J Cerebrovasc Endovasc Neurosurg.  2023 Jun;25(2):208-213. 10.7461/jcen.2022.E2022.06.007.

Retreatment of a recurrent giant aneurysm of the internal carotid artery after treatment with a flow-diverting stent

• Kim G
• Kim J
• Park SK
• Chung J

• KMID: 2543518
• DOI: http://doi.org/10.7461/jcen.2022.E2022.06.007

Abstract

Flow-diverting stents (FDSs) have proven advantageous for the treatment of large, fusiform, and dissecting aneurysms that are otherwise difficult to treat. Retreatment strategies for recurrent large or giant aneurysms after FDSs are limited to overlapping implantation of an additional FDS or definitive occlusion of the parent vessel. We report a recurrent giant aneurysm that was initially treated with an FDS with coils and was successfully treated with an additional FDS. Visual symptoms due to the mass effect of the recurrent aneurysm were completely resolved, and follow-up digital subtraction angiography revealed complete obliteration of the aneurysm. Additional FDS implantation for the retreatment of incompletely occluded aneurysms after the initial FDS treatment may be feasible and safe. Further studies are required to validate these results.

Keyword

Endovascular treatment; Flow diverter; Internal carotid artery; Intracranial aneurysm; Recurrence

Figure

• 

  Fig. 1. Radiological findings from another hospital. (A) Right middle cerebral artery infarction was seen on magnetic resonance images. (B) Computed tomography angiography revealed an incidental giant aneurysm on the right internal carotid artery with a maximum diameter of approximately 26.3 mm.

• 

  Fig. 2. Three weeks after the cerebral infarction, the giant aneurysm was treated by a flow diverting stent (Surpass Evolve, 5.0 mm×20 cm;Stryker Neurovascular, Kalamazoo, MI, USA) and additional partial coil insertion at the other hospital. After 3 months, the patient’s visual field gradually began to narrow, and he came to our hospital near blindness. (A) Visual field examination revealed that bitemporal hemianopsia overlapped pre-existing left homonymous hemianopsia. (B) On the follow-up magnetic resonance images, the size of the aneurysm increased with a mass effect on the optic nerves. As the aneurysm grew, the optic chiasm was compressed by the mass effect, causing the bitemporal hemianopsia. (C) Digital subtraction angiography was performed, and a recurrence was observed in the neck of the aneurysm.

• 

  Fig. 3. Six months after retreatment with a flow diverting stent (Surpass Evolve, 4.5 mm×20 cm, Stryker Neurovascular, Kalamazoo, MI, USA) deployed inside the previous flow diverting stent, (A) the bitemporal hemianopsia had improved, the visual field became wider, and (B) complete obliteration was achieved on the follow-up digital subtraction angiography.

Reference

1. Brinjikji W, Lanzino G, Cloft H, Siddiqui A, Boccardi E, Cekirge S, et al. Risk factors for ischemic complications following pipeline embolization device treatment of intracranial aneurysms: results from the IntrePED study. Am J Neuroradiol. 2016; Sep. 37(9):1673–8.

2. Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke. 2013; 44(2):442–7.

3. Carneiro A, Rane N, Küker W, Cellerini M, Corkill R, Byrne JV. Volume changes of extremely large and giant intracranial aneurysms after treatment with flow diverter stents. Neuroradiology. 2014; Jan. 56(1):51–8.

4. Daou B, Atallah E, Chalouhi N, Starke RM, Oliver J, Montano M, et al. Aneurysms with persistent filling after failed treatment with the pipeline embolization device. J Neurosurg. 2018; Apr. 1–7.

5. Fang Y-B, Lin A, Kostynskyy A, Agid R, Tymianski M, Radovanovic I, et al. Endovascular treatment of intracranial vertebrobasilar artery dissecting aneurysms: parent artery occlusion versus flow diverter. Eur J Radiol. 2018; Feb. 99:68–75.

6. Goertz L, Hesse N, Liebig T, Ahmad W, Abdullayev N, Krischek B, et al. Retreatment strategies for recurrent and residual aneurysms after treatment with flow-diverter devices. Neuroradiology. 2020; Aug. 62(8):1019–28.

7. Halbach VV, Higashida RT, Dowd CF, Barnwell SL, Fraser KW, Smith TP, et al. The efficacy of endosaccular aneurysm occlusion in alleviating neurological deficits produced by mass effect. J Neurosurg. 1994; Apr. 80(4):659–66.

8. King B, Vaziri S, Singla A, Fargen KM, Mocco J. Clinical and angiographic outcomes after stent-assisted coiling of cerebral aneurysms with Enterprise and Neuroform stents: a comparative analysis of the literature. J Neurointerv Surg. 2015; Dec. 7(12):905–9.

9. Lv X, Yang H, Liu P, Li Y. Flow-diverter devices in the treatment of intracranial aneurysms: a meta-analysis and systematic review. Neuroradiol J. 2016; Feb. 29(1):66–71.

10. Muskens IS, Hertgers O, Lycklama à Nijeholt GJ, Broekman ML, Moojen WA. Outcomes of retreatment for intracranial aneurysms—a meta-analysis. Neurosurgery. 2019; Dec. 85(6):750–61.

11. Oishi H, Teranishi K, Yatomi K, Fujii T, Yamamoto M, Arai H. Flow diverter therapy using a pipeline embolization device for 100 unruptured large and giant internal carotid artery aneurysms in a single center in a Japanese population. Neurol Med Chir (Tokyo). 2018; Nov. 58(11):461.

12. Piotin M, Blanc R, Spelle L, Mounayer C, Piantino R, Schmidt PJ, et al. Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke. 2010; Jan. 41(1):110–5.

13. Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke. 2003; Jun. 34(6):1398–403.

14. Rouchaud A, Leclerc O, Benayoun Y, Saleme S, Camilleri Y, d’Argento F, et al. Visual outcomes with flow-diverter stents covering the ophthalmic artery for treatment of internal carotid artery aneurysms. Am J Neuroradiol. 2015; Feb. 36(2):330–6.

15. Shapiro M, Becske T, Nelson PK. Learning from failure: persistence of aneurysms following pipeline embolization. J Neurosurg. 2017; Feb. 126(2):578–85.

16. Zhu D, Yan Y, Zhao P, Duan G, Zhao R, Liu J, et al. Safety and efficacy of flow diverter treatment for blood blister–like aneurysm: a systematic review and meta-analysis. World Neurosurg. 2018; Oct. 118:e79–86.