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Chen L, Leng X, Zheng C, Shan Y, Wang M, Bao X, Wu J, Zou R, Liu X, Xu S, Xiang J, Wan S. Computational fluid dynamics (CFD) analysis in a ruptured vertebral artery dissecting aneurysm implanted by Pipeline when recurrent after LVIS-assisted coiling treatment: Case report and review of the literatures. Interv Neuroradiol 2023; 29:442-449. [PMID: 35484808 PMCID: PMC10399494 DOI: 10.1177/15910199221097766] [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: 01/17/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUNDS Hemodynamics plays an important role in the natural history of the process of rupture and recurrence of intracranial aneurysms. This study aimed to investigate the role of hemodynamics for recurrence in a vertebral artery dissecting aneurysm (VADA). METHODS A patient with a ruptured VADA firstly treated by low-profile visualized intraluminal support (LVIS)-assisted coiling, and was implanted with a Pipeline Embolization Device (PED) after aneurysm recurrence. Finite element analysis and computational fluid dynamics simulations were conducted in 6 serial imaging procedures, and the calculated hemodynamics was correlated with aneurysm recurrence. RESULTS Wall shear stress (WSS) was not effectively suppressed, resulting in aneurysm recurrence with initial entry tear to occur above the protuberance after 7 months of LVIS stent-assisted coiling. With the implantation of PED, WSS, inflow stream and velocity at the aneurysm neck significantly decreased. During the 3-month follow-up after PED deployment, there was significant shrinkage of the sac and the blood flow in the sac was reduced considerably. The 27-month follow-up after PED deployment indicated the aneurysm was stable. CONCLUSIONS The present case study suggests that insufficient suppression of high WSS and high inflow velocity at the neck of the parent artery, especially near the posterior inferior cerebellar artery, might be associated with aneurysm recurrence.
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Affiliation(s)
- Linhui Chen
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | - Chaobo Zheng
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yejie Shan
- ArteryFlow Technology Co., Ltd. Hangzhou, China
| | - Ming Wang
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiang Bao
- Department of Neurosurgery, Jinhua Central Hospital, Jinhua, China
| | - Jiong Wu
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Rong Zou
- ArteryFlow Technology Co., Ltd. Hangzhou, China
| | - Xiaobo Liu
- Department of Neurosurgery, Jinhua Central Hospital, Jinhua, China
| | - Shanhu Xu
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | - Shu Wan
- Brain Center, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
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2
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Wei H, Yao K, Tian Q, Han S, Gao W, Han W, Liu S, Wang G, Chen Q, Li M. Low Wall Shear Stress and High Intra-aneurysmal Pressure are Associated with Ruptured Status of Vertebral Artery Dissecting Aneurysms. Cardiovasc Intervent Radiol 2023; 46:240-248. [PMID: 36653659 DOI: 10.1007/s00270-022-03353-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 12/26/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE The morphological and hemodynamic features of patients with vertebral artery dissecting aneurysms (VADAs) are yet unknown. This study sought to elucidate morphological and hemodynamic features of patients with ruptured and unruptured VADAs based on computed flow simulation. METHODS Fifty-two patients (31 unruptured and 21 ruptured VADAs) were admitted to two hospitals between March 2016 and October 2021. All VADAs were located in the intradural segment, and their clinical, morphological, and hemodynamic parameters were retrospectively analyzed. The hemodynamic parameters were determined through computational fluid dynamics simulations. Univariate statistical and multivariable logistic regression analyses were employed to select significantly different parameters and identify key factors. Receiver operating characteristic (ROC) analysis was used to assess the discrimination for each key factor. RESULTS Four hemodynamic parameters were observed to significantly differ between ruptured and unruptured VADAs, including wall shear stress (WSS), low shear area, intra-aneurysmal pressure (IAP), and relative residence time. However, no significant differences were observed in morphological parameters between ruptured and unruptured VADAs. Multivariable logistic regression analysis revealed that low WSS and high IAP were significantly observed in the ruptured VADAs and demonstrated adequate discrimination. CONCLUSIONS This research indicates significant hemodynamic differences, but no morphological differences were observed between ruptured and unruptured VADAs. The ruptured group had significantly lower WSS and higher IAP than the unruptured group. To further confirm the roles of low WSS and high IAP in the rupture of VADAs, large prospective studies and long-term follow-up of unruptured VADAs are required.
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Affiliation(s)
- Heng Wei
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Kun Yao
- Department of Neurosurgery, Jingzhou Central Hospital, Jingzhou, 434020, China
| | - Qi Tian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Shoumeng Han
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Wenhong Gao
- Department of Neurosurgery, Jingzhou Central Hospital, Jingzhou, 434020, China
| | - Wenrui Han
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Sheng Liu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Guijun Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China.
