Delayed Aneurysm Rupture Following Endovascular Treatment with Contour Device: A Case Report
Article information
Abstract
Delayed rupture of intracranial aneurysms after endovascular treatment is a rare but serious complication. We report the first documented case of late aneurysmal rupture following treatment with a Contour intrasaccular device. A patient in their 60s with a basilar tip aneurysm underwent endovascular treatment using a 14-mm Contour device. Fifteen months later, the patient presented with a fatal intraventricular hemorrhage, and imaging revealed device displacement and aneurysm growth. This case underscores the importance of meticulous device sizing and follow-up, especially for large aneurysms.
INTRODUCTION
Delayed rupture of intracranial aneurysms after endovascular treatment, especially using coils, is an undesirable yet well-known late complication among interventionists, with a rate of 0.17% [1]. This complication has been reported in a few case reports on aneurysms treated with WEB devices (MicroVention), although recanalization and re-treatment occur more frequently in approximately 10% of patients treated [2]. In endovascular treatments performed with the Contour intrasaccular device, device displacement has been reported in a few cases; however, late hemorrhagic complications have not been previously documented [3,4]. We present the first case of delayed bleeding following treatment of an aneurysm with the Contour device (Cerus), a new generation intrasaccular flow disruptor.
CASE REPORT
A patient in their 60s presented with a severe headache. He had a history of diabetes, hypertension, and heavy smoking. Magnetic resonance angiography revealed a wide neck basilar tip aneurysm. The multidisciplinary team decided to proceed with endovascular treatment for the aneurysm. He was administered an initial dose of 180 mg Ticagrelor and 300 mg Acetylsalicylic acid, followed by a maintenance regimen of 90 mg Ticagrelor twice a day and 100 mg Acetylsalicylic acid one a day for 2 days before the intervention. Under general anaesthesia, a triaxial system was used, consisting of a 6F NeuronMax long sheath (Penumbra), a Phenom Plus intermediate catheter, and a Phenom 27 microcatheter (Medtronic), through the right femoral access. The procedure was conducted under heparin anticoagulation, with an initial bolus dose of 5,000 IU administered at the start, followed by hourly doses of 1,000 IU, monitored using the activated clotting time system. Digital subtraction angiography (DSA) revealed a wide neck basilar tip aneurysm. The aneurysm neck width measured 9.2 mm, 10.4 mm in width, and had a maximum distal diameter of 12.4 mm (Fig. 1A, B). A 14-mm Contour device was chosen for the procedure based on the manufacturer’s recommendations. The 14-mm Contour device was deployed into the aneurysm. The stabilization of the device was confirmed prior to its detachment (Fig. 1C). Postoperative DSA confirmed that the device was appropriately positioned relative to the aneurysm size, with contrast stagnation observed within the aneurysm (Fig. 1D, E, F). The patient was discharged with an intact neurological condition. The patient did not attend his scheduled clinical or radiological follow-up. Fifteen months later, he collapsed suddenly and was intubated at the emergency department. Computed tomography (CT) revealed an intraventricular hemorrhage, while CT angiography revealed a larger basilar tip aneurysm with displacement of the Contour device. Vaso CT showed that the Contour device had shifted to the aneurysm dome and was distorted into a reversed umbrella shape (Fig. 1G, H). The aneurysm exhibited a significant growth, which had a neck size of 9.2 mm, a width of 13.1 mm, and a maximum diameter of 15.3 mm (Fig. 1I). As a result, the aneurysm was embolized using the Y-stent coiling technique, using a Neuroform Atlas stent (Stryker Neurovascular) and Target detachable micro coils (Stryker Neurovascular) (Fig. 1J).
