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On examination, a 48-year-old female with a history of high blood pressure and Sjögren syndrome has an incidental finding of a right MCA aneurysm. On digital subtraction angiography (DSA) this small-neck aneurysm is seen to have an irregular shape and a smaller second aneurysm, a daughter sac, at the origin of the bifurcation.
How would you choose to treat? Join Prof. Jacques Moret and the Kremlin Bicêtre team in this live case from the 2019 edition of LINNC Paris . Commented by Prof. Laurent Spelle and the LINNC expert panel, follow each step as they demonstrate their strategy using a Medtronic Pipeline flow diverter and coils for these bifurcation aneurysms. See their systematic use of balloon test occlusions, in this case measuring collateral circulation to decide in which branch to place the flow diverter. Discover the “indirect” flow diversion strategy, why placing the flow diverter in the lower branch could be “easier” than the upper branch in this specific situation and why the decision is taken to introduce coils into the larger aneurysm sac in order to induce – and ensure – better thrombosis. Consider the issue of clotting in the covered branch or the possibility of one aneurysm being slower to thrombose than another. In addition, see the use of the SIM&CURE simulation program in planning the intervention: how it provides information in advance concerning flow diverter length depending on such attributes as compression, wall apposition and mesh density. Enter the debate, as the expert panel asks, “Why use an endovascular approach when you can accomplish this with a mini-craniotomy using clips?”
What do you think?
This LIVE case corresponds to the highest ethical standards in medicine and is posted on LINNC Online for educational purposes only to allow medical professionals to improve their knowledge about these procedures and how to best treat their patients.