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Hall S, Steinfort B, Dexter M. Giant aneurysms of the distal posterior inferior cerebellar artery - systematic review. Br J Neurosurg 2024; 38:687-693. [PMID: 34279172 DOI: 10.1080/02688697.2021.1950631] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/10/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Posterior inferior cerebellar artery (PICA) aneurysms are uncommon and are typically found at the origin or proximal segments of the vessel. Giant aneurysms are uncommon and present unique treatment challenges. Giant distal PICA aneurysms are exceedingly rare and have traditionally been managed via open surgical approaches. METHODS A total of 207 studies were assessed, identifying 26 cases of giant distal PICA aneurysms from 26 separate publications. One additional case is described followed by a review of presentation, anatomical characteristics, treatment and outcome. RESULTS Presentation was due to local mass effect in 19 (70%), hydrocephalus in 4 (15%) and acute haemorrhage in 5 (19%). All reported cases were partially (86%) or completely (14%) thrombosed. The telovelotonsillar segment was involved in 18/24 (75%) cases. Two cases (7%) were associated with an arteriovenous malformation. Twenty-two (81%) were managed surgically and 5 (19%) managed endovascularly. Outcome was good in 22 (85%) and poor in one (4%). CONCLUSIONS Giant distal PICA aneurysms can be managed effectively through a variety of open surgical and endovascular techniques.
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Affiliation(s)
- Samuel Hall
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia
| | | | - Mark Dexter
- Department of Neurosurgery, Westmead Hospital, Sydney, Australia
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2
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Oliveira LDB, Sousa MP, Semione G, Ferreira MY, Batista S, Palavani LB, Andreão FF, Diniz JBC, Rabelo NN, Bertani R, Welling LC, Lawton MT, Figueiredo EG. Posterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery Bypass versus Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for Treating Posterior Circulation Aneurysms: A Systematic Review and Comparative Meta-Analysis. World Neurosurg 2024; 185:403-416.e7. [PMID: 38458251 DOI: 10.1016/j.wneu.2024.02.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/28/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND When traditional therapies are unsuitable, revascularization becomes essential for managing posterior inferior cerebellar artery (PICA) or vertebral artery aneurysms. Notably, the PICA-PICA bypass has emerged as a promising option, overshadowing the occipital artery-PICA (OA-PICA) bypass. The objective was to compare the safety and efficacy of OA-PICA and PICA-PICA bypasses. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review and meta-analysis to evaluate the safety and efficacy of OA-PICA and PICA-PICA bypasses for treating posterior circulation aneurysms. RESULTS We analyzed 13 studies for the PICA-PICA bypass and 16 studies on the OA-PICA bypass, involving 84 and 110 patients, respectively. The median average follow-up for PICA-PICA bypass was 8 months (2-50.3 months), while for OA-PICA, it was 27.8 months (6-84 months). The patency rate for OA-PICA was 97% (95% confidence interval [CI]: 92%-100%) and 100% (95% CI: 95%-100%) for PICA-PICA. Complication rates were 29% (95% CI: 10%-47%) for OA-PICA and 12% (95% CI: 3%-21%) for PICA-PICA. Good clinical outcomes were observed in 71% (95% CI: 52%-90%) of OA-PICA patients and 87% (95% CI: 75%-100%) of PICA-PICA patients. Procedure-related mortality was 1% (95% CI: 0%-6%) for OA-PICA and 1% (95% CI: 0%-10%) for PICA-PICA. CONCLUSIONS Both procedures have demonstrated promising results in efficacy and safety. PICA-PICA exhibits slightly better patency rates, better clinical outcomes, and fewer complications, but with a lack of substantial follow-up and a smaller sample size. The choice between these procedures should be based on the surgeon's expertise and the patient's anatomy.
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Affiliation(s)
| | - Marcelo Porto Sousa
- Department of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gabriel Semione
- Department of Neurosurgery, University of West Santa Catarina, Joaçaba, Santa Catarina, Brazil
| | - Marcio Yuri Ferreira
- Department of Neurosurgery, Ninth of July University, São Paulo, São Paulo, Brazil
| | - Sávio Batista
- Department of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lucca B Palavani
- Department of Neurosurgery, Max Planck University Center, Indaiatuba, São Paulo, Brazil
| | - Filipi F Andreão
- Department of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Leonardo C Welling
- Department of Neurosurgery, State University of Ponta Grossa, Ponta Grossa, Paraná, Brazil
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Cao R, Mattar A, Torche E, Riva R, Laubacher M, Moreno-Gomez R, Turjman F, Falini A, Panni P, Eker OF. Clinical and angiographic characteristics of ruptured and unruptured distal cerebral aneurysms: a review of a large series of cases in a high-volume center. J Neurointerv Surg 2024:jnis-2023-021164. [PMID: 38443187 DOI: 10.1136/jnis-2023-021164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE To evaluate clinical, angiographic features, and endovascular approach of ruptured and unruptured distal intracranial aneurysms (DIAs). METHODS From January 2013 to February 2022, details of all consecutive intracranial aneurysms (IAs) treated endovascularly in our center were collected and retrospectively reviewed. IAs involving the anterior cerebral artery, middle cerebral artery, and posterior cerebral artery (distal to anterior communicating artery, limen insula, and P1 segment, respectively), and those distal to superior cerebellar artery, anterior-inferior cerebellar artery, and posterior inferior cerebellar artery's first segment were classified based on their etiology, location, size, and shape. Demographic, clinical, angiographic, and procedural variables, as well as follow-up outcomes were evaluated. RESULTS Of 2542 IAs, 151 (5.9%) DIAs were counted (average size 5.4±2.9 mm), including 61 (40.4%) unruptured and 90 (59.6%) ruptured. No difference in the aneurysmal size was observed, but aneurysms smaller than 4 mm were observed more frequently in the ruptured group (36.7% vs 18%; P=0.01). In addition, ruptured DIAs were more often non-saccular (40% vs 18%; P=0.004) and irregular (93.3% vs 59%; P<0.001), They were treated mostly by coiling, glue, and parent artery sacrifice (P=0.02, P=0.006, and P=0.001), whereas unruptured DIAs were treated by stent-assisted coiling and flow-diverter stents (P=0.001 and P<0.001, respectively), without any differences in occlusion (81.6% vs 82.5%) and recanalization (21.1% vs 17.5%) rates. Procedure-related complications occurred in 20/151 (13.2%) patients, without any differences between subgroups. Ruptured DIAs were more often re-treated (18.4% vs 5.3%, P=0.02). In multivariate analyses, irregular shape appeared as an independent predictor of ruptured presentation (OR=8.1, 95% CI 3.0 to 21.7; P<0.001). CONCLUSIONS Compared with unruptured DIAs, ruptured DIAs were more often non-saccular, irregular, and smaller than 4 mm. Despite different therapeutical approaches, ruptured and unruptured DIAs presented comparable occlusion and recanalization rates.
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Affiliation(s)
- Roberta Cao
- Hôpital Pierre Wertheimer, Department of Neuroradiology, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Adonis Mattar
- Hôpital Pierre Wertheimer, Department of Neuroradiology, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Esteban Torche
- Hôpital Pierre Wertheimer, Department of Neuroradiology, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Roberto Riva
- Hôpital Pierre Wertheimer, Department of Neuroradiology, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Morgane Laubacher
- Hôpital Pierre Wertheimer, Department of Neuroradiology, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Ricardo Moreno-Gomez
- Hôpital Pierre Wertheimer, Department of Neuroradiology, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Francis Turjman
- Hôpital Pierre Wertheimer, Department of Neuroradiology, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Andrea Falini
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Pietro Panni
- Department of Neuroradiology and Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Omer F Eker
- Hôpital Pierre Wertheimer, Department of Neuroradiology, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
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Haruma J, Sugiu K, Ebisudani Y, Kimura R, Edaki H, Yamaoka Y, Kawakami M, Soutome Y, Hiramatsu M. Endovascular Treatment for Intracranial Artery Dissections in Posterior Circulation. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:92-102. [PMID: 38559451 PMCID: PMC10973565 DOI: 10.5797/jnet.ra.2023-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/11/2023] [Indexed: 04/04/2024]
Abstract
Intracranial artery dissections (IADs), although uncommon, are an important cause of cerebral infarction and subarachnoid hemorrhage (SAH). Some IADs can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis. Meanwhile, others can progress to stroke that requires treatment. The incidence of IAD in the posterior circulation is higher than that in the anterior circulation. Anterior circulation dissections are more likely to develop into ischemia and posterior circulation lesions into hemorrhage. The mortality rate after IAD among patients with SAH is 19%-83%. Further, the mortality rate of IAD without SAH is 0%-3%. Patients with SAH commonly undergo surgery or receive neuroendovascular treatment (EVT) to prevent rebleeding. However, the treatment of IADs is empirical in the absence of data from randomized controlled trials. Recently, EVT has emerged and is considered for IADs because of its less invasiveness and perceived low rates of procedure-related morbidity with good efficacy. EVT strategies can be classified into deconstructive (involving sacrifice of the parent artery) and reconstructive (preserving blood flow via the parent vessel) techniques. In particular, the number of reports on reconstructive techniques is increasing. However, a reconstructive technique for ruptured IADs has not yet been established. This review aimed to provide an overview of IADs in the posterior circulation managed with EVT by performing a literature search.
