Neurointervention.  2021 Nov;16(3):293-297. 10.5469/neuroint.2021.00241.

PulseRider Treated Aneurysm with Significant Artifact on Postoperative Magnetic Resonance Angiography: A Case Report and Literature Review

• Nguyen AV
• Reed LK
• Lesley WS

• KMID: 2522045
• DOI: http://doi.org/10.5469/neuroint.2021.00241

Abstract

The PulseRider is a neuroendovascular adjunct for wide-necked intracranial aneurysms. The decreased metal burden of the PulseRider theoretically reduces artifact on radiologic imaging. However, we report here on a case of a patient who underwent PulseRider-assisted stent-coiling of a basilar tip aneurysm. He returned 19 months later for intermittent diplopia and darkening of vision but was neurologically intact on exam. Both contrast-enhanced and time-of-flight magnetic resonance angiography (MRA) demonstrated absence of signal in the basilar artery in the proximal anchors of the PulseRider. Given his lack of reproducible symptoms and high functional status, it is presumed that the imaging reflected artifact and not thrombosis/stenosis. Although the PulseRider is a useful treatment option for wide-necked intracranial aneurysms, the clinician should be aware that even contrast-enhanced MRA can produce artifact that resembles thrombosis/stenosis. Non-angiogram radiologic imaging modalities may be appropriate for evaluation for residual aneurysm but not patency of the parent artery.

Keyword

PulseRider; Intracranial aneurysm; Stent-assisted coiling; Neuroendovascular surgery; Neurosurgery

Figure

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  Fig. 1. Diagnostic cerebral angiogram demonstrating wide-necked basilar tip aneurysm (A). Diagnostic cerebral angiogram demonstrating patent basilar artery terminating in the bilateral posterior cerebral arteries status-post PulseRider-assisted coiling (B). Black horizontal arrows denote the medial markers of the PulseRider residing in the basilar artery, and black vertical arrows denote the markers of the PulseRider residing in the posterior cerebral arteries. A black box denotes the proximal radio-opaque markers of the PulseRider where the stainless-steel proximal anchors reside. Magnetic resonance angiography (MRA) of the head utilizing time-of-flight (TOF) techniques without contrast (C) and of the neck with contrast-enhanced techniques (D). In TOF-MRA, there is complete loss of signal at the proximal portion of the PulseRider (white box) and decreased but not absent signal within the proximal P1 segments of the bilateral posterior cerebral arteries (white arrows outlined in black). In CE-MRA, the artifact is again demonstrated in the proximal portion of the PulseRider (white box). There is signal distally without filling of the aneurysm. These results indicate that flow of the basilar artery to the posterior cerebral artery is not compromised and that there is no residual or recurrent aneurysm. A coronal reconstruction of computed tomographic angiography (CTA) demonstrates significant coil artifact and also two foci of PulseRider metal artifact resembling (white arrow outlined in black) in the proximal anchoring portion of the PulseRider (E). The stainless-steel retained in the proximal anchors are likely the culprit of the MRA and CTA artifact.

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