Endovascular treatment of ruptured vertebral artery dissection in the acute stage

Clinical Characteristics of Cerebellar Infarction Due to Arterial Dissection

Objectives and Background:

Arterial dissection (AD) of the vertebral artery (VA) or its branches may cause ischemic stroke of the posterior circulation. However, clinical and radiological characteristics of patients with AD-related cerebellar infarction (CI) have rarely been reported.

Methods:

Forty-nine patients with CI admitted to our department from April 2008 to March 2015 were identified from our database. After dichotomization into the AD and non-AD group, their demographics and presenting symptoms were compared. Subsequently, a multivariate regression analysis was performed to identify variables that correlated with AD.

Results:

During the 7-year period, 14 and 35 patients were identified in the AD and non-AD group, respectively. The AD group was significantly younger than the non-AD group (55.0 ± 16.3 vs. 69.7 ± 10.7 years, P = 0.001) and was also more likely to experience acute pain at onset (86% vs. 17%, P < 0.001). Using a multivariate regression analysis, these two variables and the male sex were found to correlate with AD. AD was located in extracranial VA (n = 3); intracranial VA (n = 8); posterior inferior cerebellar artery (PICA) (n = 3); and superior cerebellar artery (n = 1). Identification of AD was delayed in one patient with an extracranial VA and one patient with a PICA dissection.

Conclusions:

AD was responsible for approximately 30% of CI in our cohort. Pain at onset may be a useful symptom to identify patients with AD-related CI. While intracranial VA was the most common location of AD, physicians should be aware of the possibility of extracranial VA or PICA dissection in patients with seemingly unremarkable radiological findings.

Treatment Strategies of Subarachnoid Hemorrhage from Bilateral Vertebral Artery Dissection: A Case Report and Literature Review Focusing on the Availability of Stent Placement

BACKGROUND

Bilateral vertebral artery dissection (VAD) may result in subarachnoid hemorrhage (SAH). However, a variety of factors contribute to the difficulties with treating SAH. We report a case of bilateral VAD with SAH, as well as a literature review.

CASE DESCRIPTION

A 32-year-old woman developed headache. Computed tomography demonstrated diffuse SAH, and 3-dimensional computed tomography indicated bilateral VAD. Her left vertebral artery was severely stenosed, and the basilar artery retrogradely flowed via the posterior communicating artery. Her bilateral VAD was trapped with the use of staged craniotomy. The postoperative course was uneventful for 13 days; however, severe neurologic deterioration remained in the area of the cerebral infarction, due to vasospasm of the internal carotid artery. This is the first report of hemorrhagic bilateral VAD treated with bilateral trapping and aggressive spasm treatment in the acute phase. However, the treatment was not successful.

CONCLUSIONS

Because of the increasing use of stent therapy, there has been a shift toward this treatment choice. For cases in which stents cannot be used, treatment methods based on prestenting protocols are helpful. A literature review indicated that conservative treatment for 2 weeks, in which vasospasm and rebleeding are controlled, may be considered compared with acute-stage stent treatment. Following our literature review, in situations in which stents cannot be used, only the ruptured side should be trapped with strict blood pressure control and detailed radiological images should be observed for 2 weeks. In conclusion, patient selection is essential to subject the patient to open surgery in such cases.

Stent-assisted coil embolisation for bilateral vertebral artery dissecting aneurysms presenting with subarachnoid haemorrhage

Bilateral dissecting aneurysms presenting with subarachnoid haemorrhage are rare. The treatment strategy for bilateral vertebral artery dissecting aneurysms is controversial because the contralateral vertebral artery is already dissected and can easily undergo enlargement or bleed after non-reconstructive treatment procedures such as trapping or proximal occlusion. Here, we report a case of bilateral vertebral artery dissecting aneurysm presenting with subarachnoid haemorrhage that was treated with stent-assisted coiling for the ruptured side. A 42-year-old man was admitted to our hospital with sudden headache (WFNS grade 1). Computed tomography showed a high-density region in the basal cistern and posterior fossa with more haemorrhage on the right side (Fisher group 3). Three-dimensional computed tomography and three-dimensional rotational angiography demonstrated a bilateral round protrusion on the vertebral arteries with a diameter of 5 mm just distal to the posterior inferior cerebellar artery. Stent-assisted coiling was performed for the ruptured right side and conservative therapy was selected for the contralateral side. The ruptured side was well embolised, and the contralateral side was stable over the 12-month follow-up period after treatment. The treatment strategy for bilateral vertebral artery dissecting aneurysms presenting with subarachnoid haemorrhage is different from that for unilateral vertebral artery dissecting aneurysms. Non-reconstructive treatment procedures such as trapping may cause contralateral enlargement or rupture; therefore, reconstructive treatment may be appropriate for the ruptured side.

