Operative and Endovascular Management of Extracranial Vertebral Artery Aneurysm in Ehlers-Danlos Syndrome: A Clinical Dilemma

Outcomes following surgical and endovascular treatment of extracranial vertebral artery aneurysms (VAA): a systematic evaluation of the literature

Extracranial vertebral artery aneurysms are rare complications resulting from trauma and multiple different diseases. However, the difference between clinical and surgical profiles is well understood. To investigate the clinical and interventional outcomes following extracranial vertebral artery aneurysms (VAA) treatment through a systematic review of the literature to date, an electronic database search for full-text English articles was conducted following PRISMA guidelines. The search yielded results on clinical and surgical outcomes for extracranial VAAs. These results included patient-specific risk factors, indications, and techniques. Our literature search resulted in 561 articles, of which 36 studies were qualified to be included in the analysis. A total of 55 patients with multiple various extracranial VAA incidents were included. The mean age of subjects was 42 years (ranging from 13.0 to 76.0 years), and the majority of patients were males (71%, n =39). Blunt trauma was the most frequent risk factor for extracranial VAA formation (35%, n = 19). The majority of aneurysms (60%) were dissected in nature. The most common form of treatment for extracranial VAAs was the use of a flow diverter (24%, n=13). Overall, five (9%) patients had long-term adverse neurological complications following intervention with 5% (n=3) mortality, 2% (n=1) resulting in unilateral vocal cord paralysis, and 2% (n=1) resulted in a positive Romberg sign. The mortality rate is 15.7% in the surgical group, whereas the endovascular treatment did not result in any mortality. The endovascular approach is a safe and effective treatment of extracranial VAAs due to its relatively low overall complication rate and lack of resulting mortality. This is in contrast to the surgical approach which results in a higher rate of complications, recurrence, and mortality outcomes. An understanding of the factors and clinical outcomes associated with the incidence of extracranial VAAs is essential for the future improvement of patient outcomes.

Neuroendovascular Procedures in Patients with Ehlers-Danlos Type IV: Multicenter Case Series and Systematic Review

BACKGROUND

Ehlers-Danlos type IV or vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder characterized by profound vascular fragility resulting from defective production of type III procollagen. Cerebrovascular diseases including spontaneous dissections, cerebral aneurysms, and cavernous carotid fistulae are common. Endovascular therapies in this patient population are known to be higher risk, although many studies (before 2000) involved older techniques and equipment. The purpose of this study is to investigate the safety and efficacy of modern neuroendovascular techniques in the treatment of cerebrovascular diseases in patients with vEDS.

METHODS

We combined a multi-institutional retrospective case series at 3 quaternary-care centers with a systematic literature review of individual case reports and case series spanning 2000-2021 to evaluate the safety and efficacy of neuroendovascular procedure in patients with vEDS with cerebrovascular diseases.

RESULTS

Fifty-nine patients who underwent 66 neuroendovascular procedures were evaluated. Most of the patients had direct cavernous carotid fistulas (DCCF). Neuroendovascular procedures had a 94% success rate, with a complication rate of 30% and a mortality of 7.5%.

CONCLUSIONS

Neuroendovascular procedures can be performed with a high rate of success in the treatment of cerebrovascular diseases in patients with vEDS, although special care is required because complication rates and mortality are high. Access site and procedure-related vascular injuries remain a significant hurdle in treating vEDS with cerebrovascular diseases, even with modern techniques.

External carotid artery-radial artery-vertebral artery bypass for surgical treatment of radiculopathy caused by an extracranial vertebral artery aneurysm: A case report and review of the literature

Background

Vertebral artery (VA) aneurysm is a rare etiology of cervical radiculopathy and there is a paucity of case reports described in the literature.

Case Description

We describe a case of a patient with no history of trauma presenting with a large right VA aneurysm at the C5-C6 level compressing the C6 nerve root and causing a painful radiculopathy. The patient underwent successful external carotid artery-radial artery-VA bypass followed by trapping of the aneurysm and decompression of the C6 nerve root.

Conclusion

VA bypass is an effective tool for treatment of symptomatic large extracranial VA aneurysms and a rare cause of radiculopathy.

