RESUMEN
Spontaneous rupture of brain aneurysmal subarachnoid hemorrhage (aSAH) is a debilitating disease, half of which occurs in individuals under 50 years old. Challenges in its management arise from the decision-making process regarding the preferred method of definitive aneurysm obliteration, whether through surgical intervention or endovascular approach. This study described the role of flow diverter stent as an effective endovascular approach to obliterate aSAH in the acute phase. A 70-yearold female presented with thunderclap headache, slight right hemiparesis, and pupillary-sparing left oculomotor palsy corresponding with ruptured brain aSAH. Endovascular management of flow diverter stent was preferred and inserted within the third day onset. Double antiplatelet was administered prior to and following the procedure. Three-day follow-up showed resolution of brain aSAH with no neurological sequelae. Flow diverter stent offers several advantages over coiling when treating wide-neck, giant, saccular, or fusiform aneurysm. It is also safer for elderly, especially with multiple comorbids, compared with clipping. However, it has risks of either parent/ distal artery occlusion due to its thrombogenic properties or the potential for rebleeding following dual antiplatelet administration. Effective management and thorough evaluation are essential to maximize the likelihood of favorable outcomes when employing this approach. Flow diverter stent is a promising endovascular management for ruptured brain aSAH, particularly in elderly with many comorbids and wide neck/ giant aneurysm at anterior circulation which is not candidate for coiling or clipping. It is also crucial to monitor, evaluate, and manage risk of rebleeding and thrombosis to ensure long-term success of this management approach.
RESUMEN
Extracranial carotid artery dissection (ECAD), although infrequent, represents the predominant form of artery dissection within the brain. It accounts for 25% of young-onset ischemic strokes in adults. Its atypical presentation and limited availability of high-quality evidence underscore the importance of precision medicine in its management. This study aimed to illustrate a combined approach utilizing multiple scaffolding Leo stents and Silk flow-diverting stents to manage asymptomatic ECAD a week after the onset of acute ischemic stroke. A 40-year old Indian male with uncontrolled hypertension was admitted due to acute vestibular syndrome. His brain computed tomography (CT) scan showed cerebellar infarct. However, his angiographic cervical CT scan showed asymptomatic ECAD, which was confirmed with digital subtraction angiography. He was therefore managed with optimal antihypertensive agents and dual antiplatelet. The endovascular reconstruction procedure initiated one week after the onset of stroke by employing one scaffolding Leo stent and one Silk flow-diverting stent at his right internal carotid artery. He was discharged three days following the endovascular procedure and presented no complications until three-month follow-up. This safe approach could be considered for individuals with ECAD to help prevent secondary strokes, particularly among those in the productive age group.
RESUMEN
Vertebrobasilar dolichoectasia (VBD) is a rare vascular anomaly of increased diameter, length, and tortuosity of vertebral and/or basilar artery, but debilitating due to its risk of ischemia, hemorrhage, and nerve or brain compression. The management is also controversial due to various possible clinical manifestation and outcome. This study aimed to describe a combined approach of multiple scaffolding Leo stents and nondominant vertebral artery occlusion as a definitive approach to reconstruct vertebrobasilar arteries. A 40-year old male presented with severe headache and reduced consciousness, which was explained with brain CT findings of subarachnoid hemorrhage and hydrocephalus. Further etiologic approach until digital subtraction angiography revealed VBD. An endovascular reconstruction approach was considered one month following the event onset using multiple scaffolding Leo stents from left vertebral to basilar artery with right vertebral artery occlusion. This stent had the best radial strength, lowest bending stiffness, highest kink resistance, highest bending wall coverage, and lowest cell size, which provided strong vascular reconstruction properties. Combined nondominant vertebral artery occlusion was also performed to avoid the disturbance of flow-diverting pathway by the stents. Double antiplatelet was administered from three weeks following the event onset afterwards. The patient抯 condition improved at three-month follow-up. This case report presented that combined multiple Leo stents and nondominant vertebral artery occlusion may be considered as an approach to successful endovascular reconstruction for symptomatic VBD.