Discrepancy between preoperative imaging and postoperative pathological finding of ruptured intracranial dissecting aneurysm, and its surgical treatment: case report

The choice of therapeutic strategy for intracranial dissecting aneurysm is often based on radiographic features, including characteristic geometry (e.g., irregular stenosis, segmental stenosis, aneurysm formation [pearl-and-string sign]), irregular fusiform or aneurysmal dilation, double lumen, and tapering occlusion. However, there is often a discrepancy between preoperative radiographic data and actual dissecting length. The present report describes three cases in which there was a discrepancy between preoperative radiographic data and actual dissecting length in patients undergoing direct trapping with or without revascularization. All three cases experienced good outcomes, but these cases underscore the fact that open surgery is a good option for management of ruptured intracranial dissecting aneurysms for determination of the rupture point, dissecting length, and the relationship between dissecting area and small arteries arising from the associated vessel.

Indications and practical application of strategies in the endovascular management of intracranial aneurysms

The occlusion of intracranial aneurysms is more successful and stable by properly planning the approach and application of endovascular techniques. The next step is a relentless analysis of the different indications of endovascular treatment, tailoring a strategy suitable for the specific case, and making more rational choices for the management of aneurysms. Indications and strategies according to the analysis of the aneurysmal complex are given, as well as pros and cons of the endovascular technique according to different anatomical locations

Subarachnoid haemorrhage with bilateral intracranial vertebral artery dissecting aneurysms treated by staged endovascular stenting

Bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid haemorrhage (SAH) are an exceedingly rare and deadly clinical dilemma. Prompt intervention in the case of unilateral VADAs is advocated to prevent rebleed; however, in the case of bilateral VADAs, the optimal therapeutic intervention is unclear. We describe the case of a patient presenting with SAH with bilateral VADAs treated by staged endovascular stenting. This led to resolution of the aneurysms with patency of both vertebral arteries. Stent-based therapy of the symptomatic aneurysm followed by staged stenting of the asymptomatic, contralateral aneurysm appears to be a viable treatment option. This method allows the ability to preserve flow in both vertebral arteries with minimal changes in flow characteristics that may threaten the contralateral, asymptomatic VADA, and appears to be the ideal treatment in these rare cases.

Endovascular treatment of bilateral intracranial vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage

BACKGROUND

Optimal management of bilateral vertebral artery dissecting aneurysms (bi-VDAs) causing subarachnoid hemorrhage (SAH) remains unclear.

OBJECTIVE

To investigate the treatment methods and outcomes of bi-VDA causing SAH.

METHODS

Seven patients were treated endovascularly for bi-VDA causing SAH. Treatment methods and outcomes were evaluated retrospectively.

RESULTS

Two patients were treated with 2 overlapping stents for both ruptured and unruptured VDAs, 2 with 2 overlapping stents and coiling for ruptured VDA and with conservative treatment for unruptured VDA, 1 with internal trapping (IT) for ruptured VDA and stent-assisted coiling for unruptured VDA, 1 with IT for ruptured VDA and 2 overlapping stents for unruptured VDA, and 1 with IT for ruptured VDA and a single stent for unruptured VDA. None had rebleeding during follow-up (range, 15-48 months). All patients had favorable outcomes (modified Rankin Scale score, 0-2). On follow-up angiography at 6 to 36 months, 9 treated and 2 untreated VDAs revealed stable or improved state, whereas 3 VDAs in 2 patients showed regrowth. Of the 3 recurring VDAs, 1 was initially treated with IT but recurred owing to retrograde flow to the ipsilateral posterior inferior cerebellar artery (PICA), the second was treated with single stent but enlarged, and the last was treated with 2 overlapping stents and coiling but recurred from the remnant sac harboring the PICA origin. All 3 recurred VDAs were retreated with coiling with or without stent insertion.

