Patient with Recurrent Anterior Cerebral Artery Dissecting Aneurysm After Stent-Assisted Coil Embolization Successfully Treated with A3-A3 Anastomosis

Fusiform aneurysms of anterior cerebral artery: center experience and systematic literature review

Fusiform aneurysms of the anterior cerebral artery (ACA) are uncommon, and the natural history of this entity is poorly characterized. Along with our center experience, we conducted a systematic literature review to help shed light on the clinical course of ACA fusiform aneurysms. We queried our institutional database to identify cases with fusiform aneurysms of ACA. In addition, following the PRISMA algorithm, we identified all reported cases published in the English literature from the inception of PubMed until December 2022. We categorized clinical presentations into three categories: (i) traumatic/iatrogenic, (ii) spontaneous symptomatic ruptured/unruptured, and (iii) spontaneous asymptomatic aneurysms. We utilized descriptive statistics. We identified seven cases from our center along with 235 patients from published literature. Blunt trauma was responsible for the development of 19 aneurysms. Sixty-three percent of these aneurysms tend to rupture within 2 weeks from the initial trauma, and despite treatment, only 74% of these patients had good clinical outcomes. Spontaneous symptomatic presentation occurred in 207 patients and was often associated with previous/concomitant ACA dissection. Subarachnoid hemorrhage from ruptured aneurysms was the most common presentation. Spontaneous symptomatic fusiform aneurysm is rapidly evolving lesions, and treatment is necessary. Three of our own cases were treated with an endovascular flow diverter (pipeline) stenting with good outcomes. Spontaneous asymptomatic aneurysms were reported in nine patients. These lesions are often associated with other vascular abnormalities. Treatment included surgical clipping with good clinical outcomes. Instead, four patients from our center database were managed conservatively with equally good outcomes. Our study demonstrates good clinical outcomes when fusiform aneurysms of ACA, especially when symptomatic, are treated promptly with either reconstructive or deconstructive therapies.

Evolution of Intracranial-Intracranial Bypass Surgery: A Bibliometric Analysis

OBJECTIVE

Modern cerebrovascular bypass surgery uses either extracranial-intracranial (EC-IC) or intracranial-intracranial (IC-IC) approaches. Compared with EC-IC bypasses, IC-IC bypasses allow neurosurgeons to safely address tumors, aneurysms, and other lesions using shorter grafts that are well matched to the size of recipient vessels. Fewer than 100 articles have been published on IC-IC bypasses compared with more than 1000 on EC-IC bypasses. This study examined the increase of interest and innovation in IC-IC bypass.

METHODS

PubMed and Web of Science were searched using keywords specific to IC-IC bypass, yielding 717 articles supplemented with 36 reports from other databases and gray literature. The articles were reviewed, and 98 articles were selected for further evaluation. Final articles were categorized as innovations or retrospective studies. Publication metrics were passed through an analytic program to assess statistical measures of growth.

RESULTS

The number of publications describing innovations (n = 52) and retrospective studies (n = 46) in IC-IC surgical techniques increased exponentially (R2 = 0.983 and R2 = 0.993, respectively), with both interest and research in the field increasing. The rate of publications in each group also increased. In recent years, increasing numbers of global institutions have researched and published on IC-IC bypasses.

CONCLUSIONS

As more work is undertaken on IC-IC bypasses, it is critical for knowledge to be shared through research, collaboration, publication, and early teaching within residency training programs. This field has increased exponentially in the past 2 decades and has yet to reach an inflection point, indicating possible additional interest and growth over time.

A Case of Ruptured Anterior Cerebral Artery Dissection Prevented from Re-rupture with Stenting and Modification of Antiplatelet Agents

A case of ruptured anterior cerebral artery (ACA) dissection was treated with multiple neck-bridge stents, with modification of antiplatelet administration according to changes in the shape of the aneurysm in the acute phase. A 67-year-old woman presented with severe subarachnoid hemorrhage and fusiform dilatation was observed in the left ACA between the A1 and A2 segments. The use of stents in the acute phase is associated with high risk of ischemic complications. Prasugrel administration, which is considered to have low drug resistance, may have allowed safe stent use in the acute phase.

A3-A3 Anastomosis in the Management of Complex Anterior Cerebral Artery Aneurysms: Experience With in Situ Bypass and Lessons Learned From Pseudoaneurysm Cases

BACKGROUND

A3-A3 side-to-side bypass is an intracranial-to-intracranial (IC-IC) revascularization option when aneurysm treatment involves occlusion of one anterior cerebral artery (ACA).

OBJECTIVE

To describe applications of A3-A3 side-to-side bypass in the management of ACA true and pseudoaneurysms along with a review of pertinent literature.

METHODS

Six consecutive patients undergoing an A3-A3 bypass as part of their aneurysm management, representing a single-surgeon experience in a 2-yr period, were included in this retrospective review of a prospectively collected database.

RESULTS

Three male and three female patients with a median (range) age of 41.5 (11-69) years representing four ruptured and two unruptured aneurysms were included. Two of the aneurysms were communicating while four were postcommunicating from which three were pseudoaneurysms. Complete aneurysm obliteration was achieved in 5/6 cases. Bypass patency was evaluated in all cases intra- and postoperatively. Good outcomes (modified Rankin Scale score ≤ 2) at follow-up were observed in 4/6 patients. An improvement in mRS scores at the most recent follow-up as compared to preoperative status was achieved in three while scores remained the same in two patients. Ischemic complications related to aneurysm treatment were observed in two patients, both of which achieved good functional recovery upon follow-up. One patient deceased postoperatively due to progression of vasospasm-related infarcts.

