Surgical Management of Intracranial Artery Dissection

Dissecting and fusiform aneurysms of the superior cerebellar artery: anatomy, clinical presentation, and treatment outcomes

The management of superior cerebellar aneurysms is still controversial. Although several techniques are available, the deep localization of the lesion and the limited number of cases increase the complexity of decision-making for optimal treatment. Only a few cases of dissecting and fusiform aneurysms of the superior cerebellar artery (SCA) are described in the literature, many of which are without long follow-ups. The study aims to offer an exhaustive retrospective analysis of patients affected by SCA fusiform and dissecting aneurysms treated at our institution from 2008 to 2023, highlighting outcomes and complications. Moreover, a comprehensive narrative review was performed. A total of seven patients were treated at our institution. After a title and abstract screen, fifty-five papers met the criteria for inclusion in the review. In our case series, conservative treatment was proposed as the first therapeutic option in four cases (57.1%), while endovascular treatment (EVT) was in three cases (42.9%). A good recovery was observed in 66% of patients presenting with subarachnoid hemorrhage (SAH), while every patient without SAH achieved a good clinical outcome. A poor outcome was observed only in one patient with a dissecting aneurysm causing SAH, who also suffered a pontine infarction. In the literature review, conservative treatment was proposed as a first therapeutic option in eleven cases (16.6%), open microsurgical techniques in 19 patients (28.8%), and EVT in 31 patients (46.9%). Fatal outcome was documented in five patients (7.5%), all characterized by the rupture of the vascular lesion, while 6.1% of cases had non-fatal poor outcomes.

Microsurgical partial trapping for the treatment of unclippable vertebral artery aneurysms: Experience from 27 patients and review of literature

BACKGROUND

The efficacy and safety of partial trapping for the treatment of unclippable vertebral artery aneurysms (UVAs) are still questionable. The partial trapping method (proximal or distal occlusion) was used in the treatment of aneurysms to simplify the surgical procedure and avoid postoperative complications.

METHODS

This study included 27 patients with UVAs who underwent microsurgical partial trapping between January 2015 and August 2022, and their postoperative outcomes and complications were retrospectively reviewed and evaluated.

RESULTS

Ruptured UVAs were detected in 25 (92.6%) patients, and 13 (48.1%) patients had poor-grade status. Fusiform dissection, dissecting, and fusiform aneurysms were observed in 17 (63%), 7 (25.9%), and 3 (11.1%) patients, respectively. By location, preposterior inferior cerebellar artery (PICA), PICA, post- PICA, and non-PICA types were noted in 7 (25.9%), 9 (33.3%), 6 (22.2%), and 5 (18.5%) patients, respectively. Microsurgical partial trapping was performed in all patients (blind-alley formation in 96.3%). Complete aneurysm obliteration was achieved in 26 (96.3%) patients. Immediate complete obliteration was achieved in 21 (77.8%) patients, delayed thrombosis within 7 days in 5 (18.5%), and nearly complete obliteration in 1 (3.7%). No re-bleeding was detected in all patients. Favorable outcomes 3 months after the operation were achieved by 92.9% of the patients in the good-grade group and 85.2% overall.

CONCLUSIONS

Microsurgical partial trapping, especially the blind-alley formation technique, was a safe and effective treatment of UVAs with high rates of aneurysm thrombosis. The appropriate sites for clip occlusion were dependent on the angioarchitecture of UVAs.

Advantages of Extradural Anterior Clinoidectomy and Extradural Approach with Dural Incision for Blood Blister Aneurysm or Pseudoaneurysm in the Internal Carotid Artery: Two Case Reports

Blood blister aneurysms (BBAs) or pseudoaneurysms (PAs) in the internal carotid artery (ICA) have fragile necks; therefore, conventional neck clipping is difficult. The standard treatment for BBAs or PAs is trapping with high or low flow bypass. However, there is no consensus on whether or not anterior clinoidectomy should be performed together. Two patients with ruptured ICA PA (anterior protrusion) or BBA (posterior protrusion) were presented to our hospital. Complete trapping was safely performed for both types of aneurysms via extradural anterior clinoidectomy and the extradural approach with dural incision. The advantages of the procedure are 1) safe proximal clipping, 2) early identification of the ICA C3 portion, 3) minimized frontal lobe retraction, 4) optic canal opening to allow mobility of the optic nerve, and 5) dural ring incision to allow mobility of the ICA.

Superficial Temporal Artery-middle Cerebral Artery Anastomosis for Ischemic Stroke due to Dissection of the Intracranial Internal Carotid Artery with Middle Cerebral Artery Extension

A 31-year-old man presented with a sudden-onset headache, right hemiparesis, and dysarthria on day 0 and was diagnosed with acute ischemic stroke due to dissection of the left intracranial internal carotid artery with middle cerebral artery extension. His symptoms progressed despite the institution of treatment, suggesting progression of the dissection. On day 5 after symptom onset, the patient underwent superficial temporal artery-middle cerebral artery anastomosis. No new ischemic stroke event occurred after surgery. Cerebral angiography performed 6 months after surgery showed spontaneous resolution of the dissection. The patient recovered to a modified Rankin Scale score of 2 and was able to return to work. The results of the present case suggest that superficial temporal artery-middle cerebral artery anastomosis is an effective treatment for ischemic stroke due to dissection of the intracranial internal carotid artery with middle cerebral artery extension.

Coil and Single-Stent Placement for Ruptured Dissecting Aneurysm of Middle Cerebral Artery: A Case Report

BACKGROUND

Ruptured dissecting aneurysms located at the middle cerebral artery (MCA) are rare, and their standard treatment has not been defined. Furthermore, lenticulostriate artery involvement in the dissecting segment makes treatment extremely difficult, and no previous reports have described successful treatment for such conditions.

CASE DESCRIPTION

We herein report the case of a 74-year-old woman who presented with sudden severe headache from subarachnoid hemorrhage due to dissection in the proximal M1 segment of left MCA involving lenticulostriate arteries. Digital subtraction angiography on day 6 showed that the dissecting aneurysm had enlarged despite strict blood pressure control. On day 8, the patient was treated successfully with a self-expanding closed cell stent and coil embolization, preserving blood flow in the lenticulostriate arteries as well as the MCA.

CONCLUSIONS

Follow-up digital subtraction angiography performed 5 weeks after endovascular therapy showed healing of the dissecting lesion, and the patient was discharged neurologically intact.

Overlapping stent-assisted coil embolization for a ruptured intracranial vertebral artery dissection

Ruptured intracranial vertebral artery dissection is a cause of non-traumatic subarachnoid hemorrhage. Urgent intervention should be considered to prevent fatal rebleeding. Endovascular parent artery occlusion, which is the initial treatment of choice, is not suitable for patients with a hypoplastic or occlusive contralateral vertebral artery. We report a case of ruptured vertebral artery dissection, which was successfully treated with double overlapping stent-assisted coiling.