Successful Endovascular Trapping for Symptomatic Thrombosed Giant Unruptured Aneurysms of the V1 and V2 Segments of the Vertebral Artery: Case Report and Literature Review

A thrombosed giant aneurysm of the V1 and V2 segments of the vertebral artery (VA) is rare. Therefore, there is controversy regarding its optimal treatment. A case of a symptomatic giant VA aneurysm located in the V1 to V2 segments on the left treated successfully by endovascular trapping of the VA is reported. A 68-year-old woman presented with swelling in the left anterior neck. Computed tomography angiography (CTA) showed a giant aneurysm measuring 47 × 58 × 47 mm³ in the left neck. Ten days after her first visit, she presented with sudden onset of left anterior neck pain. Repeated CTA showed a partial thrombus in the aneurysm. Angiography showed two thrombosed giant aneurysms located in the V1 to V2 segments of the left VA. After endovascular trapping for the aneurysms, the anterior neck pain resolved and the aneurysm gradually shrank. This case demonstrates that endovascular surgery is better than open surgery because it is less invasive. When performing endovascular treatment, trapping will be an alternative strategy for a symptomatic giant thrombotic aneurysm of the V1 and V2 segments of the VA if the patient can tolerate ischemia.

Stent-Graft Treatment of a Giant Asymptomatic Extracranial Vertebral Artery Aneurysm: Case Report and Literature Review

With the widespread appliance of endovascular techniques, a plethora of options is available in the treatment of extracranial vertebral artery aneurysms. If the vertebral artery can be sacrificed, embolization with coiling, liquid injection, or parent artery exclusion can be done. We hereby present a case of a 74-year-old male patient presenting with an asymptomatic atherosclerotic giant extracranial vertebral artery aneurysm in the V1 segment of the vertebral artery, successfully treated with balloon expandable stent-graft deployment. No neurologic symptoms occurred, and the stent-graft was patent with no signs of endoleak at 24 months follow-up with computed tomography angiography.

Endovascular Treatment of a Primary Extracranial Vertebral Artery Aneurysm Causing Ischemic Stroke

Background and Aims

Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; various surgical and endovascular treatment options are available.

Methods

We report a 44-year-old man with a symptomatic proximal extracranial vertebral artery aneurysm of unclear etiology. The patient presented with brainstem infarction, and the diagnosis of primary extracranial vertebral artery aneurysm was made by computed tomography angiography (CTA).

Results

This patient's aneurysm was definitively treated using an endovascular approach with placement of a covered stent in the right proximal vertebral artery.

Conclusion

Although aneurysms of this location are traditionally repaired with open aneurysmectomy, we show that endovascular treatment can be a safe and effective alternative approach. In the case reported here, primary extracranial vertebral artery aneurysm presenting with embolic stroke was successfully treated with a covered stent. Complete exclusion of the aneurysm from blood circulation is advisable to achieve full resolution of the embolic source.

Successful endovascular treatment for thrombosed giant aneurysm of the V1 segment of the vertebral artery: A case report

Thrombosed giant aneurysm of the V1 segment of the vertebral artery is rare, and there is controversy regarding the optimal method of treatment in this portion. Here, we report a thrombosed giant aneurysm of the V1 segment of the vertebral artery with a good clinical course with endovascular proximal artery occlusion of the vertebral artery. A 59-year-old woman presented with a large mass in the left side of the neck. Echographic examination revealed a mass measuring 42 × 38 × 48 mm in the left neck. Angiography showed a thrombosed giant aneurysm of the V1 segment of the left vertebral artery. Endovascular proximal artery occlusion of the vertebral artery was performed, and the aneurysm lessened gradually. Although a number of procedures have been developed to treat extracranial vertebral artery aneurysms, endovascular proximal artery occlusion is a good option to treat aneurysms in this portion.

Vertebral Artery Aneurysm Mimicking as Left Subclavian Artery Aneurysm in a Patient with Transforming Growth Factor Beta Receptor II Mutation

We report successful endovascular repair of a left vertebral artery aneurysm in a patient with transforming growth factor beta receptor II mutation. The patient was initially diagnosed with a left subclavian artery aneurysm on computed tomography angiography. The patient consented to publication of this report.

Giant vein graft aneurysm complicated by Loeys-Dietz syndrome

Loeys-Dietz syndrome (LDS) is a recently reported autosomal dominant aortic aneurysm syndrome with widespread systemic involvement. Although connective tissue diseases carry a theoretical risk of aneurysmal degeneration in vein grafts, there are no reports of vein graft aneurysm (VGA) in patients with connective tissue disease. We herein report the first case of a giant VGA that was manifested 5 years after the reconstruction of a popliteal artery aneurysm associated with LDS. A pathologic examination of the VGA revealed high proteoglycan deposition and medial degeneration of the diffuse type in the VGA; these findings conformed to LDS.

Bypass and embolization for a vertebral artery aneurysm in a patient with Marfan syndrome

Extracranial vertebral artery aneurysms represent an uncommon presentation of collagen vascular disease. We performed staged proximal embolization of large left vertebral artery aneurysm after distal common carotid-to-vertebral bypass at C2 in a young adult patient with Marfan syndrome and a hypoplastic contralateral vertebral artery. Dilation of the autogenous saphenous vein graft occurred at 1 year with proximal graft stenosis requiring operative revision. Subsequent dilation of the basilar artery led to symptoms of pontine compression at 18 months that have resolved at 31 months of follow-up.

