Complex Wide-necked and Lobulated Aneurysm of the Middle Cerebral Artery Bifurcation
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CORRESPONDENCE
Complex Wide-necked and Lobulated Aneurysm of the Middle Cerebral Artery Bifurcation Treatment with a pCONUS2 Neck Bridging Device and p48MW Flow Modulation Device Alexander Sirakov1 · Marta Aguilar-Perez2 · Muhammad AlMatter2 · Hans Henkes2,3 Received: 13 October 2019 / Accepted: 18 November 2019 © The Author(s) 2019
Introduction
Case Report
With the recent improvement of the techniques, armamentarium and operator skills, a growing number of intracranial aneurysms can be endovascularly treated; however, some aneurysms, particularly those located on arterial bifurcations, remain a challenge for the traditional endovascular techniques and demand a more complex approach [1]. Balloon remodeling and stent-assisted coiling have limitations while being applied in the case of complex anatomy [2]. More recently, dedicated devices such as the pCONUS (phenox, Bochum, Germany), the PulseRider (Pulsar Vascular, Los Gatos, CA, USA) and the eCLIPs (Evasc Medical Systems, Vancouver, Canada) have entered the market. These devices share the common feature of providing extra coverage at the aneurysm neck to prevent coil prolapse into the parent vessel. Endoluminal flow diversion (FD) appears to be a straightforward solution for complex and unfavorable anatomy with good angiographic results and acceptable complication rates; however, the fate of the covered branches and the delayed aneurysm occlusion are still a major concern [3]. We present a case where the combination of a pCONUS2 neck-bridging device and p48MW Flow Modulation Device were used for the treatment of a complex, wide-necked aneurysm of the right middle cerebral artery (MCA).
A 72-year-old female patient was admitted for treatment of an incidentally found aneurysm of the right MCA. Magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) examinations confirmed the MCA aneurysm measuring 5.5 × 5 mm with a neck width of 5.7 mm. Aneurysmal irregularities with a secondary lobule adjacent to the inferior trunk was also noted on the rotational angiography and 3D reconstructions. The goal of the treatment was the prevention of a future rupture of the aneurysm. The lobulated irregularities of the aneurysmal sac and the wide neck were a major concern. Microsurgical clipping was recommended to and declined by the patient but pCONUS-assisted coiling was considered feasible. The intended treatment, together with potential alternatives, respective chances, and risks were explained to the patient. Informed consent was obtained in written form. With the patient under general anesthesia and using a standard right common femoral approach, an 8 Fr Softip guide catheter (Boston Scientific, Marlborough, MA, USA) was tracked into the right internal carotid artery. Initially, the aneurysm was catheterized using a Prowler Select Plus microcatheter (Cerenovus, Irvine, CA, USA), and a pCONUS2 4–15–6 mm was then deployed but not detached. A SL10 microcatheter (Stryker Neurovascular, Fremont, CA, USA) was then navigated inside the aneurysm though the pCONUS2
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