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Lv X, Yu J, Zhang W, Zhao X, Zhang H. Acute hemorrhagic cerebral artery dissection: Characteristics and endovascular treatment. Neuroradiol J 2020; 33:112-117. [PMID: 32124670 PMCID: PMC7140309 DOI: 10.1177/1971400920907824] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Acute hemorrhagic cerebral artery dissection may show a subtle stenosis and bulge on an angiogram, for which diagnosis and treatment are difficult. This report describes seven cases of acute hemorrhagic cerebral artery dissection treated by endovascular techniques. PATIENTS AND METHODS From January 2018 to April 2019, seven patients (22-76 years old) were diagnosed with subarachnoid hemorrhage caused by cerebral artery dissection. Six patients were treated by low-profile visualized intraluminal support stent-assisted coiling and there was a sacrifice of the posterior cerebral artery in one patient. Cerebral angiography results were obtained immediately after intervention and at follow-up. Clinical outcome was evaluated by a modified Rankin Scale score. RESULTS Four dissections were angiographic changes of subtle stenosis and small bulges; three were apparent angiographic changes of stenosis or fusiform morphologies. All seven aneurysms were completely obliterated, a low-profile visualized intraluminal support stent was used in six patients and coil occlusion of the parent artery in one patient. Complications occurred in two cases of proximal posterior cerebral artery dissection. One bleeding complication was observed intra-procedure and one ischemic complication was observed after stent-assisted coiling. The angiographic and clinical follow-up was obtained at 3-8 months in five patients. Good recovery was achieved for six patients (modified Rankin Score 0); one patient who presented Weber syndrome caused by ischemic complication had a modified Rankin Score of two at 8 months follow-up. CONCLUSION Hemorrhagic cerebral artery dissection may show subtle stenosis, small bulges or fusiform morphologies on angiograms. Treatment of proximal posterior cerebral artery dissection is challenging. Endovascular reconstruction with a low-profile visualized intraluminal support stent was effective depending on the angiographic morphology.
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Affiliation(s)
- Xianli Lv
- Neurosurgery Department, Beijing
Tsinghua Changgung Hospital, School of Clinical Medicine,
Tsinghua
University, China
| | - Jianjun Yu
- Neurosurgery Department, Linyi People
Hospital, Weifang Medical College, China
| | - Wei Zhang
- Neurosurgery Department, Beijing
Tsinghua Changgung Hospital, School of Clinical Medicine,
Tsinghua
University, China
| | - Xuelian Zhao
- Neurosurgery Department, Beijing
Tsinghua Changgung Hospital, School of Clinical Medicine,
Tsinghua
University, China
| | - Huifang Zhang
- Neurosurgery Department, Beijing
Tsinghua Changgung Hospital, School of Clinical Medicine,
Tsinghua
University, China
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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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Mahajan A, Goel G, Das B, Narang K. Dissecting aneurysm of vertebral artery involving the origin of posteroinferior cerebellar artery treated with retrograde stent placement and coil embolization in the era of flow diverter. Asian J Neurosurg 2018; 13:910-913. [PMID: 30283580 PMCID: PMC6159080 DOI: 10.4103/ajns.ajns_59_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ruptured vertebral artery (VA) dissecting aneurysm carries high risk of rerupture and mortality if not treated immediately. Dissecting aneurysm of the VA involving the posteroinferior cerebellar artery (PICA) origin is difficult to treat by surgical and endovascular route. With the availability of flow diversion device for reconstructive procedure, endovascular treatment has now become easy to treat difficult aneurysm while maintaining the patency of the PICA. However, instead of using flow diverter (FD) in our case, we successfully treated dissecting VA aneurysm involving the PICA origin with retrograde stent placement from distal right VA to the left PICA to maintain the patency of PICA and occlusion of dissecting aneurysm of VA with detachable coils instead of performing surgical bypass and FD placement.