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Affiliation(s)
- Jun Haruma
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Kenji Sugiu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yuki Ebisudani
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Ryu Kimura
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Hisanori Edaki
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yoko Yamaoka
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Masato Kawakami
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yuta Soutome
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Masafumi Hiramatsu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
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Sathya A, Enriquez-Marulanda A, Young M, Shutran M, Taussky P, Ogilvy CS. Flow Diversion for the Treatment of Posterior Inferior Cerebellar Aneurysms: A Novel Classification of Posterior Inferior Cerebellar Artery Origin. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00980. [PMID: 38038473 DOI: 10.1227/ons.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/06/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Flow diversion (FD) for posterior circulation aneurysms, such as proximal posterior inferior cerebellar artery (PICA) aneurysms, remains "off-label" and controversial. Although there are reports of using FD in the vertebral artery (VA) to treat PICA aneurysms, the differences between structural PICA-origin variants have not been explored. We analyzed PICA aneurysms treated with FD, assessed radiographic and clinical outcomes, and presented a novel classification of the PICA origin in relationship to aneurysm anatomy. METHODS We performed a retrospective study of prospective data for intracranial aneurysms treated with FD at a major academic institution from 2013 to 2022. Proximal PICA aneurysms that underwent FD placement in the V4 segment of the vertebral artery were included for analysis. A literature review was performed on PubMed to evaluate previously published cases. The PICA origin was characterized by 4 distinct subtypes. Type 1 describes the PICA originating adjacent/separate to the aneurysm neck, Type 2 with the PICA originating from the aneurysm neck, Type 3 with the PICA originating from the aneurysm dome, and Type 4 (True PICA aneurysm) with the aneurysm located proximally on PICA, distal to the PICA-VA junction. RESULTS Thirteen proximal PICA aneurysms were identified and included in the analysis. Patients were primarily female (76.9%), with a median age of 62 years. The aneurysm median maximum diameter was 5.8 mm. From the total sample (institutional and literature review cases), type 1 had a 100% complete and near-complete occlusion rate, type 2 had 75.0%, type 3 had 88.9%, and type 4 had 75%. The overall complete and near-complete occlusion rate was 83.3% (20/24). CONCLUSION FD in the V4 VA segment is an effective way to treat proximal PICA aneurysms. Exploring the relationship between PICA origin is a helpful method in predicting occlusion rates for proximal PICA aneurysms and may lead to improved treatment considerations.
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Affiliation(s)
- Anvitha Sathya
- Neurosurgery Department, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Young
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Phillip Taussky
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
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Metayer T, Gilard V, Piotin M, Emery E, Borha A, Robichon E, Briant AR, Derrey S, Vivien D, Gaberel T. Microsurgery and Endovascular Therapy for Distal Anterior Cerebral Artery Aneurysm: A Multicenter Retrospective Cohort Study. World Neurosurg 2023; 178:e174-e181. [PMID: 37451360 DOI: 10.1016/j.wneu.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Distal anterior cerebral aneurysm (DACA) represents 4% of intracranial aneurysms. Two treatment modalities are available: microsurgery and endovascular therapy (EVT). OBJECTIVE To compare the results between microsurgery and EVT in a modern French cohort. METHODS A multicenter retrospective cohort study of 3 French neurosurgical units was carried out from January 1, 2015, to December 31, 2020. All participants were adult patients who required treatment for a ruptured or unruptured DACA aneurysm. RESULTS A total of 69 patients were included; 16 patients (23.2%) were treated by microsurgery and 53 (76.8%) were treated by EVT. Thirty-one patients (44.9%) had ruptured aneurysms. The complication rate was low, with 1 death and 1 symptomatic ischemia. There was no difference in complications between microsurgery and EVT (P = 0.22). The number of retreatments was higher in EVT (15% vs. 0%) but not significantly (P = 0.18). CONCLUSIONS In the specific subgroup of DACA, both treatment modalities are effective in ruptured and unruptured aneurysms, with a low rate of complications. Retreatment may be more frequent in EVT but it does not lead to more complications.
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Affiliation(s)
- Thomas Metayer
- Department of Neurosurgery, University Hospital of Caen, Caen, France; Normandie Université, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Caen, France.
| | - Vianney Gilard
- Department of Neurosurgery, University Hospital of Rouen, Rouen, France
| | - Michel Piotin
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Evelyne Emery
- Department of Neurosurgery, University Hospital of Caen, Caen, France; Normandie Université, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Caen, France
| | - Alin Borha
- Department of Neurosurgery, University Hospital of Caen, Caen, France; Normandie Université, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Caen, France
| | - Erwan Robichon
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Anais R Briant
- Department of Biostatistics, University Hospital of Caen, Caen, France
| | - Stephane Derrey
- Department of Neurosurgery, University Hospital of Rouen, Rouen, France
| | - Denis Vivien
- Normandie Université, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Caen, France
| | - Thomas Gaberel
- Department of Neurosurgery, University Hospital of Caen, Caen, France; Normandie Université, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Caen, France; Medical School, University of Caen Normandy, Caen, France
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Saal-Zapata G, Rodriguez-Calienes A, Malaga M, Velasquez-Rimachi V, Moran C, Bustamante-Paytan D, Pacheco-Barrios N, Pacheco-Barrios K, Alva-Diaz C, Walker M. Microsurgical and endovascular treatment of posterior inferior cerebellar artery aneurysms: a systematic review and meta-analysis. J Neurosurg Sci 2023; 67:638-652. [PMID: 35416457 DOI: 10.23736/s0390-5616.22.05710-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Posterior inferior cerebellar artery (PICA) aneurysms are uncommon vascular lesions of the posterior fossa. In addition to aneurysmal morphology, structural anatomic considerations may confer additional procedural risk, and as a result there is currently no consensus as to whether a surgical or endovascular approach offers greater safety and efficacy for patients. EVIDENCE ACQUISITION We systematically examined peer-reviewed literature describing PICA aneurysm treatment planning from January 2000 to May 2021 using the PRISMA methodology. A meta-analysis of proportions was performed. Certainty of the evidence was assessed using the GRADE approach. EVIDENCE SYNTHESIS Fifty-eight studies including 1673 PICA aneurysms were analyzed. Overall treatment occlusion rate was 97% (95% confidence interval [CI]: 93-100%) for surgery and 85% (95% CI: 78-92%) for endovascular therapy. The recurrence rate was 6% in the endovascular group and 1% for surgery. Overall morbidity and mortality were 16% and 7%, respectively. Intraoperative complications occurred in 9% of the surgical patients. CONCLUSIONS Despite a large body of literature, analysis indicates that 62% of studies had moderate or serious risk of bias, suggesting very-low certainty results. Therefore, treatment via either approach should be determined on a case-by-case basis and according to institutional experience.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Section of Endovascular Neurosurgery, Department of Neurosurgery, Guillermo Almenara Irigoyen-EsSalud National Hospital, Lima, Peru -
| | - Aaron Rodriguez-Calienes
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
| | - Marco Malaga
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
| | - Victor Velasquez-Rimachi
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
| | - Cristian Moran
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
- Scientific University of the South, Lima, Peru
| | | | - Niels Pacheco-Barrios
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
- Faculty of Human Medicine, San Martin de Porres University, Lima, Peru
| | - Kevin Pacheco-Barrios
- Alberto Hurtado Faculty of Medicine, Cayetano Heredia Peruvian University, Lima, Peru
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, MA, USA
| | - Carlos Alva-Diaz
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
| | - Melanie Walker
- Research Unit for the Generation and Synthesis of Health Evidence, San Ignacio de Loyola University, Lima, Perú
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Shintoku R, Marushima A, Okune S, Hiramine T, Nakao J, Takahashi T, Hino T, Hosoo H, Ito Y, Hayakawa M, Ishikawa E, Matsumaru Y. Endovascular Embolization with n-Butyl Cyanoacrylate for Ruptured Distal Posterior Inferior Cerebellar Artery Dissecting Aneurysm. Asian J Neurosurg 2023; 18:651-655. [PMID: 38152529 PMCID: PMC10749849 DOI: 10.1055/s-0042-1757432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Parent artery occlusion is a definitive treatment method for preventing rebleeding of dissecting aneurysms. We herein report a case of a ruptured distal posterior inferior cerebellar artery (PICA) dissecting aneurysm treated with internal trapping using n-butyl-2-cyanoacrylate (NBCA). A 65-year-old man visited our hospital with a complaint of headache and neck pain that began 1 week before his arrival. He had a history of spontaneous subarachnoid hemorrhage of unknown cause. Computed tomography of the brain revealed a small amount of subarachnoid hemorrhage, and distal subtraction angiogram showed a distal PICA dissecting aneurysm. We placed a guiding catheter in the left vertebral artery and an intermediate catheter in the PICA. A microcatheter was guided toward the proximal side of the aneurysm and was wedged into the parent artery. The dissecting aneurysm was treated with parent artery occlusion using 50% NBCA. The postoperative course was uneventful, and the patient was discharged 3 weeks after treatment without any neurological deficit. Parent artery occlusion with internal trapping using NBCA could be a safe and definitive treatment method for distal PICA dissecting aneurysms. Angiographical evaluation of the collateral network in the distal branch of PICA before embolization and wedged microcatheter technique in the parent artery are important for successful embolization using NBCA.
