Bridging the neck: eCLIPS for a previously ruptured middle cerebral artery aneurysm

Author: DIESTRO Jose Danielo B

Find out how Dr. Jose Danilo B. Diestro (St. Michael’s Hospital, University of Toronto, Department of Medical Imaging Toronto, Canada) treated a 61-year-old male patient suffering from a ruptured middle cerebral artery aneurysm.

• Case

  CASE PRESENTATION

  • Initial measurement 9mm x 5mm x 6mm, with murphy’s teat and a neck of 3mm
  • Angio 8mm on maximal diameter
  • 4mm to 7mm filling remnant on MRI July to October.      
  • February post-treatment 3mm remnant   
  • Also with pericallosal and acomm complex aneurysm

  

   

  INITIAL NEUROIMAGING: 07-2019

  

   

  ENDOVASCULAR REPAIR: 07-2019

  • 2 coils placed
  • 6mm by 26mm Cosmos Microplex
  • 6mm by 6mm Hypersoft Helical

   

  

   

  PRE AND POST REPAIR IMAGING

  • MRI done a day after: 4mm remnant from previous 5mm

   

  

   

  RECURRENCE: JULY TO OCTOBER 2019

  • 4mm to 7mm remnant

   

  

   

  ENDOVASCULAR REPAIR: 2-2020

  • Red arrow on larger M2 branch measuring 2mm in width

   

  

   

  eCLIPS DEVICE

   

  

   

  

   

  eCLIPS + COILS: BILATERAL GROIN ACCESS

  • Two Vascular Access PointsRight: 6F x 80 cm Shuttle + 0.072 x 105cm
  • Navien Intermediate Catheter + Headway 27 Microcatheter + eCLIPS device
  • Left: 5F x 11 cm Femoral sheath + 5F x 100cm Envoy catheter + Headway 17 microcatheter + Coils

   

   

  ENDOVASCULAR REPAIR PLAN

  • Secure the neck
    • Deploy the eCLIPS through the Headway 27 in the inferior M2 branch and across the neck of the aneurysm
  • Coil the residual

    • Coil the residual portion of the aneurysm by crossing the eCLIPS leaf with the Headway 17

       

  

   

  eCLIPS POSITIONING

   

  

   

  COILING THROUGH eCLIPS

  • 5mM x 15 helis
  • 3mm x 4cm helix
  • 3mm x 4cm helix
  • 2.5mm x 3cm
  • 2.5mm x 3cm
  • 2.5mm x 6cm
  • 2.5mm x 4cm
  • ALL HELIX

   

  

   

  PRE AND POST REPAIR IMAGING

  • MRI one day after recoiling: 3mm remnant

     

  

   

  PHYSIOLOGIC REMODELING

   

  

   

  

   

  

   

  CLINICAL OUTCOMES

  • Thirty-three patients were treated between June 2013 and September 2015. Twenty-five (76%) patients had successful placement of an eCLIPs device; 23 (92%) of these 25 patients had complete data. Eight cases of non-deployment occurred during the 1st year of use, consistent with a learning curve; no failures of deployment occurred thereafter. 
  • Two periprocedural transient ischemic attacks and 2 asymptomatic thrombotic events occurred. Twenty-one (91%) of 23 patients underwent follow-up at an average of 8 months (range 3–18 months); 9 (42.9%) of these 21 patients demonstrated an improvement in Raymond grade at follow-up; no cases of worsening Raymond grade were recorded, and 17 (81.0%) patients sustained a modified Raymond-Roy Classification class of I or II angiographic result at follow-up.
  • Two delayed ruptures were recorded, both in previously coiled, symptomatic giant aneurysms where the device was used as a part of a salvage strategy.

   

  

   

  

   

  POINTS FOR DISCUSSION

  • Clipping on initial presentation? 
  • Would other devices have gotten better results?
  • What are the properties of the eCLIPS device that make it unique?
  • What aneurysm characteristics make it suitable for the eCLIPS device?

   

  ENDOVASCULAR FIRST FOR RUPTURED MCAs

   

  

   

  ONGOING TRIALS: EESIS