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Durongwatana N, Sriamornrattanakul K, Wongsuriyanan S, Akharathammachote N. Microsurgical treatment of vertebral artery dissection: Surgical strategies and treatment outcomes. World Neurosurg 2021; 159:e375-e388. [PMID: 34954059 DOI: 10.1016/j.wneu.2021.12.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Nithipat Durongwatana
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Kitiporn Sriamornrattanakul
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
| | - Somkiat Wongsuriyanan
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Nasaeng Akharathammachote
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Park GJ, Cho JH, Kim KH. Angiographic characteristics of ruptured versus unruptured vertebral artery dissecting aneurysm. J Cerebrovasc Endovasc Neurosurg 2021; 24:10-15. [PMID: 34695886 PMCID: PMC8984639 DOI: 10.7461/jcen.2021.e2021.06.012] [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: 06/29/2021] [Accepted: 08/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Vertebral artery dissecting aneurysm (VADA) is a rare and critical disease. VADA rupture can cause subarachnoid hemorrhage which is a major complication of VADA due to their high rebleeding rate and poor outcome. In the present study, ruptured and unruptured VADAs were compared by analyzing angiographic findings to determine useful predisposing factors for VADA rupture for appropriate treatment selection. Methods Subjects with VADA treated during a 10-year period were retrospectively identified. The 57 cases diagnosed with VADA were divided into ruptured (n=15) and unruptured (n=42) groups. In addition, each case was analyzed using angiographic 3-dimensional (3-D) reconstructed images. Factors such as length, dilated and stenotic diameter, shape, and vessel around the vertebral artery (VA) were measured and statistically compared. Results In the ruptured group, stenotic findings of the affected lesion were more common and severe than in the unruptured group. The average stenotic diameter was 2.27 mm (vs. 2.84 mm). And stenotic degree was 62% and 53% in the ruptured and unruptured groups, respectively. Posterior communicating artery (PcomA) flow was more common in the ruptured group (87% vs. 55%, p=0.028). Conclusions Based on angiographic findings, stenotic lesions, which may be influenced by PcomA flow, are more common in ruptured VADAs.
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Affiliation(s)
- Gi Jeong Park
- Department of Neurosurgery, Daegu Catholic University Hospital, Daegu, Korea
| | - Jae Hoon Cho
- Department of Neurosurgery, Daegu Catholic University Hospital, Daegu, Korea
| | - Ki Hong Kim
- Department of Neurosurgery, Daegu Catholic University Hospital, Daegu, Korea
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Chen JA, Garrett MC, Mlikotic A, Ausman JI. Treatment of intracranial vertebral artery dissecting aneurysms involving the posterior inferior cerebellar artery origin. Surg Neurol Int 2019; 10:116. [PMID: 31528452 PMCID: PMC6744774 DOI: 10.25259/sni-281-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 05/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background Vertebral artery dissecting aneurysm (VADA) involving the origin of the posterior inferior cerebellar artery (PICA) is a complex disease entity in which the dual goals of preventing future rebleeding and maintaining perfusion of the lateral medulla must be considered. We present an illustrative case and review the literature surrounding treatment strategies. Case Description We report a patient presenting with extensive subarachnoid hemorrhage due to rupture of an intracranial VADA involving the PICA origin. After consideration of the patient's cerebral vasculature and robustness of collaterals, a flow-diverting stent was placed with angiographic resolution of the lesion and maintenance of antegrade PICA flow. Ultimately, the patient experienced a contralateral intraparenchymal hemorrhage leading to death. Review of the literature identified 124 cases of VADA involving the PICA origin described over the past decade. The methods of surgical and endovascular treatment of these cases were reviewed, with particular focus on the rationale of treatment, outcomes, and complications. Conclusion Numerous treatment options for VADA involving PICA have been reported with different risk and benefit profiles. Flow-diverting stents appear to offer the most favorable balance of securing the aneurysm and avoiding medullary infarction, but the risks and optimal anti-thrombotic treatment strategy are incompletely understood. In select cases, in which the surgical risk is low or in which the anatomy is favorable (e.g., nondominant parent vessel or robust collateral circulation in the involved territories), parent artery trapping with or without microsurgical revascularization can be considered.
