Neurointervention.  2024 Nov;19(3):162-168. 10.5469/neuroint.2024.00353.

Technical Approaches for Coil Embolization of Unruptured Small Anterior Choroidal Artery Aneurysms: A Focus on Anatomical Flow Preservation of the Anterior Choroidal Artery

• Suh DC

• KMID: 2560220
• DOI: http://doi.org/10.5469/neuroint.2024.00353

Abstract

The anterior choroidal artery (AChA) supplies the corticospinal tract related to the motor function of the upper and lower limbs. Aneurysms arising at the AChA are not common and exhibit various patterns of involvement of the AChA. Hence, managing an AChA aneurysm poses a high risk of neurological deficits. We report technical issues related to the outcome of coil embolization for unruptured AChA aneurysms. We obtained Institutional Review Board approval for this study. In the past 2 years, 18 consecutive patients (6 males and 12 females, aged 32–68) with unruptured AChA aneurysms were treated using embolization. We present technical details, pre- and post-procedural patient statuses, angiographic outcomes, and recurrence during a mean follow-up period of 12 months (range 3–25). The patients with AChA (n=18) underwent stent-assisted coiling (n=14), coiling (n=2), or stenting only (n=2). The technical strategy for aneurysm embolization included a low-lying approach into the aneurysm, stent-strut abutting (protecting) coil framing to block inflow and avoid compromising AChA flow, and direct intra-aneurysmal angiography via a microcatheter. Angiographic results showed complete occlusion (n=11), neck remnant (n=5), and sac remnant (n=2). During the follow-up, there were 2 recurrences, and 1 of them required a re-procedure. All patients showed no change in clinical status (modified Rankin scale score=0) and did not experience any ischemic or hemorrhagic events during the follow-up period. AChA aneurysms can be managed through embolization using various techniques. Such technical concepts may enhance the safety and improve the outcomes of AChA aneurysm embolization.

Keyword

Aneurysm; Coil embolization; Anterior choroidal artery; Technique

Figure

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  Fig. 1. Schematic technical concept diagrams of stent-assisted coiling for an anterior choroidal artery (AChA) aneurysm. (A) After a stent is deployed, a microcatheter enters the aneurysm using a low-angle approach technique just above the AChA origin through the stent. (B) Coils were packed by creating a vertical barrier between the stent and the adjacent aneurysm wall to ensure that the flow into the AChA was not compromised. (C) Note the triangular-shaped inflow zone (asterisks in a magnified box figure) designed to protect the inflow zone to the aneurysm and preserve the flow into the AChA.

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  Fig. 2. To show the anterior choroidal artery (AChA) origin within the aneurysm, (A) intra-aneurysmal injection (B) was performed to demonstrate the exact origin of the AChA, which arose from the aneurysm sac (arrow).

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  Fig. 3. An anterior choroidal artery (AChA) aneurysm with a distinctive bleb (Case 12). (A) Note the AChA arises in the sac. (B) A coil was introduced to establish a flow barrier between the stent strut and the aneurysm wall (long arrow) using a low-lying microcatheter (short arrow) positioned in front of the AChA origin. (C) The final angiogram shows a remnant sac diverting the flow into the AChA (arrow). (D) A 15-month follow-up magnetic resonance angiography shows no recurrence of the aneurysm.

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  Fig. 4. A male in his forties (Case 11) with tandem aneurysms (A) at the origin of the right anterior choroidal artery. One year after stent-assisted coiling (B), there was a recurrence (C). Re-embolization was performed by adding more coils within the recurrent sac (not shown).

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