NEQSTENT-Assisted Coiling of Left MCA Bifurcation Aneurysm: A Novel Device
Year: 2024
Type: article
Study design: Case Report
Abstract: Key Message: The NEQSTENT device appears to be safe and effective based on our experience and can provide a good treatment option for the management of complex wide- necked aneurysms. Also, NEQSTENT-assisted coiling can be beneficial in cases of ruptured aneurysms as there is no requirement for antiplatelets during or after the procedure. Wide-necked bifurcation aneurysms constitute the majority of the middle cerebral artery (MCA) aneurysms. The majority of the unruptured aneurysms are asymptomatic and are often discovered incidentally, but rupture of the aneurysms results in a potentially life-threatening subarachnoid or intracerebral hemorrhage. The MCA is the largest of all the cerebral arteries and is a common site for aneurysms accounting for almost one-fourth of all intracranial aneurysms.[1] Current options for the management of ruptured or unruptured MCA aneurysms include microsurgical clipping and endovascular therapy. Since MCA bifurcation aneurysms tend to have a broad neck and most of the time incorporate one or both the bifurcating branches, endovascular therapy in such cases becomes a challenging task. However, with the advances in endovascular techniques, endovascular therapy is emerging as an attractive and preferred treatment modality in MCA bifurcation aneurysms.[2,3] Endovascular therapy for the management of wide-necked MCA aneurysms includes traditional simple coiling, balloon-assisted coiling, stent-assisted coiling, intraluminal devices such as flow diverters, pCONus stent devices (Phenox, Bochum, Germany), and the newly launched endosaccular devices such as Woven Endobridge (WEB) device (Aliso Viejo, CA, United States), Contour device (Cerus Endovascular, Fremont, CA, United States), and the NEQSTENT device (NQS; Cerus Endovascular, Ltd).[4] The NEQSTENT (NQS; Cerus Endovascular, Ltd) device was launched in 2018 for the treatment of wide-necked intracranial aneurysms. It is an intrasaccular device that blocks the neck of the aneurysm on deployment and simultaneously can be penetrated by a coiling microcatheter for further packing the aneurysm with detachable coils.[5,6] Herein, we report a case of a ruptured left MCA bifurcation aneurysm which is technically challenging due to a broad neck and dysmorphic geometry but was successfully occluded by endovascular therapy using NEQSTENT-assisted coiling. Case Report A 55-year hypertensive male was admitted with chief complaints of sudden severe headache and altered sensorium for 1 day. On examination, the patient was irritable and confused (Hunt and Hess grade II) and pupils were bilaterally normal size and normal reacting. A plain CT (computed tomography) head revealed diffuse SAH (subarachnoid hemorrhage) and hematoma in the left Sylvian cistern (modified Fischer grade 3). CT angiography brain showed a saccular aneurysm arising from left MCA bifurcation. Subsequently, a DSA (digital subtraction angiography) brain was done to analyze the architecture of the aneurysm and plan the treatment approach accordingly. DSA brain confirmed a 12.3 mm × 10.3 mm, wide-necked saccular aneurysm, arising at the left MCA bifurcation with a neck diameter of 11.9 mm and both the M2 segments arising from the neck of the aneurysm. After a thorough assessment of the morphology of the aneurysm, we chose NEQSTENT-assisted coiling of the aneurysm. After explaining the procedure and obtaining well-informed consent, the patient was shifted to a digital subtraction angiography (DSA) suit. The patient was placed supine on the table. General anesthesia (GA) was given, and the right inguinal region was prepared for femoral access. Using the Seldinger technique, the right femoral artery was punctured and accessed using an 8-French femoral sheath (Cook Medical). Then a 6-French 100 cm Envoy guide catheter (Codman Neuro, Raynham, MA, USA) was advanced to the aortic arch, and sequential angiograms of right ICA, right ECA, left ICA, and left ECA were taken. Then a roadmap of the left ICA angiogram was taken and an 8-Fr Neuron max long sheath (Penumbra Inc., Alameda, CA, USA) was advanced till the proximal part of ICA and Navien-6 intermediate