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Wang X, Tong X, Liu J, Shi M, Shang Y, Wang H. Petrous Carotid to Upper Posterior Circulation Bypass for the Treatment of Basilar Trunk Aneurysm: A Novel High-Flow Intracranial-Intracranial Skull Base Bypass for Posterior Circulation. Oper Neurosurg (Hagerstown) 2023; 24:301-309. [PMID: 36729820 DOI: 10.1227/ons.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/11/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Basilar trunk aneurysms are the most surgically challenging, and the spectrum covers small fusiform to dolichoectatic aneurysms and may lead to rupture, brain ischemia, or direct brainstem compression. The current strategy remains cerebral revascularization coupled with aneurysm trapping. Available bypass options for upper posterior circulation (UPC) are based on (1) different flow volumes from diverse blood supplies and (2) distinct modulation purposes for cerebral revascularization; however, the potential compromise of eloquent perforators of the basilar trunk and the occurrence of fatal brainstem infarcts remain unacceptable. OBJECTIVE To innovate a high-flow intracranial-intracranial skull base bypass for posterior circulation to afford robust retrograde flow and shorten the graft length. METHODS We retrospectively reviewed our experience in the treatment of a patient with basilar trunk aneurysm and reported a novel bypass alternative supplied by petrous internal carotid artery to augment blood flow to the UPC by a pretemporal approach. RESULTS The postoperative course was uneventful, and there was no pons or midbrain ischemia or other complications. Postoperative computed tomography angiogram revealed the patency of bypass. There was no further development or rerupture observed during follow-up. CONCLUSION Petrous internal carotid artery as a donor site is a reliable bypass modality for UPC. This approach provides the utmost retrograde flow to alleviate the development of dissecting aneurysms, preserves eloquent perforators of the basilar trunk, maintains bypass patency, and shortens the graft course. Therefore, this novel therapeutic alternative could be beneficial for improving the prognosis of basilar trunk aneurysms.
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Affiliation(s)
- Xuan Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| | - Xiaoguang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| | - Jie Liu
- Department of Neurosurgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Minggang Shi
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Yanguo Shang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Hu Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
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2
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Sato Y, Niizuma K, Ota H, Endo H, Tominaga T. Basilar artery dissection with rupture 6 years after accidental detection: A case report. Surg Neurol Int 2021; 12:4. [PMID: 33500819 PMCID: PMC7827296 DOI: 10.25259/sni_735_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/15/2020] [Indexed: 11/21/2022] Open
Abstract
Background: Chronic basilar artery dissection (BAD) is a rare pathology, and only a few reports have been mentioned in the literature. The imaging features of chronic BAD, especially those that develop into a subarachnoid hemorrhage (SAH), are unknown. Case Description: We report a unique case of a chronic BAD with a split intimal flap that developed into an SAH. A 74-year-old man was diagnosed with BAD. After considering all treatment options, conservative treatment was selected for the patient. We continued imaging follow-up of the patient in our outpatient clinic once a year. The BA gradually dilated and the internal flap split. The patient and his family refused surgical treatment; therefore, conservative treatment was continued. Six years and 2 months from the first diagnosis, he developed a massive SAH and died. Conclusion: In the case of this patient, the weakened condition of the internal elastic lamina may have caused dissection of the intimal flap between the intima and media. Furthermore, the dissection may have developed and connected the true lumen to the pseudolumen and induced BA rupture. Thereby, split of the internal flap could be a risk factor for rupture in chronic BAD.
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Affiliation(s)
- Yoshimichi Sato
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Tohoku University, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Tohoku University, Japan.,Department of Neurosurgical Engineering and Translational Neuroscience, Graduate School of Biomedical Engineering, Tohoku University, Japan.,Department of Neurosurgical Engineering and Translational Neuroscience, Tohoku University Graduate School of Medicine, Japan
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Tohoku University, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Tohoku University, Japan
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3
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Hirano Y, Ono H, Inoue T, Aono T, Tanishima T, Tamura A, Saito I. Superficial temporal artery-superior cerebellar artery bypass and proximal occlusion through anterior petrosal approach for subarachnoid hemorrhage due to basilar artery dissection. Surg Neurol Int 2020; 11:256. [PMID: 33024594 PMCID: PMC7533090 DOI: 10.25259/sni_402_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/05/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Subarachnoid hemorrhage (SAH) due to rupture of basilar artery dissection (BAD) is extremely rare and often has a poor prognosis. Since ruptured BAD has high rate of rebleeding and mortality, treatment to prevent rerupture is mandatory in the acute phase. However, to date, no optimal treatment has been established which satisfies secure prevention of rerupture and ischemia simultaneously. Herein, we report a case of SAH due to BAD treated with proximal occlusion of basilar artery with superficial temporal artery (STA)-superior cerebellar artery (SCA) bypass, preventing rebleeding securely and ensuring adequate blood flow in the upper basilar region. Case Description: A 48-year-old male presenting with headache and altered mental status was found to have SAH and BAD. To prevent rerupture, proximal occlusion of basilar artery with STA-SCA bypass using anterior transpetrosal approach was performed. The postoperative course was relatively good and there is no evidence of recurrent arterial dissection. Conclusion: Proximal occlusion of the basilar artery combined with STA-SCA bypass was successful in preventing rerupture of BAD and ensuring blood flow in the upper basilar region. Although there is controversy regarding acute treatment for ruptured BAD, direct proximal occlusion with sufficient revascularization using bypass skull base technique may be one of the optimal treatments even in this era of endovascular treatment.