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Affiliation(s)
- Anshu Mahajan
- Department of Neurosciences, Medanta - The Medicity, Gurgaon, Haryana
| | - Gaurav Goel
- Department of Neurosciences, Medanta - The Medicity, Gurgaon, Haryana
| | - Biplab Das
- Department of Neurosciences, Medanta - The Medicity, Gurgaon, Haryana
| | - Karanjit Narang
- Department of Neurosciences, Medanta - The Medicity, Gurgaon, Haryana
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Kidani N, Sugiu K, Hishikawa T, Hiramatsu M, Haruma J, Nishihiro S, Takahashi Y, Date I. De novo vertebral artery dissecting aneurysm after internal trapping of the contralateral vertebral artery. Acta Neurochir (Wien) 2017; 159:1329-1333. [PMID: 28493024 DOI: 10.1007/s00701-017-3204-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
We present the case of a de novo vertebral artery dissecting aneurysm (VADA) after endovascular trapping of a ruptured VADA on the contralateral side. The first ruptured VADA involved the posterior inferior cerebellar artery, which was successfully treated by endovascular internal trapping using a stent. A follow-up study at 3 months revealed a de novo VADA on the contralateral side. The second VADA was successfully embolized using coils while normal arterial flow in the vertebral artery was preserved using a stent. Increased hemodynamic stress may cause the development of a de novo VADA on the contralateral side.
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Jeong HW, Seung WB. Outcomes of Stent-assisted Coil Embolization of Wide-necked Intracranial Aneurysms Using the Solitaire™ AB Neurovascular Remodeling Device. J Cerebrovasc Endovasc Neurosurg 2016; 17:301-12. [PMID: 27066440 PMCID: PMC4823427 DOI: 10.7461/jcen.2015.17.4.301] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/12/2015] [Accepted: 12/19/2015] [Indexed: 11/27/2022] Open
Abstract
Objective This retrospective study presents our experience with respect to the clinical and angiographic outcomes of patients treated with stent-assisted coil embolization using Solitaire™ AB stents. Materials and Methods From March 2011 to December 2014, 50 patients with 55 wide-necked and/or complex intracranial aneurysms were evaluated. Four patients presented with an acute subarachnoid hemorrhage. Stent deployment was performed with a standard coiling procedure in 49 aneurysms. Three patients underwent bailout stenting, 2 patients were treated by temporary stenting and one patient was treated only by stenting without coiling for dissecting aneurysm. Results Successful placement of the Solitaire AB stent was achieved in all the cases. Based on the postprocedural angiographic results, a Raymond 1 was obtained in 32 (59%) of 54 aneurysms, excluded by one case of dissecting aneurysm, and a Raymond 2 in 13 (24%), and a Raymond 3 in 9 (17%). There was one thromboembolic (2%) and three hemorrhagic complications (6%). However, procedure-related morbidity or mortality was not found. Annual follow-up angiographic results from the embolization were obtained in 40 (74.1%) of 54 cases. These results were represented as Raymond 1 in 27 (67.5%), class 2 in 9 (22.5%), and class 3 in 4 (10%) cases. Angiographic improvement associated with progressive thrombosis of the aneurysm was obtained in 10 aneurysms. Four aneurysms were recanalized without requiring additional treatment. In-stent stenosis was found in one aneurysm, but stent migration was not seen on follow-up angiography. Conclusion Stent-assisted coil embolization using the Solitaire AB stent for treating wide-necked and/or complex intracranial aneurysms was found to be safe and effective immediately post-embolization and after follow-up. Long-term follow-up will be required to identify the effect of the Solitaire AB stent on recanalization rates.
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Affiliation(s)
- Hae Woong Jeong
- Department of Diagnostic Radiology, Busan Baik Hospital, Inje University, Busan, Korea
| | - Won-Bae Seung
- Department of Neurosurgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
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Chen YA, Qu RB, Bian YS, Zhu W, Zhang KP, Pang Q. Stent placement to treat ruptured vertebral dissecting aneurysms. Interv Neuroradiol 2013; 19:479-82. [PMID: 24355153 DOI: 10.1177/159101991301900412] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/24/2013] [Indexed: 11/17/2022] Open
Abstract
Conventional endovascular treatment may have limitations for vertebral dissecting aneurysm involving the origin of the posterior inferior cerebellar artery (PICA). We report our experiences of treating vertebral dissecting aneurysm with PICA origin involvement by placing a stent from the distal vertebral artery (VA) to the PICA to save the patency of the PICA. Stenting from the distal VA to the PICA was attempted to treat ruptured VA dissecting aneurysm involving the PICA origin with sufficient contralateral VA in eight patients. The procedure was successfully performed in seven patients with one failure because of PICA origin stenosis, which was treated with two overlapping stents. In the seven patients, PICAs had good patency on postoperative angiography and transient lateral brainstem ischemia represents a procedure-related complication. Follow-up angiographies were performed in seven patients and showed recanalization of the distal VA in three patients without evidence of aneurysmal filling. There was no evidence of aneurysm rupture during the follow-up period, and eight patients had favorable outcomes (mRS, 0 - 1). Placing a stent from the distal VA to the PICA with VA occlusion may present an alternative to conventional endovascular treatment for vertebral dissecting aneurysm with PICA origin involvement with sufficient contralateral VA.
