Neurointerventional Report

Neuroform Stent-Assisted Coil

Embolization of a Ruptured A1

Segment Anterior Cerebral

Artery Aneurysm

Rishi Gupta, MD

Michael B. Horowitz, MD

Steven Gilman, MD

A B S T R A C T

We report a case of a 71-year-old woman who presented with

a ruptured wide-necked proximal anterior cerebral artery (ACA)

aneurysm that was successfully embolized using Neuroform

stent-assisted coiling.

Key words: Neuroform stent, aneurysm, anterior cerebral

artery.

Gupta R, Horowitz MB, Gilman S.

Neuroform stent-assisted coil embolization of a ruptured A1

segment anterior cerebral artery aneurysm.

J Neuroimaging 2006;16:117-119.

DOI: 10.1111/j.1552-6569.2006.00033.x

Introduction

Proximal A1 anterior cerebral artery (ACA) aneurysms

are responsible for less than 4% of cerebral aneurysms

and are associated with a multiplicity of aneurysms.1 They

represent a technical challenge for surgical clipping due

to the frequent adherence of basal perforating arteries to

Received June 6, 2005, and in revised form August 10,2005. Accepted for publication October 26, 2005.

From the Department of Neurology, Stroke Institute,University of Pittsburgh Medical Center, Pittsburgh, PA(RG); Department of Neurosurgery, University of Pitts-burgh Medical Center, Pittsburgh, PA (MH); Departmentof Neurosurgery, Erie Medical Center, Erie, Pennsylvania(SG).

Address correspondence to Michael B. Horowitz, MD,Department of Neurosurgery, University of PittsburghMedical Center, 200 Lothrop Street, Suite B-400, Pitts-burgh, PA 15213. E-mail: horowitzmb@upmc.edu.

the aneurysm and thus carry a morbidity of 10-18% de-

pending on the case series.2,3 These aneurysms are often

fusiform and irregular, but can present with a wide neck

configuration.1

Endovascular treatment of wide-necked aneurysm

represents a technical challenge due to suboptimal

aneurysm occlusion and coil herniation into the parent

vessel. The use of balloon remodeling4 has allowed for

improved treatment of these aneurysms, but the recent

approval of the self-expanding Neuroform stent (Boston-

Scientific/Target Therapeutics, Fremont, CA) has yielded

an alternative method of treatment. There have been

several published reports and case series on the use of

stent-assisted coiling of the posterior circulation, carotid

artery, and middle cerebral artery aneurysms,5-8 but little

is known of utilizing this technique for the uncommon

proximal ACA aneurysm.

Case Report

A 71-year-old woman with a history of hypertension pre-

sented to our institution with a Hunt and Hess grade

IV/Fisher III subarachnoid hemorrhage. CT scan of

the head revealed early hydrocephalus with blood in

the interhemispheric fissure and basilar cistern. After

placement of an external ventricular drainage system,

the patient underwent cerebral angiography to deter-

mine the aneurysm’s location. The initial angiogram re-

vealed a wide-necked 7 × 10 mm left A1 segment ACA

aneurysm (Fig 1A). An injection from the right com-

mon carotid artery with cross-compression showed fill-

ing of both ACAs. Consideration was thus given to trap-

ping the aneurysm but there was concern for the loss of

the basal perforating branches and the recurrent artery

of Heubner from the A1 segment. Thus, stent-assisted

coiling was considered. After placement of a 6-French

Envoy guide catheter (Cordis, Miami Lakes, FL) in the

Copyright ◦C 2006 by the American Society of Neuroimaging 117

Fig 1. (A) A wide-necked proximal left A1 segment of the anterior cerebral artery aneurysm measuring 7 × 10 mm (white

arrow). (B) A 3.5 × 20 mm Neuroform stent (black arrowheads) was deployed across the neck of the aneurysm in the A1

segment in order to prevent coil herniation and loss of basal perforators. (C) A Prowler-14 microcatheter (white dashed arrow)

was navigated into the aneurysm through the interstices of the stent (black arrowheads). (D) A final angiographic run shows

preservation of the proximal anterior cerebral artery with complete occlusion of the aneurysm (black arrow).

left internal carotid artery (ICA), a Prowler-14 (Cordis,

Miami Lakes, FL) microcatheter and Transend (Boston

Scientific, Fremont, CA) microwire were gently navigated

across the neck of the aneurysm into the ipsilateral A2-A3

segment of the ACA. A 0.014-inch microwire (Transend

300 cm) was then exchanged through the microcatheter.

A 3.5 × 20 mm Neuroform self-expanding stent (Boston-

Scientific/Target Therapeutics, Fremont, CA) was de-

ployed across the neck of the aneurysm in the A1 segment

(Fig 1B).

The aneurysm was then catheterized through the in-

terstices of the stent using a Prowler-14 microcatheter

(Cordis, Miami Lakes, FL) and a Transcend (Boston-

Scientific/Target Therapeutics) 0.014-inch microwire

118 Journal of Neuroimaging Vol 16 No 2 April 2006

(Fig 1C). Coil embolization was performed using two

10-mm Micrus (Micrus Corp., Mountain View, CA) fram-

ing coils followed by sequential placement of GDC

(Boston-Scientific/Target Therapeutics, Fremont, CA)

coils to tightly pack the aneurysm. Post-embolization

angiography revealed a complete obliteration of the

aneurysm (Fig 1D). The patient was given a heparin bolus

of 30 units/kg when the guide catheter was placed in the

ICA with additional doses given to maintain an activated

clotting time between 250 and 300 seconds. A heparin

drip of 500 units/hour was maintained for 12 hours post-

procedure and then discontinued. The patient was also

given a clopidogrel load of 450 mg9 and aspirin, 325 mg,

immediately post-procedure. There were no technical or

neurological complications noted post-procedure.

Discussion

This case report demonstrates the feasibility of stent-

assisted coiling of a proximal ACA aneurysm. Surgical

clipping of such aneurysms can represent a challenge

as the perforators are often adherent to the aneurysm

making preservation of the A1 segment difficult.1 Given

the patient’s age and poor neurological grade, endovas-

cular therapy was considered as the primary therapeu-

tic modality for this patient. The Neuroform stent is the

only FDA-approved stent under the human device ex-

emption (HDE) protocol for use in treating wide-necked

aneurysms. Its flexibility and ease of navigation through

tortuous intracranial vessels allow for delivery to loca-

tions inaccessible to coronary stents. The ACA is par-

ticularly difficult due to its small luminal diameter and

acute angle of origin from the carotid terminus. As illus-

trated in this case, placement of the Neuroform stent is

feasible due to its flexibility and is potentially less trau-

matic due to its reduced radial force and self-expanding

nature.

Caution must be applied with this technology, as there

have been reports of stent migration when attempting to

catheterize the aneurysm through the interstices of the

stent.10 Additionally, the use of antiplatelet agents in the

setting of a ruptured cerebral aneurysm may pose poten-

tial for bleeding complications, as other procedures may

be required during acute hospitalization. There is also the

potential of stent thrombosis leading to thromboembolic

events,11 thus patients must be placed and maintained on

a dual antiplatelet regimen with clopidogrel and aspirin.

This report demonstrates that stent-assisted coiling of

a proximal ACA aneurysm is feasible and may be an

alternative therapy to the treatment of this uncommon

aneurysm.

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Gupta et al: Neuroform Stent-Assisted Coil Embolization 119