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Affiliation(s)
- Yudai Hirano
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Higashigotanda, Tokyo, Japan
| | - Toshiya Aono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Takeo Tanishima
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Akira Tamura
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Isamu Saito
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
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4
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Sonobe S, Yoshida M, Niizuma K, Tominaga T. Ruptured Basilar Artery Dissection Diagnosed Using Magnetic Resonance Vessel Wall Imaging and Treated with Coil Embolization with Overlapping LVIS Stents: A Case Report. NMC Case Rep J 2020; 7:75-79. [PMID: 32322456 PMCID: PMC7162815 DOI: 10.2176/nmccrj.cr.2019-0141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/28/2019] [Indexed: 11/20/2022] Open
Abstract
The diagnosis and treatment of patients with ruptured basilar artery dissection (rBAD) are often difficult. We present a case of rBAD diagnosed with magnetic resonance vessel wall imaging (MR-VWI) and treated with coil embolization with overlapping low-profile visualized intraluminal support (LVIS) stents. The case is of a 49-year-old woman with subarachnoid hemorrhage. digital subtraction angiography (DSA) showed irregularity in an anterior wall of the middle portion of the basilar artery, indicating the presence of a false lumen. MR-VWI showed local enhancement in an arterial wall, which was consistent with the wall irregularity observed in DSA. Overlapping stents (two LVIS stents) was performed in the basilar artery and coils were placed in the false lumen. The false lumen was completely thrombosed, and anterograde blood flow of the basilar artery was preserved. Dual antiplatelet therapy was administered, and the patient underwent an uneventful postoperative course. DSA performed 6 months later showed a white-collar sign. MR-VWI has attracted attention as a useful modality for detecting a ruptured lesion in patients with subarachnoid hemorrhage. This is the first report, to the best of our knowledge, describing the practical use of MR-VWI for rBAD. MR-VWI is suggested to improve diagnostic accuracy for rBAD. There are no established treatments for rBAD; reconstructive endovascular treatments comprising stent placement and coil embolization of a false lumen are promising. The LVIS stent has a braided design and high metal coverage ratio and is considered to be reasonable for use in rBAD. Coil embolization of a false lumen with overlapping LVIS stents may be effective for rBAD.
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Affiliation(s)
- Shinya Sonobe
- Department of Neurosurgery, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Masahiro Yoshida
- Department of Neurosurgery, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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5
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Patra DP, Krishna C, Turkmani A, Abi-Aad KR, Welz ME, Bendok BR. Letter: Management of a Previously Coiled Anterior Cerebral Artery Aneurysm in a Child: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 17:E93-E94. [PMID: 31250906 DOI: 10.1093/ons/opz144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Devi P Patra
- Department of Neurological Surgery Mayo Clinic Phoenix, Arizona.,Precision Neuro-Therapeutics Innovation Lab Mayo Clinic Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab Mayo Clinic Phoenix, Arizona
| | - Chandan Krishna
- Department of Neurological Surgery Mayo Clinic Phoenix, Arizona.,Precision Neuro-Therapeutics Innovation Lab Mayo Clinic Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab Mayo Clinic Phoenix, Arizona
| | - Ali Turkmani
- Department of Neurological Surgery Mayo Clinic Phoenix, Arizona
| | - Karl R Abi-Aad
- Department of Neurological Surgery Mayo Clinic Phoenix, Arizona.,Precision Neuro-Therapeutics Innovation Lab Mayo Clinic Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab Mayo Clinic Phoenix, Arizona
| | - Matthew E Welz
- Department of Neurological Surgery Mayo Clinic Phoenix, Arizona.,Precision Neuro-Therapeutics Innovation Lab Mayo Clinic Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab Mayo Clinic Phoenix, Arizona
| | - Bernard R Bendok
- Department of Neurological Surgery Mayo Clinic Phoenix, Arizona.,Precision Neuro-Therapeutics Innovation Lab Mayo Clinic Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab Mayo Clinic Phoenix, Arizona.,Department of Otolaryngology Mayo Clinic Phoenix, Arizona.,Department of Radiology Mayo Clinic Phoenix, Arizona
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6
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State-of-art in surgical treatment of dissecting posterior circulation intracranial aneurysms. Neurosurg Rev 2016; 41:31-45. [PMID: 27215913 DOI: 10.1007/s10143-016-0749-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/17/2016] [Accepted: 04/09/2016] [Indexed: 11/27/2022]
Abstract
Vertebrobasilar (VB) intracranial dissecting aneurysms (IDAs) pose difficult therapeutic issues and are especially among the most difficult to manage surgically. There are, however, some cases where selective aneurysm obliteration by endovascular approach is impossible or is associated with an unacceptable risk of morbidity. This is particularly true when the aneurysm is dissecting, giant, or has a large neck. In such cases, surgical treatment may be the only alternative. Optimal management of these lesions is therefore challenging and treatment decisions have to be made on a case-by-case basis. Ideal treatment should be a complete surgical excision of the lesion; however, this procedure might only be possible after distal and proximal vessel wall occlusion which might not be tolerated by the patient depending on the location of the aneurysm. Therefore, formulation of recommendations concerning the surgical strategy remains still difficult due to inconsistency of surgical outcomes. The literature describing surgical strategy of VB IDAs is varying in quality and content, and many studies deal with only a few patients. In the presented review, the authors summarize the current knowledge on the incidence, pathogenesis, clinical presentation, and diagnostic procedures with special emphasis on surgical treatment of IDAs in posterior circulation.
