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Haruma J, Sugiu K, Ebisudani Y, Kimura R, Edaki H, Yamaoka Y, Kawakami M, Soutome Y, Hiramatsu M. Endovascular Treatment for Intracranial Artery Dissections in Posterior Circulation. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:92-102. [PMID: 38559451 PMCID: PMC10973565 DOI: 10.5797/jnet.ra.2023-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/11/2023] [Indexed: 04/04/2024]
Abstract
Intracranial artery dissections (IADs), although uncommon, are an important cause of cerebral infarction and subarachnoid hemorrhage (SAH). Some IADs can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis. Meanwhile, others can progress to stroke that requires treatment. The incidence of IAD in the posterior circulation is higher than that in the anterior circulation. Anterior circulation dissections are more likely to develop into ischemia and posterior circulation lesions into hemorrhage. The mortality rate after IAD among patients with SAH is 19%-83%. Further, the mortality rate of IAD without SAH is 0%-3%. Patients with SAH commonly undergo surgery or receive neuroendovascular treatment (EVT) to prevent rebleeding. However, the treatment of IADs is empirical in the absence of data from randomized controlled trials. Recently, EVT has emerged and is considered for IADs because of its less invasiveness and perceived low rates of procedure-related morbidity with good efficacy. EVT strategies can be classified into deconstructive (involving sacrifice of the parent artery) and reconstructive (preserving blood flow via the parent vessel) techniques. In particular, the number of reports on reconstructive techniques is increasing. However, a reconstructive technique for ruptured IADs has not yet been established. This review aimed to provide an overview of IADs in the posterior circulation managed with EVT by performing a literature search.
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Affiliation(s)
- Jun Haruma
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Kenji Sugiu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yuki Ebisudani
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Ryu Kimura
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Hisanori Edaki
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yoko Yamaoka
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Masato Kawakami
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yuta Soutome
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Masafumi Hiramatsu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
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Zhou M, Wu Z, Maalim AA, Zeng Y, Guo X, Zhang Z, Yuan X, Enos ZM, Shu K, Lei T, Zhu M. Overlapping Stent Treatment for Ruptured Dissecting Aneurysms in Posterior Circulation. Brain Sci 2023; 13:1507. [PMID: 38002469 PMCID: PMC10669846 DOI: 10.3390/brainsci13111507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Ruptured dissecting aneurysms in posterior intracranial circulation present significant clinical challenges and often cause poor prognoses. Our cohort used overlapping stents as the primary treatment. We analyzed the medical records of 27 patients (18 men/nine women) with ruptured posterior circulation dissecting aneurysms (PCDAs). Their average age was 52 years. We selected 11 patients who used Enterprise (EP) and LVIS stents overlappingly and matched them 1:1 with counterparts who received either EP or LVIS stents individually. Overlapping stents was a feasible treatment in all 27 cases. We successfully followed up 26 patients for ≥6 months. Regrettably, one patient died from intracranial hypertension on Day 7 post-procedure. Immediate post-procedure angiographies indicated Raymond grade I, II, and III occlusions of PCDAs in 16 (59.3%), 7 (25.9%), and 4 (14.8%) cases, respectively. At an average follow-up duration of 16.2 months, 25 patients (96.2%) had modified Rankin Scale scores of 0-2, signifying positive outcomes. One patient (3.8%) had a score of 3-4. Recurrence rates for the EP and LVIS stent groups were higher than those of the overlapping stent group (45.45% vs. 9.09%, p = 0.15 and 27.27% vs. 9.09%, p = 0.59, respectively). No significant difference in recurrence rates existed between the overlapping and single-stent groups. Similarly, follow-up outcomes were consistent between the two groups. Overlapping stents could be an efficient method for treating ruptured PCDAs.
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Affiliation(s)
- Minghui Zhou
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zengbao Wu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ali Abdi Maalim
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ying Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiao Guo
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zhenhua Zhang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiaohong Yuan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zacharia Majaliwa Enos
- Department of Neurosurgery, Tongji Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430030, China;
| | - Kai Shu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Mingxin Zhu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
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Rennert RC, Nguyen VN, Abedi A, Atai NA, Carey JN, Tenser M, Amar A, Mack WJ, Russin JJ. Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series. Front Neurol 2023; 14:1102496. [PMID: 37153667 PMCID: PMC10160605 DOI: 10.3389/fneur.2023.1102496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/29/2023] [Indexed: 05/10/2023] Open
Abstract
Background and purpose The treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk. Materials and methods Retrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization/occlusion for complex intracranial aneurysms from 1/2016 to 6/2022. Results Ten patients (4 male [40%]; mean age 51.9 ± 8.7 years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9/10 (90%), were ruptured and 8/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7/10 [70%]) and extracranial-to-intracranial (EC-IC; 3/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm/vessel sacrifice in 9/10 patients) were performed early after surgery (0.7 ± 1.5 days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4-72 months). Good outcomes (defined as a Glasgow Outcomes Scale ≥4 and modified Rankin Scale ≤2) occurred in 6/10 patients (60%). Conclusion A variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.
