J Korean Neurosurg Soc.  2025 Mar;68(2):234-240. 10.3340/jkns.2024.0178.

Strategic Dual Approach for the Management of a Symptomatic Giant Partially Thrombosed Aneurysm at the Basilar Tip - Integrating Intrasaccular Flow Diversion and Endovascular Flow Reversal

• Kim SY
• Lee JM
• Kwon SC

• KMID: 2565281
• DOI: http://doi.org/10.3340/jkns.2024.0178

Abstract

Managing giant partially thrombosed intracranial aneurysms presents significant challenges due to their unfavorable natural history and the lack of standardized treatment approaches. Conventional treatments, whether open surgical or endovascular, often struggle to manage these aneurysms effectively, resulting in high recurrence rates or significant morbidity. The patient was a 62-year-old male with a symptomatic giant partially thrombosed aneurysm at the tip of the basilar artery, presenting with left-sided hemiparesis and dysarthria. Diagnostic imaging revealed a giant aneurysm with a wide-necked, canalized portion. A two-stage endovascular treatment was conducted, involving a balloon occlusion test and intraoperative monitoring for maximum patient safety. The treatment utilized stent-assisted Woven EndoBridge (WEB) embolization and serial bilateral vertebral artery trapping. The procedure successfully isolated the aneurysm and postoperative imaging confirmed the absence of recanalization, preserving the intact posterior circulation. The patient showed stable recovery and no neurological deficits during the 12-month follow-up period. This technical note demonstrates the feasibility and efficacy of strategically integrating intrasaccular flow diversion using a WEB device and flow reversal through bilateral vertebral artery trapping for treating giant partially thrombosed aneurysms.

Keyword

Giant intracranial aneurysm; Basilar artery; Endovascular procedures; Stents

Figure

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  Fig. 1. Preoperative brain computed tomography (CT) and magnetic resonance imaging (MRI). A : Mass compressing the midbrain (CT). B : Axial T1-weighted MRI showing a hyperintense crescent-shaped area along the lesions’ lateral wall indicates intramural hemorrhage (arrows). C : Axial T2-weighted MRI displays heterogeneous signal intensities representing varying stages of thrombus formation within the partially thrombosed 25×23 mm interpeduncular aneurysm. D : Axial T1-weighted enhanced MRI showing uniform wall enhancement of the aneurysm lumen.

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  Fig. 2. Cerebral angiogram showing a patent segment of the aneurysm (10.01×10.96 mm), with a wide neck (7.42 mm). A : Anteroposterior view. B : Lateral view.

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  Fig. 3. Cerebral angiograms obtained during and after the first-stage operation. A : Stent-assisted Woven EndoBridge (WEB) embolization. A 10×5 mm WEB SL was deployed inside the sac, and a 4×30 mm stent was implanted from the left PCA to the basilar artery. B : Procedure for trapping the left vertebral artery. C and D : Post first-stage operation. Flows in the left PCA and left PICA remained intact, and flow stasis within the aneurysm sac was observed on the final angiogram. SL : single layer, PCA : posterior cerebral artery, PICA : posterior inferior cerebellar artery.

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  Fig. 4. Cerebral angiograms obtained during and after the second-stage surgery. A : During the balloon test, occlusion of the right vertebral artery was observed before the second-stage operation. B and C : Angiogram was performed at approximately 15-minute point into the balloon occlusion test, and intact flows of the basilar artery and both posterior inferior cerebellar artery were confirmed. D : Procedure for trapping the right vertebral artery. E and F : Post second-stage operation. The basilar artery aneurysm occlusion and intact flow reversal were observed on the final angiogram.

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  Fig. 5. Follow-up transfemoral cerebral angiography at postoperative month 7 showed no signs of aneurysm sac recanalization, with sustained flow of the upper basilar artery through the posterior communicating artery. A : Anteroposterior view. B : Lateral view.

Reference

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