March 2018

A 55-year-old Woman with Progressive Diplopia

History:
A 55-year-old female patient was referred to the outpatient clinic with double vision x3-4 weeks. Her vision gets worse when she looks on right side and improves with closure of her right eye. She denied any other symptoms.

Exam:
Awake, alert and oriented to time, place, person
Cranial nerves: Right 6th nerve palsy (right lateral rectus palsy); other CNs are intact
Strength 5/5 throughout
Sensations intact bilaterally to pinprick, light touch and temperature
DTRs – 2+ symmetric

Axial T1

Axial T2

Coronal T1 Gad+

Fig 1

Fig 2

Fig 3

Fig 4

Fig 5

Fig 6

 
1. Based on the information available, how would you classify first aneurysm with respect to its size?
2. What endovascular method is the most preferred for the treatment of this patient’s complex right cavernous aneurysm?
3. What are the long term (~5 year) complete occlusion rates after the treatment of complex cavernous aneurysm using preferred endovascular method?
4. Which of the following describes you?
5. I practice in one of the following locations.
6. Comments
7. This patient also found to have incidental left internal carotid artery bifurcation aneurysm. The aneurysm projects anteriorly. Based on morphology being the sole criteria what is the best way to treat this aneurysm?

Case Explanation 

Question 1: (Answer – C)
 
Based on size the cerebral aneurysms are classified as below:
Small: <5mm
Medium: 5-15mm
Large: 16-25mm
Giant: >25mm
 
The maximum dimension of this patient’s cavernous aneurysm is 20.1mm. Hence, it would be classified as “Large” aneurysm.
Question 2: (Answer – D)
 
Large and complex cavernous aneurysms are often difficult to treat. Thanks to recent addition in neuroendovascular tools of flow diverters. The flow diverters are high mesh density stents that helps exclude the aneurysm from parent artery. This flow diversion promotes neointimal proliferation and covering on the surface of the flow diverter stent. Ultimate result of this process is aneurysm obliteration.
 
Pipeline embolization device (PED) was introduced in 2008 and remains the only FDA approved flow diverter stent in the United States.  
Question 3: (Answer – D)
 
PUFS is a multicenter, single-arm, prospective study that evaluated the short/medium term efficacy of PED in the treatment of complex ICA aneurysms. It revealed 86.8% complete aneurysm occlusion at 1 year. Recently, 5-year results of PUFS trial were published. The study revealed 95.2% complete occlusion rates of this aneurysm with 96.3% of evaluated patients had mRS <2.
 
Question 4: (Answer – A)
 
ICA bifurcation aneurysms can be treated with both surgical and endovascular methods. Aneurysm orientation is one of the most important factors in choosing safe method of treatment. Anteriorly projecting aneurysms favors surgical while posteriorly projected aneurysms favor endovascular treatment. This is because in anteriorly projecting aneurysms surrounding lenticulostriate perforators are more visible. At the same time, anterior angulation can lead to unstable catheter position making coil embolization more challenging with possibility of incomplete results. On the contrary, posteriorly projecting aneurysms are better treated with endovascular methods.

References

  • Ishibashi T, Murayama Y, Urashima M, Saguchi T, Ebara M, Arakawa H, Irie K, Takao H, Abe T. Unruptured intracranial aneurysms: incidence of rupture and risk factors. Stroke. 2009 Jan;40(1):313-6. 
  • Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ, Woo HH, Lopes DK, Berez AL, Cher DJ, Siddiqui AH, Levy EI, Albuquerque FC, Fiorella DJ, Berentei Z, Marosfoi M, Cekirge SH, Nelson PK. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. 2013 Jun;267(3):858-68.
  • Becske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, Levy EI, McDougall CG, Szikora I, Lanzino G, Woo HH, Lopes DK, Siddiqui AH, Albuquerque FC, Fiorella DJ, Saatci I, Cekirge SH, Berez AL, Cher DJ, Berentei Z, Marosfoi M, Nelson PK. Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid Artery Aneurysms: Five-Year Results of the Pipeline for Uncoilable or Failed Aneurysms Trial. Neurosurgery. 2017 Jan 1;80(1):40-48.

Recommended Products:

Nexus Case

SANS: Vascular Module 

Guidelines for the Management of Patients with Unruptured Intracranial Aneurysms