Information received from the article: munich sa, tan la, keigher km, et al.The pipeline embolization device for the treatment of posterior circulation fusiform aneurysms: lessons learned at a single institution.J neurosurg.2014; 121:1077¿1084.A database of patients that were treated with the pipeline was reviewed and identified 12 patients who had vfas (vertebrobasilar fusiform aneurysms).The clinical features, complications, and outcomes of these patients were analyzed.At an average follow-up of 11 months, the mean modified rankin scale score was 1.9.Complete aneurysm occlusion was seen in 90% of the patients with radiographic follow-up.Three patients suffered new neurological deficits postoperatively.One of these patients died, while the remaining 2 demonstrated significant clinical improvement at follow-up.Case 12: the presented with new onset of right facial droop and slurred speech.Workup revealed a left vfa and a basilar artery wide neck, sidewall aneurysm located just rostral to the fusiform aneurysm.The patient was placed on a regimen of aspirin 325 mg and clopidogrel 75 mg daily for 2 days.She was also given an additional loading dose of clopidogrel 600 mg the night prior to her procedure.The patient was diagnosed with a posterior fusiform aneurysm and was to undergo treatment.During routine preoperative testing immediately before her procedure, she was noted to have a pru (p2y12 reaction units) of 314.Although this value does not indicate therapeutic platelet inhibition, the physician was reluctant to administer a third antiplatelet agent (e.G., abciximab) intra-operatively because the patient had a history of significant gastrointestinal hemorrhage requiring blood transfusion.Therefore, it was decided to administer an additional 600 mg of clopidogrel prior to the start of the procedure.Three pipelines (4.5mm x 20 mm, 4mm x 35 mm, and 4.75mm x 20 mm) were deployed across the neck of the fusiform aneurysm.Given that fusiform dilation was present in the rostral basilar artery, an enterprise stent (codman, 4.5 x 37 mm) was placed extending from the right posterior cerebral artery to the distal end of the pipeline construct in the basilar artery.The pipeline construct was intentionally deployed proximal to the anterior inferior cerebellar arteries (aicas).The stent with lower metalto-artery coverage (enterprise) was selected to cover the area with more clinically relevant perforators and a sidewall aneurysm at the right aica take off.The patient awoke from the procedure with a mild left hemiparesis (motor examination grade 3/5) and was found to have multiple infarcts in the right posterior cerebral artery territory that were due to atherosclerotic emboli during the procedure.We also chose not to sacrifice the contralateral vertebral artery to avoid abrupt thrombosis of the large aneurysm sac.The patient returned 2 months after this procedure for the addition of coils into the sidewall aneurysm.At that time, we found the vertebrobasilar aneurysm to be completely occluded despite patency of the contralateral vertebral artery.The patient was discharged home from this procedure with an mrs score of 3.The information was received from the same article as mdr# 2029214-2015-00038 and 2029214-2015-00039.
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