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Affiliation(s)
- Jason A Chen
- Department of Neurosurgery, University of California, Los Angeles
| | | | - Anton Mlikotic
- Department of Radiology, Harbor-UCLA Medical Center, Torrance, California, USA
| | - James I Ausman
- Department of Neurosurgery, University of California, Los Angeles
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Updates in the Management of Cerebral Infarctions and Subarachnoid Hemorrhage Secondary to Intracranial Arterial Dissection: A Systematic Review. World Neurosurg 2019; 121:51-58. [DOI: 10.1016/j.wneu.2018.09.153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 01/10/2023]
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Tanaka K, Kanamaru H, Morikawa A, Kawaguchi K. Central Hypoventilation Syndrome Complicated with Lateral Medullary Infarction after Endovascular Treatment of the Vertebral Artery Dissecting Aneurysm: A Case Report. NMC Case Rep J 2017; 3:133-136. [PMID: 28664015 PMCID: PMC5386165 DOI: 10.2176/nmccrj.cr.2016-0067] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/15/2016] [Indexed: 11/25/2022] Open
Abstract
Lateral medullary infarction rarely leads to central hypoventilation syndrome (CHS). CHS is a life-threatening disorder characterized by hypoventilation during sleep. We report the first case of CHS as a complication of lateral medullary infarction after endovascular treatment. A 65-year-old man presented twice with severe headache. Computed tomography revealed subarachnoid hemorrhage and cerebral angiography showed a right vertebral dissecting aneurysm involving the posterior inferior cerebellar artery. After emergent endovascular patent artery occlusion, he developed Wallenberg syndrome and experienced apnea and a conscious disturbance episode due to CHS on postoperative days 6 and 16. Intensive respiratory care including intubation, tracheostomy, mechanical ventilation, and rehabilitation prevented subsequent recurrence of apnea and the CHS resolved completely. CHS after unilateral medullary infarction involving respiratory centers tends to occur in the acute and subacute phase and may be lethal without careful respiratory management.
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Affiliation(s)
- Katsuhiro Tanaka
- Department of Neurosurgery, NHO Mie Chuo Medical Center, Mie, Japan
| | - Hideki Kanamaru
- Department of Neurosurgery, Suzuka General Hospital, Suzuka, Mie, Japan
| | - Atsunori Morikawa
- Department of Neurosurgery, Suzuka General Hospital, Suzuka, Mie, Japan
| | - Kenji Kawaguchi
- Department of Neurosurgery, Suzuka General Hospital, Suzuka, Mie, Japan
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Zhang Y, Tian Z, Sui B, Wang Y, Liu J, Li M, Li Y, Jiang C, Yang X. Endovascular Treatment of Spontaneous Intracranial Fusiform and Dissecting Aneurysms: Outcomes Related to Imaging Classification of 309 Cases. World Neurosurg 2016; 98:444-455. [PMID: 27890754 DOI: 10.1016/j.wneu.2016.11.074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/14/2016] [Accepted: 11/15/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To propose a modified classification system for spontaneous intracranial dissecting aneurysms (IDAs) that can guide treatment decisions. METHODS Between January 2010 and December 2015, 3183 consecutive patients were referred to our department for endovascular treatment of a cerebral aneurysm. Among this group, 309 patients harboring a total of 323 spontaneous IDAs were identified. Based on a modified imaging classification system, spontaneous IDAs were classified into 4 subtypes: classic dissecting aneurysm, segmental ectasia, dolichoectatic dissecting aneurysm, and large mural bleeding ectasia. A logistic regression analysis was conducted to identify predictors of clinical outcomes. RESULTS Of the 323 IDAs, 216 (66.87%) were treated with stent-assisted coiling, 47 (14.55%) with internal trapping, and 60 (18.58%) with sole stenting. Of the 309 patients, 8 (2.59%) suffered intraoperative complications, 40 (12.94%) experienced postoperative complications, 9 died (2.79%), and 1 (0.32%) had severe disability. The mean duration of clinical follow-up of the 309 patients was 10.40 months (range, 3-72 months). Imaging follow-up was available for 262 patients (274 IDAs), with a mean duration of 7.10 months (range, 3-60 months), and 24 aneurysm recurrences (9.16%) were noted. Aneurysm type was the sole independent predictor of different outcomes on logistic regression analysis (P = 0.004). CONCLUSIONS There was a strong relationship between the subtypes of spontaneous IDAs and clinical course. Our classification system is confirmed to be helpful in assessing patients' prognosis and guiding their treatment.
