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NEUROIMAGE
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1740-1741

Anterior Circulation Infarct Following the Placement of Flow-Diverting Stent for Basilar Artery Aneurysm – A Conundrum


1 Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
2 Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India

Date of Submission29-Nov-2021
Date of Decision03-Feb-2022
Date of Acceptance17-May-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Balaji Vaithialingam
Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355092

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How to cite this article:
Vaithialingam B, Vankayalapati S. Anterior Circulation Infarct Following the Placement of Flow-Diverting Stent for Basilar Artery Aneurysm – A Conundrum. Neurol India 2022;70:1740-1

How to cite this URL:
Vaithialingam B, Vankayalapati S. Anterior Circulation Infarct Following the Placement of Flow-Diverting Stent for Basilar Artery Aneurysm – A Conundrum. Neurol India [serial online] 2022 [cited 2022 Oct 7];70:1740-1. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1740/355092




A 60-year-old female presented with severe headache for 5 days. The patient was neurologically intact without any deficit. A noncontrast computed tomography (NCCT) revealed a thick subarachnoid hemorrhage (SAH) without an intraventricular bleed. A 4 × 2 mm fusiform distal basilar artery aneurysm with a neck diameter of 1.9 mm was revealed by digital subtraction angiography (DSA). No vascular pathology was detected in the anterior circulation with a normal bilateral internal carotid artery. A pipeline embolization device (PED) was deployed in the left P1 segment of the posterior cerebral artery (PCA) [Figure 1]a as the angiography revealed a left fetal PCA. An incidental left anterior inferior cerebellar artery (AICA) aneurysm was detected intraprocedurally which was not intervened. Intravenous tirofiban infusion was started at 0.4 mcg/kg/min after the PED deployment and single-dose aspirin (300 mg) and ticagrelor (180 mg) were administered through the nasogastric tube. Post-procedure check angiogram revealed severe ipsilateral vasospasm [Figure 1]c involving the anterior circulation territory that was treated with 3 mg of intra-arterial nimodipine flush immediately. The patient was electively ventilated overnight in the neuro-intensive care unit (NICU) with the institution of induced hypertension to combat vasospasm. A 24-h post-procedure NCCT revealed left anterior and left middle cerebral artery infarct [Figure 1]b that was absent pre-procedure. Intravenous milrinone infusion was started at 0.75 mcg/kg/min and an intra-arterial nimodipine flush was administered on a daily basis for 5 days. There was no improvement in vasospasm and the patient suffered cardiac arrest with no return of spontaneous circulation on day 6 of the NCCU.
Figure 1: (a) NCCT of the brain showing the flow-diverting stent in the P1 segment of the left PCA. (b) NCCT of brain showing left anterior circulation infarct 24 h after the placement of the flow-diverting stent. (c) Post-procedure check angiogram showing left anterior circulation perfusion defect due to severe vasospasm

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Flow-diverting stents have been used successfully for basilar artery aneurysms.[1] Side branch occlusion following flow-diverting stent is common in posterior circulation aneurysms that can lead to infarct in the corresponding vascular territory.[2],[3] To the best of our knowledge, there are no previous reports of distant anterior circulation infarct following PCA flow-diverting stent placement. Since we did not premeditate the patient with oral antiplatelets pre-procedure in view of SAH, we strongly suspect a microembolization of a thrombus to the anterior circulation through the posterior communicating artery during the flow diverter deployment as a causative factor.

To conclude, an ipsilateral anterior circulation infarct due to severe unilateral vasospasm following flow diverter is a unique entity that requires further exploration.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fiorella D, Kelly ME, Albuquerque FC, Nelson PK. Curative reconstruction of a giant midbasilar trunk aneurysm with the pipeline embolization device. Neurosurgery 2009;64:212-7.  Back to cited text no. 1
    
2.
D'Urso PI, Lanzino G, Cloft HJ, Kallmes DF. Flow diversion for intracranial aneurysms: A review. Stroke 2011;42:2363-8.  Back to cited text no. 2
    
3.
Starke RM, Turk A, Ding D, Crowley RW, Liu KC, Chalouhi N, et al. Technology developments in endovascular treatment of intracranial aneurysms. J Neurointerv Surg 2016;8:135-44.  Back to cited text no. 3
    


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