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Affiliation(s)
- Ryosuke Shintoku
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Aiki Marushima
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Sho Okune
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Takato Hiramine
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Junzo Nakao
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Toshihide Takahashi
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tenyu Hino
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Hisayuki Hosoo
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yoshiro Ito
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Mikito Hayakawa
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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9
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Dolas I, Unal TC, Gulsever CI, Sahin D, Huseynov H, Barburoglu M, Ozturk O, Can H, Adiyaman AE, Dagdeviren HE, Sabanci PA, Aydoseli A, Aras Y, Sencer A, Sencer S. Endovascular treatment of posterior circulation aneurysms: Results from a single-team experience of 81 cases including 13 flow diversion treatment. NEUROCIRUGIA (ENGLISH EDITION) 2023:S2529-8496(22)00097-1. [PMID: 36774258 DOI: 10.1016/j.neucie.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/29/2022] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Relatively constant surgical risks and rapid advances in endovascular treatment have caused a major shift toward endovascular management of posterior circulation aneurysms. This paper presents the results of a series of endovascularly treated posterior circulation aneurysms. METHODS A total of 81 patients who underwent endovascular treatment of posterior circulation aneurysms performed by a single team between 2009 and 2019 were included. Demographic, clinical, radiologic, and management details were retrospectively obtained from hospital records. RESULTS Among the included patients, 50 (61.7%) and 31 (38.3%) were female and male, respectively. Subarachnoid hemorrhage was observed in 30 patients (37%). Moreover, 40 (49.3%) aneurysms were treated with stent-assisted coiling, 1 (1.2%) aneurysm was treated with parent artery occlusion, 2 (2.4%) aneurysms were coiled using balloon assistance, 24 (29.6%) aneurysms were coiled primarily, 1 (1.2%) patient had an unsuccessful treatment attempt, and 13 (16.0%) aneurysms were treated with flow-diverter stents or stent monotherapy. During the last follow-up, 57 (83.8%) aneurysms were completely occluded, whereas 6 (8.8%) and 2 (2.9%) aneurysms did and did not have a residual neck, respectively. Flow diversion was used to treat 13 patients, among whom 8 had total occlusion or stable residue. A total of 7 deaths (8.6%) were encountered in this series. CONCLUSION Endovascular treatment should be considered as the primary treatment modality for posterior circulation aneurysms. Despite the high morbidity and mortality rates, promising results can be achieved with correct patient selection. Flow diversion can be a feasible alternative for complex aneurysms that are difficult to treat.
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Affiliation(s)
- Ilyas Dolas
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Tugrul Cem Unal
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Cafer Ikbal Gulsever
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.
| | - Duran Sahin
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Heydar Huseynov
- Department of Radiology, Istanbul Atlas University, Istanbul, Turkey
| | - Mehmet Barburoglu
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Onur Ozturk
- Department of Neurosurgery, Istanbul Bilim University, Istanbul, Turkey
| | - Halil Can
- Department of Neurosurgery, Istanbul Atlas University, Istanbul, Turkey
| | - Ali Ekrem Adiyaman
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Huseyin Emre Dagdeviren
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Pulat Akin Sabanci
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Aydin Aydoseli
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Yavuz Aras
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Altay Sencer
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Serra Sencer
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
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10
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Metayer T, Piotin M. Letter to the Editor Regarding "Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysm: Systematic Review and Meta-analysis". World Neurosurg 2022; 166:302. [PMID: 36192858 DOI: 10.1016/j.wneu.2022.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Thomas Metayer
- Department of Neurosurgery, University Hospital of Caen, Caen, France; Normandie University, UNICAEN, INSERM, Institute of Blood and Brain, Caen, France.
| | - Michel Piotin
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, France
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11
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Yang Z, Song J, Quan K, Li P, An Q, Shi Y, Liu P, Yu G, Tian Y, Zhou L, Zhu W. Microsurgical treatment of posterior inferior cerebellar aneurysms based on angioarchitecture supplemented by high-resolution vessel wall MRI: a case series report. Stroke Vasc Neurol 2022; 7:337-344. [PMID: 35387894 DOI: 10.1136/svn-2021-001115if:9.893q1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/07/2022] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Surgical treatment of posterior inferior cerebellar artery (PICA) aneurysms is challenging because many are nonsaccular and atherosclerotic. We report our tailored approach to PICA aneurysms, which is based on angioarchitecture supplemented by high-resolution vessel wall MRI (HR-VW MRI) findings. METHODS From March 2010 to September 2020, 27 patients with 29 PICA aneurysms underwent surgical treatment in our institution. Since October 2016, HR-VW MRI has been used for aneurysmal wall assessment. Clinical characteristics, radiological data and surgical outcomes were analysed. RESULTS Nineteen proximal PICA aneurysms (vertebral artery (VA), P1, P2 and P3) were treated using the far-lateral approach. Ten distal PICA aneurysms (P4, P5) were treated using the suboccipital midline approach. Direct clipping or clip reconstruction was achieved in 19 aneurysms. Ten were trapped in conjunction with extracranial-intracranial or intracranial-intracranial bypass, including three occipital artery-PICA reimplantations, three PICA-VA reimplantations, two PICA-PICA side-to-side anastomoses, one PICA-PICA reimplantation and one PICA-PICA reanastomosis. All aneurysms were eventually completely obliterated and all bypasses remained patent. At the last follow-up, 26 patients (96.2%) achieved a good outcome (modified Rankin Scale score <3). Eight patients underwent HR-VW MRI. Among these, the six aneurysms with focal wall enhancement required bypass and the two with negative enhancement were successfully clipped. CONCLUSION PICA aneurysms have a higher frequency of complex features such as large or giant size and fusiform or dissecting morphology. Favourable outcomes were achieved with individualised microsurgical strategies based on angioarchitecture. HR-VW MRI may be used as a promising technique to predict aneurysmal atherosclerosis.
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Affiliation(s)
- Zixiao Yang
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jianping Song
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peiliang Li
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Qingzhu An
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peixi Liu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Guo Yu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yanlong Tian
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Liangfu Zhou
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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12
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Dolas I, Unal TC, Gulsever CI, Sahin D, Huseynov H, Barburoglu M, Ozturk O, Can H, Adiyaman AE, Dagdeviren HE, Sabanci PA, Aydoseli A, Aras Y, Sencer A, Sencer S. Endovascular treatment of posterior circulation aneurysms: Results from a single-team experience of 81 cases including 13 flow diversion treatment. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Hou K, Yu J. Case Report: Can Ruptured Aneurysms in the Hypoplastic and Plexiform Posterior Inferior Cerebellar Arteries Be Safely Occluded? Front Neurol 2022; 13:904863. [PMID: 35812084 PMCID: PMC9263357 DOI: 10.3389/fneur.2022.904863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022] Open
Abstract
Aneurysms arising from the posterior inferior cerebellar artery (PICA) are not rare and may originate from the proximal or peripheral segment of the PICA. However, when the affected PICA is hypoplastic and plexiform, it is difficult to occlude the aneurysm without sacrificing the parent vessel, the PICA. This type of aneurysm is rare, and whether it is safe to occlude the aneurysm and the parent artery, in cases of a ruptured aneurysm of the hypoplastic and plexiform PICA, has not been adequately studied and is still open to debate. In this report, two patients with ruptured aneurysms in the hypoplastic and plexiform PICA were presented. Both patients were admitted to our hospital for subarachnoid hemorrhage. After team discussions between the neurosurgeons and neurointerventionalists, the aneurysm and parent PICA had to be occluded via endovascular treatment under general anesthesia. One of the patients developed postprocedural brainstem infarction and exhibited favorable recovery. The other patient died of pulmonary infection, although improvement in the postoperative state was observed. Although rare, aneurysms can originate from the hypoplastic and plexiform PICA. Occluding the aneurysm and hypoplastic parent PICA via endovascular treatment might be a reasonable option.
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14
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Ali AMS, Hannan CJ, Islim AI, Mascitelli JR, Javadpour M. Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysms: Systematic Review and Meta-Analysis. World Neurosurg 2022; 162:e168-e177. [PMID: 35257955 DOI: 10.1016/j.wneu.2022.02.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The optimal treatment modality for saccular aneurysms of the posterior inferior cerebellar artery (PICA) remains unclear. A previous meta-analysis on the topic included a heterogenous study population, limiting the conclusions that can be drawn from its results. The aim of this study was to perform a systematic review and meta-analysis to compare outcomes of microsurgical and endovascular treatment (EVT) of these aneurysms. METHODS A search of 4 online databases was performed for studies describing the management of saccular PICA aneurysms. The primary outcome was complete aneurysm occlusion. Data were also collected on neurologic outcomes, cranial nerve palsies, and requirement for re-treatment. A random effects model was used for calculation of pooled proportions. Our protocol was registered with PROSPERO (CRD42021232784). RESULTS A total of 17 studies were included in the final analysis, reporting the treatment outcomes of 455 aneurysms, with a mean follow-up of 20 months. The pooled occlusion rates were 94.8% (95% confidence interval [CI] 90.6%-97.8%) for surgical treatment and 69.1% (95% CI 55.0%-81.7%) for EVT. Pooled rates of good neurologic outcome (modified Rankin scale score ≤2, Glasgow Outcome Scale score ≥4) at last follow-up were 78.1% (95% CI 67.4%-87.1%) for surgery and 77.6% (95% CI 67.9%-86.0%) for EVT. CONCLUSIONS This meta-analysis demonstrates that in the treatment of saccular PICA aneurysms, microsurgical clipping results in superior angiographic outcomes, similar functional outcomes, but higher rates of lower cranial nerve palsy compared with EVT. Further studies are required to assess the duration and severity of cranial nerve palsies following surgical treatment, and long-term aneurysm occlusion and the requirement for re-intervention following EVT.
