Endovascular treatment of intracranial artery dissection: clinical and angiographic follow-up

Endovascular treatments of intracranial vertebral and internal carotid arteries dissections: An interactive systematic review and meta-analysis

INTRODUCTION

Management of intracranial artery dissection (IAD) remains elusive in medical practice. Intracranially, vertebral artery dissection (VAD) is more commonly encountered than internal carotid artery dissection (ICAD). Deconstructive (EVT-d) and reconstructive (EVT-r) endovascular techniques have been utilized to treat VAD and ICAD. This meta-analysis investigates the safety and efficacy of EVT-r and EVT-d in the management of VAD and ICAD.

METHODS

The literature was searched for all studies with consecutive patient series evaluating EVT-d or EVT-r for VAD or ICAD management. Baseline characteristics and outcomes were compared between EVT-r and EVT-d groups using the random-effect model and meta-regression approaches.

RESULTS

Overall, 1095 cases pooled from 56 studies were included. There was no statistically significant difference in baseline characteristics between VAD and ICAD. EVT-r was applied in 647 cases (59.1%) and EVT-d in the rest There was no statistical difference in the rate of procedural complications between EVT-r and EVT-d. Although EVT-d was significantly associated with higher rates of complete aneurysm occlusion (86.4%), lower rates of good clinical outcomes (72.1%) and higher mortality (15.1%) were achieved compared to EVT-r (70.2%, 83.3%, and 9.5%; respectively). The mortality rate was higher, and good clinical outcomes were less common in ruptured aneurysms. Ischemic presentation was statistically associated with poor outcomes (mRS 3-5) but low mortality. ICAD often tended to grow following treatment and resulted in poor neurological outcomes.

CONCLUSIONS

IAD has favorable outcomes when treated appropriately. Novel reconstructive endovascular techniques are promising and should be integrated well in endovascular practice. Further studies are warranted.

Endovascular Management of Spontaneous Subclavian Artery Dissection

Spontaneous subclavian artery dissection (SCAD) is a rare clinical observation with very few cases reported in the medical literature. We describe a rare case of a 50-year-old female patient who presented with symptoms of critical limb ischemia of the right upper extremity. A digital subtraction angiogram (DSA) revealed a dissection in the proximal course of the subclavian artery (SCA). Prompt recanalization with endovascular therapy produced an excellent result.

Ischemic stroke caused by spontaneous anterior circulation intracranial arterial dissections: patient series

BACKGROUND

Intracranial arterial dissections (IADs) are classically associated with the vertebrobasilar system, yet are a devastating cause of ischemic stroke within the anterior circulation. Current literature regarding the surgical management of anterior circulation IAD is lacking. As a result, data on 9 patients presenting with ischemic stroke due to spontaneous anterior circulation IAD between 2019 and 2021 were collected in a retrospective manner. Symptoms, diagnostic modalities, treatment, and outcomes are presented for each case. Patients who underwent endovascular procedures had 10-minute follow-up angiography performed to identify signs of reocclusion, which prompted initiation of glycoprotein IIb/IIIa therapy and stent placement.

OBSERVATIONS

Seven patients underwent emergent endovascular intervention (stenting: n = 5; thrombectomy alone: n = 2). The remaining 2 were managed medically. Two patients developed progressive flow limiting stenosis requiring further intervention, 2 developed asymptomatic progressive stenosis/occlusion with robust collateral formation and the remainder have patent vasculature upon follow up imaging at 6 to 12 months. Seven patients had a modified Rankin Scale score of 1 or less at the 3-month follow-up.

LESSONS

IAD is a devastating yet rare cause of anterior circulation ischemic stroke. The treatment algorithm proposed resulted in positive clinical and angiographic outcomes warranting future consideration and study in the emergent management of spontaneous anterior circulation IAD.

Deconstructive versus reconstructive endovascular approaches for intracranial dissecting aneurysms

Background

The annual incidence of the intracranial dissecting aneurysms is about 1 to 1.5 per 100,000. This is a well-known cause of stroke and subarachnoid hemorrhage in young and middle-aged patients (Santos-Franco et al. in Neurosurg Rev, 2008. https://doi.org/10.1007/s10143-008-0124-x). Various surgical and endovascular treatment methods have been proposed for intracranial dissecting aneurysms. All treatment methods aim to reduce the blood flow in the dissected region. Deconstructive techniques sacrifice the parent artery, whereas reconstructive techniques aim to maintain a parent artery (Stéphanie et al. in Lancet Neurol 14(6):640–654, 2015. https://doi.org/10.1016/S1474-4422(15)00009-5). Due to its dissecting nature, wall friability can make surgical clipping difficult and even risky. On the other hand, recanalization after coiling alone is almost certain. Therefore, deconstructive modalities of treatment like trapping or parent vessel occlusion, performed either surgically or endovascularly, have predominated for managing those lesions, usually with good results. Nevertheless, in absence of efficient collateral pathways, the deconstructive technique carries an ischemic risk. In situations in which parent artery preservation is mandatory, the use of stent-assisted techniques may be the most appropriate choice (de Barros Faria et al. in Am J Neuroradiol 32(11):2192–2195, 2011. https://doi.org/10.3174/ajnr.A2671). However, the usage of stent with recently ruptured aneurysms is always perplexing due to the necessity of dual antiplatelet administration. Hence the management of dissecting aneurysms remain challenging.