catheter (Medtronic; Irvine, CA, USA) was advanced till the distal part of ICA. Then an Excelsior XT-27 microcatheter (Stryker, Fremont, CA) was taken and advanced under roadmap guidance and parked in distal 1/3rd of the aneurysmal sac. Then we advanced an Eschelon-10 microcatheter (Medtronic, Dublin, Ireland) and parked it in the M1 segment of the left MCA, which will be used for coil placement. Then we started deploying the NEQSTENT device (NQS; Cerus Endovascular, Ltd), which adapted itself in the lower part of the aneurysm, covering the neck. After deploying the NEQSTENT device, we took an angiogram. Then we advanced the Eschelon-10 microcatheter (Medtronic, Dublin, Ireland) into the aneurysm and deployed the first framing coil (Target 360-degree coils, Stryker, Fremont, CA). After deploying the first framing coils, we detached the NEQSTENT device. This is done because the electrolytic detachment process of the device may face some issues after dense packing of coils. We took a repeat angiogram to look for the filling of the branching vessels. Then we deployed the coils again till the aneurysmal sac was densely packed. After completion of the packing of the aneurysm with coils, we took an angiogram to look for the patency of the parent vessel, the bifurcating branches, and the filling of the aneurysm if any. After completion of the procedure, we did a Vaso CT head, which confirmed the proper positioning of the device along with completely obliterated aneurysm and patent both M2 segments. The procedure was uneventful, and the postoperative CT head showed the deployed NEQSTENT and coils as an artifact and with no fresh SAH, IVH, or ICH. Also, there was no evidence of any infarct seen in the CT head. The patient was discharged on a GCS 15 with no significant neurological deficits. The patient is doing fine in the follow-up, and an MR angiography brain is advised after 3 months to look for the status of the aneurysm and patency of the vessels. Video link https://youtu.be/9nfqS0dmLl0 QR Code: Video Timeline with Audio Transcript 04.02-09.00: This video depicts the NEQSTENT-assisted coiling of left MCA bifurcation aneurysm. 09.00-32.00: A 55-year hypertensive male was admitted with chief complaints of sudden severe headache and altered sensorium for 1 day. On examination, the patient was irritable and confused (Hunt and Hess grade II) and pupils were bilaterally normal size and normal reacting. Plain CT head done revealed diffuse SAH and hematoma in left sylvian cistern (modified Fischer grade 3) as shown with the arrows. 34.23-41.12: CT angiography brain done showed a saccular aneurysm arising from left MCA bifurcation marked with red arrows. 41.15-47.15: This is the 3-D film of CT angiography brain showing the aneurysm marked with arrows. 47.16-01.10.15: Subsequently, a DSA brain was done to analyze the architecture of the aneurysm and planning treatment approach accordingly. DSA brain confirmed a 12.3 mm × 10.3 mm, wide-necked saccular aneurysm, arising at the left MCA bifurcation with a neck diameter of 11.9 mm and both the M2 segments arising from the neck of the aneurysm. 01.11.02-01.18.08: This is the biplanar DSA of left ICA, antero-posterior and lateral view, showing the aneurysm. 01.19.02-01.26.24: This is the 3-D video of the DSA with reconstructed 3-D image showing a wide-necked aneurysm at left MCA bifurcation as shown by the green arrow. 01.27.05-01.42.09: These are the dimensions of the aneurysm: The neck was 11.9 mm, the length was 10.3 mm, the width was 12.3 mm, and the dome-to-neck ratio was 1.03. As the dome-to-neck ratio is less than 2, it signifies a wide-necked aneurysm. 01.43.02-02.04.09: These were the treatment options available with us. - Microsurgical clipping of the aneurysm - Endovascular approach Simple coiling using detachable coils Balloon-assisted coiling Stent-assisted coiling using Y-stents or a pCONUS stent device Flow diverters Intrasaccular devices such as contour, web devices, and NEQSTENT devices 02.04.15-02.26.16: Microsurgical clipping was risky in this case as both the M2 segments were arising from the neck of the aneurysm and a STA-MCA bypass may be required after clipping to secure the patency of the M2 segments. STA-MCA bypass is a technically demanding task to perform in this case as the M2 segments lye deep in the sylvian fissure, and it unnecessarily increases the procedure morbidity. 