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Affiliation(s)
- Yong-An Chen
- Department of Neurosurgery, Qilu Hospital, Shandong University; Jinan, China - Department of Neurosurgery, Yantai Yuhuangding Hospital, Qingdao University School of Medicine; Yantai, China -
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Lv X, Li Y, Jiang C, Yang X, Wu Z. Potential advantages and limitations of the Leo stent in endovascular treatment of complex cerebral aneurysms. Eur J Radiol 2011; 79:317-22. [PMID: 20619988 DOI: 10.1016/j.ejrad.2010.06.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 06/09/2010] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The Leo self-expandable stent is a new retractable stent that is delivered via a conventional catheter. The aim of this study was to evaluate the use of this stent for endovascular treatment of complex aneurysms. METHODS Twenty-eight complex cerebral aneurysms (27 saccular and 1 fusiform) in 28 patients were treated electively. They were located at the internal carotid artery (17), basilar trunk (3), anterior cerebral artery (1), anterior communicating artery (3), vertebral artery (2) and middle cerebral artery (2). One aneurysm exhibited recanalization after primary endovascular treatment without stent. Clinical outcome was assessed with the modified Glasgow Outcome Scale. RESULTS Deployment of Leo stent was successful in 26 lesions, and difficulties in stent positioning due to tortuous cerebral circulation in 2 cases, which were treated with Neuroform stent. Additional coil embolization was performed in 26 lesions. No permanent neurological deficits were encountered consequent to endovascular procedure. Complete or partial occlusion immediately after stent deployment was achieved in all aneurysms. There was no immediate coil embolization was chosen in 3 cases because of subsequent reduced filling of the aneurysms with contrast agent on angiograms. There were 3 asymptomatic parent artery occlusion related to the deployment of the Leo stent, one stent migration. Follow-up revealed patent stents in the remaining cases. No angiographic recurrences arose. CONCLUSION The Leo stent is very useful for endovascular treatment of complex cerebral aneurysms because it is easy to navigate and place precisely. A drawback is that in-stent thrombosis caused by stent placement and stiffer delivery catheters to place larger stents.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, 6, Tiantan Xili, 100050 Hebei, Beijing, People's Republic of China
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Lv X, Jiang C, Li Y, Wu Z. Clinical outcomes of lower cranial nerve palsies caused by vertebral artery-posteroinferior cerebellar artery aneurysms after endovascular embolization. Neurol Res 2010; 32:796-800. [PMID: 20444322 DOI: 10.1179/016164109x12478302362455] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To report clinical outcomes of lower cranial nerve palsy (LCNP) caused by vertebral artery (VA) aneurysms. METHODS Seventy-two patients with VA aneurysms, who were treated endovascularly between 2001 and 2008, were retrospectively studied to identify patients presenting LCNP without hemorrhage. RESULTS LCNP occurred in 12 patients (16·7%) initially caused by VA aneurysms: four located at vertebral artery-posteroinferior cerebellar artery (PICA) complex, seven at distal to PICA segment and one at proximal to PICA segment. Among these patients, ten patients were diagnosed as having dissecting aneurysms of the intracranial VA, and two were diagnosed having saccular aneurysms. Two patients were treated by sole stent placement, five patients were treated by stent coil embolization and five were treated by vertebral artery occlusion. Nosocomial pneumonia did not occur in our patients. Post-operative LCNP resolved completely within 6 months in nine patients (75%) and within 9 months in ten patients (83%). Two (1·9%) patients died of aneurismal bleeding and brainstem ischemia, respectively. CONCLUSION The results of this study can help to identify the effect and natural history of LCNP caused by VA aneurysms. These lesions can be effectively treated by endovascular embolization, even by VA occlusion.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Zhang J, Zhang R, Wu Z, Lv X, Liu B. Results of endovascular management for mid-basilar artery aneurysms. Interv Neuroradiol 2010; 16:249-54. [PMID: 20977855 PMCID: PMC3277990 DOI: 10.1177/159101991001600303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 06/07/2010] [Indexed: 02/05/2023] Open
Abstract
We evaluated the results of endovascular management of patients with mid-basilar artery aneurysm (mBAA). During a seven year period, 14 patients (mean age 39.6 years, male/female ratio 1:1) with mBAA were treated with endovascular techniques at our institute. Pretreatment clinical grades were determined using the Hunt-Hess scale. Outcome was evaluated using the Glasgow Outcome Scale scores (GOS) during a mean follow-up period of 15.6 months (range, three to 70 months). Fourteen patients with 15 mBAAs were treated endovascularly. Four (28.6%) patients died of rebleeding within one day after embolization. In ten mBAAs, immediate postprocedural angiograms showed that complete occlusion was achieved, subtotal occlusion in one, and incomplete occlusion in four. Follow-up angiographic results in ten patients confirmed complete occlusion of 11 aneurysms. Long-term outcome was good (GOS Score 4 or 5) in ten patients (71.4%) and fatal (GOS Score 1) in four (28.6%). Favorable overall long-term outcome can be achieved in 78.6% patients with mBAAs. Endovascular management of mBAAs is an effective treatment in the long-term. In our experience, the natural history of mBAAs is dismal.
