Treatment of unruptured vertebral dissecting aneurysms: internal trapping or stent-assisted coiling

Delayed fatal rupture of vertebral artery after treated with flow-diverter in fibromuscular dysplasia patient: A case report and review of the literature

Fibromuscular dysplasia (FMD) is a noninflammatory arterial diseases that affects predominantly women. Multiple studies have demonstrated an increased prevalence of FMD in patients who experience carotid or vertebral artery dissection (VAD). This case report presents a 57-year-old female who presented with a headache and was diagnosed with partially thrombosed giant aneurysm of vertebral artery. This aneurysm was successfully treated with flow-diverter and coil, but new onset rupture of vertebral artery was detected two weeks later, leading to internal trapping. This case report underscores the need for awareness and understanding of treatment of dissection and aneurysm in patient who is suspected FMD.

Endovascular Treatment for Intracranial Artery Dissections in Posterior Circulation

Intracranial artery dissections (IADs), although uncommon, are an important cause of cerebral infarction and subarachnoid hemorrhage (SAH). Some IADs can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis. Meanwhile, others can progress to stroke that requires treatment. The incidence of IAD in the posterior circulation is higher than that in the anterior circulation. Anterior circulation dissections are more likely to develop into ischemia and posterior circulation lesions into hemorrhage. The mortality rate after IAD among patients with SAH is 19%-83%. Further, the mortality rate of IAD without SAH is 0%-3%. Patients with SAH commonly undergo surgery or receive neuroendovascular treatment (EVT) to prevent rebleeding. However, the treatment of IADs is empirical in the absence of data from randomized controlled trials. Recently, EVT has emerged and is considered for IADs because of its less invasiveness and perceived low rates of procedure-related morbidity with good efficacy. EVT strategies can be classified into deconstructive (involving sacrifice of the parent artery) and reconstructive (preserving blood flow via the parent vessel) techniques. In particular, the number of reports on reconstructive techniques is increasing. However, a reconstructive technique for ruptured IADs has not yet been established. This review aimed to provide an overview of IADs in the posterior circulation managed with EVT by performing a literature search.

Recurrent vertebrobasilar strokes and transient-ischemic attacks with challenging workup: Case report

Detecting the stroke etiology in young patients can be challenging. Among others, determining causality between ischemic stroke and patent foramen ovale (PFO) remains a complicated task for stroke neurologists, given the relatively high prevalence of PFOs. Thorough diagnostic workup to identify incidental vascular risk factors and rare embolic sources is crucial to avoid premature PFO closure suggesting successful secondary stroke prevention. In this paper, we report on a 38-year-old patient with recurrent vertebrobasilar territory, especially right posterior inferior cerebellar artery (PICA) territory strokes. After the initial suspicion of a left vertebral artery (VA) dissection was not confirmed by ultrasound and magnetic resonance imaging (MRI) and other major risk factors were excluded, a PFO was detected and closed. Successful PFO closure was confirmed by transesophageal echocardiography, yet recurrent transient-ischemic attacks and vertebrobasilar strokes, especially during nighttime and in the early morning, occurred despite various antiplatelet and antithrombotic regimes and a persistent right-to-left shunt was detected by bubble transcranial Doppler. Finally, MRI after another vertebrobasilar infarction detected a transient left VA occlusion that finally led to the diagnosis of a left VA pseudoaneurysm from an incident emboligenic dissection in the atlas segment. This pseudoaneurysm together with an anatomical variant of the right PICA originating with the right anterior inferior cerebellar artery from the basilar artery finally explained the recurrent ischemic events of the patient. After successful treatment with coil occlusion, the patient suffered no further stroke and recovered completely. In summary, stroke in the young remains a diagnostic challenge. The incidental finding of a PFO should not deter from thorough stroke workup and the follow-up of these patients including PFO closure verification should be performed under the guidance of vascular neurologists.

Flow Diverter Devices for the Treatment of Unruptured Vertebral Artery Dissecting Aneurysm

Objective

Vertebral artery dissecting aneurysm (VADA) is a very rare subtype of intracranial aneurysms; when ruptured, it is associated with significantly high rates of morbidity and mortality. Despite several discussions and debates, the optimal treatment for VADA has not yet been established. In the last 10 years, flow diverter devices (FDD) have emerged as a challenging and new treatment method, and various clinical and radiological results have been reported about their safety and effectiveness. The aim of our study was to evaluate the clinical and radiological results with the use of FDD in the treatment of unruptured VADA.

Methods

We retrospectively evaluated the data of all patients with unruptured VADA treated with FDD between January 2018 and February 2021 at our hybrid operating room. Nine patients with unruptured VADA, deemed hemodynamically unstable, were treated with FDD. Among other parameters, the technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcomes were evaluated.