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7
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Saliou G, Power S, Krings T. Flow diverter placement for management of dissecting ruptured aneurysm in a non-fused basilar artery. Interv Neuroradiol 2015; 22:58-61. [PMID: 26628453 DOI: 10.1177/1591019915617324] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/01/2015] [Indexed: 12/25/2022] Open
Abstract
Intracranial vertebral artery dissection can be associated with subarachnoid hemorrhage (SAH) and pseudoaneurysm formation. Dissecting aneurysms have a high risk of rebleeding in the acute phase. To our knowledge, the management of an acute vertebrobasilar junction dissecting aneurysm associated with a basilar non-fusion has not been previously reported. We report here a case of SAH due to rupture of a dissecting aneurysm involving the vertebrobasilar junction and extending to involve the right limb and proximal junction of a non-fused basilar artery, managed by insertion of a flow-diverting stent with excellent clinical outcome and long-term patency of the flow diverter.
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Affiliation(s)
| | - Sarah Power
- Neuroradiology, Toronto Western Hospital & University Health Network, Canada
| | - Timo Krings
- Neuroradiology, Toronto Western Hospital & University Health Network, Canada
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8
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Nakajima H, Ishiguro T, Komiyama M. Basilar Artery Dissection Presenting with Subarachnoid Hemorrhage: Report of Two Cases. NMC Case Rep J 2015; 2:97-100. [PMID: 28663975 PMCID: PMC5364892 DOI: 10.2176/nmccrj.2014-0450] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/01/2015] [Indexed: 12/25/2022] Open
Abstract
Basilar artery dissection (BAD) presenting with subarachnoid hemorrhage (SAH) is life-threatening, but its treatment has not been established yet. We treated two patients with ruptured BAD. They were 40-year-old and 41-year-old women. Both of them were treated conservatively during the acute stage. In one patient, radiological abnormality of BAD improved spontaneously. In another patient, reconstructive endovascular treatment (stent with coiling) was required in the chronic stage because the lesion deteriorated morphologically. Neither of them suffered from rebleeding and both had favorable outcome. We reported two patients with ruptured BAD treated conservatively during the acute stage and their outcomes were favorable. We reviewed the literature of BAD presenting with SAH and discussed the management for these lesions.
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Affiliation(s)
- Hideki Nakajima
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Osaka
| | - Tomoya Ishiguro
- Department of Neurointervention, Osaka City General Hospital, Osaka, Osaka
| | - Masaki Komiyama
- Department of Neurointervention, Osaka City General Hospital, Osaka, Osaka
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9
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Li H, Zhang X, Li XF, He XY, Zhu GH, Fang QR, Wang ZQ, Duan CZ. Predictors of Favorable Outcome of Intracranial Basilar Dissecting Aneurysm. J Stroke Cerebrovasc Dis 2015; 24:1951-6. [PMID: 26082343 DOI: 10.1016/j.jstrokecerebrovasdis.2015.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 05/08/2015] [Accepted: 05/13/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Management of intracranial basilar dissecting aneurysms has been controversial and challenging, and surgical and conservative treatments usually have a bad prognosis. Our study aimed at evaluating the outcomes of endovascular treatment for these lesions and exploring the predictors of favorable outcome. METHODS We retrospectively reviewed 50 consecutive patients with basilar dissecting aneurysms from January 2006 to January 2013. Twenty-four patients underwent stent-assisted coiling whereas 26 patients underwent conservative treatment. Follow-up outcomes were evaluated using modified Rankin Scale (mRS) score. RESULTS Of the patients treated with stent-assisted coiling, 20 patients had a favorable outcome (mRS score, 0-1), post-treatment recurrence occurred in 3 patients, 1 had rebleeding, and 2 had no rebleeding. Of the patients treated with conservative therapy (observation or anticoagulation), 10 patients had an unfavorable outcome, 2 patients with ruptured aneurysms developed rebleeding, and 8 patients had poor outcome because of infarct progression. Stent-assisted coiling group had a more favorable outcome than the conservatively treated group (83.3% versus 55.2%, P = .019). Initial complete obliteration was related to the favorable outcome in endovascular-treated group (P = .042). Stent placement was the only independent predictor of favorable outcome in the logistic regression analysis (P = .030; odds ratio = 5.828; 95% confidence interval, 1.192-28.503). CONCLUSIONS Patients with basilar artery dissecting aneurysms treated with stent-assisted coiling had a more favorable outcome than the conservatively treated patients. Stent placement and initial complete occlusion were the favorable factors in patients with basilar dissecting aneurysm.
