Basilar Artery Bifurcation Aneurysm: Recurrence and Significant Growth After Stent-Assisted Coil Occlusion, Hemodynamic Treatment Using pCANvas and Medina Embolization Devices

Abstract

An initially asymptomatic wide-necked basilar bifurcation aneurysm was treated using the waffle cone technique for assisted coil occlusion. Four years later, the patient presented with gait disturbance, visual impairment, and cognitive decline. The MRI examination revealed an increase of the now, largely thrombosed aneurysm with subsequent compression of the mid-brain and hydrocephalus. After implantation of a ventriculo-peritoneal shunt system, recoiling was performed and the patient improved moderately. However, follow-up MRI at 6 months revealed again a significant recurrence of the aneurysm. At this time, the hemodynamic treatment included the implantation of pCANvas (phenox) in combination with Medina Embolization Devices (MED, Medtronic) with the expectation of achieving better coverage of the aneurysm neck while redirecting the flow away from the aneurysm entrance and providing dense packing of the aneurysm sac. Aneurysm recurrence due to coil compaction, secondary aneurysm growth, and coil migration into an intrasaccular thrombus is a potential issue after coil occlusion alone and occurs in particular in large aneurysms. This case illustrates the challenge of treating broad-neck bifurcation aneurysms and highlights the potential advantage of an intra- and extrasaccular flow diversion and flow disruption concept for these patients.