02.27.00-02.37.11: Simple coiling was also not possible due to the risk of coil protrusion into the parent vessel and distal migration of coils into branching vessels, leading to thromboembolic complications. 02.37.15-02.47.23: The problem in introducing a stent is the high risk of parent vessel and branching vessel occlusion due to thrombus formation, which requires a lifelong dual antiplatelet drug. 02.48.18-03.14.02: Next is the flow diverter, which works by redirecting the blood flow away from the aneurysm into the parent vessel, thus promoting stasis and thrombosis in the aneurysm. Also, flow diverters have a risk of occluding the parent vessels and branching vessels, thereby requiring antiplatelets drugs. Flow diverters take a long time for completely obliterating the aneurysm by thrombosis, so there is also a risk of delayed aneurysm rupture. 03.15.00-03.32.15: Then pCONUS stents could have been a good option in this case, but it is currently not available in INDIA. These are newly launched intraluminal devices for the treatment of complex wide-necked bifurcation aneurysms. It is designed to support the deployed coil mass at the level of the neck. Also, these require lifelong antiplatelet drugs. 03.33.06-04.01.08: Then the next option was the WEB device. The WEB device works as an endosaccular flow disrupter. Currently available sizes of the WEB devices ranged from 3 to 11 mm, and in our case, the dimensions of the aneurysm were larger. Also, WEB devices are reported to be associated with a phenomenon known as “web compression”, in which the height of the WEB device reduces to as much as 30% of its initial size and can result in the reperfusion of the aneurysm and subsequent risk of rerupture. 04.02.00-04.33.08: Next, the Contour device by Cerus endovascular is developed as an intrasaccular flow diverter and flow disrupter, which when deployed adapts to the contour of the aneurysm and targets the neck of the aneurysm. But the problem with the Contour is that it takes a longer time for recanalization of vessels and hence poses a risk for use in cases of ruptured aneurysms. Also, due to “endoluminal flow phenomenon”, there is a risk of reperfusion of aneurysm, leading to delayed rupture. 04.34.20-05.03.21: After a thorough assessment of the morphology of the aneurysm, we chose NEQSTENT-assisted coiling of the aneurysm. NEQSTENT is a woven neck bridging device that exhibits flow-diverting properties and simultaneously can also be penetrated with a microcatheter for subsequent coiling. It is a circular dual-layered structure of 48 drawn-filled tube wires. It is radiopaque and retrievable until electrolytically detached. On deployment through a microcatheter, it adapts to the lower half of the aneurysm, thus covering the neck. 05.04.00-05.47.10: These were the hardware’s and anticoagulation agents required during the procedure. - 5000 IU of heparin at the beginning of procedure - Additional 1000 IU of heparinized saline flushed every hour Hardware used: 8 F femoral sheath Guiding catheter Envoy 6 Fr Long sheath 6F Neuron max Intermediate supporting catheter Navien 6F Two Microcatheters: Excelsior XT 27 Eschelon 10 NEQSTENT Guidewires Microwires Target 360° coils 05.49.00-06.21.08: After explaining the procedure and obtaining well-informed consent, the patient was shifted to a DSA suit. The patient was placed supine on the table. General anesthesia (GA) was given, and the right inguinal region was prepared for femoral access. Using the Seldinger technique, the right femoral artery was punctured and accessed using an 8-French femoral sheath. Then a 6-French 100 cm Envoy guide catheter (Codman Neuro, Raynham, MA, USA) was advanced to the aortic arch, and sequential angiograms of right ICA, right ECA, left ICA, and left ECA were taken. 06.23.00-06.30.18: This is the angiogram of Left ICA (AP and lateral view) showing a saccular aneurysm arising at the left MCA bifurcation. 