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Affiliation(s)
- Hui Li
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, Guangzhou, Guangdong, China
| | - Xin Zhang
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, Guangzhou, Guangdong, China
| | - Xi-Feng Li
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, Guangzhou, Guangdong, China
| | - Xu-Ying He
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, Guangzhou, Guangdong, China
| | - Guo-Hui Zhu
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, Guangzhou, Guangdong, China
| | - Qin-Rui Fang
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, Guangzhou, Guangdong, China
| | - Ze-Qun Wang
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, Guangzhou, Guangdong, China
| | - Chuan-Zhi Duan
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, Guangzhou, Guangdong, China.
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10
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Cui QK, Liu WD, Liu P, Li XY, Zhang LQ, Ma LJ, Ren YF, Wu YP, Wang ZG. Arterial occlusion to treat basilar artery dissecting aneurysm. Neurol Neurochir Pol 2015; 49:99-106. [PMID: 25890924 DOI: 10.1016/j.pjnns.2015.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 01/22/2015] [Accepted: 02/23/2015] [Indexed: 11/27/2022]
Abstract
OBJECT To explore the clinical feasibility of employing occlusion to treat basilar artery dissecting aneurysm. METHODS One patient, male and 46 years old, suffered transient numbness and weakness on the right limbs. Cerebral angiography indicated basilar artery dissecting aneurysm. The patient underwent the stent-assisted coil embolization of aneurysm and the result is satisfactory. Digital subtraction angiography (DSA) reviews were performed at 1 month and 4.5 months, respectively after the operation and indicate that the basilar artery is unobstructed and there was no recurrence of the aneurysm. DSA review 1 year after the first treatment indicates the aneurysm recurrence, stent-assisted coils dense embolization of aneurysm was performed again and the result was satisfactory. Ten months after the second operation, DSA review found the basilar artery aneurysm recurrence again and occlusion of the basilar artery was performed. RESULTS The basilar artery occlusion was effective. The bilateral posterior inferior cerebellar arteries and the bilateral posterior cerebral arteries are unobstructed. Five months of follow-up found that the patient recovered well. DSA reviews performed 5 months after occlusion indicate no recurrence of the aneurysm. CONCLUSIONS Occlusion to treat basilar artery dissecting aneurysm is clinically feasible, but surgical indications should be considered strictly.
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Affiliation(s)
- Qing Ke Cui
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, PR China; Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, PR China.
| | - Wei Dong Liu
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, PR China.
| | - Peng Liu
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, PR China.
| | - Xue Yuan Li
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, PR China.
| | - Lian Qun Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, PR China.
| | - Long Jia Ma
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, PR China.
| | - Yun Fei Ren
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, PR China.
| | - Ya Ping Wu
- Zhong Yuan Academy of Biological Medicine, Liaocheng College of Medicine, Liaocheng University, Liaocheng People Hospital, Liaocheng, PR China; Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Zhi Gang Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, PR China.
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11
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Fu C, Zhao C, Zhao H, Li D, Yu W. Growing dissecting aneurysm of basilar trunk treated with stent-assisted coiling. J Stroke Cerebrovasc Dis 2014; 24:e5-9. [PMID: 25270634 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 07/04/2014] [Accepted: 07/28/2014] [Indexed: 11/20/2022] Open
Abstract
Growing basilar dissecting aneurysm is a scarce but increasingly recognized entity, accounting for a significant risk of death and disability. Controversy exists regarding the optimal management. A 61-year-old man presented with dysarthria and left hemiparesis attributable to a basilar trunk dissecting aneurysm. Antiplatelet therapy was instituted, and the patient's clinical condition markedly improved. However, he developed severe headache, dysarthria, and left hemiparesis 35 days later. Angiography revealed significant enlargement of the aneurysm, and stent-assisted coiling was then uneventfully performed. The patient remained clinically stable with only mild left-sided hemiparesis at the 2-year clinical follow-up.
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Affiliation(s)
- Chao Fu
- Department of Neurosurgery, The Third Bethune Hospital (China-Japan Union Hospital), Norman Bethune Health Science Center of Jilin University, Changchun, Jilin Province, People's Republic of China
| | - Conghai Zhao
- Department of Neurosurgery, The Third Bethune Hospital (China-Japan Union Hospital), Norman Bethune Health Science Center of Jilin University, Changchun, Jilin Province, People's Republic of China
| | - Hang Zhao
- Department of Neurosurgery, The Third Bethune Hospital (China-Japan Union Hospital), Norman Bethune Health Science Center of Jilin University, Changchun, Jilin Province, People's Republic of China
| | - Dongyuan Li
- Department of Neurosurgery, The Third Bethune Hospital (China-Japan Union Hospital), Norman Bethune Health Science Center of Jilin University, Changchun, Jilin Province, People's Republic of China
| | - Weidong Yu
- Department of Neurosurgery, The Third Bethune Hospital (China-Japan Union Hospital), Norman Bethune Health Science Center of Jilin University, Changchun, Jilin Province, People's Republic of China.