(A, B) Digital subtraction angiography (DSA) and 3D rotational angiography images show wide neck basilar tip aneurysm. (C) Non subtracted images show that Contour device (Cerus) has stabilized prior to release. (D, E) After releasing Contour device, non-subtracted images showing mild contrast stasis in the aneurysm. (F) Vaso computed tomography (CT) revealed that the device was in good position of the aneurysm neck. (G, H) Fifteen months later, Vaso CT reveals a ruptured aneurysm larger than previously observed with an irregular form. In addition, the Contour device displaced to the aneurysm dome and changed to reversed umbrella shape. (I) 3D rotational angiography indicated that the aneurysm had enlarged and developed into an irregular shape. (J) DSA images show that the aneurysm is treated with Y-stent coiling technique.
DISCUSSION
Contour device displacement has been previously reported [3,4]. Recently, Bellanger et al. [5] described the concept of the “reversed umbrella Contour device,” referring to a specific instance of device displacement. Device displacement is not exclusive to the Contour device but also has been observed with the WEB device [6]. This complication occurs due to the undersizing selection of the device size [7]. In this case, despite the aneurysm dimensions being close to the largest size of device on the manufacturer’s size chart, we believe it is advisable to avoid selecting a device that is in the manufacturer’s suggestion. Moreover, due to the fact that the lateral wall pressure is lower in larger WEB devices than in the smaller ones, Kutbay and Algin [8] recommended that large-sized aneurysms should be treated with wider devices. The proposed method of choosing a larger size for the WEB device may be beneficial for larger aneurysms when applied to the Contour device.
Because the widest diameter of the aneurysm is located far from the area where the device would be positioned, the width of the aneurysm—an essential factor in determining the appropriate size of the Contour device—may not be as important in this case [9]. In our case, since the widest diameter of the aneurysm is quite distal, we ignored this when choosing the device size. Although the device was placed in the neck of the aneurysm, the large diameter at the distal end may have resulted in displacement of the device. Therefore, careful assessment is necessary when determining the device size for deployment in aneurysms with a significant distal diameter.
The patient’s history of heavy smoking, uncontrolled hypertension, and diabetes likely contributed to elevated pressure on a device that was appropriate for the size of the aneurysm. As the aneurysm grew and changed shape from the initial angiography, there was concern about possible early device migration. Unfortunately, we do not have angiographic follow-up data to support this hypothesis. Although thromboembolic complications are relatively common, hemorrhagic complications are rare with the Contour device. There have been few reports of hemorrhagic complications occurring during the procedure itself [10,11]. Although delayed aneurysmal rupture has been reported with WEB device, it has not been reported with the Contour device [2]. To the best of our knowledge, this is the first reported case of delayed aneurysmal rupture following treatment with the Contour device.
Wodarg et al. [9] described the Contour-assisted coiling with jailed-microcatheter-for-better-occlusion technique (CoCoJaMBO), where additional coil embolization to the Contour device provided sufficient protection against rebleeding, especially in large aneurysms. They also claimed that the stability of the device was increased by the direct pressure of the additional coils against the aneurysm neck [10]. We believe that this technique will be beneficial in stabilizing the device and preventing late bleeding complications, particularly in large aneurysms with a dome wider than the neck that has irregular contours.
This case highlights that the selection of the appropriate Contour device size is as crucial as the procedure itself. It is important to proceed with caution, especially when choosing devices according to the manufacturer’s size table, as strict compliance with this table may not always be necessary. When coils are added to the treatment and larger devices are used, it may provide benefits in terms of device stabilization, especially in large aneurysms.
Notes
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Ethics Statement
Informed written consent was taken from the patient and first-degree relatives. In addition, IRB approved. We anonymized patient information in the case report, such as sex and age, to prevent the identification of individuals.
Conflicts of Interest
The authors have no conflicts to disclose.
Author Contributions
Concept and design: OK. Analysis and interpretation: OK. Data collection: OK. Writing the article: OK. Critical revision of the article: OK, MM, EM, AA, and AO. Final approval of the article: OK, MM, EM, AA, and AO. Overall responsibility: OK.