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Affiliation(s)
- Ahmad M S Ali
- The Walton Centre for Neurology and Neurosurgery, Liverpool, England
| | | | | | | | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; School of Medicine, Trinity College Dublin, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
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15
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Yang Z, Song J, Quan K, Li P, An Q, Shi Y, Liu P, Yu G, Tian Y, Zhou L, Zhu W. Microsurgical treatment of posterior inferior cerebellar aneurysms based on angioarchitecture supplemented by high-resolution vessel wall MRI: a case series report. Stroke Vasc Neurol 2022; 7:337-344. [PMID: 35387894 PMCID: PMC9453843 DOI: 10.1136/svn-2021-001115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/07/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Surgical treatment of posterior inferior cerebellar artery (PICA) aneurysms is challenging because many are nonsaccular and atherosclerotic. We report our tailored approach to PICA aneurysms, which is based on angioarchitecture supplemented by high-resolution vessel wall MRI (HR-VW MRI) findings. METHODS From March 2010 to September 2020, 27 patients with 29 PICA aneurysms underwent surgical treatment in our institution. Since October 2016, HR-VW MRI has been used for aneurysmal wall assessment. Clinical characteristics, radiological data and surgical outcomes were analysed. RESULTS Nineteen proximal PICA aneurysms (vertebral artery (VA), P1, P2 and P3) were treated using the far-lateral approach. Ten distal PICA aneurysms (P4, P5) were treated using the suboccipital midline approach. Direct clipping or clip reconstruction was achieved in 19 aneurysms. Ten were trapped in conjunction with extracranial-intracranial or intracranial-intracranial bypass, including three occipital artery-PICA reimplantations, three PICA-VA reimplantations, two PICA-PICA side-to-side anastomoses, one PICA-PICA reimplantation and one PICA-PICA reanastomosis. All aneurysms were eventually completely obliterated and all bypasses remained patent. At the last follow-up, 26 patients (96.2%) achieved a good outcome (modified Rankin Scale score <3). Eight patients underwent HR-VW MRI. Among these, the six aneurysms with focal wall enhancement required bypass and the two with negative enhancement were successfully clipped. CONCLUSION PICA aneurysms have a higher frequency of complex features such as large or giant size and fusiform or dissecting morphology. Favourable outcomes were achieved with individualised microsurgical strategies based on angioarchitecture. HR-VW MRI may be used as a promising technique to predict aneurysmal atherosclerosis.
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Affiliation(s)
- Zixiao Yang
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jianping Song
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peiliang Li
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Qingzhu An
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peixi Liu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Guo Yu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yanlong Tian
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Liangfu Zhou
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China .,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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16
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Smith-Davidson M. What is causing this patient's lower back pain? JAAPA 2022; 35:62-64. [PMID: 35076443 DOI: 10.1097/01.jaa.0000805860.81177.9f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Maggie Smith-Davidson
- Maggie Smith-Davidson practices in emergency medicine at David Grant Medical Center at Travis Air Force Base in northern California. The author has disclosed no potential conflicts of interest, financial or otherwise
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17
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Lauzier DC, Root BK, Kayan Y, Almandoz JED, Osbun JW, Chatterjee AR, Whaley KL, Tipps ME, Moran CJ, Kansagra AP. Pipeline embolization of distal posterior inferior cerebellar artery aneurysms. Interv Neuroradiol 2021; 27:821-827. [PMID: 33892602 PMCID: PMC8673893 DOI: 10.1177/15910199211013195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/04/2021] [Accepted: 03/29/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Flow diversion is commonly used to treat intracranial aneurysms in various regions of the cerebral vasculature, but is only approved for use in the internal carotid arteries. Treatment of distal PICA aneurysms with PED is sometimes performed but has not been well studied. Here, we report our experience with flow diversion of distal PICA aneurysms with PED. MATERIALS AND METHODS Clinical and angiographic data of eligible patients was retrospectively obtained and assessed for key demographic characteristics and clinical and angiographic outcomes. Principal outcomes included rates of aneurysm occlusion, ischemic or hemorrhagic complication, technical complication, and in-stent stenosis. RESULTS Three female and 2 male patients underwent placement of PED in the PICA for treatment of 5 distal PICA aneurysms. Clinical and angiographic follow-up was obtained for all patients. Complete aneurysm occlusion was observed in 100% (5/5) of treated aneurysms at 6 month and longest angiographic follow-up. While there were no ischemic or device-related complications, delayed hemorrhagic complications occurred in 20% (1/5) of patients. CONCLUSION Pipeline embolization of distal PICA aneurysms can be performed in select patients. Further study is necessary in larger cohorts to better define clinical scenarios in which flow diversion in the distal PICA should be considered.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brandon K Root
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kayla L Whaley
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Megan E Tipps
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
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18
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Chang Mulato JE, Riechelmann GS, Alejandro SA, Paganelli SL, Vela Rojas EJ, Dória-Netto HL, Campos Filho JM, Chaddad-Neto F. Microsurgical Treatment for a Ruptured Posterior Inferior Cerebellar Artery Aneurysm: A 3-Dimensional Surgical Video and Anatomic Landmarks Review. World Neurosurg 2021; 158:180. [PMID: 34856402 DOI: 10.1016/j.wneu.2021.11.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
Aneurysms are the most frequent issue for the posterior inferior cerebellar artery (PICA). PICA aneurysms account for 1.4% to 4.5% of all intracranial aneurysms.1-3 Although the majority of PICA aneurysms arise from their junction with the vertebral artery, they can be found in any of 5 segments.4,5 Although PICA is more prone to form nonsaccular aneurysms than other intracranial arteries, ruptured aneurysms are usually saccular.6 Nearly all PICA aneurysms are located intracranially, above the foramen magnum. Extracranial PICA aneurysms are rare, with few reports in literature.7 Microsurgical clipping remains a good treatment alternative for these aneurysms. Higher risk of rerupture has even been reported with embolization of the distal PICA aneurysm with parent artery preservation.8 Here we present the case of a 64-year-old male patient who presented right after a thunderclap headache, followed by a temporary loss of consciousness and disorientation. He was diagnosed with a modified Fisher 4 and Hunt and Hess 2 subarachnoid hemorrhage and found to have a partially thrombosed left PICA saccular aneurysm of the caudal loop just below the foramen magnum. The lesion was approached via a midline suboccipital craniotomy with C1 laminectomy. Microsurgical clipping of the aneurysm was performed without any complications (Video 1). Postoperatively, the patient was discharged without neurologic deficits. We present the first surgical video of the necessary steps in order to perform a microsurgical clipping of an extracranially located caudal loop PICA aneurysm through a midline suboccipital craniotomy with C1 laminectomy.
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Affiliation(s)
| | | | | | | | | | - Hugo Leonardo Dória-Netto
- Department of Neurology & Neurosurgery, Universidade Federal de São Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil
| | - Jose Maria Campos Filho
- Department of Neurology & Neurosurgery, Universidade Federal de São Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil
| | - Feres Chaddad-Neto
- Department of Neurology & Neurosurgery, Universidade Federal de São Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil.
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19
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Liu X, Bao K, Luo W, Wan W, Peng T, Huang C. Flow diverters for the posterior inferior cerebellar artery aneurysms: A systematic review and a single-arm meta-analysis. Interv Neuroradiol 2021; 28:482-488. [PMID: 34519241 PMCID: PMC9326854 DOI: 10.1177/15910199211035902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The treatment of posterior inferior cerebellar artery aneurysms is controversial. Recently, flow diverters have emerged as an attractive treatment option. Here, we performed a systematic review and meta-analysis of the angiographic and clinical outcomes of flow diverter-treated posterior inferior cerebellar artery aneurysms. METHODS We searched the PubMed, EMBASE and Web of Science databases for studies published from inception to January 2021. We included studies that described flow diverters procedures for posterior inferior cerebellar artery aneurysms with ≥2 patients. The outcomes were the complete occlusion rate and flow diverter-related complication rate. Meta-analysis was performed using a random or fixed effects model based on heterogeneity. RESULTS We included six studies involving 46 posterior inferior cerebellar artery aneurysms. There were 14 ruptured aneurysms. All flow diverters were successfully released and the technical success rate was 100%. The complete occlusion rate was 81% (95% confidence interval = 65-93%; I2 = 0.00%; P < 0.01). The flow diverter-related complication rate was 18% (95% confidence interval = 5-36%; I2 = 0.00%; P < 0.01). One patient died of rebleeding. The mortality rate was <1% (95% confidence interval = -1-1%; I2 = 0.00%; P = 0.951). CONCLUSIONS Treatment of posterior inferior cerebellar artery aneurysms with flow diverters is feasible and carries a high degree of technical success. However, this treatment is underutilized in patients with posterior inferior cerebellar artery aneurysms due to a higher complication rate and lower occlusion rate compared with clipping and traditional endovascular treatment. Further well-designed prospective and randomized studies are required to fully understand the effects of flow diverters especially in posterior inferior cerebellar artery aneurysms patients requiring endovascular treatment.