Results

Successful FDD deployment was achieved in all cases, and the immediate follow-up angiography showed intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of facial numbness and palsy was noted in one patient; however, the symptoms had completely disappeared when followed up at the outpatient clinic 2 weeks after the procedure. The 3–6 months follow-up angiography (n=9) demonstrated complete/near-complete obliteration of the aneurysm in seven patients, and partial obliteration and segmental occlusion in one patient each. In the patient who achieved only partial obliteration, there was a sac 13 mm in size, and there was no change in the 1-year follow-up angiography. In the patient with segmental occlusion, the cause could not be determined. The clinical outcome was modified Rankin Scale 0 in all patients.

Conclusion

Our preliminary study using FDD to treat hemodynamically unstable unruptured VADA showed that FDD is safe and effective. Our study has limitations in that the number of cases is small, and it is not a prospective study. However, we believe that the study contributes to evidence regarding the safety and effectiveness of FDD in the treatment of unruptured VADA.

Reconstructive endovascular treatment of vertebral artery dissecting aneurysms with the Low-profile Visualized Intraluminal Support (LVIS) device

Introduction

The Low-profile Visualized Intraluminal Support (LVIS) device is a new generation of self-expanding braided stent recently introduced in China for stent assisted coiling of intracranial aneurysms. The aim of our study is to evaluate the feasibility, safety, and efficacy of the LVIS device in reconstructive treatment of vertebral artery dissecting aneurysms (VADAs).

Methods

We retrospectively reviewed the neurointerventional database of our institution from June 2014 to May 2016. Patients who underwent endovascular treatment of VADAs with LVIS stents were included in this study. Clinical presentation, aneurysmal characteristics, technical feasibility, procedural complications, and angiographic and clinical follow-up results were evaluated.

Results

38 patients with VADAs who underwent treatment with LVIS stent were identified, including 3 ruptured VADAs. All VADAs were successfully treated with reconstructive techniques including the stent-assisted coiling (n = 34) and stenting only (n = 4). Post-procedural complications developed in 3 patients (7.9%) including two small brainstem infarctions and one delayed thromboembolic event. Complications resulted in one case of minor permanent morbidity (2.6%). There was no procedure-related mortality. The follow-up angiogram was available in 30 patients at an average of 8.3 months (range, 2 to 30 months), which revealed complete occlusion in 23 patients (76.7%), residual neck in five patients (16.7%), and residual sac in two patients (6.7%). The follow-up of 25 aneurysms with incomplete immediate occlusion revealed 22 aneurysms (88%) with improvement in the Raymond class. One aneurysm (3.3%) showed recanalization and required retreatment. Clinical followed-up at 5–28 months (mean 14.1 months) was achieved in 36 patients because two patients died of pancreatic cancer and basal ganglia hemorrhage, respectively. No new neurologic deterioration or aneurysm (re)bleeding was observed.

Conclusions

Our preliminary experience with reconstruction of VADAs with the LVIS device demonstrates that this treatment approach is feasible with good short-term angiographic and clinical outcomes. Long-term and larger cohort studies are necessary to determine long-term outcomes of this therapy.

Endovascular treatment for ruptured and unruptured vertebral artery dissecting aneurysms: a meta-analysis

Background

Different endovascular modalities have been applied to the treatment of vertebral artery dissecting aneurysms, the most commonly used being internal trapping and stent-assisted coiling, although the ideal treatment remains controversial.

Objective

To perform a meta-analysis to study clinical outcomes of patients with vertebral artery dissecting aneurysms who were treated with internal trapping or stent-assisted coiling.

Materials and methods

We conducted a meta-analysis of eight retrospective studies that compared internal trapping with stent-assisted coiling for the treatment of vertebral artery dissecting aneurysms. The primary outcomes of this study were immediate occlusion, long-term occlusion, good outcome ratio, perioperative mortality, and angiographic recurrence. Subgroup analyses were conducted of patients with ruptured versus unruptured vertebral artery dissecting aneurysms.

Results

Eight studies comprising a total of 188 patients were included in the analysis. For ruptured cases, in comparison with stent-assisted coiling groups, the patients treated with trapping techniques had a higher rate of immediate postoperative occlusion (OR=0.165; 95% CI 0.067 to 0.405; p<0.01), although there was no significant difference in long-term occlusion (OR=1.059; 95% CI 0.033 to 34.121; p=0.974), good clinical outcome rates, recurrence rates, and perioperative mortality. For unruptured cases, patients in the trapping groups also had higher immediate occlusion rates than those who underwent stent-assisted coiling (OR=0.175; 95% CI 0.043 to 0.709; p=0.015), while rates of both recurrence and good clinical outcome were similar between the two groups.

Conclusions

Both internal trapping and stent-assisted coiling are technically feasible for ruptured vertebral artery dissecting aneurysms, with high rates of good long-term neurologic outcomes and low recurrence and mortality rates. For unruptured aneurysms, conservative treatment is recommended. When a posterior inferior cerebellar artery (PICA) origin is involved, bypass surgery or vertebral artery-to-PICA stent placement plus coil embolization should be considered.