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Affiliation(s)
- Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Binbin Sui
- Department of Neuroimaging, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, First Affiliated Hospital, Nanchang University, Nanchang, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Miao Li
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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9
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Shi L, Xu K, Sun X, Yu J. Therapeutic Progress in Treating Vertebral Dissecting Aneurysms Involving the Posterior Inferior Cerebellar Artery. Int J Med Sci 2016; 13:540-55. [PMID: 27429591 PMCID: PMC4946125 DOI: 10.7150/ijms.15233] [Citation(s) in RCA: 16] [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: 02/09/2016] [Accepted: 06/01/2016] [Indexed: 12/04/2022] Open
Abstract
Among the variations of vertebral artery dissecting aneurysms (VDAs), VDAs involving the posterior inferior cerebellar artery (PICA), especially ruptured and high-risk unruptured aneurysms, are the most difficult to treat. Because the PICA is an important structure, serious symptoms may occur after its occlusion. Retained PICAs are prone to re-bleeding because VDAs are difficult to completely occlude. There is therefore confusion regarding the appropriate treatment for VDAs involving the PICA. Here, we used the PubMed database to review recent research concerning VDAs that involve the PICA, and we found that treatments for VDAs involving the PICA include (i) endovascular treatment involving the reconstruction of blood vessels and blood flow, (ii) occluding the aneurysm using an internal coil trapping or an assisted bypass, (iii) inducing reversed blood flow by occluding the proximal VDA or forming an assisted bypass, or (iv) the reconstruction of blood flow via a craniotomy. Although the above methods effectively treat VDAs involving the PICA, each method is associated with both a high degree of risk and specific advantages and disadvantages. The core problem when treating VDAs involving the PICA is to retain the PICA while occluding the aneurysm. Therefore, the method is generally selected on a case-by-case basis according to the characteristics of the aneurysm. In this study, we summarize the various current methods that are used to treat VDAs involving the PICA and provide schematic diagrams as our conclusion. Because there is no special field of research concerning VDAs involving the PICA, these cases are hidden within many multiple-cases studies. Therefore, this study does not review all relevant documents and may have some limitations. Thus, we have focused on the mainstream treatments for VDAs that involve the PICA.
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Affiliation(s)
- Lei Shi
- 1. Department of Neurosurgery, First Hospital of Jilin University, Changchun, China, 130021
| | - Kan Xu
- 1. Department of Neurosurgery, First Hospital of Jilin University, Changchun, China, 130021
| | - Xiaofeng Sun
- 2. Department of Ultrasonography, First Hospital of Jilin University, Changchun, China, 130021
| | - Jinlu Yu
- 1. Department of Neurosurgery, First Hospital of Jilin University, Changchun, China, 130021
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Alexiades NG, Ellis JA, Meyers PM, Connolly ES. Subarachnoid hemorrhage then thrombosis of posterior inferior cerebellar artery dissection: is early surgical exploration warranted? J Neurointerv Surg 2015; 8:e22. [PMID: 25987592 DOI: 10.1136/neurintsurg-2015-011740.rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/04/2022]
Abstract
The natural history of spontaneous cerebral artery dissection and thrombosis remains uncertain. Concurrent subarachnoid hemorrhage further complicates the therapeutic approach. Thus the best strategy for managing patients with acute vessel thrombosis in the setting of subarachnoid hemorrhage is unclear. Here we present a case of spontaneous posterior inferior cerebellar artery dissection presenting with subarachnoid hemorrhage and acute thrombosis. Although the patient was initially managed conservatively, angiographic follow-up demonstrated recanalization of the diseased vessel, necessitating definitive treatment. Thus we propose that angiographic follow-up is necessary in the management of patients with subarachnoid hemorrhage in association with apparent vessel thrombosis.
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Affiliation(s)
- Nikita G Alexiades
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Jason A Ellis
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Philip M Meyers
- Department of Radiology and Neurological Surgery, Columbia University, New York, New York, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
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11
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Alexiades NG, Ellis JA, Meyers PM, Connolly ES. Subarachnoid hemorrhage then thrombosis of posterior inferior cerebellar artery dissection: is early surgical exploration warranted? BMJ Case Rep 2015; 2015:bcr-2015-011740. [PMID: 25969489 DOI: 10.1136/bcr-2015-011740] [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: 11/03/2022] Open
Abstract
The natural history of spontaneous cerebral artery dissection and thrombosis remains uncertain. Concurrent subarachnoid hemorrhage further complicates the therapeutic approach. Thus the best strategy for managing patients with acute vessel thrombosis in the setting of subarachnoid hemorrhage is unclear. Here we present a case of spontaneous posterior inferior cerebellar artery dissection presenting with subarachnoid hemorrhage and acute thrombosis. Although the patient was initially managed conservatively, angiographic follow-up demonstrated recanalization of the diseased vessel, necessitating definitive treatment. Thus we propose that angiographic follow-up is necessary in the management of patients with subarachnoid hemorrhage in association with apparent vessel thrombosis.
