure 1], distl to the posterior inferior cereellr rtery (PICA) origin, extended to the VA silr junction. Mgnetic resonnce imging (MRI) of the posterior foss confirmed the presence of gint neurysm [Figure 2], prtilly thromosed, with mss effect on the rinstem. After eginning ntipltelet therpy, the ptient underwent two stent insertions: the first PED 3 14 (Medtronic/ Covidien, Irvine, CA) in the left VA silr junction to exclude the dissecting segment of the right VA, nd the second Silk 3 18 in the right VA PICA junction (Blt Extrusion, Montmorency, Frnce). Before dischrge, VA ngiogrms demonstrted correct plcement of diversion flow stents [Figure 3] nd n initil stsis of contrst [Figure 4]. During the following dys, the ptient experienced moderte improvements in oth convergent strismus nd initil symptoms. Unfortuntely, susequent mgnetic resonnce imging (MRI) nd ngiogrm [Figure 5] performed t 9 months fter endovsculr stenting showed persistent filling nd continued growth of the neurysm, which remined prtilly thromosed nd mintined remrkle mss effect on the rinstem. The ptient egn to deteriorte fter 6 months developing dizziness nd git txi. The ptient ws referred to our neurosurgicl center 1 yer fter the stenting, with 6 month history of worsening spstic prpresis, mild swllowing disturnce, light dysphoni, nd diplopi. A right nd left verterl ngiogrm with n occlusion test [Figure 6] ws performed using temporry occlusion silicone lloon ctheter plced t the right VA just proximl to the stent in the VA PICA. The ngiogrm showed the ptency of the PICA, the proximl prt of the VA, nd the prtil thromosed neurysm. There ws no ptency t the distl prt of the VA in conjunction with the silr rtery where the second stent ws positioned. The contrlterl left verterl ngiogrphy did not show ny reflux into the right VA. After scertining tht the ptient hd Figure 1: Cererl ngiogrphy displying gint prtilly thromosed right verterl rtery (VA, V4) dissecting the neurysm from the PICA origin to the VA silr junction Figure 2: Mgnetic resonnce imging (MRI) showing the prtilly thromosed gint neurysm with mss effect on the rinstem Figure 3: VA ngiogrms demonstrting the plcement of two diversion flow stents (rrows): the first in the left VA silr junction to exclude the right VA nd the second in the right VA PICA junction (). An initil intr neurisml stsis of contrst is visile () tolerted 15 minute test occlusion, the lloon ws removed. In ddition, the ngiogrphy indicted tht left smll rtery from the left VA supplied the neurysm.

3 Surgicl Neurology Interntionl 2018, 9:6 On second dmission, the ptient underwent right suoccipitl crniectomy followed y prtil neurysmectomy. The surgicl procedure ws preceded y the plcement of nondetchle flow dependent lloon ctheter (Blt B1, Blt Extrusion, Frnce) to e inflted during reduction of the intr neurysml thromosis nd clip positioning. The exct position nd the infltion nd defltion volume of the lloon were crefully checked severl times. A 3,000 unit of heprin olus ws injected t the eginning of the procedure. The ctheter hd een successively wshed with heprinized sline solution (5,000 units/l). When we were sure of the correct position nd the dequte volume of lloon infltion, we moved the ptient with the complete rteril femorl system to the neurosurgicl thetre. [15] Opertion We performed right suoccipitl crniotomy with the ptient under generl nesthesi long with neurophysiologicl monitoring. An endotrchel tue with electrodes ws used for monitoring the vocl cords. Upon opening the cistern mgn, the segment of VA PICA contining the flow diversion stent ws exposed. The neurysml sc ws identified nd isolted from the surrounding tissue nd crnil nerves [Figure 7]. We then inflted the lloon in the VA positioned proximlly to the PICA ecuse no temporry clipping ws possile due to the stent wheres temporry Ysrgil clip (Aesculp, Center Vlley, PA, USA) ws positioned on the distl prt of the PICA. To reduce the temporry distl occlusion of the PICA, the neurysml sc ws opened in the most proximl prt close to the PICA ifurction. Inside thromus ws rpidly removed using n ultrsonic spirtor. The decompression nd prtil neurysmectomy proceeded until it ws possile to pply fenestrted clip to mintin the PICA ptency nd exclude the distl neurysml VA dilttions [Figures 8 nd 9]. Moderte venous leeding from the neurysm wll occurred. At the end of the resection, we