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Amoukhteh M, Hassankhani A, Valizadeh P, Jannatdoust P, Ghozy S, Kobeissi H, Kallmes DF. Flow diverters in the treatment of intracranial dissecting aneurysms: a systematic review and meta-analysis of safety and efficacy. J Neurointerv Surg 2024:jnis-2023-021117. [PMID: 38212103 DOI: 10.1136/jnis-2023-021117] [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: 10/10/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Intracranial dissecting aneurysms present clinical challenges, demanding immediate intervention due to their high bleeding risk. While traditional treatments have limitations, the potential of flow diverters shows promise but remains a subject of ongoing debate for optimal management. The aim of this study was assess the safety and efficacy of flow diverters in the treatment of intracranial dissecting aneurysms. METHODS A systematic review and meta-analysis was performed following established guidelines. The search encompassed PubMed, Scopus, Web of Science, and Embase databases up to July 20, 2023. Eligible studies reporting outcomes of interest were included, and relevant data were extracted and analyzed using R software. RESULTS The analysis, based on data pooled from 20 included studies involving 329 patients, revealed a favorable functional outcome rate of 89.7% at the last follow-up. The mortality rate during the follow-up period was 2.4%, decreasing to 0.9% when excluding the outlier study. In the final angiographic follow-up, a complete occlusion rate of 71.7% and an adequate occlusion rate of 88.3% were observed. Notably, studies with longer angiographic follow-up times exhibited lower rates of complete (P=0.02) and adequate (P<0.01) occlusion. A minimal aneurysm recurrence/rebleeding rate of 0.1% was noted, while in-stent stenosis/thrombosis occurred at a rate of 1.14%. Additionally, ischemic events/infarctions were seen in 3.3% of cases. The need for retreatment was minimal, with a rate of 0.9%, and the technical success rate was impressively high at 99.1%. CONCLUSION This study highlights the safety and efficacy of flow diverters in treating intracranial dissecting aneurysms. Further research, encompassing larger multicenter studies with extended follow-up periods, is crucial for comprehending occlusion dynamics, refining treatment strategies, improving long-term outcomes, and addressing methodological limitations.
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Affiliation(s)
- Melika Amoukhteh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Parya Valizadeh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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2
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Zhang Y, Zhang F, Turhon M, Huang J, Li M, Peng Q, Zheng Z, Liu J, Zhang Y, Liu J, Zhang H, Li T, Song D, Zhao Y, Aisha M, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Guan S. Treatment of Intracranial Vertebral Artery Dissecting Aneurysms Using Pipeline Embolization Devices : A Multicenter Cohort Study. Clin Neuroradiol 2023; 33:1105-1114. [PMID: 37380901 DOI: 10.1007/s00062-023-01318-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/24/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE Intracranial vertebral artery dissecting aneurysm (IVADA) is a rare type of aneurysm with high morbidity and mortality. Recently, the application of pipeline embolization devices (PEDs) has been extended to IVADAs. Here, we aim to investigate the safety and effectiveness of PEDs for IVADAs. METHOD We retrospectively reviewed the PLUS database to identify patients who had IVADAs and were treated with PEDs from 2014 to 2019 at 14 centers across China. Data including patient and aneurysm characteristics, procedure details, angiographic and clinical results, relationship with the ipsilateral posterior inferior cerebellar artery (PICA), and patency of the PICA following PED coverage were analyzed. RESULTS In this study 52 consecutive patients with 52 IVADAs were included. The mean age was 52.33 years and 82.7% were male. With a median follow-up of 10.5 months, the complete occlusion rate was 93.8% (45/48) and no recurrence or in-stent stenosis was detected. The total postoperative complication rate and mortality were 11.5% and 1.9%, respectively. Complications occurred in 9.6% (5/52) of patients within 30 days after the operation, including ischemic stroke in 3 and hemorrhagic stroke in 2. Another patient suffered an ischemic stroke at follow-up, 78.8% (41/52) PICAs were covered by PEDs, 1 case (2.4%) had a functional disability due to PICA occlusion, while 39.0% (16/41) had reduced flow during follow-up but hardly caused any obvious neurological deficits. Patients with IVADA involving PICA had a trend towards more complications (66.7% vs. 51.1%; P = 1). CONCLUSION Treating IVADAs with PEDs may be a safe and effective option, with favorable clinical and angiographic outcomes; however, complications associated with this treatment should not be ignored. REGISTRATION http://www. CLINICALTRIALS gov . Unique identifier: NCT03831672.