Results

Between January 2017 and July 2019, 19 patients presenting with intracranial dissecting aneurysms were referred to our department for endovascular treatment. Among the nineteen patients, 11 cases were treated by parent artery occlusion representing 57.9% of the cases, and 7 cases (36.8%) were treated by artery preserving technique, and only one case (5.3%) was treated by combination of parent artery occlusion and artery preserving technique. One week after the intervention 26.3% of patients had no disability (mRS = 0), 47.4% had no significant disability (mRS = 1), 15.8% had slight disability (mRS = 2) and 10.5% had moderate to severe disability (mRS = 3–4). After three months we found an overall improvement of the clinical outcome, as 57.9% of patients had no disability (mRS = 0), 26.3% had no significant disability (mRS = 1) and 15.8% had mild disability (mRS = 2). Finally, after six months reassessment with angiography showed that 89.5% of patients had stable aneurysmal occlusion, and 10.5% had recurrence of aneurysm.

Conclusions

Both endovascular approaches, whether parent artery occlusion or artery preserving technique showed favorable outcome which indicates the safety and efficacy of both approaches if selected properly according to the morphology of the aneurysm.

ESO guideline for the management of extracranial and intracranial artery dissection

The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.

Low-profile visible intraluminal support stent-assisted embolization therapy for intracranial dissecting aneurysms: A retrospective analysis of six cases

Endovascular Embolization (EVE) of aneurysms is a very effective and efficient treatment modality. Nevertheless, a few complications have been reported after EVE of aneurysms. Our study therefore evaluated the safety and efficacy of Low-profile Visible Intraluminal Support (LVIS) stentassisted EVE for intracranial Dissecting Aneurysms (DAs). We conducted a retrospective study to identify patients with DAs who were treated with LVIS stent from July 2015 to September 2018. The DAs were categoried into ruptured and unruptured. The arteries harbouring the aneurysm were identified in all cases. LVIS device stent assisted coil EVE treatment modality was utilized to treat all the patients. Surgical safety, immediate surgery outcome, recurrence rate and imaging follow-up results of all patients were analysed. The Glasgow Outcome Scale (GOS) score of all patients where assessed during discharge. Cerebral angiography of all patients were reevaluated on scheduled visits from three months up to one year after their operations. A total of Six DA patients were identified during our analysis. Four of the cases were ruptured DAs while two cases were unruptured. The DAs originated from the Internal Carotid Artery (ICA) in two cases, while in the remaining four cases, the DAs originated from vertebral artery (VA). Stents and coils were successfully implanted in all six patients. The DAs were embolized satisfactorily and the parent arteries were patent immediately after the operations. We obsereved 5 points GOS score in four cases and 4 points in two cases. No aneurysmal recurrece, no stent collapse or displacement was obsereved in all cases during follow-ups. Our study suggests that, LVIS stent-assisted EVE is simple, safe and effective in the treatment of DAs.

Arterial dissection as a cause of intracranial stenosis: A narrative review

Intracranial artery dissection (IAD) is an underdiagnosed, non-atherosclerotic cause of stroke with various clinical manifestations. To identify all the potential studies investigating the epidemiology, risk factors, symptoms, radiology findings, and treatment methods of IAD, we conducted a literature search screening PubMed, SCOPUS, EMBASE, and BIREME. According to the results of several studies, IAD is the major cause of ischemic stroke in at least one-third of the cervical-cranial artery dissection (CCAD) cases presenting with ischemic stroke. Mechanical causes are associated with cervical artery dissections (CAD) in up to 40 % of the cases. However, the risk factors for IAD are still not completely understood. Antithrombotic therapy with either antiplatelet or classic anticoagulants is the mainstay of treatment for preventing further thromboembolic complication after a stroke. Endovascular or surgical treatment options can be considered when medical therapies are not effective or when there is a high rate of recurrence or increased risk of bleeding. The observational studies have shown that these methods are very effective in preventing recurrence and significantly improving morbidity and mortality in patients with ruptured dissections. Clinical trials are required to establish the best option for each mechanism of ischemic lesion.

Comparison of Endovascular Treatments of Ruptured Dissecting Aneurysms of the Intracranial Internal Carotid Artery and Vertebral Artery with a Review of the Literature

Objective

Subarachnoid hemorrhage (SAH) caused by rupture of an internal carotid artery (ICA) or vertebral artery (VA) dissecting aneuryesm is rare. Various treatment strategies have been used for ruptured intracranial dissections. The purpose of this study is to compare the clinical and angiographic characteristics and outcomes of endovascular treatment for ruptured dissecting aneurysms of the intracranial ICA and VA.

Methods

The authors retrospectively reviewed a series of patients with SAH caused by ruptured intracranial ICA and VA dissecting aneurysms from March 2009 to April 2014. The relevant demographic and angiographic data were collected, categorized and analyzed with respect to the outcome.

Results

Fifteen patients were identified (6 ICAs and 9 VAs). The percentage of patients showing unfavorable initial clinical condition and a history of hypertension was higher in the VA group. The initial aneurysm detection rate and the percentage of fusiform aneurysms were higher in the VA group. In the ICA group, all patients were treated with double stent-assisted coiling, and showed favorable outcomes. In the VA group, 2 patients were treated with double stent-assisted coiling and 7 with endovascular trapping. Two patients died and 1 patient developed severe disability.

Conclusion

Clinically, grave initial clinical condition and hypertension were more frequent in the VA group. Angiographically, bleb-like aneurysms were more frequent in the ICA group and fusiform aneurysms were more frequent in the VA group. Endovascular treatment of these aneurysms is feasible and the result is acceptable in most instances.