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Affiliation(s)
- Nikita G Alexiades
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Jason A Ellis
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Philip M Meyers
- Department of Radiology and Neurological Surgery, Columbia University, New York, New York, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
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12
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Boogaarts HD, van Lieshout JH, van Amerongen MJ, de Vries J, Verbeek ALM, Grotenhuis JA, Westert GP, Bartels RHMA. Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis. J Neurosurg 2015; 122:921-8. [DOI: 10.3171/2014.12.jns14931] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Aneurysmal rerupture prior to treatment is a major cause of death and morbidity in aneurysmal subarachnoid hemorrhage. Recognizing risk factors for aneurysmal rebleeding is particularly relevant and might help to identify the aneurysms that benefit from acute treatment. It is uncertain if the size of the aneurysm is related to rebleeding. This meta-analysis was performed to evaluate whether an association could be determined between aneurysm diameter and the rebleeding rate before treatment. Potentially confounding factors such age, aneurysm location, and the presence of hypertension were also evaluated.
METHODS
The authors systematically searched the PubMed, Embase, and Cochrane databases up to April 3, 2013, for studies of patients with aneurysmal subarachnoid hemorrhage that reported the association between aneurysm diameter and pretreatment aneurysmal rebleeding. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were used to evaluate study quality.
RESULTS
Seven studies, representing 2121 patients, were included in the quantitative analysis. The quality of the studies was low in 2 and very low in 5. Almost all of the studies used 10 mm as the cutoff point for size among other classes, and only one used 7 mm. An analysis was performed with this best unifiable cutoff point. Overall rebleeding occurred in 360 (17.0%) of 2121 patients (incidence range, from study to study, 8.7%–28.4%). The rate of rebleeding in small and large aneurysms was 14.0% and 23.6%, respectively. The meta-analysis of the 7 studies revealed that larger size aneurysms were at a higher risk for rebleeding (OR 2.56 [95% CI 1.62–4.06]; p = 0.00; I2 = 60%). The sensitivity analysis did not alter the results. Five of the 7 studies reported data regarding age; 4 studies provided age-adjusted results and identified a persistent relationship between lesion size and the risk of rebleeding. The presence of hypertension was reported in two studies and was more prevalent in patients with rebleeding in one of these. Location (anterior vs posterior circulation) was reported in 5 studies, while in 4 there was no difference in the rebleeding rate. One study identified a lower risk of rebleeding associated with posterior location aneurysms.
CONCLUSIONS
This meta-analysis showed that aneurysm size is an important risk factor for aneurysmal rebleeding and should be used in the clinical risk assessment of individual patients. The authors' results confirmed the current guidelines and underscored the importance of acute treatment for large ruptured aneurysms.
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Affiliation(s)
| | | | | | | | | | | | - Gert P. Westert
- 4Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Sikkema T, Uyttenboogaart M, van Dijk JMC, Groen RJM, Metzemaekers JDM, Eshghi O, Mazuri A, Bakker NA, Luijckx GJ. Clinical features and prognosis of intracranial artery dissection. Neurosurgery 2015; 76:663-70; discussion 670-1. [PMID: 25714522 DOI: 10.1227/neu.0000000000000696] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intracranial artery dissections (IADs) are an important cause of stroke or subarachnoid hemorrhage (SAH). Outcome of IAD in the anterior circulation or presentation without SAH is rarely investigated and might be different. OBJECTIVE To evaluate the clinical features and prognosis of patients with IAD, with special emphasis on the location (anterior vs posterior circulation) and clinical presentation (SAH or cerebral ischemia). METHODS Between January 1998 and May 2012, 60 patients with IAD were included in this single-center cohort study. Clinical features, functional outcome, mortality, and prognostic factors were evaluated. Unfavorable functional outcome was defined as a modified Rankin scale score of 3 to 6. RESULTS In 18 patients (30%), IAD was located in the anterior circulation. At a median follow-up of 6.4 months, 35.3% of patients with IAD in the anterior circulation had an unfavorable functional outcome vs 39.0% in patients with IAD in the posterior circulation (P = .79). Forty-two patients (70%) presented with SAH. Clinical presentation with SAH was not significantly associated with poor functional outcome (41.5% vs 29.4%, P = .39). Low Glasgow Coma Scale score on admission (odds ratio, 0.72, P = .003) and older age (odds ratio, 1.04, P = .04) were independent predictors of unfavorable functional outcome. Mortality rate was 13% and did not significantly differ with location or clinical presentation. CONCLUSION Low Glasgow Coma Scale score on admission and older age were independent predictors of unfavorable functional outcome. IAD presenting with SAH was not significantly associated with poor functional outcome.
