Surgical Management of Intracranial Artery Dissection

Intracranial artery dissection (IAD) is a relatively rare cause of stroke, but it has been recognized increasingly with recent advances of the neuroimaging technique. Since rebleeding occurs frequently in the acute stage in the ruptured IAD, urgent surgical treatment should be performed to prevent rebleeding. On the other hand, surgical treatment for unruptured IAD is controversial because it has little risk for bleeding. However, surgical treatment for unruptured IAD may be considered if the formation or enlargement of the aneurysmal dilatation has been confirmed. Since there are several proposed surgical strategies for IAD, it is important to select an appropriate strategy on a case-by-case basis. If the risk of infarction due to vessel occlusion is high, combined bypass surgery should be considered.

Endovascular Treatment of Ruptured Blister-Like Aneurysms: A Systematic Review and Meta-Analysis with Focus on Deconstructive versus Reconstructive and Flow-Diverter Treatments

BACKGROUND AND PURPOSE

Various endovascular techniques have been applied to treat blister-like aneurysms. We performed a systematic review to evaluate endovascular treatment for ruptured blister-like aneurysms.

MATERIALS AND METHODS

We performed a comprehensive literature search and subgroup analyses to compare deconstructive versus reconstructive techniques and flow diversion versus other reconstructive options.

RESULTS

Thirty-one studies with 265 procedures for ruptured blister-like aneurysms were included. Endovascular treatment was associated with a 72.8% (95% CI, 64.2%-81.5%) mid- to long-term occlusion rate and a 19.3% (95% CI, 13.6%-25.1%) retreatment rate. Mid- to long-term neurologic outcome was good in 76.2% (95% CI, 68.9%-8.4%) of patients. Two hundred forty procedures (90.6%) were reconstructive techniques (coiling, stent-assisted coiling, overlapped stent placement, flow diversion) and 25 treatments (9.4%) were deconstructive. Deconstructive techniques had higher rates of initial complete occlusion than reconstructive techniques (77.3% versus 33.0%, P = .0003) but a higher risk for perioperative stroke (29.1% versus 5.0%, P = .04). There was no difference in good mid- to long-term neurologic outcome between groups, with 76.2% for the reconstructive group versus 79.9% for the deconstructive group (P = .30). Of 240 reconstructive procedures, 62 (25.8%) involved flow-diverter stents, with higher rates of mid- to long-term complete occlusion than other reconstructive techniques (90.8% versus 67.9%, P = .03) and a lower rate of retreatment (6.6% versus 30.7%, P < .0001).

CONCLUSIONS

Endovascular treatment of ruptured blister-like aneurysms is associated with high rates of complete occlusion and good mid- to long-term neurologic outcomes in most patients. Deconstructive techniques are associated with higher occlusion rates but a higher risk of perioperative ischemic stroke. In the reconstructive group, flow diversion carries a higher level of complete occlusion and similar clinical outcomes.