Recent studies have shown the safety and efficacy of the Woven EndoBridge (WEB, Microvention) in the endovascular treatment of intracranial aneurysms.1-5 Here, we present a patient with a history of prior aneurysmal subarachnoid hemorrhage treated endovascularly, who presented to an outside hospital with a left temporal intracerebral hemorrhage. Patient consent was obtained for procedures described and for research use. Imaging revealed a ruptured left middle cerebral artery wide-necked bifurcation aneurysm, which was confirmed angiographically and treated with a WEB the following day. The patient experienced moderate/severe vasospasm on postprocedure days 1 and 3 treated with intra-arterial vasodilators, with stasis in the aneurysm sac. Postprocedure day 13 angiogram showed increased filling of the aneurysm with some thrombosis. After discussion, we returned to the operating room for clipping of the WEB-treated aneurysm. Multiple attempts were made to place a clip across the neck, each time sliding inferiorly on the WEB stenosing the bifurcation and parent vessels. The aneurysm was trapped and dome resected, dividing the WEB. A clip was placed across the WEB remnant and aneurysm neck. Intraoperative angiography showed complete obliteration of the aneurysm with bifurcation narrowing because of mild herniation of the WEB. The patient was discharged on postoperative day 10. Imaging at 10 months showed no residual aneurysm filling. The WEB is compressible but may obstruct the aneurysm neck during clipping directly or by intradevice thrombus. In these cases, the WEB may be cut and opened to facilitate clip application. Early aneurysm filling as a predictor of repeat rupture remains unclear.
Contributor Information
Anil Roy, Email: Anil.roy@vcuhealth.org.
Matthew Kole, Email: Matthew.J.Kole@uth.tmc.edu.
Spiros L. Blackburn, Email: spiros.blackburn@uth.tmc.edu.
Funding
This study did not receive any funding or financial support. Dr Blackburn reports NIH funding.
Disclosures
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
COMMENT
Advancements in endovascular devices have revolutionized the treatment of cerebral aneurysms, yet as the use of endovascular techniques increases, so too does the potential for aneurysm residuals and/or recurrences. While some of these recurrences may be appropriate for observation, and others best treated with additional endovascular means, at least some will necessitate open microsurgical techniques to achieve satisfactory aneurysm obliteration. The authors present a case of a ruptured, wide-necked left middle cerebral artery aneurysm initially treated with a Woven EndoBridge (WEB) device, complicated by early recurrence necessitating open microsurgical repair. This case illustrates important nuances of clipping a previously WEB-embolized aneurysm, including understanding the adherence of the WEB device to the aneurysm wall and the tendency for clip herniation to the neck of the aneurysm. The authors provide a thoughtful discussion of the alternatives and rationale for microsurgical intervention, as well as the intraoperative challenges that should be anticipated.
Jennifer E. Kim
Justin M. Caplan
Baltimore, Maryland, USA
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