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Affiliation(s)
- J Zhang
- Suqian People's Hospital Drum Tower Hospital Group, Nanjing, China
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Lv X, Jiang C, Li Y, Wu Z. Clinical outcomes of ruptured and unruptured vertebral artery-posterior inferior cerebellar artery complex dissecting aneurysms after endovascular embolization. AJNR Am J Neuroradiol 2010; 31:1232-5. [PMID: 20395384 PMCID: PMC7965462 DOI: 10.3174/ajnr.a2087] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Surgical treatment of VA-PICA dissecting aneurysms is difficult and complication of LCNP is common. These lesions can be approached easily with endovascular technique, but complete obliteration can only be achieved in a small number of cases. Our aim was to report the clinical outcomes of VA-PICA dissecting aneurysms treated by endovascular embolization. MATERIALS AND METHODS Between 2001 and 2007, the authors treated 22 consecutive patients (15 men and 7 women; ranging in age from 12 to 59 years; mean age, 43 years) with VA-PICA dissecting aneurysms. Diagnosis of VA-PICA dissecting aneurysm was based on clinical, MR imaging, and cerebral angiography studies. RESULTS Of the 22 patients, 6 had unruptured aneurysms. One patient presented with headaches, whereas the remaining 5 patients showed brain stem ischemia. Four were treated with stent-only or stent-coil embolization, and 2 were treated with unilateral VA occlusion. Among 16 patients presenting with SAH, 10 were treated with stent-only or stent-coil embolization. The other 6 patients with SAH were treated by using unilateral endovascular VA occlusion. One patient could not return to his previous daily activities. CONCLUSIONS VA-PICA aneurysms are rare lesions associated with significant morbidity, and endovascular treatment strategies for these lesions were stent deployment with or without coil embolization and VA occlusion. Favorable clinical outcomes can be achieved with endovascular techniques.
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Affiliation(s)
- X Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Chongwen, Beijing, P.R. China
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Zhang J, Lv X, Jiang C, Li Y, Yang X, Wu Z. Endovascular treatment of cerebral aneurysms with the use of stents in small cerebral vessels. Neurol Res 2010; 32:119-22. [PMID: 19825275 DOI: 10.1179/174313209x459110] [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] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To report the results of the Neuroform, Leo and Wingspan stents used to treat cerebral aneurysms in vessels of small caliber. MATERIALS AND METHODS We reviewed 12 cases of wide-necked aneurysms treated with stent deployment into small cerebral vessels with diameter range from 1.0 to 2.5 mm. All stents were deployed for aneurysm treatment in combination with coiling. Aneurysm locations were as follows: A1 (n=4), anterior communicating artery (n=2), A2 (n=1), M1 (n=2), M2 (n=1) and P1 (n=2). Clinical follow-up ranged from 3 to 12 months. Imaging follow-up (range: 3-6 months) was performed with cerebral angiography. RESULTS Twelve self-expanding stents (six Neuroform stents, three Leo stents and three Wingspan stents) were deployed for 12 wide-necked cerebral aneurysms arising from vessels measuring < or =2.5 mm in diameter. Eleven procedures were successfully performed without immediate or delayed device-related complications with one stent misplacement. Intraprocedural thrombus developed within the stent in one patient. There were no clinical neurological symptoms related to the treated vessel territory at clinical follow-up. CONCLUSION Development of newer small endovascular devices, such as Neuroform, Leo and Wingspan stents, allow access and ability to treat lesions farther out in the smaller cerebral vessels.
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Affiliation(s)
- Jingbo Zhang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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