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12
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Nakajima H, Ishiguro T, Komiyama M. Basilar Artery Dissection Presenting with Subarachnoid Hemorrhage: Report of Two Cases. NMC Case Rep J 2014. [DOI: 10.2176/nmccrj.cr.2014-0450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
| | - Tomoya Ishiguro
- Departments of Neurointervention, Osaka City General Hospital
| | - Masaki Komiyama
- Departments of Neurointervention, Osaka City General Hospital
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13
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Endovascular Treatment for the Basilar Artery Dissection. Cardiovasc Intervent Radiol 2013; 37:646-56. [DOI: 10.1007/s00270-013-0737-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 08/20/2013] [Indexed: 12/19/2022]
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14
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He K, Zhu W, Chen L, Mao Y. Management of distal choroidal artery aneurysms in patients with moyamoya disease: report of three cases and review of the literature. World J Surg Oncol 2013; 11:187. [PMID: 23938115 PMCID: PMC3765104 DOI: 10.1186/1477-7819-11-187] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 07/26/2013] [Indexed: 11/21/2022] Open
Abstract
Prevention of rebleeding plays an important role in the treatment of hemorrhagic moyamoya disease, because rebleeding results in high mortality and morbidity. We discuss possible treatment for patients with moyamoya disease accompanied with distal choroidal artery aneurysms and review the literature to summarize clinical treatment and mechanisms. The cases of three male patients who suffered from intraventricular hemorrhage are presented. Computed tomography (CT) and digital subtractive angiography (DSA) revealed that bleeding was believed to be caused by ruptured aneurysms originating from distal choroidal artery aneurysms. Two patients successfully underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) and the obliteration of the aneurysm. The follow-up DSA or CT scan demonstrated that the aneurysms completely disappeared with the patency of the reconstructed artery. Neither of the patients experienced rebleeding during the follow-up period (up to 34 months). Given conservative treatment, the third patient experienced recurrent hemorrhages 4 months after the first ictus. This study describes treatment for moyamoya disease accompanied with distal choroidal artery aneurysms. Our experience suggests that cerebral revascularization combined with obliteration of the complicated distal aneurysm in the same session is a possible treatment.
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Affiliation(s)
- Kangmin He
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China
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15
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Cook DJ, Mukerji N, Steinberg GK. Clip reconstruction of midbasilar aneurysms. World Neurosurg 2012; 79:675-7. [PMID: 23111225 DOI: 10.1016/j.wneu.2012.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 10/23/2012] [Indexed: 10/27/2022]
Affiliation(s)
- D J Cook
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
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16
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Defillo A, Nussbaum ES, Zelensky A, Nussbaum L. Multiple non-branching dissecting aneurysms of the mid-basilar trunk presenting with sequential subarachnoid hemorrhages. Surg Neurol Int 2011; 2:127. [PMID: 22059122 PMCID: PMC3205486 DOI: 10.4103/2152-7806.85059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 08/22/2011] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE We describe a rare case of a patient with subarachnoid hemorrhage (SAH) due to a ventral dissecting mid-basilar aneurysm that was treated surgically. One week after surgery, the patient experienced sudden deterioration due to a new SAH caused by the development of a new aneurysm of the basilar trunk distinct from the previously clipped aneurysm. CASE DESCRIPTION A 54-year-old woman with acute subarachnoid hemorrhage was found to have a small, broad-based aneurysm arising from the ventral aspect of the mid-basilar artery. This complicated lesion was treated with a microsurgical clipping via a translabyrinthine pre-sigmoidal sub-temporal approach. One week postoperatively, the patient suffered a new SAH and was found to have developed a distinct basilar artery aneurysm. The patient was returned to the Operating Room for microsurgical clipping via the previous craniotomy. After surgery, the patient made a slow, but steady, recovery. She underwent repeated angiographic imaging, demonstrating a stable appearance. Two years post surgery, the patient had returned to work and had no obvious neurological deficit, with the exception of unilateral iatrogenic hearing loss. CONCLUSION We describe a rare case of multiple aneurysms originating in relation to a mid-basilar dissection, resulting in multiple episodes of SAH. These are difficult and dangerous lesions that can be treated with open microsurgical reconstruction or possibly via an endovascular approach. The intricate location of the lesions poses a particular challenge to neurosurgeons attempting to directly treat mid-basilar lesions.