06.31.08-06.45.22: A roadmap of the left ICA angiogram was taken, and a long sheath was advanced till the proximal part of ICA and Navien-6 intermediate catheter was advanced till the distal part of ICA (as marked with the arrows) 06.46.15-07.05.08: Then an Excelsior XT-27 microcatheter was taken and advanced under roadmap guidance and parked in distal 1/3rd of the aneurysmal sac. This is done because when we deploy the NEQSTENT device, the microcatheter is pushed backward and if the microcatheter is kept proximally, then there is a risk of extrusion of the microcatheter from aneurysm. 07.06.02-07.18.18: Then we advanced an Eschelon-10 microcatheter and parked it in the M1 segment of the left MCA, which will be used for coil placement (the image in the corner is depicting the diagrammatic representation of the same). 07.21.19-07.28.16: We started deploying the NEQSTENT device, which adapted itself in the lower part of the aneurysm, covering the neck. 07.34.00-07.38.02: After deploying the NEQSTENT device, we took an angiogram. 07.41.12-07.46.18: Then we advanced the Eschelon-10 microcatheter into the aneurysm and deployed the first framing coil. 07.53.20-07.57.20: A DSA was then again taken. 08.00.12-08.06.12: Now we have detached the NEQSTENT device as you can see the separation, shown by the arrows. 08.09.00-08.15.18: After detachment of the NEQSTENT device, a repeat angiogram was taken to see the filling of the branching vessels. 08.22.09-08.28.02: Then we started deploying the coils again till the aneurysmal sac is densely packed. 08.31.05-08.48.15: After completion of the packing of the aneurysm with coils, we took an angiogram to look for the patency of the parent vessel and the bifurcating branches and the filling of the aneurysm if any. Here, we can see that both the branching vessels are patent with good flow and the aneurysm filling is absent. 08.49.06-08.57.21: This is the biplanar DSA of the left ICA taken after completion of the procedure showing complete obliteration of the aneurysm (Raymond Roy class 1). 08.58.00-09.17.15: This is the beautiful fluoroscopic view showing the NEQSTENT device along with the densely packed coils. After completion of the procedure, we did a Vaso CT head, which confirmed the proper positioning of the device along with completely obliterated aneurysm and patent both M2 segments. 09.18.00-09.30.05: The procedure was uneventful, and the postoperative CT head showed the deployed NEQSTENT and coils as an artifact and with no fresh SAH, IVH, or ICH. Also, there was no evidence of any infarct seen in the CT head. The patient was discharged on a GCS 15 with no significant neurological deficits. The patient is doing fine in the follow-up, and an MR angiography brain is advised after 3 months to look for the status of the aneurysm and patency of the vessels. 09.30.14-09.34.35: These are the references. Discussion Wide-necked bifurcation aneurysms constitute the majority of the MCA aneurysms. The majority of the unruptured aneurysms are asymptomatic and are often discovered incidentally, but rupture of the aneurysms results in a potentially life-threatening subarachnoid or intracerebral hemorrhage.[1] Current options for the management of ruptured or unruptured MCA aneurysms include microsurgical clipping and endovascular therapy. Endovascular coiling of the intracranial aneurysm is a proven treatment modality, but occasionally, it becomes a challenging task owing to the geometry of the aneurysms. Neck size is an important descriptor of aneurysm treatment. Aneurysms with a neck diameter of more than 4 mm or a dome-to-neck ratio of less than 2 are typically classified as wide-necked aneurysms.[7] Wide-necked aneurysms make complete occlusion of the aneurysm a challenging task due to the risk of coil protrusion into the parent vessel potentially, resulting in thromboembolic complications.[6] To overcome these limitations of simple coiling in wide-necked bifurcation aneurysms, stent-assisted coiling became popular and has been an endovascular procedure of choice in cases of wide-necked aneurysm due to an increased packing density without risk of coil prolapse.[8,9] But despite this advantage, stent-assisted coiling is associated with higher rates of thromboembolic complications, leading to life-long requirements for dual antiplatelet therapy.[10]Also, it is a matter of debate to use stent-assisted coiling in cases of ruptured aneurysms. Amenta et al.