Neurointervention.  2021 Nov;16(3):267-274. 10.5469/neuroint.2021.00269.

Use of Distal Intracranial Catheters for Better Working View of Cerebral Aneurysms Hidden by Parent Artery or Its Branches: A Technical Note

• Mahmoud E
• Lenell S
• Nyberg C
• Borota L

• KMID: 2522041
• DOI: http://doi.org/10.5469/neuroint.2021.00269

Abstract

A good working view is critical for safe and successful endovascular treatment of cerebral aneurysms. In a few cases, endovascular treatment of cerebral aneurysms may be challenging due to difficulty in obtaining a proper working view. In this report of 6 cases, we described the advantage of using a distal intracranial catheter (DIC) to achieve better visualization of cerebral aneurysms hidden by a parent artery or its branches. Between September 2017 and January 2021, we treated 390 aneurysms with endovascular techniques. In 6 cases in which it was difficult to obtain a proper working view, the DIC was placed distally close to the aneurysm in order to remove the parent artery projection from the working view and obtain better visualization of the aneurysm. Clinical and procedural outcomes and complications were evaluated. The position of the DIC was above the internal carotid artery siphon in the 6 cases. All aneurysms were successfully embolized. Raymond–Roy class 1 occlusion was achieved in all 4 unruptured aneurysms, while the result was class 2 in the 2 ruptured aneurysms. Placement of the DIC was atraumatic without dissections or significant catheter-induced vasospasm in all patients. Transient dysphasia was seen in 2 cases and transient aphasia in 1. Using this technique, we have found it possible to better visualize the aneurysm sac or neck and thereby treat cases we otherwise would have considered untreatable.

Keyword

Aneurysm; Intracranial aneurysm; Cerebral angiography; Endovascular techniques; Neuroimaging

Figure

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  Fig. 1. (A) 3D reconstruction showing the best working view and the aneurysm sac hidden by the ICA. (B) Same working projection after the ICA had been sculpted. (C) DIC tip (arrow) located in proximal A1 segment. (D) Contrast injection into the ICA proximally, showing aneurysm sac hidden by the ICA. (E) Contrast injection into the DIC in the A1 segment with better visualization of aneurysm sac and neck. (F) Post coiling angiographic control demonstrates aneurysm obliteration. 3D, 3-dimensional; ICA, internal carotid artery; DIC, distal intracranial catheter.

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  Fig. 2. (A) 3D reconstruction showing the best working view and the neck of the MCA aneurysm and origin of lower M2 segment hidden by the ICA. (B) Contrast injection into the left ICA shows aneurysm neck hidden by the ICA. (C) Contrast injection into the DIC in the M1 segment with better visualization of the aneurysm neck and origin of M2 segments. (D) Microcatheter placed in lower M2 segment (arrow). (E) Angiographic run without subtraction showing both stents in place (arrows) and microcatheter jailed in the aneurysm. (F) Post coiling angiographic control demonstrates obliteration of the aneurysm. 3D, 3-dimensional; MCA, middle cerebral artery; ICA, internal carotid artery; DIC, distal intracranial catheter.

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  Fig. 3. (A) 3D reconstruction showing the best working view and the Acom aneurysm sac hidden by the ICA. (B) Same working projection after the ICA had been sculpted. (C) Contrast injection into DIC in the carotid terminus showing better visualization of aneurysm sac and neck (arrow). (D) Post coiling angiographic control showing obliteration of the aneurysm. (E) Angiogram obtained by contrast injection into the ICA proximally shows the aneurysm sac hidden by the ICA. (F) Post-coiling 3D reconstruction confirms the obliteration of the aneurysm and preservation of the parent vessels. 3D, 3-dimensional; Acom, anterior communicating artery; ICA, internal carotid artery; DIC, distal intracranial catheter.

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