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Affiliation(s)
- Archie Defillo
- Department of Neurosurgery, National Brain Aneurysm Center, Health East St. Joseph's Hospital, St. Paul, MN 55102, USA
| | - Eric S. Nussbaum
- Department of Neurosurgery, National Brain Aneurysm Center, Health East St. Joseph's Hospital, St. Paul, MN 55102, USA
| | - Andrea Zelensky
- Department of Neurosurgery, National Brain Aneurysm Center, Health East St. Joseph's Hospital, St. Paul, MN 55102, USA
| | - Leslie Nussbaum
- Department of Neurosurgery, National Brain Aneurysm Center, Health East St. Joseph's Hospital, St. Paul, MN 55102, USA
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Kim BM, Suh SH, Park SI, Shin YS, Chung EC, Lee MH, Kim EJ, Koh JS, Kang HS, Roh HG, Won YS, Chung PW, Kim YB, Suh BC. Management and clinical outcome of acute basilar artery dissection. AJNR Am J Neuroradiol 2008; 29:1937-41. [PMID: 18687744 DOI: 10.3174/ajnr.a1243] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE There have been inconsistencies on the prognosis and controversies as to the proper management of acute basilar artery dissection. The aim of this study was to evaluate acute basilar artery dissection and its outcome after management. MATERIALS AND METHODS A total of 21 patients (mean age, 53 years; range, 24-78 years) with acute basilar artery dissection were identified between January 2001 and October 2007. Clinical presentation, management, and outcomes were retrospectively evaluated. RESULTS The patients presented with subarachnoid hemorrhage (n = 10), brain stem ischemia (n = 10), or stem compression sign (n = 1). Ruptured basilar artery dissections were treated by stent placement with coiling (n = 4), single stent placement (n = 3), or conservatively (n = 3). Of the patients treated with endovascular technique, 6 had favorable outcome (modified Rankin scale [mRS], 0-2) and the remaining patient, who was treated by single stent placement, died from rebleeding. All 3 conservatively managed patients experienced rebleeding, of whom 2 died and the other was moderately disabled. Unruptured basilar artery dissections were treated conservatively (n = 7) or by stent placement (n = 4). Of the patients with unruptured basilar artery dissection, 9 had favorable outcome and the remaining 2 patients, both of whom were conservatively managed, had poor outcome because of infarct progression. The group with the ruptured basilar artery dissection revealed a higher mortality rate than the group with the unruptured dissection (30% vs 0%). The group treated with endovascular means revealed more favorable outcome than the group that was treated with conservative measures (90.9% vs 50%). CONCLUSION The ruptured basilar artery dissections were at high risk for rebleeding, resulting in a grave outcome. Stent placement with or without coiling may be considered to prevent rebleeding in ruptured basilar dissections and judiciously considered in unruptured dissections with signs of progressive brain stem ischemia.
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Affiliation(s)
- B M Kim
- Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
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18
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Yang X, Mu S, Lv M, Li L, Wu Z. Endovascular treatment of huge dissecting aneurysms involving the basilar artery. Experience and lessons from two cases. Interv Neuroradiol 2008; 13:369-80. [PMID: 20566106 DOI: 10.1177/159101990701300408] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Accepted: 11/12/2007] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Dissecting aneurysms involving the basilar artery (BA) are lesions with significant morbidity and mortality. Their management is controversial and often difficult. There is no generally approved strategy. Two cases of huge dissections involving the BA presented with subarachnoid hemorrhage in one case and mass effect in both cases. The dissection of case 1 involved the upper two thirds of the BA distal to the anterior inferior cerebellar arteries (AICA). Another dissection of case 2 involved the bilateral vertebral arteries (VA) distal to bilateral PICA and extended to upper third of the BA. After making a basket with coils inside the pseudoaneursym, proximal dissection was totally occluded in case 1. Dissection on the bilateral VA distal to the bilateral PICA and proximal BA was occluded in case 2 with a small residual dissection on the left VA. Case 1 had an excellent recovery with a durable image and clinical result. But recanalization and regrowth occurred in case 2, which might have originated from the residual dissection on the left VA, induced acute mass effect and sudden coma six weeks after the initial treatment. The residual and regrown dissection had to be occluded in a second intervention. The patient died two days later. BA occlusion is safe and efficient for dissections involving the BA as in our case and the literature. Proximal occlusion might be enough for huge and long lesions like ours. It seems that completely dense packing of proximal dissection is the key point to prevent recanalization.
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Affiliation(s)
- X Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing; China -
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19
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Patroclo CB, Puglia Jr P, Leite CDC, Yamamoto FI, Ciríaco JGM, Scaff M, Conforto AB. Endovascular treatment of a basilar artery dissecting aneurysm. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:1012-4. [DOI: 10.1590/s0004-282x2007000600019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 08/04/2007] [Indexed: 11/22/2022]
Abstract
Basilar artery (BA) dissecting aneurysms pose difficulties to treatment because both bleeding and thrombosis can happen in the same patient, clinical course is unpredictable and high morbidity is usual. We report the case of a 37-year-old woman with a BA aneurysm probably caused by arterial dissection, presenting embolic and hemorrhagic complications. The aneurysm was submitted to endovascular treatment with stenting and coil embolization. Clinical and radiological results were excellent and no complications were observed, suggesting that BA stenting and coil embolization may be a safe and effective treatment for this condition.
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20
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Henkes H, Liebig T, Reinartz J, Miloslavski E, Kirsch M, Kühne D. Endovaskulärer Verschluss der A. basilaris zur Behandlung dissektionsbedingter und dysplastischer fusiformer Aneurysmen. DER NERVENARZT 2006; 77:192, 194-6, 198-200. [PMID: 15902394 DOI: 10.1007/s00115-005-1926-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Dissecting aneurysms of the basilar artery trunk frequently affect young adults. Fusiform shape and narrowing of the proximal parent artery are typical features. Changes in aneurysm size and geometry may be observed more rapidly than in atherosclerotic or dysplastic aneurysms. Dissecting aneurysms carry a significant risk of rupture. Thrombotic or embolic occlusion of small pontine branches may cause ischemic symptoms. Sufficiently large aneurysms compress the adjacent brainstem. The operative treatment of these aneurysms is associated with unacceptable risks. At least one posterior communicating artery with normal calibre together with the ipsilateral P1 segment needs to provide adequate collateral flow to the upper basilar artery to allow endovascular coil occlusion of the segment that is affected by the dissection and/or fusiform aneurysmal dilatation. Four illustrative cases of endovascular coil occlusion of the basilar artery for the treatment of fusiform aneurysms are presented and discussed.