left the outer wll of the neurysm ttched to the rinstem, which ppered to e otherwise cler nd pulsting. The presence of mrkedly developed vs vsorum necessitted prolonged cogultion of the neurysm wll. Neurophysiologicl multimodl monitoring, used throughout the procedure, showed mild fluctutions in the electrophysiologicl prmeters. Figure 4: Three months lter the ngiogrphy shows good initil results for the endovsculr procedure with dimensionl reduction of the neurysml sc (). The closure of the neurysm ptency from the left verterl rtery flow () Figure 5: Angiogrm () nd MRI () in the following 9 months shows n enlrgement of the ptency of the neurysm nd of the mss effect on the rinstem Figure 6: Angiogrphy performed t 1 yer fter stenting. Blloon (lue rrow) test occlusion of the right verterl rtery nd right PICA. Collterl rteries (red rrow) from the right SCA supplying the territory of the ipsilterl PICA nd filling smll prt of the neurysm (green rrow) Figure 7: The neurysml sc identified nd isolted from the surrounding tissue nd crnil nerves

4 Surgicl Neurology Interntionl 2018, 9:6 Postopertive course After trnsient dmission to the intensive cre unit, the ptient ws trnsferred to the wrd. A postopertive CT scn showed no hemorrhge or ischemi in the posterior foss. During the postopertive course, the ptient experienced temporry mild worsening of her dysphoni nd dysphgi, new development of right prtil plsy of the VII crnil nerve plsy (III HB) nd left superior rm therml hypoesthesi. Lryngel endoscopy highlighted right prtil vocl cord presis with only mild dysphgi. There ws no mrked effect on her git disturnce. Speech nd rehilittion therpy ws scheduled. An ngiogrphy performed 10 dys lter showed complete resolution of the neurysm ptency, however, unfortuntely lso the PICA occlusion even if without sequele. MRI confirmed n initil reduction of mss effect on the rinstem nd cereellum nd no evidence of PICA distriution ischemi. However, the ptient s condition improved grdully; she ws dischrged 18 dys fter the surgery to rehilittion unit. After 4 months, the ptient experienced progressive nd lmost complete recovery. Now she multes independently without ssistnce, hs norml diet, nd hs right HB 1 fcil presis. Follow up ngiogrphy nd MRI were performed t 4 months fter the surgery. The ngiogrm confirmed the right PICA occlusion nd the exclusion of the neurysm from the circultion [Figure 10]. It lso showed some nstomosis etween the right superior cereellr rtery (SCA) nd terminl rnches of right PICA. MRI highlighted significnt reduction of mss effect [Figure 11]. DISCUSSION In the cse of gint VA neurysms, symptoms commonly result from the compression of neuronl structures, ischemic stroke, or neurysm rupture. Most cses reported in the literture descrie progressive enlrgement with the deteriortion of symptoms, even fter repeted endovsculr tretments. Although this enlrgement phenomenon hs een extensively studied, there is no consensus regrding the mechnisms underlying the increse of lmost completely thromosed gint neurysms presenting s mss lesions. [13,14] The tretment of similr cses is scrcely reported in the literture with every cse presenting its own unique fetures. Surgery my represent too high risk, ut on the other hnd, emoliztion lone does not gurntee the reduction of the mss effect. Quite often, the opposite result is otined, with the enlrging of the sc nd it is necessry to dopt different customized pproches to solve the prolem. [3,6,7,10,14] Moreover, ruptures following the plcement of flow diverters for lrge nd gint neurysms hve previously een reported. [2,4,5,9] Figure 8: A temporry Ysrgil clip positioned on the distl prt of the PICA, prtil neurysmectomy nd ppliction of fenestrted clip to mintin the PICA ptency Figure 9: The photogrph shows the plcement of the fenestrted clip nd the progression of neurysmectomy fter the removl of the temporry clip Figure 10: Postopertive ngiogrm (performed 4 months fter surgery) showing complete occlusion of the neurysm nd lso the PICA (, lterl view;, nteroposterior view) Attempts to tret ptients with gint verterosilr junction neurysm with comintion of flow diversion nd ypss surgery hve een chronicled previously. [8] Despite initil successful