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Affiliation(s)
- Xiang Liu
- Department of Neurosurgery, 556508The Affiliated Hospital of Southwest Medical University, P.R. China.,Sichuan Clinical Research Centre for Neurosurgery, P.R. China.,Academician (Expert) Workstation of Sichuan Province, P.R. China
| | - Kunyang Bao
- Department of Neurosurgery, 556508The Affiliated Hospital of Southwest Medical University, P.R. China.,Sichuan Clinical Research Centre for Neurosurgery, P.R. China.,Academician (Expert) Workstation of Sichuan Province, P.R. China
| | - Wenzhang Luo
- Department of Neurosurgery, 556508The Affiliated Hospital of Southwest Medical University, P.R. China.,Sichuan Clinical Research Centre for Neurosurgery, P.R. China.,Academician (Expert) Workstation of Sichuan Province, P.R. China
| | - Weifeng Wan
- Department of Neurosurgery, 556508The Affiliated Hospital of Southwest Medical University, P.R. China.,Sichuan Clinical Research Centre for Neurosurgery, P.R. China.,Academician (Expert) Workstation of Sichuan Province, P.R. China
| | - Tangming Peng
- Department of Neurosurgery, 556508The Affiliated Hospital of Southwest Medical University, P.R. China.,Sichuan Clinical Research Centre for Neurosurgery, P.R. China.,Academician (Expert) Workstation of Sichuan Province, P.R. China
| | - Changren Huang
- Department of Neurosurgery, 556508The Affiliated Hospital of Southwest Medical University, P.R. China.,Sichuan Clinical Research Centre for Neurosurgery, P.R. China.,Academician (Expert) Workstation of Sichuan Province, P.R. China
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20
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Larson AS, Mehta T, Grande AW. Neurosurgical management of aneurysms of the vertebrobasilar system: increasing indications for endovascular therapy with a continued role for open microneurosurgery. Neurosurg Rev 2021; 44:2469-2476. [PMID: 33409762 DOI: 10.1007/s10143-020-01460-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/16/2020] [Accepted: 12/09/2020] [Indexed: 11/26/2022]
Abstract
Aneurysms of the vertebrobasilar system remain among the most challenging subsets of aneurysms to treat with an open surgical approach. Since Charles Drake's pioneering work in the 1960s, several advances in microsurgical techniques have improved outcomes and feasibility in the open surgical management of these aneurysms. In parallel, the field of endovascular neurosurgery has provided several safe and effective treatment options. Multiple trials have suggested that endovascular therapy for aneurysms of the vertebrobasilar system is superior to open surgical management in most cases. In some instances, however, open surgical management likely represents a more effective and durable option relative to endovascular therapy. Therefore, continued training of future cerebrovascular specialists in open surgery of vertebrobasilar aneurysms remains crucial. With widespread utilization of endovascular techniques, however, proper exposure of trainees to such aneurysms is growing increasingly difficult. In this review, we discuss the recent advances in the endovascular management of vertebrobasilar aneurysms while also emphasizing the continued importance of open microneurosurgery in such cases.
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Affiliation(s)
- Anthony S Larson
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA.
| | - Tapan Mehta
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA
- Department of Interventional Neuroradiology and Neurology, Ayer Neuroscience Institute, Hartford Healthcare, West Hartford, CT, USA
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA
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21
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Multidisciplinary Treatments of True Posterior Inferior Cerebellar Artery Aneurysms: Single-Center Retrospective Study and Treatment Algorithm. World Neurosurg 2020; 139:e45-e51. [PMID: 32194274 DOI: 10.1016/j.wneu.2020.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND True posterior inferior cerebellar artery (PICA) aneurysms outside the vertebral artery-PICA region are rare, with approximately 30 cases reported in just a few papers; no treatment paradigm has been advocated. The objective of this study was to present detailed clinical features and outcomes for several treatments for true PICA aneurysms and suggest an algorithm for treatment strategies. METHODS We retrospectively analyzed outcomes of patients treated for PICA aneurysms with microsurgical and endovascular treatments. We also investigated the influence of several factors on the modified Rankin Scale score. RESULTS Cases with PICA aneurysms (n = 36) outside the vertebral artery-PICA region were identified angiographically. Aneurysm locations included anterior medullary (n = 7), lateral medullary (n = 10), tonsillomedullary (n = 4), telovelotonsillar (n = 12), and cortical (n = 3) segments of the PICA. Aneurysm morphology was as follows: dissecting: 22; fusiform: 6; and saccular: 8. On multivariate analysis, age (P = 0.028) and lack of vermian infarction (P =0.037) were associated with a significantly better prognosis. Prognosis was not significantly different for the 5 aneurysm locations and among the 4 treatment groups: clipping/coiling, trapping/parent artery occlusion, trapping/parent artery occlusion + bypass, and observation including external ventricular drainage. CONCLUSIONS This study suggests that factors associated with significantly better prognosis include age, clip/coil treatments, and no vermian infarction complication. A treatment algorithm for true PICA aneurysms was supported according to pretreatment H and K grade, PICA segments, aneurysm morphology, and 3 types of ischemia linked to the brainstem, cerebellar hemisphere, or vermis.
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22
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Deora H, Nayak N, Dixit P, Vikas V, Rao KVLN, Pruthi N, Srinivas D, Shukla DP, Bhat DI, Malla BR, Devi BI, Somanna S. Surgical Management and Outcomes of Aneurysms of Posterior Inferior Cerebellar Artery: Location-Based Approaches with Review of Literature. J Neurosci Rural Pract 2020; 11:34-43. [PMID: 32269450 PMCID: PMC7138643 DOI: 10.1055/s-0039-3399486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background
Posterior inferior cerebellar artery (PICA) is a tortuous, variable, and uncommon site for aneurysms. Surgical management of PICA aneurysms involves careful selection of approach based on the location of the aneurysm and meticulous dissection of the neurovascular structures and perforators.
Materials and Methods
We did a retrospective review of all the PICA aneurysms operated at our institute in the past 10 years along with the site, presentation, and approach used for the same. Preoperative World Federation of Neurosurgical Society scores and follow-up modified Rankin scores (mRS) were also evaluated. During the same period, data for intervention cases of PICA aneurysm were also collected with follow-ups for a comparative analysis.
Results
A total of 20 patients with 21 PICA aneurysms were reviewed. All the reviewed cases presented with subarachnoid hemorrhage, and the most common location was the lateral medullary segment and vertebral artery (VA)–PICA junction. Midline approaches were used for distal PICA cases, with far-lateral approach reserved for anterior medullary/VA–PICA junction. No lower cranial nerve palsies were recorded at follow-up. Four cases needed cerebrospinal fluid diversion and two developed cerebellar infarcts. All cases were mRS 0 to 2 at follow-up.
Conclusion
Our series compares well with some of the larger surgical series of PICA aneurysms. This may be due to early referral patterns and early surgery (<24 hours) policy at our institution. Anatomical knowledge of PICA anatomy and sound perioperative management are keys to good outcomes in these cases.
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Affiliation(s)
- Harsh Deora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nitish Nayak
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Priyadarshi Dixit
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - V Vikas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - K V L Narasinga Rao
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhananjay I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Bhaskara Rao Malla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Bhagvatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sampath Somanna
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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23
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Miao HL, Zhang DY, Wang T, Jiao XT, Jiao LQ. Clinical Importance of the Posterior Inferior Cerebellar Artery: A Review of the Literature. Int J Med Sci 2020; 17:3005-3019. [PMID: 33173421 PMCID: PMC7646108 DOI: 10.7150/ijms.49137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022] Open
Abstract
The posterior inferior cerebellar artery (PICA), with its unique anatomical complexity, is of great clinical importance and involved in many diseases including aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM), and brain tumor. However, a comprehensive systematic review of the importance of the PICA is currently lacking. In this study, we perform a literature review of PICA by searching all the associated papers in the PUBMED database hoping to provide a better understanding of the artery. The PICA has tortuous and variable course and territory, divided into 5 segments. Various aneurysms involving PICA were not uncommon, of which the treatment is challenging. The PICA infarct typically manifests lateral medullary syndrome (LMS) and is more likely to cause mass effects. The PICA frequently compresses the medulla and the cranial nerves resulting in various neurovascular compression syndromes (NVCS). Arteriovenous malformation (AVM) fed by PICA are associated with aneurysm and dissection which have high risk of rupture and worse outcome. PICA injured by head trauma can cause fatal SAH. VA terminating in PICA probably cause Bow hunter's syndrome (BHS). The PICA supplies many brain tumors and can be used in intracerebellar chemotherapy. The PICA can be exposed and injured during surgeries especially in telovelar approach, and it also plays an important role in bypass surgeries, hinting the surgical importance of PICA. In conclusion, PICA is very important in clinical practice.