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Affiliation(s)
- H Henkes
- Klinik für Radiologie und Neuroradiologie, Alfried-Krupp-Krankenhaus, Essen.
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21
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Sakamoto S, Ohba S, Shibukawa M, Kiura Y, Okazaki T, Arita K, Kurisu K. Staged bilateral vertebral artery occlusion for ruptured dissecting aneurysms of the basilar artery: a report of 2 cases. ACTA ACUST UNITED AC 2005; 64:456-61; discussion 461. [PMID: 16253701 DOI: 10.1016/j.surneu.2005.01.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2004] [Accepted: 01/17/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Dissecting aneurysm of the basillary artery BA is rare. Although mortality rate is high, management remains controversial. We report 2 cases of dissecting aneurysm of the BA presenting with subarachnoid hemorrhage (SAH), both of which were successfully treated using staged occlusion of bilateral vertebral arteries (VAs). CASE DESCRIPTION A 64-year-old man and a 34-year-old woman presented with SAH associated with ruptured dissecting aneurysm of the BA. After endovascular occlusion of a single VA, blood flow in the dissected lumen was reduced. However, one aneurysm rebled and the bleb of the other did not change. Vertebral arteries were also occluded using endovascular techniques at 4 and 2 weeks after initial treatment, respectively. On the second intervention, stump pressure ratios of VAs intended for occlusion were 62.5% and 50.6%, respectively. The patients tolerated temporary occlusion of bilateral VAs well. Subsequent permanent occlusion of bilateral VAs resulted in no neurological complication. Complete obliteration of the aneurysmal lumen was demonstrated on magnetic resonance angiography performed 72 and 5 months later, respectively. CONCLUSION Staged bilateral VA occlusion might be the last recourse to prevent further hemorrhage from BA dissecting aneurysm. The technique can be safely applied when the stump pressure ratio is 50.6% or greater and when the patient tolerates temporary occlusion, which suggests the existence of sufficient collateral flow from the anterior circulation.
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Affiliation(s)
- Shigeyuki Sakamoto
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima 734-8551, Japan.
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22
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O'Shaughnessy BA, Getch CC, Bendok BR, Batjer HH. Late morphological progression of a dissecting basilar artery aneurysm after staged bilateral vertebral artery occlusion: case report. ACTA ACUST UNITED AC 2005; 63:236-43; discussion 243. [PMID: 15734510 DOI: 10.1016/j.surneu.2004.05.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2004] [Accepted: 05/10/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND The authors present a patient who experienced late (5-year follow-up) morphological progression of a dissecting aneurysm of the distal basilar artery after treatment with a combined microsurgical and neuroendovascular Hunterian strategy. In addition to postulating about the possible reasons underlying the evolution of this lesion, the role of stenting is discussed. CASE DESCRIPTION The patient was 37 years old when she suffered a subarachnoid hemorrhage from spontaneous basilar artery dissection. At the time of the hemorrhage, minimal aneurysmal enlargement was noted angiographically, and she was therefore treated nonoperatively. On reimaging 5 months later, massive enlargement of the aneurysm was noted. The patient was treated with staged bilateral vertebral artery sacrifice using a combination of microsurgical and neuroendovascular techniques. The dominant vertebral artery was clip-ligated distal to the posteroinferior cerebellar artery, whereas the contralateral vertebral artery was coil-occluded cervically 1 week later. CONCLUSIONS Despite the patient remaining asymptomatic, follow-up angiography 5 years after the initial hemorrhage revealed further enlargement of the aneurysm as well as a newly discovered inferiorly projecting daughter sac measuring 5 mm in diameter. Clearly, certain aneurysms exist for which indirect approaches involving hemodynamic attenuation fail to prevent progression. With greater refinements in stent technology, such lesions may be more effectively treated.
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Affiliation(s)
- Brian A O'Shaughnessy
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Abstract
Object. Little is understood about the clinical manifestations of basilar artery (BA) dissections, which can present with subarachnoid hemorrhage (SAH), brainstem compression, or ischemia. In any instance, the prognosis seems poorer than that for vertebral artery (VA) dissection. The authors analyzed clinical presentations and radiological features of BA dissection with and without rupture.
Methods. Between 1998 and 2003, the authors treated 10 patients (eight men and two women, ranging in age from 32–78 years; mean age 54 years) with BA dissection. Diagnosis was based on clinical and radiological findings, including those from magnetic resonance imaging and cerebral angiography studies.
Of the 10 patients, five had impaired consciousness at disease onset. Among four patients presenting with SAH, two were treated conservatively and had fair outcomes without recurrent hemorrhage. The other two patients with SAH were treated using unilateral endovascular VA occlusion, but one of them subsequently suffered fatal rebleeding. A fifth patient presented with progressive signs of a mass involving the brainstem, whereas the remaining five patients showed brainstem ischemia; all were treated conservatively. Four patients could not return to their previous daily activities.
