Successful Treatment of Growing Basilar Artery Dissecting Aneurysm by Pipeline Flow Diversion Embolization Device

Pipeline embolization device retraction and foreshortening after internal carotid artery blister aneurysm treatment

Background Subarachnoid hemorrhage (SAH) secondary to rupture of a blister aneurysm (BA) results in high morbidity and mortality. Endovascular treatment with the pipeline embolization device (PED) has been described as a new treatment strategy for these lesions. We present the first reported case of PED retraction and foreshortening after treatment of a ruptured internal carotid artery (ICA) BA. Case description A middle-aged patient presented with SAH secondary to ICA BA rupture. The patient was treated with telescoping PED placement across the BA. After 5 days from treatment, the patient developed a new SAH due to re-rupture of the BA. Digital subtraction angiography revealed an increase in caliber of the supraclinoid ICA with associated retraction and foreshortening of the PED that resulted in aneurysm uncovering and growth. Conclusions PED should be oversized during ruptured BA treatment to prevent device retraction and aneurysm regrowth. Frequent imaging follow up after BA treatment with PED is warranted to ensure aneurysm occlusion.

Off-label uses of the Pipeline embolization device: a review of the literature

The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.

Endovascular management of ruptured basilar artery dissection with two overlapping Low-profile Visualized Intraluminal Support stents

The optimal endovascular treatment method of ruptured basilar artery dissection still remains controversial. We reported a case with ruptured basilar artery dissection involving the left anterior inferior cerebellar artery. The dissecting aneurysm was successfully treated with two overlapping Low-profile Visualized Intraluminal Support stents and the preservation of antegrade blood flow of the anterior inferior cerebellar artery was achieved. Three-month and six-month follow-ups revealed good clinical and angiographic results, although controversies regarding long-term stability remained to be addressed.

Treatment of posterior circulation non-saccular aneurysms with flow diverters: a single-center experience and review of 56 patients

BACKGROUND AND PURPOSE

Non-saccular aneurysms of the posterior fossa are an uncommon pathology with no clear treatment strategy. The use of flow-diverting stents (FDS) has had mixed results. We sought to evaluate our experience of FDS for the treatment of this pathology.

METHODS

We retrospectively reviewed our database of prospectively collected information for all patients treated only with flow diversion for an unruptured non-saccular aneurysm of the posterior circulation between February 2009 and April 2016. The aneurysms were classified as dolichoectasia, fusiform or transitional, and imaging characteristics including maximal diameter, disease vessel segment, MRI features (intra-aneurysmal thrombus, T1 hyperintensity in the aneurysmal wall, infarctions in the territory of the posterior circulation, and mass effect) were recorded alongside clinical and follow-up data.

RESULTS

We identified 56 patients (45 men) with 58 aneurysms. The average age of the patients was 63.5 years. Twenty-two patients were symptomatic from the aneurysms at presentation. The majority of the lesions were vertebrobasilar in location (44.8%) with isolated vertebral lesions representing 29.3% of aneurysms. Transitional aneurysms were the most common (48.2%). The mean maximal diameter of the aneurysms was 11 mm. Angiographic exclusion of the aneurysms was seen in 57.4% of aneurysms with follow-up (n=47). During the follow-up period nine patients died.

CONCLUSIONS

Treatment of non-saccular aneurysms of the posterior fossa is technically possible. Early treatment, particularly of the fusiform and transitional subtypes, is recognized, as is treatment prior to the development of symptoms. A 'watch and wait' strategy with regular imaging follow-up could be employed for asymptomatic dolichoectasia.

Endovascular Treatment in Ruptured Middle Cerebral Artery Dissection Preservation of Arterial Continuity

Rupture of spontaneous dissecting aneurysms of the middle cerebral artery (MCA) is rare and its etiology remains obscure, although the risk of rebleeding is greater than with saccular aneurysms. Most reports concerning the treatment of a ruptured dissecting aneurysm of the anterior circulation involve surgical trapping or wrapping. Here, we report on a case of an MCA dissecting rupture treated with endovascular procedures. A 22-year-old female presented with sudden stuporous mental change following severe headache and left side hemiparesis. A computed tomography scan showed a diffuse subarachnoid hemorrhage and diffusion MR showed diffusion restriction at the right putamen and internal capsule. A 3-hour follow-up digital subtraction angiography (DSA) showed a dissecting aneurysm, which was not seen on an initial DSA. A stent assisted coil embolization was performed and double stents were applied to achieve flow diversion effects. A small remnant area of the dissecting aneurysm had disappeared at 60-day and was not observed on 12-month follow-up DSA.

Treatment of vertebrobasilar fusiform aneurysms with Pipeline embolization device

OBJECT

Treatment of complex intracranial aneurysms with Pipeline embolization device (PED) (ev3/Covidien Vascular Therapies) has gained recent popularity. One application of PEDs that is not well described in the literature is the utility and long-term safety in treatment of vertebrobasilar fusiform (VBF) aneurysms. Despite the advancements in endovascular therapy, VBF aneurysms continue to challenging pathology. The authors provide long-term follow-up of VBF aneurysms treated with PEDs.

METHODS

We retrospectively reviewed four patients that were treated at Louisiana State University Health Sciences Center in Shreveport with PEDs for VBFs from 2012 to 2014. Each patient was discussed in a multidisciplinary setting between neurosurgeons and neurointerventionalists. Each patient underwent platelet function tests to ensure responsiveness to anti-platelet agents and was treated by one neurointerventionalist (HC). All patients were placed on aspirin and Plavix and were confirmed for therapeutic response prior to discharge.

RESULTS

Follow-up ranged from 12 to 25 months, with a mean of 14.25 months. Two cases presented with a recurrence after the initial treatment, both of which required subsequent treatment. Of the four patients treated, one patient developed hemiparesis and three died.

CONCLUSION

Despite reports describing successful treatment of VBF aneurysms with PEDs, delayed complications after obliteration and remodeling can occur. We describe our institutional experience of VBFs treated with PEDs. Treatment of holobasilar fusiform aneurysms may carry a worse prognosis after treatment. Further long-term follow-up will provide a better understanding of this pathology.

Growing dissecting aneurysm of basilar trunk treated with stent-assisted coiling

Growing basilar dissecting aneurysm is a scarce but increasingly recognized entity, accounting for a significant risk of death and disability. Controversy exists regarding the optimal management. A 61-year-old man presented with dysarthria and left hemiparesis attributable to a basilar trunk dissecting aneurysm. Antiplatelet therapy was instituted, and the patient's clinical condition markedly improved. However, he developed severe headache, dysarthria, and left hemiparesis 35 days later. Angiography revealed significant enlargement of the aneurysm, and stent-assisted coiling was then uneventfully performed. The patient remained clinically stable with only mild left-sided hemiparesis at the 2-year clinical follow-up.