CONCLUSION

Bilateral VDAs presenting with SAH were safely treated with endovascular methods. However, endovascular treatment may be limited for VDAs with PICA origin involvement.

Overview of spontaneous cervicocephalic arterial dissection in Japan

Spontaneous cervicocephalic arterial dissection (SCAD) has been recognized as an uncommon cause of cerebral stroke. Although it has been viewed as an important cause of stroke, especially in juvenile cases, its natural course and pathophysiology have yet to be fully clarified, and no treatment criteria have been established. Recent studies have suggested that clinical features of SCAD in Japan are different from those in European countries. Herein, we reviewed the current status of the management of SCAD in Japan, and clarified its clinical characteristics to establish an appropriate treatment.

Use of the sole stenting technique for the management of aneurysms in the posterior circulation in a prospective series of 20 patients

Object

The use of intracranial stents in stent-assisted coil embolization is now a current neurosurgical practice worldwide. The clinical utility of these stents in the sole stenting (SS) technique, however, has not been thoroughly described, and the published reports of this experience are scarce. This study was designed to evaluate SS treatment of dissecting and nondissecting aneurysms of the posterior circulation.

Methods

This prospective and descriptive study was conducted in 20 consecutive patients who harbored single aneurysms of the posterior circulation and who were treated using the SS approach in the last 3 years. The clinical and radiological assessment and follow-up of the patients were evaluated using the modified Rankin scale as well as with computed tomography angiography and digital subtraction angiography at discharge and at 1, 3, 6, and 12 months.

Results

Eleven of the 20 patients had subarachnoid hemorrhages, 3 presented with ischemia, 1 presented with brainstem compression, and the remaining 5 patients had incidentally discovered, asymptomatic lesions. Only 1 patient had a complication (occipital infarction) attributable to the SS procedure. One patient died of rebleeding 2 weeks after the procedure. At 1 month, 40% of the patients had a subtotal or total occlusion, which increased to 55% at 3 months and 85% at 6 months, with a final subtotal or total occlusion rate of 80% at 1 year. The SS procedure in 1 case was considered a failure at 6 months because no change had been noted since the 1-month follow-up. One case showed partial occlusion and 1 case showed recanalization.

Conclusions

Use of SS for aneurysms in the posterior circulation complex is a safe and effective technique, demonstrating an occlusion rate of 80% at the 1-year follow up.

Dissection of the V4 segment of the vertebral artery: clinicoradiologic manifestations and endovascular treatment

Intracranial vertebral artery (VA) dissection has three clinical presentations: ischemia, hemorrhage, and mass effect. Imaging findings of intracranial VA dissections vary according to clinical presentation. Irregular stenosis or occlusion of the VA is the most common finding in patients with posterior fossa infarction, whereas a dissecting aneurysm is the main feature in those with acute subarachnoid hemorrhage. A chronic, giant, dissecting aneurysm can cause mass effect on the brain stem or cranial nerves, as well as distal embolism. Magnetic resonance imaging is useful for detection of intramural hematomas and intimal flaps, both of which are diagnostic of VA dissection. Multidetector computed tomography angiography is increasingly used for diagnosis of VA dissection. Catheter angiography is still beneficial for evaluation of precise endoluminal morphology of the dissection before surgical or endovascular intervention. Endovascular treatment is now considered a major therapeutic option for patients with a ruptured dissecting aneurysm or a chronic dissecting aneurysm. Anticoagulation therapy is currently considered the initial treatment of choice in patients with posterior circulation ischemic symptoms. Endovascular treatment, such as stent-assisted angioplasty or coil occlusion at the dissection site, can be performed in selected patients with posterior fossa ischemic symptoms.