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Affiliation(s)
- Hui-Lei Miao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Deng-Yan Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China.,School of General Practice and Continuing Education, Capital Medical University, Beijing 100069,China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
| | - Xiao-Tian Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
| | - Li-Qun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
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24
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Pilipenko Y, Eliava S, Okishev D, Okisheva E, Spyrou A. Vertebral artery and posterior inferior cerebellar artery aneurysms: Results of microsurgical treatment of eighty patients. Surg Neurol Int 2019; 10:227. [PMID: 31819820 PMCID: PMC6884955 DOI: 10.25259/sni_326_2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/24/2019] [Indexed: 11/04/2022] Open
Abstract
Background The choice of surgical approaches and options for the microsurgical vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms repair remains controversial. Methods A retrospective analysis of the clinical, surgical, and angiographic data of 80 patients with VA and PICA aneurysms treated from 2012 to 2018 was performed. Results The aneurysms were saccular in 50 cases (62.5%) and fusiform in 30 cases (37.5%). The median suboccipital craniotomy was the most common approach (73.8%). Retrosigmoid craniotomy was performed in 25% of patients. There were the following types of microsurgical operations: neck clipping (61.25%), clipping with the artery lumen formation (13.75%), trapping (10%), proximal clipping (5%), and deconstruction with anastomosis (10%). Fifty-seven (71.3%) patients were discharged without worsening of the clinical signs after surgery. The most common postoperative neurological disorder was palsy of IX and X cranial nerve revealed in 14 (17.5%) patients. No fatal outcomes or patients in vegetative state were identified. The complete occlusion of PICA and VA aneurysms according angiography was in 77 (96.3%) cases. Conclusion Microsurgical treatment is an effective method for VA and PICA aneurysms. The majority of VA and PICA aneurysms do not require complex basal approaches. A thorough preoperative planning, reconstructive clipping techniques, and anastomoses creation, as well as patient selection based on the established algorithms and consultations with endovascular surgeons, may reduce the number of complications and increase the rate of complete microsurgical occlusion in VA and PICA aneurysms.
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Affiliation(s)
- Yuri Pilipenko
- 3 Department (vascular pathology), Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation
| | - Shalva Eliava
- 3 Department (vascular pathology), Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation
| | - Dmitry Okishev
- 3 Department (vascular pathology), Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation
| | - Elena Okisheva
- Department of Internal Diseases, Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Andronikos Spyrou
- 3 Department (vascular pathology), Federal State Autonomous Institution "N. N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation
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25
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Eliava SS, Pilipenko YV, Shechtman OD, Kheyreddin AS, Okishev DN, Konovalov AN, Spiru AM, Kisariev SA, Gorozhanin VA, Varyukhina MD. [Microsurgical treatment of aneurysms of vertebral and posterior-lower cerebellar arteries: surgical approaches, exclusion options, treatment results]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 83:5-17. [PMID: 31577266 DOI: 10.17116/neiro2019830415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aneurysms of vertebral (VA) and posterior inferior cerebellar arteries (PICA) are relatively rare pathologies and account for 3.4% of the total number of intracranial aneurysms. MATERIAL AND METHODS The experience of microsurgical treatment of 67 patients with VA and PICA aneurysms in N.N. Burdenko National Medical Research Center for Neurosurgery of the RF Ministry of Health from 2012 to 2017 is presented. RESULTS Most patients underwent reconstructive microsurgical interventions: clipping of the aneurysm neck in 42 (62.7%) patients and complex clipping with the formation of arterial opening - in 10 (14.9%). Exclusion of the aneurysm together with the carrier artery (trapping, proximal clipping) was performed on 10 (14.9%) patients. In 5 (7.5%) patients, deconstruction of the carrier artery of the aneurysm was performed after creating local anastomoses. The radical exclusion of aneurysms in the studied group was 95.5%. Postoperative dysfunction of the caudal group of cranial nerves was detected in 11 (16.4%) patients. There were no lethal outcomes, or cases with vegetative status outcomes. CONCLUSION Microsurgical intervention is an effective way to treat VA and PICA aneurysms, subject to the principles of patient selection based on existing treatment algorithms as well as adherence to an interdisciplinary approach.
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Affiliation(s)
| | | | | | | | - D N Okishev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A M Spiru
- Burdenko Neurosurgical Center, Moscow, Russia
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26
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Dissecting distal cerebellar artery aneurysms: options beyond a parent vessel sacrifice. Neurosurg Rev 2019; 43:771-780. [PMID: 31144196 DOI: 10.1007/s10143-019-01119-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/15/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
Abstract
Parent vessel occlusion (PVO) is the conventional endovascular treatment (EVT) for dissecting distal cerebellar artery aneurysms (DCAA). The associated ischemic sequelae are often well-tolerated. However, at the outset, the magnitude of this risk is uncertain. Meanwhile, non-PVO endovascular treatments (EVT) are deemed to provide incomplete protection from a rebleed. This study reviews our experience in the management of dissecting DCAA with emphasis on the effectiveness of parent vessel-preserving endovascular strategies as compared to PVO. Our institutional database was reviewed for all the dissecting DCAA aneurysms treated by endovascular means between Nov 2015 and Oct 2018. Their clinical presentations, imaging findings, EVT techniques, and clinical outcomes were retrospectively evaluated. Eighteen dissecting DCAA were identified: 13 in the posterior-inferior cerebellar artery (PICA), 3 in anterior-inferior cerebellar artery (AICA), and 2 in superior cerebellar artery (SCA). Median patient age was 61 years (range 40-86; average 60.7 years) with a 5:1 female predominance. Nine (6 in the PICA and 3 in the AICA) patients were managed by parent vessel-preserving strategies (6 with isolated endosaccular coiling and 3 with telescoping stents) while the remaining 9 (7 in the PICA and 2 in the SCA) were treated by PVO.The frequency of early rebleed was the same (11%) in both the treatment arms. One patient from the PVO arm suffered an extensive cerebellar infarct that mandated decompressive craniectomy and adversely affected her recovery. There were no such complications in patients treated with parent vessel-preserving strategies. No recurrence/rebleed was encountered in the 3 aneurysms secured using telescoping stents. Overall, excellent clinical outcomes (mRS of 0 and 1) were sparsely seen in the patients who had PVO (89 vs 23%). In dissecting DCAA, aforedescribed, parent vessel-preserving strategies are as effective as the more frequently used option of PVO in preventing an early rebleed. However, these are technically challenging, may be feasible in a smaller proportion of patients, and would need meticulous imaging follow-up in the acute period. When successfully implemented, these strategies can deliver excellent clinical outcomes and eliminate the uncertain risk of ischemic complications associated with PVO.
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27
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El Ouadih Y, Coll G, Jean B, Coste A, Chaix R, Sakka L, Lemaire JJ. A rare complication of flow diverter: delayed migration causing aneurysm expansion and brainstem compression. Br J Neurosurg 2019:1-4. [PMID: 31130025 DOI: 10.1080/02688697.2019.1617406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Flow-diverting stents (FD) are admitted therapeutic devices for challenging aneurysms. Delayed migrations of FD remain exceptional, particularly with brainstem compression. We report a case of delayed migration of pipeline embolization device (PED) responsible of medulla oblongata compression due to expansion of posterior inferior cerebellar artery (PICA) aneurysm. This is the first report of brainstem compression due to delayed migration of FD. Among the seven previously reported cases of FD delayed migration, two led to death. Our case illustrates the importance of technical issues of stenting and the role of surgery facing the clinical emergency of vascular compression of lower brainstem. We wanted to warn neurosurgeons of this rare and delayed complication, which likely could become less exceptional with the increase of indications and utilizations of FD.
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Affiliation(s)
- Youssef El Ouadih
- a Service de Neurochirurgie , CHU Gabriel Montpied , Clermont-Ferrand , France
| | - Guillaume Coll
- a Service de Neurochirurgie , CHU Gabriel Montpied , Clermont-Ferrand , France
| | - Betty Jean
- a Service de Neurochirurgie , CHU Gabriel Montpied , Clermont-Ferrand , France
| | - Aurélien Coste
- a Service de Neurochirurgie , CHU Gabriel Montpied , Clermont-Ferrand , France
| | - Rémi Chaix
- a Service de Neurochirurgie , CHU Gabriel Montpied , Clermont-Ferrand , France
| | - Laurent Sakka
- a Service de Neurochirurgie , CHU Gabriel Montpied , Clermont-Ferrand , France
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28
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Maduri R, Starnoni D, Rocca A, Bervini D, Zumofen DW, Stienen MN, Schatlo B, Fung C, Robert T, Seule MA, Burkhardt JK, Maldaner N, Rothlisberger M, Blackham KA, Marbacher S, D’Alonzo D, Remonda L, Machi P, Gralla J, Bijlenga P, Saliou G, Ballabeni P, Levivier M, Messerer M, Daniel RT. Ruptured posterior circulation aneurysms: epidemiology, patterns of care, and outcomes from the Swiss SOS national registry. Acta Neurochir (Wien) 2019; 161:769-779. [PMID: 30680461 DOI: 10.1007/s00701-019-03812-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/12/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The treatment of ruptured posterior circulation aneurysms remains challenging despite progresses in the endovascular and neurosurgical techniques. OBJECTIVE To provide epidemiological characterization of subjects presenting with ruptured posterior circulation aneurysms in Switzerland and thereby assessing the treatment patterns and neurological outcomes. METHODS This is a retrospective analysis of the Swiss SOS registry for patients with aneurysmal subarachnoid hemorrhage. Patients were divided in 3 groups (upper, lower, and middle third) according to aneurysm location. Clinical, radiological, and treatment-related variables were identified and their impact on the neurological outcome was determined. RESULTS From 2009 to 2014, we included 264 patients with ruptured posterior circulation aneurysms. Endovascular occlusion was the most common treatment in all 3 groups (72% in the upper third, 68% in the middle third, and 58.8% in the lower third). Surgical treatment was performed in 11.3%. Favorable outcome (mRS ≤ 3) was found in 56% at discharge and 65.7% at 1 year. No significant difference in the neurological outcome were found among the three groups, in terms of mRS at discharge (p = 0.20) and at 1 year (p = 0.18). High WFNS grade, high Fisher grade at presentation, and rebleeding before aneurysm occlusion (p = 0.001) were all correlated with the risk of unfavorable neurological outcome (or death) at discharge and at 1 year. CONCLUSIONS In this study, endovascular occlusion was the principal treatment, with a favorable outcome for two-thirds of patients at discharge and at long term. These results are similar to high volume neurovascular centers worldwide, reflecting the importance of centralized care at specialized neurovascular centers.