[11] reported a 15% major complication rate in acutely ruptured aneurysms due to antiplatelet therapy used in stent-assisted coiling. Using stents may also hamper the flow in the side branches and the perforating vessels. Flow diverters have more recently been applied to the treatment of wide-necked bifurcation and side-wall aneurysms since the advent of braiding technology. Flow diverters work by redirecting the blood flow away from the aneurysm and vessel wall remodeling; however, there is a requirement for antiplatelet therapy. Also, the placement of flow diverters may result in parent artery luminal reduction, thromboembolism, or branching vessel occlusion. Since two flow diverters cannot be placed in the bifurcation, there is a potential risk of incomplete coverage of the aneurysmal neck, leading to incomplete aneurysmal occlusion.[3,12] A newer development in the endovascular management of aneurysms is the intrasaccular devices. These work by disrupting the intra-aneurysmal flow and creating intra-aneurysmal thrombosis. These intrasaccular devices divert the flow away from the aneurysm by creating a border at the level of the neck with no implant in the parent artery. The currently available intrasaccular devices are Woven Endobridge (WEB) devices (Aliso Viejo, CA, United States), Contour Neurovascular System (Cerus Endovascular, Fremont, CA, United States), Luna embolization system (Medtronic, Irvine, CA, United States), and NEQSTENT devices (NQS; Cerus Endovascular, Ltd). These devices have the advantage of being used in cases of ruptured aneurysms as there is no requirement for antiplatelet drugs during or after the procedure.[3,12] NEQSTENT (NQS; Cerus Endovascular, Ltd) is a nitinol-based woven neck bridging device that exhibits flow-diverting properties and simultaneously can also be penetrated by a microcatheter for subsequent coiling. The NEQSTENT device stays within the aneurysm and maintains the coils within the aneurysm. It is radio-opaque and retrievable until electrolytically detached. On deployment through a microcatheter, it adapts to the lower half of the aneurysm. Other endosaccular devices such as WEB or Contour devices usually require multiple aspects of the aneurysm sizes such as width, height, and neck to choose the correct size of the device, but in the case of the NEQSTENT device, only the neck size is required for device selection. NEQSTENT has the advantage in cases of ruptured aneurysm as no antiplatelet therapy is required during its deployment and additional intra-aneurysmal coiling can potentially reduce the recurrence or rerupture of the aneurysm.[5,6] Through this case report and procedural video, we share our experience and technical outcome of endovascular management of left MCA bifurcation aneurysm treated using NEQSTENT-assisted coiling. Very few cases and case series have been reported of this novel device in the past literature, and to our best knowledge, this is the first case reported of using this device in a ruptured MCA bifurcation aneurysm. Key message The management of large, wide-necked aneurysms remains a challenging task due to the proximity of the branching vessels and the higher rates of recurrences. The NEQSTENT device appears to be safe and effective based on our experience and can provide a good treatment option for the management of complex wide-necked aneurysms. Also, NEQSTENT-assisted coiling can be beneficial in cases of ruptured aneurysms as there is no requirement for antiplatelets during or after the procedure. NEQSTENT-assisted coiling can sometimes result in delayed recanalization and growth of the aneurysm, and hence, a regular follow-up is required. Abbreviations HMCA- Middle cerebral artery ICA- Internal carotid artery ECA- External carotid artery SAH- Subarachnoid hemorrhage IVH- Intraventricular hemorrhage ICH- Intracerebral hemorrhage DSA- Digital subtraction angiography CT- Computed tomography MRI- Magnetic resonance imaging Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Neurology India
Authors: Deepak Kumar Singh, Prevesh Kumar Sharma, Neha Singh, Kuldeep Yadav, Mohammad Kaif, Vineet Kumar Mishra, Vipin Kumar Chand
Institution: Dr. Ram Manohar Lohia Institute of Medical Sciences
Language: English
Subfield: Neurology
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4405507882