Conclusions. Basilar artery dissections are rare lesions associated with significant morbidity and death. The natural course of and the treatment options for BA dissection differ considerably from those for VA dissections. Management of these lesions is controversial and difficult, and requires particular care.
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Affiliation(s)
- Yuhei Yoshimoto
- Department of Neurosurgery, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan.
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Albuquerque FC, Fiorella DJ, Han PP, Deshmukh VR, Kim LJ, Mcdougall CG. Endovascular management of intracranial vertebral artery dissecting aneurysms. Neurosurg Focus 2005. [DOI: 10.3171/foc.2005.18.2.4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and dramatic neurological injury. The authors reviewed the management of 23 cases in an effort to evaluate treatment efficacy and outcomes.
Methods
The records of 23 patients who underwent endovascular treatment were reviewed to determine symptoms, type of therapy, complications, and clinical outcomes. All patients were evaluated using records kept in a prospectively maintained database.
Ten men and 13 women (age range 35–72 years; mean age 49 years) were treated over an 8-year period. Twelve patients presented with poor-grade SAH, five with good-grade SAH, three with headache, and two with stroke. The other patient's aneurysm was discovered incidentally. Treatment included coil occlusion of the artery at the aneurysm in 21 patients and stent-assisted coil placement in two. Parent artery sacrifice was successful in all cases, whereas both patients treated with stent-assisted coil insertion suffered recurrences. No patient sustained permanent complications as a result of treatment. Two patients died due to the severity of their original SAH. Findings were normal in 14 patients on follow-up review (including five of the 12 presenting with poor-grade SAH), five had fixed neurological deficits but were able to care for themselves, and one was permanently disabled.
Conclusions
Despite their often aggressive neurological presentation, intracranial VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery. Even patients presenting in poor neurological condition may improve dramatically.
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25
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O'Shaughnessy BA, Getch CC, Bendok BR, Parkinson RJ, Batjer HH. Progressive Growth of a Giant Dolichoectatic Vertebrobasilar Artery Aneurysm after Complete Hunterian Occlusion of the Posterior Circulation: Case Report. Neurosurgery 2004; 55:1223. [PMID: 15791739 DOI: 10.1227/01.neu.0000140990.91277.85] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE:
Dolichoectatic vertebrobasilar artery aneurysms are often extremely difficult, if not impossible, to treat with microneurosurgical clip reconstruction. As such, a Hunterian strategy via vertebral or basilar artery sacrifice is often used. We have encountered a patient in whom deliberate bilateral vertebral artery sacrifice was insufficient to avoid progressive expansion of a giant dolichoectatic vertebrobasilar artery aneurysm. On the basis of a review of the literature, we are unaware of another reported case.
CLINICAL PRESENTATION:
A 60-year-old man presented with signs and symptoms of brainstem compression from a large fusiform aneurysm involving the distal dominant vertebral and proximal basilar arteries. Results of angiographic evaluation were highly characteristic of underlying dolichoectasia.
INTERVENTION:
The patient was treated initially with staged bilateral vertebral artery occlusion and adjunctive posterior circulation revascularization. After this therapy failed, he underwent a trapping procedure and aneurysm deflation.
CONCLUSION:
Unclippable aneurysms of the vertebrobasilar system are formidable lesions. They are not uniformly treatable by direct surgical reconstruction, and their growth is not consistently stabilized by the implementation of a complete Hunterian strategy. Future developments related to the use of endovascular stent technology may offer a more successful treatment approach for patients with these complex cerebrovascular lesions.
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Affiliation(s)
- Brian A O'Shaughnessy
- Department of Neurological Surgery, Northwestern University, McGaw Medical Center, 233 East Erie Street, Suite 614, Chicago, IL 60611, USA.
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Evans JJ, Sekhar LN, Rak R, Stimac D. Bypass Grafting and Revascularization in the Management of Posterior Circulation Aneurysms. Neurosurgery 2004; 55:1036-49. [PMID: 15509310 DOI: 10.1227/01.neu.0000140822.64362.c6] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2003] [Accepted: 07/01/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
To describe the bypass techniques, cranial base approaches, results of treatment, causes of failure, and lessons that are learned in patients with posterior circulation aneurysms requiring revascularization.
METHODS:
Retrospectively, 19 patients with posterior fossa aneurysms requiring revascularization procedures operated on between 1991 and 2002 were reviewed. Preoperative and postoperative clinical information, neurological examinations, imaging data, and updated follow-ups were reviewed. Patient outcome is reported as the most current Karnofsky Performance Scale score.
RESULTS:
A total of 22 arterial bypasses were performed in 19 patients for posterior fossa circulation aneurysms between 1991 and 2002. The mean follow-up was 41 months. Total graft patency rate (including patients requiring reoperation) was 86.4% (before) and 100% (after) salvage procedures. Patient outcome was 84.2% with Karnofsky Performance Scale score 80 to 90, and three deaths occurred perioperatively. Only one death could be attributed to the failure of the radial artery graft because of spasm and subsequent rupture during angioplasty.
CONCLUSION:
Certain graft selection criteria and technical considerations contribute to the success or failure of bypass grafts in the management of posterior circulation aneurysms. Bypass procedures remain an important method of management of complex posterior circulation aneurysms, in addition to endovascular procedures.
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Affiliation(s)
- James J Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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