PMC9484819_01
Preoperative findings.
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(A) Magnetic resonance angiography showing two-hump-like (white arrow, white arrowhead) cerebral aneurysm at the left vertebral artery (VA)-posterior inferior cerebral artery (PICA) bifurcation. (B) Basi-parallel anatomical scanning magnetic resonance imaging and (C) computed tomography angiography showing that the two cerebral aneurysms are in contact, and kissing aneurysms (white arrow, white arrowhead) are suspected. (D) Digital subtraction angiography (left vertebral angiography) and three-dimensional rotational angiography showing a saccular aneurysm (white arrow) with a maximum diameter of approximately 5.5 mm on the left VA-PICA bifurcation and another aneurysm with a maximum diameter of approximately 2.5 mm on the nonbranched PICA, which are in contact with each other.
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Magnetic resonance angiography revealed a two-humped cerebral aneurysm in the left VA-PICA portion (Fig. 1A), and basi-parallel anatomical scanning magnetic resonance imaging revealed two cerebral aneurysms in contact with a separate neck (Fig. 1B). The original image of computed tomography angiography confirmed the contact (Fig. 1C). Three-dimensional rotational angiography of digital subtraction angiography (DSA; left vertebral angiography) revealed a saccular aneurysm with a maximum diameter of approximately 5.5 mm on the left VA-PICA and a saccular aneurysm with a maximum diameter of approximately 2.5 mm on the nonbranched PICA (Fig. 1D).
Treatment method schema.
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(A) A microcatheter for stenting is guided toward the left VA through the vertebrobasilar junction, and a microguidewire is guided to the PICA. (B) Two microcatheters are inserted into each aneurysm. (C) One coil is inserted into each cerebral aneurysm (anchor coil technique). (D) A microcatheter for stenting is inserted into the PICA. (E) The stent is placed. (F) An additional coil is inserted.
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Therefore, first, only a microguidewire was guided to the PICA from the contralateral side, and microcatheters were inserted into each cerebral aneurysm, the coil was inserted into each cerebral aneurysm to serve as an anchor (anchor coil technique), and then the microcatheter for stenting was guided to the PICA (Fig. 2).
Intraoperative/postoperative images (working angle).
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(A) Kissing aneurysms (white arrow, white arrowhead) are found at the left vertebral artery (VA)-posterior inferior cerebral artery (PICA) bifurcation. (B) A microcatheter for stenting (black arrow) is guided toward the left VA through the vertebrobasilar junction, and a microguidewire is guided to the PICA (white arrow). (C) A coil is inserted into each cerebral aneurysm, leaving a microcatheter for stenting (black arrow) in the left VA. (D) The stent is placed (white arrowhead), and an additional coil is inserted. (E) Left VA angiography just after embolization. (F) Left VA angiography after 6 months.
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A microcatheter (Excelsior SL-10, Stryker, Fremont, CA, USA) was guided from the right VA to the left VA through the vertebrobasilar junction (VBJ) (Fig. 3A), and only a microguidewire (Synchro2 soft, Stryker) was guided to the left PICA (Fig. 3B). SL-10 x2) were guided to each cerebral aneurysm, and a detachable coil was individually inserted (Fig. 3C). Subsequently, a microcatheter for stenting was guided to the left PICA, and a stent (Neuroform Atlas 3.0 x 21 mm, Stryker) was placed from the left PICA to the distal side of the left VA. Finally, six and three detachable coils were inserted into each cerebral aneurysm (Fig. 3D), and the procedure was completed with mild dome filling (Fig. 3E). Complete occlusion was confirmed by DSA 6 months later (Fig. 3F).