A successful hybrid repair for vertebral arteriovenous fistula with extracranial vertebral artery aneurysm

A 40-year-old female presented with general fatigue. Echocardiography and computed tomography revealed a cervical vertebral arteriovenous fistula (VAF) with an extracranial vertebral artery aneurysm (VAA). She had closure of an atrial septal defect via right jugular vein catheterization at 5 years of age. Considering the anatomical location, a hybrid endovascular and surgical procedure was successfully performed to exclude both the VAF and VAA from the arterial circulation. This procedure may be considered an alternative to treat vertebral arterial pathology.

Acute brain ischemia as a complication of the Ehlers-Danlos syndrome, the case series

Vascular type of Ehlers-Danlos syndrome involves many severe complications leading not only to organ-specific symptoms but often ends in a sudden death. The aim of this paper was to present a diagnostic possibilities and its efficiency rate in patients with vascular complications of Ehlers-Danlos syndrome who suffered from artery dissection resulting in acute brain or limb ischemia. We analysed three patients with diagnosed Ehlers-Danlos syndrome who were referred to radiology department for diagnostic imaging of affected vascular beds, each experienced brain ischemia. The paper also aims at offering some general recommendations for patients suffering from possible complications of type IV Ehlers-Danlos syndrome basing on our own experience and available literature data.

Treatment of vascular Ehlers-Danlos syndrome: a systematic review

OBJECTIVE

To provide the collected evidence from all literature reports.

BACKGROUND

Vascular Ehlers-Danlos syndrome (EDS) is a rare connective tissue disorder with serious hemorrhagic consequences. Most experience on treatment is based on case reports and small case series.

METHOD

A systematic literature review was performed. PubMed and reference lists were scrutinized.

RESULTS

A total of 231 patients were identified with no gender preponderance. Aneurysms were present in 40%, often multiple. In 33%, there was an arterial rupture without an underlying aneurysm. Carotidocavernous fistula was seen in 18%. After open surgery the mortality was 30%; after endovascular procedures, it was 24%; in a group of miscellaneous cases, it was 60%; and the overall mortality was 39%. The median age of patients at death was 31 years. The median follow-up time was 12 months (5 days-7 years), but in 20% cases, it was not reported. In only 29 of the 119 recent patients (24%) the mutation was verified with molecular genetic testing.

CONCLUSIONS

Vascular EDS is a serious disorder with high mortality, which does not seem to have been influenced by new treatment methods. Invasive methods should be used only when necessary, primarily to save the patients' life. Whenever possible, the genetic molecular defect should be identified. The results of this review may be affected by publications bias. Ideally, a prospective registry should be created.

Endovascular treatment of a symptomatic extracranial vertebral artery aneurysm

Aneurysms of the extracranial vertebral artery are uncommon, with most cases attributed to penetrating head and neck trauma. We report a 29-year-old man with a symptomatic proximal extracranial vertebral artery aneurysm of unclear etiology. This patient's aneurysm was definitively treated after a successful balloon occlusion test of his affected vertebral artery. An endovascular approach was used combining coil embolization of the distal vertebral artery and a covered stent graft in the subclavian. Although aneurysms of this size and location are traditionally repaired with open aneurysmectomy, we show that endovascular approaches can be a safe and effective alternative.

Hereditary connective tissue diseases in young adult stroke: a comprehensive synthesis

Though the genetic background of ischaemic and haemorrhagic stroke is often polygenetic or multifactorial, it can in some cases result from a monogenic disease, particularly in young adults. Besides arteriopathies and metabolic disorders, several connective tissue diseases can present with stroke. While some of these diseases have been recognized for decades as causes of stroke, such as the vascular Ehlers-Danlos syndrome, others only recently came to attention as being involved in stroke pathogenesis, such as those related to Type IV collagen. This paper discusses each of these connective tissue disorders and their relation with stroke briefly, emphasizing the main clinical features which can lead to their diagnosis.

Fusiform aneurysm presenting with cervical radiculopathy in ehlers-danlos syndrome

Ehlers-Danlos syndrome (EDS) type IV is characterized by its clinical manifestations, which are easy bruising, thin skin with visible veins, and rupture of arteries, uterus, or intestines. Arterial complications are the leading cause of death in vascular EDS because they are unpredictable and surgical repair is difficult due to tissue fragility. The authors report a case presented with cervical radiculopathy due to a segmental fusiform aneurysm of the cervical vertebral artery. Transfemoral cerebral angiography (TFCA) was done to verify the aneurysmal dilatation. However, during TFCA, bleeding at the puncture site was not controlled, skin and underlying muscle was disrupted and profound bleeding occurred during manual compression after femoral catheter removal. Accordingly, surgical repair of the injured femoral artery was performed. At this time it was possible to diagnose it as an EDS with fusiform aneurysm on cervical vertebral artery. Particularly, cervical fusiform aneurysm is rare condition, and therefore, connective tissue disorder must be considered in such cases. If connective tissue disorder is suspected, the authors suggest that a noninvasive imaging modality, such as, high quality computed tomography angiography, be used to evaluate the vascular lesion to avoid potential arterial complications.