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29
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Cai Q, Guo Q, Zhang W, Ji B, Chen Z, Chen Q. Surgical treatment of a posterior inferior cerebellar artery aneurysm via transcranial neuroendoscopic approach: A case report. Medicine (Baltimore) 2019; 98:e15304. [PMID: 31027095 PMCID: PMC6831349 DOI: 10.1097/md.0000000000015304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Posterior inferior cerebellar artery (PICA) aneurysms are rare and heterogeneous in both location and morphology, and the management of proximal PICA aneurysms is challenging. In 2011, Joaquim reported a successfully treated VA-PICA ruptured aneurysm using a pure endoscopic endonasal transclival approach for the first time. However, the patient suffered CSF rhinorrhea and underwent an additional operation to repair the CSF leak. In this case report, we describe the treatment of proximal PICA aneurysm by transcranial neuroendoscopic approach. PATIENT CONCERNS A 68-year-old woman presented with a sudden onset of severe headache followed by loss of consciousness and computed tomography of the head showed a mild SAH, located predominantly in the posterior fossa. Clinical signs and symptoms included headache and a positive meningeal irritation sign; no other neurological symptoms were found. DIAGNOSIS A 3-dimensional CT angiography revealed the diagnosis as left VA-PICA junction aneurysm. INTERVENTIONS After a medical treatment, the patient regained consciousness and the aneurysm was treated by pure neuroendoscopy via a modified far-lateral surgical approach. OUTCOMES The patient recovered well after the procedure, and the post-operation image view shows a proper placement of the clip, obliteration of the aneurysm, and the parental artery was unobstructed. LESSONS To our best knowledge, this is the first reported case of treating aneurysm by neuroendoscopic transcranial approach and the second reported case treated by endoscopy. In the present report, we propose that ruptured VA-PICA junction aneurysms could be treated by a pure transcranial neuroendoscopic approach. The advantages of this approach included no risk of CSF rhinorrhea compared with the endoscopic endonasal transclival approach.
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30
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Bender MT, Colby GP, Coon AL. Commentary: Radial Artery Access for Treatment of Posterior Circulation Aneurysms Using the Pipeline Embolization Device: Case Series. Oper Neurosurg (Hagerstown) 2019; 17:E139-E140. [DOI: 10.1093/ons/opz052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/18/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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31
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Algra AM, Lindgren A, Vergouwen MDI, Greving JP, van der Schaaf IC, van Doormaal TPC, Rinkel GJE. Procedural Clinical Complications, Case-Fatality Risks, and Risk Factors in Endovascular and Neurosurgical Treatment of Unruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:282-293. [PMID: 30592482 PMCID: PMC6439725 DOI: 10.1001/jamaneurol.2018.4165] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/02/2018] [Indexed: 01/16/2023]
Abstract
Importance The risk of procedural clinical complications and the case-fatality rate (CFR) from preventive treatment of unruptured intracranial aneurysms varies between studies and may depend on treatment modality and risk factors. Objective To assess current procedural clinical 30-day complications and the CFR from endovascular treatment (EVT) and neurosurgical treatment (NST) of unruptured intracranial aneurysms and risk factors of clinical complications. Data Sources We searched PubMed, Excerpta Medica Database, and the Cochrane Database for studies published between January 1, 2011, and January 1, 2017. Study Selection Studies reporting on clinical complications, the CFR, and risk factors, including 50 patients or more undergoing EVT or NST for saccular unruptured intracranial aneurysms after January 1, 2000, were eligible. Data Extraction and Synthesis Per treatment modality, we analyzed clinical complication risk and the CFR with mixed-effects logistic regression models for dichotomous data. For studies reporting data on complication risk factors, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% CIs and pooled risk estimates with weighted random-effects models. Main Outcomes and Measures Clinical complications within 30 days and the CFR. Results We included 114 studies (106 433 patients with 108 263 aneurysms). For EVT (74 studies), the pooled clinical complication risk was 4.96% (95% CI, 4.00%-6.12%), and the CFR was 0.30% (95% CI, 0.20%-0.40%). Factors associated with complications from EVT were female sex (pooled OR, 1.06 [95% CI, 1.01-1.11]), diabetes (OR, 1.81 [95% CI, 1.05-3.13]), hyperlipidemia (OR, 1.76 [95% CI, 1.3-2.37]), cardiac comorbidity (OR, 2.27 [95% CI, 1.53-3.37]), wide aneurysm neck (>4 mm or dome-to-neck ratio >1.5; OR, 1.71 [95% CI, 1.38-2.11]), posterior circulation aneurysm (OR, 1.42 [95% CI, 1.15-1.74]), stent-assisted coiling (OR, 1.82 [95% CI, 1.16-2.85]), and stenting (OR, 3.43 [95% CI, 1.45-8.09]). For NST (54 studies), the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the CFR was 0.10% (95% CI, 0.00%-0.20%). Factors associated with complications from NST were age (OR per year increase, 1.02 [95% CI, 1.01-1.02]), female sex (OR, 0.43 [95% CI, 0.32-0.85]), coagulopathy (OR, 2.14 [95% CI, 1.13-4.06]), use of anticoagulation (OR, 6.36 [95% CI, 2.55-15.85]), smoking (OR, 1.95 [95% CI, 1.36-2.79]), hypertension (OR, 1.45 [95% CI, 1.03-2.03]), diabetes (OR, 2.38 [95% CI, 1.54-3.67]), congestive heart failure (OR, 2.71 [95% CI, 1.57-4.69]), posterior aneurysm location (OR, 7.25 [95% CI, 3.70-14.20]), and aneurysm calcification (OR, 2.89 [95% CI, 1.35-6.18]). Conclusions and Relevance This study identifies risk factors for procedural complications. Large data sets with individual patient data are needed to develop and validate prediction scores for absolute complication risks and CFRs from EVT and NST modalities.
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Affiliation(s)
- Annemijn M. Algra
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Antti Lindgren
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Department of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mervyn D. I. Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jacoba P. Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene C. van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Tristan P. C. van Doormaal
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gabriel J. E. Rinkel
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Zhou J, Wang Y, Wang D, Chen Q, Wang H, Gao L. Endovascular Treatment for Ruptured Aneurysms at Distal Cerebral Arteries. World Neurosurg 2018; 123:e387-e392. [PMID: 30500584 DOI: 10.1016/j.wneu.2018.11.178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 11/17/2018] [Accepted: 11/19/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the feasibility and efficacy of endovascular treatment for ruptured aneurysms at distal cerebral arteries. METHODS A total of 30 ruptured aneurysms at distal cerebral arteries in 30 patients received endovascular treatment (EVT). Distal cerebral arteries were defined as arteries distal to the A2 or M2 segmentations in the anterior circulation, distal to the P2 segmentation in the posterior circulation, or other small branches or perforating arteries. Aneurysm occlusion was assessed using Raymond classification immediately after the procedure and during angiographic follow-up. Clinical follow-up data were retrospectively analyzed and categorized using the modified Rankin scale (MRS). RESULTS Thirty aneurysms were classified as distal anterior circulation in 17 aneurysms and posterior circulation in 13 aneurysms. EVT technically succeeded in all 30 (100%) aneurysms, with stent assistance in 1 aneurysm and coiling only in 29. Aneurysm sac coiling was done in 25 aneurysms, whereas parent artery occlusion was done in 5 aneurysms. Raymond I occlusion were immediately achieved in 19 of 30 (63.3%) aneurysms. Complications occurred in 1 patient because of aneurysm rupture. Angiographic and clinical follow-up data were obtained from 28 patients. Follow-up angiography (mean, 10.14 ± 5.31 months) revealed Raymond I classification in 22 aneurysms (78.6%). At the end of clinical follow-up (mean, 11.89 ± 5.07 months), clinical monitoring using the MRS showed a score of 0 in 18 patients, score of 1 in 5 patients, score of 2 in 2 patients, score of 3 in 2 patients, and score of 4 in 1 patient. CONCLUSIONS EVT is a feasible and effective therapy to treat ruptured aneurysms located at distal cerebral arteries.
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Affiliation(s)
- Jiang Zhou
- Department of Neurosurgery, The Tenth Affiliated People's Hospital of Shanghai Tong Ji University, Shanghai, China
| | - Yanlong Wang
- Department of Neurosurgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, China
| | - Dongfeng Wang
- Department of Neurosurgery, Ningbo City Medical Treatment Center Lihuili Hospital, Ningbo, China
| | - Qifeng Chen
- Department of Neurosurgery, Ningbo City Medical Treatment Center Lihuili Hospital, Ningbo, China
| | - Hongcai Wang
- Department of Neurosurgery, Ningbo City Medical Treatment Center Lihuili Hospital, Ningbo, China
| | - Liang Gao
- Department of Neurosurgery, The Tenth Affiliated People's Hospital of Shanghai Tong Ji University, Shanghai, China.
