Treatment of a Wide Neck Middle Cerebral Artery Aneurysm with Secondary Lobule Using Combination Woven EndoBridge and Coil Embolization
Ali Alsarah1, Rashid Ahmed1, Adam Dmytriw1, Omer Doron1, Christopher Stapleton1, William Smith1, Robert Regenhardt1, Aman Patel1
1Massachusetts General Hospital
Objective:
We present a case of a right middle cerebral artery bifurcation aneurysm treated by a WEB device and coil embolization
Background:
Middle cerebral artery bifurcation aneurysms have been historically challenging to treat endovascularly given they often have complex morphology and wide necks. The Woven EndoBridge (WEB) is an ellipsoid braided-wire embolization device designed to provide intrasaccular flow disruption along the aneurysm neck, which has been proven to be an effective method in treating a wide spectrum of wide-necked bifurcation aneurysms. Irregularities and secondary lobules at the base of the primary aneurysm can have persistent filling despite treatment
Design/Methods:
48-year-old female active smoker without significant other medical history presented with sudden onset of the worst headache of her life followed by brief loss of consciousness. She presented 2 weeks after due to persistent headache and falls but neurologic examination was intact. CT head showed acute to subacute right MCA infarction with small volume subarachnoid hemorrhage. CTA head revealed a right MCA bifurcation irregular aneurysm. Diagnostic subtraction angiography confirmed irregular right MCA bifurcation aneurysm measuring 4.3 x 4.5 x 5.7 mm. Embolization was performed with WEB SL 6 x 4 mm device. Post-deployment angiograph showed occlusion of the aneurysm dome but persistent filling of secondary lobule near the base of the aneurysm. Given this residual lobule filling, additional embolization with a HyerSoft 3D 2mm x 2cm coil was performed with resulting good occlusion of the aneurysm. She was discharged home 5 days after admission ambulating independently
Conclusions:
Many MCA bifurcation aneurysms can be treated minimally invasively, but there are some limitations to the WEB since every aneurysm is different and there are a finite number of sizes and shapes available for WEB. This case illustrates that adjunctive coil embolization can successfully treat a residual secondary base lobule after WEB embolization