Results of endovascular management for mid-basilar artery aneurysms

Analyzing the Safety and Efficacy of Flow-Diverting Stents in Pediatric Aneurysms: A Systematic Review

Ruptured intracranial aneurysms cause 50% of spontaneous subarachnoid hemorrhages in children, resulting in up to 65% mortality when left untreated. Although flow-diverting stents are especially suited to treat the fusiform and giant aneurysms more commonly found in children, the US Food and Drug Administration (FDA) has only approved their use in patients ≥22 years of age. Our objective was to assess the safety of flow-diverting stents in the treatment of pediatric patients with aneurysms through a systematic literature review using the PRISMA criteria. We used PubMed, Embase, and Web of Science to identify all published cases of pediatric aneurysms treated or retreated using flow-diverting stents from 2007 through 2019. Two independent researchers developed a consensus regarding the inclusion of all articles. Patient data were extracted from the identified articles and used to calculate the incidence rate of complications. From 1396 journal articles identified, 24 articles contained data on 37 pediatric patients that met the inclusion criteria. Of these 37 patients, 8 (21.6%) had a complication by last follow-up (death: 2; residual aneurysm: 2; parent artery occlusion: 4). This resulted in an incidence rate of 0.018 complications per patient at-risk month (95% CI 0.008-0.035). These data suggest that the use of flow-diverting stents for treatment of aneurysms in children may be safe and that FDA approval for this use should be evaluated. Although this analysis is comprised of case reports and case series, it represents the best attempt thus far to quantify the risk of using flow-diverting stents in children.

Posterior Fossa Craniectomy with Endovascular Therapy of Giant Fusiform Basilar Artery Aneurysms: A New Approach to Consider?

BACKGROUND

The prognosis of unruptured giant basilar artery (BA) aneurysms is very poor. No treatment has shown efficacy in survival. This pilot case-control study examines the overall survival (OS) benefit of combined surgical and endovascular management of giant BA aneurysms.

METHODS

Combined treatment including posterior fossa craniectomy followed by endovascular treatment was performed in 3 patients with giant BA aneurysms. OS of the 3 patients was compared with a control group of 6 patients (ratio 1:2) treated with the endovascular procedure only.

RESULTS

The mean survival time was 32.6 months in the craniectomy group (SD 9.01, 95% confidence interval [14.9, 50.3]) and 3.5 months in the control group (SD = 2.08, 95% confidence interval [0.001, 7.6]; Mantel-Cox test P < 0.04). At mean follow-up of 36.5 months (SD 10.2), 2 of 3 patients had a favorable outcome with a Glasgow Outcome Scale score of 5. Univariate analysis determined that women had a statistically higher OS than men (33.7 months vs. 3.058 months for men; log-rank test P = 0.011). A similar outcome was obtained in the presence of a circulating posterior communicating artery (P = 0.03) and in the presence of an endovascular right vertebral artery occlusion (P = 0.022).

CONCLUSIONS

Our study suggests that preventive posterior fossa craniectomy increases significantly OS of patients with giant BA aneurysms.

Natural history and management of basilar trunk artery aneurysms

BACKGROUND AND PURPOSE

Basilar trunk aneurysms (BTAs), defined as aneurysms distal to the basilar origin and proximal to the origin of the superior cerebellar artery, are rare and challenging to manage. We describe the natural history and management in a consecutive series of BTAs.

METHODS

Between 2000 and 2013, 2522 patients with 3238 aneurysms were referred to our institution for aneurysm management. A retrospective review of this database was conducted to identify all patients with BTAs.

RESULTS

In total, 52 patients had a BTA. Mean age was 56 (SD±18) years. Median clinical follow-up was 33 (interquartile range, 8-86) months, and imaging follow-up was 26 (interquartile range, 2-80.5) months. BTAs were classified into 4 causal subtypes: acute dissecting aneurysms, segmental fusiform ectasia, mural bleeding ectasia, and saccular aneurysms. Multiple aneurysms were more frequently noticed among the 13 saccular aneurysms when compared with overall population (P=0.021). There was preponderance of segmental ectasia or mural bleeding ectasia (P=0.045) in patients presenting with transit ischemic attack/stroke or mass effect. Six patients with segmental and 4 with mural bleeding ectasia demonstrated increasing size of their aneurysm, with 2 having subarachnoid hemorrhage caused by aneurysm rupture. None of the fusiform aneurysms that remained stable bled.

CONCLUSIONS

BTAs natural histories may differ depending on subtype of aneurysm. Saccular aneurysms likely represent an underlying predisposition to aneurysm development because more than half of these cases were associated with multiple intracranial aneurysms. Intervention should be considered in segmental ectasia and chronic dissecting aneurysms, which demonstrate increase in size over time as there is an increased risk of subarachnoid hemorrhage.

Combined endovascular and surgical treatment of fusiform aneurysms of the basilar artery: technical note

BACKGROUND

To present the combined treatment of fusiform basilar artery aneurysms consisting of a surgical posterior fossa decompressive craniectomy and ventriculoperitoneal (VP) shunt operation at the same sitting, before the endovascular procedure with telescopic stenting of the aneurysmatic vessel segment in four cases.

METHODS

Combined treatment involving surgical procedure consisting of ventriculoperitoneal shunt placement for hydrocephalus and an occipital bone craniectomy and C1 vertebrae posterior laminectomy to decompress the posterior fossa in the same session. After surgery, the patients were loaded with acetylsalicylic acid and clopidogrel, and then the endovascular treatment was performed.

RESULTS

All of the procedures were performed successfully without technical difficulty. The patients tolerated the procedures well and all cases showed remodelling with the overlapping stent technique. The patients were discharged home with baseline neurological situation and computed tomography (CT) angiography was performed at the 3rd month.

CONCLUSION

This technique is a safer endovascular approach to treating symptomatic fusiform basilar artery aneurysms by protecting patients from both the haemorrhagic complications of anticoagulant therapy and thrombotic complications due to the interruption of anticoagulant therapy, while treating the hydrocephalus and compression by surgical means.