5 Surgicl Neurology Interntionl 2018, 9:6 Figure 11: The MRI shows significnt reduction of the mss effect ( nd ) tretment, the long term outcomes of these ptients remin gurded. Blloon ssistnce surgery is not frequently used though it hs een descried since [12] Few reports with necdotl experience out the use of temporry lloon occlusion during the surgery of verterosilr neurysms hve previously een pulished in the literture. [1,11,17 19] Our ptient presented with gint VA neurysm tht continued to grow even fter proximl nd distl endovsculr tretment. The proximl stent mintined flow ptency to PICA, ut did not void sc filling; conversely, the distl stent successfully excluded the ck flow from the silr rtery. It ws not sufficient to stop the neurysm growing nd leve the compression on the rinstem. In our cse, comined use of the neurordiologicl nd surgicl tretments overcme the prolem. The vilility of the two stents hs proven to e very useful to the surgeon. The proximl stent on the PICA llowed sfe mnipultion [16] of the vessel nd positioning of the fenestrted clip. The distl stent, completely occluding the ptency, llowed the surgeon to open nd mnipulte the neurysm without the necessity of controlling the most distl nd difficult prt of the VA; finlly, the comintion of the intropertive temporry occlusion with lloon of the VA proximl prt enled the surgeon to sfely mnipulte nd exclude the neurysm with decompression of the stem. An lterntive tretment could e ypss surgery. Some uthors would hve preferred proximl occlusion nd nstomosis. During the plnning of the opertion, we did not consider ypss to the distl prt of the PICA considering tht the reinforced vessel would fcilitte the clipping without delyed complictions nd ecuse of the uneventful temporry lloon occlusion of the VA which shows collterl vessels supplying the territory of the PICA. Hence, we decided to void dditionl difficulties to this procedure nd to use fenestrted clip. Nevertheless, we did not void PICA occlusion. We did not check the flow with micro Doppler Ultrsound or ICG ngiogrphy during the surgery ecuse we were very confident of the vessel ptency s it ppered long quite long segment. However, we did not think tht we would e le to significntly modify the clip position in cse of flow reduction. In tht sitution, the only other option we would hve considered ws n nstomosis if fesile under the circumstnces. Furthermore, we did not use ntipltelet therpy nd ntivsospstic gent, which could void this compliction, considering the good postopertive course. Indeed, the ptient did not experience neurologicl deficits nd hd good collterl flow compenstion s postopertive ngiogrphy showed. After 4 months, she reched n lmost complete stisfctory recovery CONCLUSION In the cse of gint prtilly thromosed neurysm with thick wll nd rin compression, neurysmectomy should e considered s the gol. The chllenging cse presented here clerly illustrtes the usefulness of n endovsculr neurosurgicl comined strtegy to tret such cses. Using only one of these pproches could increse the risks of tretment, nd might not solve the prolem. Declrtion of ptient consent The uthors certify tht they hve otined ll pproprite ptient consent forms. In the form the ptient hs given her consent for her imges nd other clinicl informtion to e reported in the journl. The ptient understnds tht nme nd initil will not e pulished nd due efforts will e mde to concel identity, ut nonymity cnnot e gurnteed. Finncil support nd sponsorship Nil. Conflicts of interest There re no conflicts of interest. REFERENCES 1. Biles JE, Dee ZL, Wilson JA, Jungreis CA, Horton JA. Intropertive ngiogrphy nd temporry lloon occlusion of the silr rtery s n djunct to surgicl clipping: Technicl note. Neurosurgery 1992;30: Chow M, McDougll C, O Kelly C, Ashforth R, Johnson E, Fiorell D. Delyed spontneous rupture of posterior inferior cereellr rtery neurysm following tretment with flow diversion: A clinicopthologic study. Am J Neurordiol 2012;33:E Cikl U, Uluc K, Bsky MK. Microsurgicl clipping of gint verterosilr junction neurysm under hypothermic circultory rrest. Neurosurg Focus 2015;39(Video S):V Fox B, Humphries WE, Doss VT, Hoit D, Elijovich L, Arthur AS. Rupture of gint verterosilr neurysm following flow diversion: Mechnicl stretch s potentil mechnism for erly neurysm rupture. BMJ Cse Rep 2014;2014: Hmpton T, Wlsh D, Tolis C, Fiorell D. Murl destiliztion fter neurysm tretment with flow diverting device: A report of two cses. J Neurointerv Surg 2011;3:

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