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Affiliation(s)
- Tineke Sikkema
- *Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; ‡Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; §Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Bourbon I, Gory B, Riva R, Deiana G, Nighoghossian N, Turjman F. [Multiple intracranial dissections: association of anterior median bulbar infarct and subarachnoid hemorrhage. Therapeutic strategy?]. Rev Neurol (Paris) 2014; 170:551-3. [PMID: 25174887 DOI: 10.1016/j.neurol.2014.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 04/08/2014] [Accepted: 05/14/2014] [Indexed: 10/24/2022]
Affiliation(s)
- I Bourbon
- Service de neuroradiologie interventionnelle, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
| | - B Gory
- Service de neuroradiologie interventionnelle, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France.
| | - R Riva
- Service de neuroradiologie interventionnelle, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
| | - G Deiana
- Service de neuroradiologie interventionnelle, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
| | - N Nighoghossian
- Service d'urgences neurovasculaires, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
| | - F Turjman
- Service de neuroradiologie interventionnelle, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
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Zhao KJ, Zhao R, Huang QH, Xu Y, Hong B, Fang YB, Li Q, Yang PF, Liu JM, Zhao WY. The interaction between stent(s) implantation, PICA involvement, and immediate occlusion degree affect symptomatic intracranial spontaneous vertebral artery dissection aneurysm (sis-VADA) recurrence after reconstructive treatment with stent(s)-assisted coiling. Eur Radiol 2014; 24:2088-96. [PMID: 24895032 PMCID: PMC4127004 DOI: 10.1007/s00330-014-3225-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/12/2014] [Accepted: 05/07/2014] [Indexed: 11/23/2022]
Abstract
Objectives We aimed to evaluate risk factors of sis-VADAs recurrence after reconstructive treatment based on 113 reconstructed lesions. Methods A total of 111 patients (M:F = 68:43; median age, 47 years) with 113 sis-VADAs underwent reconstruction from October 2000 to March 2011, using stent(s) and coils. Treatments and predictors of recurrence were retrospectively analysed. Results Fifty-eight sis-VADAs underwent single-stent treatment, and the remaining 55 sis-VADAs underwent treatment with 2-4 overlapping stents. Follow-up angiography was available for 94 sis-VADAs 12 -78 months, with recurrence in ten patients, including seven angiographic recurrences and three post-treatment haemorrhagic recurrences. A higher rate of post-treatment recurrence was observed in the single stent group than in the multiple stents group (p = 0.010). The interaction between stent (s) implantation and immediate occlusion degree (odds ratio [OR] =3.152; 95 % confidence interval [CI], 1.293-7.686; p = 0.012), between stent (s) implantation and the posterior inferior cerebellar artery (PICA) involvement (OR = 4.607; 95 % CI, 1.172-18.113; p = 0.029), and between PICA involvement and immediate occlusion degree (OR = 5.018; 95 % CI, 1.263-19.933; p = 0.022) affect recurrence in the reconstructed sis-VADAs. Conclusions This single centre cohort study indicated that the interaction effect between stent (s) implantation, PICA involvement, and immediate occlusion degree were closely associated with recurrence after reconstructive treatment of sis-VADA. Key Points • The interaction between stent (s) and immediate occlusion degree affect aneurysmal recurrence • The interaction between stent and PICA involvement affect aneurysmal recurrence • The interaction between PICA involvement and immediate occlusion degree affect aneurysmal recurrence Electronic supplementary material The online version of this article (doi:10.1007/s00330-014-3225-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kai-Jun Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China,
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Zhao KJ, Fang YB, Huang QH, Xu Y, Hong B, Li Q, Liu JM, Zhao WY, Deng BQ. Reconstructive Treatment of Ruptured Intracranial Spontaneous Vertebral Artery Dissection Aneurysms: Long-Term Results and Predictors of Unfavorable Outcomes. PLoS One 2013; 8:e67169. [PMID: 23840616 PMCID: PMC3693966 DOI: 10.1371/journal.pone.0067169] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 05/14/2013] [Indexed: 11/26/2022] Open
Abstract
Introduction Few studies focused on predictors of unfavorable outcomes (modified Rankin Scale, 2–6) after reconstructive treatment of the ruptured intracranial spontaneous vertebral artery dissection aneurysms (ris-VADAs), which was evaluated based on 57 reconstructed lesions in this study. Methods Results of 57 consecutive patients (M:F = 29∶28; median age, 48 years; range, 27 to 69 years) harboring 57 ris-VADAs, which were treated with coils combined with single stent(n = 32), double overlapping stents (n = 16), and triple overlapping stents (n = 9) between October 2000 to March 2011, were retrospectively reviewed and analyzed. Results The available (n = 54) mean durations of angiographic and clinical follow-ups were 27 months (range, 12 to 78) and 62 months (range, 12 to 132), respectively. The involvement of PICA (p = 0.004), size of lesions (p = 0.000), quantity of stent (p = 0.001), and coil type (p = 0.002) affected the immediate obliteration grade, which was only risk factor for angiographic recurrences (p = 0.031). Although the post-treatment outcomes did not differ between single stent and multiple stents (p = 0.434), 5 angiographic recurrences, 1 rebleeding and 1 suspected rebleeding, all occurred in partial obliteration after single-stent-assisted coiling. Progressive thrombosis and in-stent obliteration were not detected on follow-up angiograms. Older age (odds ratio [OR] = 1.090; 95% confidence interval [CI], 1.004–1.184; p = 0.040) and unfavorable Hunt-Hess scale (OR = 4.289; 95%CI, 1.232–14.933; p = 0.022) were independent predictors of unfavorable outcomes in the reconstructed ris-VADAs. Conclusions Immediate obliteration grade was only risk factor for angiographic recurrence after reconstructive treatment. Unfavorable Hunt-Hess grade and older age were independent predictors of unfavorable outcomes in ris-VADAs.