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Kim J, Chang C, Jung YJ. Coil Embolization Results of the Ruptured Proximal Posteriori Inferior Cerebellar Artery Aneurysm: A Single-Center 10 Years' Experience. World Neurosurg 2018; 117:e645-e652. [PMID: 29945000 DOI: 10.1016/j.wneu.2018.06.105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report a single-center experience with endovascular treatment of ruptured proximal posterior inferior cerebellar artery (PICA) aneurysms. METHODS Between January 2007 and December 2016, among 1403 patients with aneurysmal subarachnoid hemorrhage, 15 with ruptured proximal PICA aneurysms underwent endovascular embolization at our institution. Aneurysmal obliteration with a single microcatheter was performed in 9 patients. Additional microcatheter or stent-assisted coil embolization was performed in 4 patients and parent artery occlusion in 2 patients. RESULTS Immediate angiographic results showed 10 complete occlusions (66.7%, 10/15). Five patients showed incomplete occlusion (remnant neck in 4 patients, remnant aneurysm in 1). Of those, 2 patients experienced recurrence and required conversion to microsurgical clipping. The remaining 2 patients remained in relatively stable condition. Procedure-related complications occurred in 3 patients (20%, with thromboembolic complications in 2 patients and intraprocedural rupture in 1). Clinical outcome was excellent: Glasgow Outcome Score 4 or 5 in 12 of 15 patients (80%). There was no rebleeding during follow-up. CONCLUSIONS Ruptured proximal PICA aneurysms may be effectively treated with endovascular coil embolization. A variety of coil embolization techniques are required to obliterate an aneurysm without parent artery occlusion. Given that recurrence is possible, follow-up is required. Surgical clipping can be performed for recurrence with a relatively low risk of complications, because the aneurysm is unruptured. Coil embolization of a proximal PICA aneurysm in the acute phase can be a good treatment modality with good patient outcomes.
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Affiliation(s)
- Jonghoon Kim
- Department of Neurosurgery, Yeungnam University Medical Center and Medical School, Namgu, Daegu, South Korea
| | - Chulhoon Chang
- Department of Neurosurgery, Yeungnam University Medical Center and Medical School, Namgu, Daegu, South Korea
| | - Young Jin Jung
- Department of Neurosurgery, Yeungnam University Medical Center and Medical School, Namgu, Daegu, South Korea.
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Bhogal P, Chudyk J, Bleise C, Lylyk I, Henkes H, Lylyk P. The use of flow diverters to treat aneurysms of the posterior inferior cerebellar artery: Report of three cases. Interv Neuroradiol 2018; 24:489-498. [PMID: 29807446 DOI: 10.1177/1591019918774877] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The objective of this study was to report our experience on the use of flow diverting stents placed within the posterior inferior cerebellar artery (PICA) as a treatment option for aneurysms of the PICA. Methods Three patients with aneurysms of the PICA, both ruptured and unruptured, underwent treatment of their aneurysms with placement of a single flow diverter in the PICA across the neck of the aneurysm. Adjunctive techniques such as coiling were not used. We present the angiographic and clinical follow-up data. Results The procedure was a technical success in all cases and there were no intraoperative complications. Follow-up data were available for two patients and this showed complete occlusion of the aneurysm with the PICA remaining patent. There was no evidence, either clinical or radiological, of medullary or pontine infarction. One patient died during the follow-up period from an unrelated medical illness (community acquired pneumonia). Conclusion Flow diverters can be successfully placed within the PICA to treat both ruptured and unruptured aneurysms, and they represent an alternative treatment option to endovascular coiling or microscopic neurosurgery.
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Affiliation(s)
- Pervinder Bhogal
- 1 Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Jorge Chudyk
- 2 Neuroradiological clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
| | - Carlos Bleise
- 2 Neuroradiological clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
| | - Ivan Lylyk
- 2 Neuroradiological clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
| | - Hans Henkes
- 1 Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany.,3 Faculty of Medicine, University Duisburg-Essen, Essen, Germany
| | - Pedro Lylyk
- 2 Neuroradiological clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
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Hou K, Guo Y, Xu B, Xu K, Yu J. Delayed Establishment of Collateral Circulation from Posterior Meningeal Artery After Proximal Occlusion of Posterior Inferior Cerebellar Artery: Case Report and Literature Review. World Neurosurg 2018; 115:334-337. [PMID: 29751186 DOI: 10.1016/j.wneu.2018.04.207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND A dissecting aneurysm on the posterior inferior cerebellar artery (PICA) is a rare entity, and endovascular embolization is often adopted. During the procedure, if the parent artery is occluded, the distal PICA is usually supplied by the ipsilateral anterior inferior artery or contralateral PICA. In extremely rare circumstances, the distal PICA can establish collateral circulation by transdural anastomosis with the posterior meningeal artery (PMA). CASE DESCRIPTION A 29-year-old woman was admitted complaining of thunderclap headache, nausea, and vomiting for 3 hours. Head computed tomography and digital subtraction angiography revealed subarachnoid hemorrhage and a dissecting aneurysm located at the tonsillomedullary segment of PICA. The parent artery distal to the aneurysm had no collateral circulation from the adjacent arteries. Selective endovascular coiling of the aneurysm with preservation of the parent artery was adopted for treatment. The patient experienced an uneventful postprocedural recovery. To our surprise, follow-up digital subtraction angiography 6 months later revealed complete occlusion of the aneurysm and parent artery at the site of aneurysm formation. A rare anastomosis between the distal PICA and PMA was established. CONCLUSIONS A report about this rare condition suggested that after occlusion of the PICA trunk, the distal PICA can form collateral circulation with the PMA. A potential collateral circulation may be present in advance between the PICA and PMA. When ischemia occurs in the distal PICA, this collateral circulation may open and could be reconstructed and enlarged to provide blood supply.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China.
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Narducci A, Xu R, Vajkoczy P. Decision Making in Surgery for Nonsaccular Posterior Inferior Cerebellar Artery Aneurysms With Special Reference to Intraoperative Assessment of Collateral Blood Flow and Neurophysiological Function. Oper Neurosurg (Hagerstown) 2018; 14:422-431. [PMID: 28973400 DOI: 10.1093/ons/opx141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/16/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Posterior inferior cerebellar artery (PICA) aneurysms represent a challenging pathology. PICA sacrifice is often necessary, due to the high proportion of nonsaccular aneurysms that can be found in this location. Several treatments are available, but the infrequency of these aneurysms and the increasing number of endovascular techniques have limited the development of a standardized algorithm for cases in which open surgery is indicated. OBJECTIVE We present our series of nonsaccular PICA aneurysms, in the attempt to define an algorithm for their surgical management. METHODS We retrospectively reviewed the operation database, identifying patients harboring nonsaccular PICA aneurysms who were surgically treated at our institution from 2007 to 2016. RESULTS During a 9-yr period, 17 patients harboring 18 nonsaccular PICA aneurysms were surgically treated at our institution. Fourteen (7.7%) aneurysms were located within the proximal PICA (including those located at the vertebral artery-PICA junction), and 4 were located distally. We performed PICA revascularization in 8 (57.1%) cases of proximal aneurysms (n = 4, PICA-PICA bypass; n = 4, occipital artery-PICA bypass). We based our decision whether to perform bypass on intraoperative test occlusion with indocyanine green (ICG) videoangiography and neurophysiological monitoring. In no cases, bypass was necessary for distal aneurysms. CONCLUSION For nonsaccular PICA aneurysms, in which vessel occlusion is often necessary, it is possible to adopt a selective use of revascularization techniques. Intraoperative occlusion test with ICG videoangiography and neurophysiological monitoring provides reliable indications, allowing real-time assessment of collateral circulation.
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Affiliation(s)
- Alessandro Narducci
- Department of Neurosurgery, Charitè-Universitätsmedizin Berlin, Berlin, Germany
| | - Ran Xu
- Department of Neurosurgery, Charitè-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charitè-Universitätsmedizin Berlin, Berlin, Germany
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Srinivasan VM, Ghali MGZ, Reznik OE, Cherian J, Mokin M, Dumont TM, Gaughen JR, Grandhi R, Puri AS, Chen SR, Johnson JN, Kan P. Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies. J Neurointerv Surg 2017; 10:663-668. [DOI: 10.1136/neurintsurg-2017-013427] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/04/2022]
Abstract
BackgroundThe pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA.MethodsInstitutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study.Results10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up.ConclusionsThe PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection.
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Affiliation(s)
| | | | - Oleg E Reznik
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jacob Cherian
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Departments of Neurology and Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Travis M Dumont
- Division of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | - John R Gaughen
- Sentara Martha Jefferson Medical and Surgical Associates, Charlottesville, Virginia, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Texas at San Antonio, San Antonio, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Stephen R Chen
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Mascitelli JR, Yaeger K, Wei D, Kellner CP, Oxley TJ, De Leacy RA, Fifi JT, Patel AB, Naidich TP, Bederson JB, Mocco J. Multimodality Treatment of Posterior Inferior Cerebellar Artery Aneurysms. World Neurosurg 2017; 106:493-503. [DOI: 10.1016/j.wneu.2017.07.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Justin R Mascitelli
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Kurt Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel Wei
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas J Oxley
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reade A De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas P Naidich
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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