CONCLUSION

A3-A3 bypass in the management of true as well as pseudoaneurysms of the ACA can achieve good postoperative outcomes in selected patients. Prompt diagnosis and aggressive surgical treatment needs to be pursued if a vessel injury with pseudoaneurysm formation is suspected.

Overlapping Stents and Coil Embolization of Ruptured Anterior Cerebral Artery Dissecting Aneurysms in the Acute Phase

Objective

To report a case of ruptured anterior cerebral artery dissection treated with stent-assisted coil embolization with overlapping stents.

Case Presentation

A 51-year-old woman developed subarachnoid hemorrhage the day after transient left hemiparesis. Angiography revealed a ruptured anterior cerebral artery dissecting aneurysm. We conducted stent-assisted coil embolization with the overlapping stent technique on the day after the hemorrhage. She recovered steadily without rebleeding. Six months after embolization, no recurrence was found on angiography.

Conclusion

Although an acceptable result was achieved in this case, the safety and efficacy of this procedure are unconfirmed. A larger number of cases should be accumulated.

Safety and efficacy of different therapeutic strategies in the endovascular treatment of anterior cerebral artery aneurysms with different features: A single centre experience

BACKGROUND

Outcomes of endovascular treatment of anterior cerebral artery (ACA) aneurysms are still not well-characterized.

OBJECTIVE

The study aimed to review the clinical effect, procedure-related complications and follow-up outcomes and to evaluate the safety and efficacy of endovascular treatment of ACA aneurysms in our center experience.

METHODS

From August 2014 to August 2018, a total of 75 consecutive patients with 77 ACA aneurysms were treated via the endovascular approach after providing informed consent. A retrospective review of the clinical, radiological, and endovascular details of these patients was conducted.

RESULTS

The mortality and the morbidity in this study were 4% and 9.3%, respectively. Compared with A1 and A2 aneurysms, intraoperative rupture was more common in A3 aneurysms (P = 0.029). Difference between the ruptured and unruptured aneurysms in the distribution of therapeutic strategy (P = 0.003) and immediate embolization degree (P = 0.004) was also significant. Statistical analysis demonstrated that the larger aneurysm (P = 0.031) was, the greater the ratio of aneurysm size to parent artery diameter (P = 0.029) was, the more likely the unruptured aneurysms were to occur ischemic events. Higher Hunt-Hess grade (P = 0.0066) was an independent risk factor for poor clinical outcome.

CONCLUSION

Endovascular treatment is feasible and effective for ACA aneurysms.

Stent-Jailing Technique Reduces Aneurysm Recurrence More Than Stent-Jack Technique by Causing Less Mechanical Forces and Angiogenesis and Inhibiting TGF-β/Smad2,3,4 Signaling Pathway in Intracranial Aneurysm Patients

Background: Stent-jailing and stent-jack are used for stent-assisted coil embolism (SCE) in intracranial aneurysm (IA) therapy, and cause different incidences of IA recurrence. Angiogenesis strongly correlates with aneurysm accumulation. Stent-jack causes higher mechanical forces in cerebral vessels than stent-jailing. Mechanical forces, as well as TGF-β/Smad2,3,4 signaling pathway, may play an important factor in IA recurrence by affecting angiogenesis.

Methods: We explored the effects of stent-jailing or stent-jack technique on IA recurrence by investigating mechanical forces, TGF-β/Smad2,3,4 signaling pathway and the incidence of angiogenesis in IA patients. One-hundred-eighty-one IA patients were assigned into stent-jailing (n = 93) and stent-jacket groups (n = 88). The clinical outcome was evaluated using Glasgow Outcome Score (GOS) and aneurysm occlusion grades. The percentage of CD34⁺EPCs (releasing pro-angiogenic cytokines) in peripheral blood was measured by flow cytometer. Endothelial cells were separated from cerebral aneurysm and malformed arteries via immunomagnetic cell sorting. Angiogenesis was measured by microvessel density (MVD) using anti-CD34 monoclonal antibody staining before using the stent, immediately after surgery and 2 years later. Meanwhile, the mechanical forces in cerebral vessels were determined by measuring endothelial shear stress (ESS) via a computational method. TGF-β and Smad2,3,4 were measured by real-time qPCR and Western Blot. Tube formation analysis was performed to test the relationship between angiogenesis and TGF-β, and the effects of different techniques on angiogenesis.

Results: After a 2-year follow-up, 85 and 81 patients from stent-jailing and stent-jack groups, respectively, completed the experiment. Stent-jailing technique improved GOS and reduced aneurysm occlusion grades higher than the stent-jack technique (P < 0.05). The counts of CD34⁺EPCs and MVD values in the stent-jailing group were lower than the stent-jack group (P < 0.05). ESS values in sent-jailing group were lower than the stent-jack group (P < 0.05), and positively correlated with MVD values (P < 0.05). TGF-β and Smad2,3,4 levels in sent-jailing group were also lower than the stent-jack group (P < 0.05). TGF-β was associated with angiogenesis incidence and stent-jack caused angiogenesis incidence more than stent-jailing.

Conclusion: Stent-jailing technique reduces IA recurrence more than stent-jack by causing less mechanical forces, angiogenesis and inhibiting TGF-β/Smad2,3,4 signaling in IA patients.