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Affiliation(s)
- Kai-Jun Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi-Bin Fang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qing-Hai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qiang Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian-Min Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (JML); (WYZ); (BQD)
| | - Wen-Yuan Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (JML); (WYZ); (BQD)
| | - Ben-Qiang Deng
- Department of Neurology, Changhai Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (JML); (WYZ); (BQD)
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Ro A, Kageyama N. Pathomorphometry of ruptured intracranial vertebral arterial dissection: adventitial rupture, dilated lesion, intimal tear, and medial defect. J Neurosurg 2013; 119:221-7. [PMID: 23581586 DOI: 10.3171/2013.2.jns121586] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Subarachnoid hemorrhage (SAH) due to ruptured intracranial vertebral artery (VA) dissection is a life-threatening disease. Angiographic and symptomatic prognostic factors for rupture and rerupture have been investigated, but the pathological characteristics have not been fully investigated. The authors aimed to investigate these features by performing a pathomorphometic study of ruptured intracranial VA dissections. METHODS This study included 50 administrative autopsy cases of fatal SAH due to ruptured intracranial VA dissection among 517 fatal nontraumatic cases of SAH occurring between March 2003 and May 2011. Pathomorphometry was performed using serial 5-μm histological cross-sections with elastica van Gieson staining from each 0.2-mm segment around the ruptured intracranial VA. The longitudinal lengths of 4 types of vascular lesions-adventitial ruptures, dilated lesions where the internal elastic lamina (IEL) was ruptured with adventitial extension, intimal tears where the IEL was ruptured, and medial defects-were calculated based on the numbers of the slides in which these lesions were continuously detected (minimum 2 adjoining slides). The distance from the vertebrobasilar junction to the center of adventitial rupture was also calculated in 37 cases. RESULTS All cases showed one adventitial rupture with a mean length of about 1.9±1.1 mm. The center of the adventitial rupture was located 5.0-26.8 mm (mean 14.6±5.5 mm) from the intracranial VA bifurcation. Adventitial ruptures existed in the centers of dilated lesions, where the adventitia was highly extended. Other vascular lesions were serially observed surrounding the adventitial rupture. The mean lengths of dilated lesions, intimal tears, and medial defects were 9.4±4.8 mm, 13.2±6.3 mm, and 15.6±7.2 mm, respectively. The lengths between proximal lesions and distal lesions from the center of the adventitial rupture for both medial defects and intimal tears were significantly longer at proximal lesions than at distal ones (chi-square test, p<0.01). CONCLUSIONS Every ruptured intracranial VA dissection has a single point of adventitial rupture where the adventitia was maximally extended, so dilation appears to be a valuable predictive factor for hemorrhagic intracranial VA dissections. The adventitial ruptures were as small as 2 mm in length, and clinically detectable dilated lesions were about 9 mm in length. However, vascular vulnerability caused by IEL ruptures and medial defects existed more widely across a length of VA of 1.3-1.5 cm. Comparatively broader protection of the intracranial VA than the clinically detected area of dissection might be desirable to prevent rebleeding. Broader protection of proximal lesions than distal lesions might be effective from the viewpoint of site distribution of vascular lesions and blood flow alteration to the pseudolumen caused by the dissecting hematoma. Medial defects are the most widely seen lesions among the 4 types of vascular lesions studied. Medial degenerative disease, known as segmental arterial mediolysis, is suspected in the pathogenesis of intracranial VA dissections.
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Affiliation(s)
- Ayako Ro
- Department of Legal Medicine, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan.