The vascular Ehlers-Danlos syndrome

Vascular Ehlers-Danlos syndrome (EDS) is a life-threatening inherited disorder of connective tissue causing severe arterial and gastrointestinal fragility and rupture, as well as complications of surgical and radiologic interventions. The diagnosis should be considered in patients under the age of 45 years who present with arterial tearing or dissection, colonic perforation, or visceral rupture. As for many orphan diseases, delayed diagnosis can lead to inaccurate care. Therefore, vascular EDS is particularly important to surgeons, radiologists, and obstetricians because knowledge of the diagnosis may help in the management of visceral complications. There are currently no specific treatments for this genetic condition, and medical intervention is limited to symptomatic treatment, precautionary measures, genetic counseling, and prenatal diagnosis. A clinical trial is ongoing to study the effectiveness of beta blockers with vasodilating properties in vascular EDS. Complications require hospitalization, observation in an intensive care unit, and sometimes emergency surgical intervention. CT, echography, and MRI are the most useful imaging modalities. Arteriography is contraindicated. Whenever possible, a wait-and-see attitude with close surveillance is preferable to unwarranted surgery. Surgical treatment carries a high mortality, whereas the mortality rate associated with endovascular treatment is unknown. To improve the likelihood of good surgical outcome, the surgeon must be informed of the patient's condition. The intent of surgery is to control hemorrhage if an artery, with or without aneurysm, has ruptured and to reconstruct the arterial vasculature. For vascular repair, simple procedures should be preferred, because more complex techniques can result in further injury and hemorrhage. Postoperative surveillance must be prolonged with close medical follow-up and serial CT scans. Pregnant women with vascular EDS should be considered high-risk cases and be provided special care.

More than one dilemma

We present an unusual case that highlights a number of management dilemmas: the cause, investigation and treatment of subarachnoid hemmorrhage in patients iwth vascular connective tissue diseases; the further investigation of small aneurysms identified on CT angiography; and the difficulties associated with anticoagulation, mechanical cardiac valves and cerebral hemorrhage.

Microsurgical anatomy of cerebral revascularization. Part II: Posterior circulation

Object. Revascularization is an important component of treatment for complex aneurysms, skull base tumors, and vertebrobasilar ischemia in the posterior circulation. In this study, the authors examined the microsurgical anatomy related to cerebral revascularization in the posterior circulation and demonstrate various procedures for bypass surgery.

Methods. The microsurgical anatomy of cerebral and cerebellar vessels as they relate to revascularization procedure and techniques, including extracranial-to-intracranial bypass grafting, arterial interposition grafting, and side-to-side anastomosis, were examined by performing stepwise dissections in 22 adult cadaveric specimens. The arteries and veins in the specimens were perfused with colored silicone.

Dominant cerebral and cerebellar revascularization procedures in the posterior circulations include superficial temporal artery (STA)—posterior cerebral artery (PCA), STA—superior cerebellar artery (SCA), occipital artery (OA)—anterior inferior cerebellar artery, OA—posterior inferior cerebellar artery (PICA), and PICA—PICA anastomoses. These procedures are effective in relatively small but critical areas including the brainstem and cerebellum. For revascularization of larger areas a saphenous vein graft is used to create a bypass between the PCA and the external carotid artery. Surgical procedures are generally difficult to perform in deep and narrow operative spaces near critical vital structures.

Conclusions. Although a clear guideline for cerebral revascularization procedures has not yet been established, it is important to understand various microsurgical techniques and their related anatomical structures. This will help surgeons consider surgical indications for treatment of patients with vertebrobasilar ischemia caused by aneurysms, tumors, or atherosclerotic diseases in the posterior circulation.

Endovascular Treatment of a Vertebral Artery Pseudoaneurysm Following Posterior C1?C2 Transarticular Screw Fixation

We present a case of vertebral artery pseudoaneurysm after a posterior C1-C2 transarticular screw fixation procedure that was effectively treated with endovascular coil occlusion. Vertebral artery pseudoaneurysm complicating posterior C1-C2 transarticular fixation is extremely rare, with only one previous case having been reported previously. Endovascular occlusion is better achieved in the subacute phase of the pseudoaneurysm, when the wall of the pseudoaneurysm has matured and stabilized. Further follow-up angiographies are mandatory in order to confirm that there is no recurrence of the lesion.