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Affiliation(s)
- Robert C. Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Vincent N. Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Nadia A. Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Joseph N. Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Matthew Tenser
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Arun Amar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - William J. Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jonathan J. Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Jonathan J. Russin,
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Hou K, Lv X, Guo Y, Yu J. Endovascular treatment of posterior inferior cerebellar artery trunk aneurysm. Acta Neurol Belg 2022; 122:1405-1417. [PMID: 34677822 DOI: 10.1007/s13760-021-01826-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The posterior inferior cerebellar artery (PICA) generally originates from the vertebral artery (VA) and is the most complex cerebellar artery. Aneurysms can occur at any site along the PICA trunk. Although most PICA aneurysms are located at the VA-PICA junction, a small proportion is located at the PICA trunk. Endovascular treatment (EVT) of aneurysms in the PICA trunk may be difficult and complex. METHODS We performed a review to expound upon EVT of PICA trunk aneurysms. RESULTS The PICA can be divided into five segments (p1-5); the p1-3 segments are proximal segments, and the p4-5 segments are distal segments. Most PICA trunk aneurysms are dissecting aneurysms. Sometimes, the PICA can give rise to flow-related aneurysms in association with cerebellar arteriovenous malformations. Most aneurysms of the PICA trunk require aggressive treatment, especially those that have ruptured. Currently, the EVT mainly includes selective coiling with/without stent assistance and parent artery occlusion. Recently, some new devices, such as flow diversion and Barricade and Kaneka ED coils, can be used to treat PICA trunk aneurysms. The risk of complications with EVT seems to be higher; however, most complications are only transient or mild, and some are even clinically silent. In addition, open surgery is still an important option. CONCLUSION For PICA trunk aneurysms, the treatment choice should be assessed on a case-by-case basis. The rate of permanent morbidity of the EVT is low. EVT is an effective method for treating PICA trunk aneurysms.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Yunbao Guo
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China.
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Ali AMS, Hannan CJ, Islim AI, Mascitelli JR, Javadpour M. Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysms: Systematic Review and Meta-Analysis. World Neurosurg 2022; 162:e168-e177. [PMID: 35257955 DOI: 10.1016/j.wneu.2022.02.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The optimal treatment modality for saccular aneurysms of the posterior inferior cerebellar artery (PICA) remains unclear. A previous meta-analysis on the topic included a heterogenous study population, limiting the conclusions that can be drawn from its results. The aim of this study was to perform a systematic review and meta-analysis to compare outcomes of microsurgical and endovascular treatment (EVT) of these aneurysms. METHODS A search of 4 online databases was performed for studies describing the management of saccular PICA aneurysms. The primary outcome was complete aneurysm occlusion. Data were also collected on neurologic outcomes, cranial nerve palsies, and requirement for re-treatment. A random effects model was used for calculation of pooled proportions. Our protocol was registered with PROSPERO (CRD42021232784). RESULTS A total of 17 studies were included in the final analysis, reporting the treatment outcomes of 455 aneurysms, with a mean follow-up of 20 months. The pooled occlusion rates were 94.8% (95% confidence interval [CI] 90.6%-97.8%) for surgical treatment and 69.1% (95% CI 55.0%-81.7%) for EVT. Pooled rates of good neurologic outcome (modified Rankin scale score ≤2, Glasgow Outcome Scale score ≥4) at last follow-up were 78.1% (95% CI 67.4%-87.1%) for surgery and 77.6% (95% CI 67.9%-86.0%) for EVT. CONCLUSIONS This meta-analysis demonstrates that in the treatment of saccular PICA aneurysms, microsurgical clipping results in superior angiographic outcomes, similar functional outcomes, but higher rates of lower cranial nerve palsy compared with EVT. Further studies are required to assess the duration and severity of cranial nerve palsies following surgical treatment, and long-term aneurysm occlusion and the requirement for re-intervention following EVT.
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Affiliation(s)
- Ahmad M S Ali
- The Walton Centre for Neurology and Neurosurgery, Liverpool, England
| | | | | | | | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; School of Medicine, Trinity College Dublin, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
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Twin Giant Intracranial Aneurysms. World Neurosurg 2021; 154:64-66. [PMID: 34314910 DOI: 10.1016/j.wneu.2021.07.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 11/20/2022]
Abstract
Giant aneurysms of the intracranial vertebral artery and posterior inferior cerebellar artery are challenging to treat as they often necessitate direct sacrifice of the diseased segment, which is thought to carry high morbidity due to brainstem and cerebellar stroke. Here, we report images of twin giant aneurysms of the left posterior inferior cerebellar artery at the brainstem and cerebellopontine angle region in a young child.
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