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Abstract
BACKGROUND Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed with adverse consequences. We assessed the frequency of head/neck pain, other neurological symptoms, and cerebrovascular events in symptomatic VAD. METHODS We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality, and clinical data were abstracted. Pooled proportions were calculated. RESULTS Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. The most common symptoms were dizziness/vertigo (58%), headache (51%), and neck pain (46%). Stroke was common (63%), especially with extracranial dissections (66% vs. 32%, P<0.0001), whereas transient ischemic attack (14%) and subarachnoid hemorrhage (10%) were uncommon. Subarachnoid hemorrhage was seen only with intracranial dissections (57% vs. 0%, P=0.003). Fewer than half of the patients had obvious trauma, and only 7.9% had a known connective tissue disease. Outcome was good (modified Rankin scale 0 to 1) in 67% and poor (modified Rankin scale 5 to 6) in 10% of patients. CONCLUSIONS VAD is associated with nonspecific symptoms such as dizziness, vertigo, headache, or neck pain. Ischemic stroke is the most common reported cerebrovascular complication. VAD should be considered in the diagnostic assessment of patients presenting with dizziness or craniocervical pain, even in the absence of other risk factors. Future studies should compare clinical findings as predictors in well-defined, undifferentiated populations of clinical VAD suspects.
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Padovani Trivelato F, Salles Rezende MT, Brito Santos R, Hilton Vieira Madeira T, Cardoso Campos R, Cordeiro Ulhôa A. Intracranial aneurysms associated with a double origin of the posterior inferior cerebellar artery. Interv Neuroradiol 2011; 17:351-6. [PMID: 22005699 DOI: 10.1177/159101991101700312] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 07/02/2011] [Indexed: 11/17/2022] Open
Abstract
The posterior inferior cerebellar artery (PICA) frequently has a variable course and target territory. However, double origin PICA is a rare finding. Its significance is uncertain, but it has been associated with intracranial aneurysms localized at the PICA proper or at a distant site. The presence of this variation imposes specific challenges. We describe two cases of double origin PICA, one of them associated with an ipsilateral PICA aneurysm. The role of this finding was critically reviewed. A literature search identified 23 cases of double origin PICA, including both cases reported in this paper. Intracranial aneurysms were strongly associated with double origin PICA (71% in 21 detailed cases of double origin PICA). The current patient harboring a PICA aneurysm was successfully treated by endovascular trapping. In the setting of double origin PICA aneurysms, this variation beneficially affects the treatment choice once the two limbs enable the safe sacrifice of the channel involved, with preservation of blood flow through the other channel.
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Affiliation(s)
- F Padovani Trivelato
- Division of Interventional Neuroradiology, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
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Yoon WK, Kim YW, Kim SR, Park IS, Kim SD, Jo KW, Baik MW. Angiographic and clinical outcomes of stent-alone treatment for spontaneous vertebrobasilar dissecting aneurysm. Acta Neurochir (Wien) 2010; 152:1477-86; discussion 1486. [PMID: 20508955 DOI: 10.1007/s00701-010-0693-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Accepted: 05/10/2010] [Indexed: 12/15/2022]
Abstract
PURPOSE Spontaneous vertebrobasilar dissecting aneurysm (VBD) is a very challenging disease with an unpredictable clinical course and controversies on treatment strategy. The present study reports radiological and clinical outcomes of stent-alone treatment (SAT) for VBD. METHODS Twenty-four VBDs treated with SAT are included in the present study. Clinical and angiographic data were reviewed retrospectively. RESULTS A total of 24 lesions in 22 patients with a mean follow-up period of 16.21 months were included. Of the 24 individual lesions, 23 were intracranial vertebral artery lesions and 1 lesion was located in the basilar artery. There were six cases of ruptured dissections with the other cases having various symptoms. The immediate post-SAT angiographic outcomes included 5 lesions with good remodeling over 90% recovery and 19 poorly remodeled lesions. The latest angiographic outcomes included 17 cases of good remodeling (remodeling rate over 90%), 6 cases of poor remodeling (remodeling rate below 70%), and 1 case with morphological aggravation. The overlapping stent technique was used in seven cases and it was significantly associated with good angiographic results. None of the rupture cases underwent re-rupture post SAT. There was one case of a symptomatic complication of a femoral arteriovenous fistula. CONCLUSIONS The SAT could be a feasible alternative for the treatment of VBD. The overlapping technique was significantly associated with good angiographic outcome. We expect that technological development of the intracranial stent will allow better procedural outcomes of SAT.
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Affiliation(s)
- Won Ki Yoon
- Department of Neurosurgery, Holy Family Hospital, The Catholic University of Korea, Sosa-dong, Wonmi-gu, Bucheon, Gyeonggi-do 429-717, Republic of Korea
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Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options. Neurosurg Rev 2008; 31:131-40; discussion 140. [DOI: 10.1007/s10143-008-0124-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 12/05/2007] [Accepted: 01/01/2008] [Indexed: 11/27/2022]
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