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Affiliation(s)
- Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Fujunhui Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mirzat Turhon
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiliang Huang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qichen Peng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhaoxu Zheng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Zhengzhou University People's Hospital, Zhengzhou, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Maimaitili Aisha
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Wang
- Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jieqing Wan
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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3
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Zhou M, Wu Z, Maalim AA, Zeng Y, Guo X, Zhang Z, Yuan X, Enos ZM, Shu K, Lei T, Zhu M. Overlapping Stent Treatment for Ruptured Dissecting Aneurysms in Posterior Circulation. Brain Sci 2023; 13:1507. [PMID: 38002469 PMCID: PMC10669846 DOI: 10.3390/brainsci13111507] [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: 07/23/2023] [Revised: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Ruptured dissecting aneurysms in posterior intracranial circulation present significant clinical challenges and often cause poor prognoses. Our cohort used overlapping stents as the primary treatment. We analyzed the medical records of 27 patients (18 men/nine women) with ruptured posterior circulation dissecting aneurysms (PCDAs). Their average age was 52 years. We selected 11 patients who used Enterprise (EP) and LVIS stents overlappingly and matched them 1:1 with counterparts who received either EP or LVIS stents individually. Overlapping stents was a feasible treatment in all 27 cases. We successfully followed up 26 patients for ≥6 months. Regrettably, one patient died from intracranial hypertension on Day 7 post-procedure. Immediate post-procedure angiographies indicated Raymond grade I, II, and III occlusions of PCDAs in 16 (59.3%), 7 (25.9%), and 4 (14.8%) cases, respectively. At an average follow-up duration of 16.2 months, 25 patients (96.2%) had modified Rankin Scale scores of 0-2, signifying positive outcomes. One patient (3.8%) had a score of 3-4. Recurrence rates for the EP and LVIS stent groups were higher than those of the overlapping stent group (45.45% vs. 9.09%, p = 0.15 and 27.27% vs. 9.09%, p = 0.59, respectively). No significant difference in recurrence rates existed between the overlapping and single-stent groups. Similarly, follow-up outcomes were consistent between the two groups. Overlapping stents could be an efficient method for treating ruptured PCDAs.
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Affiliation(s)
- Minghui Zhou
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zengbao Wu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ali Abdi Maalim
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ying Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiao Guo
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zhenhua Zhang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiaohong Yuan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zacharia Majaliwa Enos
- Department of Neurosurgery, Tongji Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430030, China;
| | - Kai Shu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Mingxin Zhu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
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Han J, Chen J, Tong X, Han M, Peng F, Niu H, Liu L, Liu F, Liu A. Morphological characteristics associated with ruptured intracranial vertebral artery dissecting aneurysms. J Neurointerv Surg 2023; 15:321-324. [PMID: 35387859 DOI: 10.1136/neurintsurg-2022-018744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/10/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Morphological risk factors for the rupture of intracranial vertebral artery dissecting aneurysms (IVADAs) have not been well characterized. In this study, we aim to identify morphological characteristics associated with IVADA rupture. METHODS We conducted a retrospective study of 249 consecutive patients with single IVADAs (31 ruptured and 218 unruptured) admitted to Beijing Tiantan Hospital between January 2016 and December 2020. Various morphological parameters were measured using three-dimensional digital subtraction angiography images. Univariate and multivariate logistic regression analyses were performed to identify morphological characteristics associated with IVADA rupture. RESULTS Univariate regression analysis revealed that the coexistence of significant proximal and distal stenosis and posterior inferior cerebellar artery (PICA) involvement were associated with IVADA rupture, while the origin from the dominant vertebral artery was inversely associated with the rupture. Multivariate regression analysis demonstrated that the coexistence of significant proximal and distal stenosis (OR 22.00, 95% CI 5.60 to 86.70, p<0.001) and PICA involvement (OR 4.55, 95% CI 1.36 to 15.20, p=0.014) were independently associated with IVADA rupture. CONCLUSION The coexistence of significant proximal and distal stenosis and PICA involvement were independently associated with IVADA rupture. These morphological characteristics may facilitate the assessment of rupture risk in patients with IVADAs.
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Affiliation(s)
- Jiangli Han
- Department of Neurosurgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jigang Chen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Tong
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fei Peng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Niu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lang Liu
- Department of Neurosurgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fei Liu
- Department of Neurosurgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China .,Department of Neurosurgery, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Aihua Liu
- Department of Neurosurgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China .,Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Centre for Neurological Diseases, Beijing, China
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5
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Nishino A, Nakamura M, Nakanishi K, Kohmura E. Stent implantation in a patient with non-hemorrhagic vertebral artery dissection associated with severe, continuously progressive stenosis in the posterior inferior cerebellar artery bifurcation region: A case report. Radiol Case Rep 2022; 17:4001-4005. [PMID: 36032204 PMCID: PMC9403900 DOI: 10.1016/j.radcr.2022.07.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/28/2022] [Accepted: 07/31/2022] [Indexed: 11/12/2022] Open
Abstract
Generally, the prognosis of non-hemorrhagic vertebral artery dissection is good. Treatment should be considered when stenosis progresses or when an aneurysm is formed. However, no clear treatment policy has been established. The purpose of this case report was to describe the treatment policy for non-hemorrhagic onset vertebral artery dissection with severe stenosis around the posterior inferior cerebellar artery (PICA) bifurcation and aneurysm, where stent placement in the vertebral artery was difficult. This report describes healing without complications with stent implantation in the PICA performed to treat non-hemorrhagic vertebral artery dissection with associated severe, continuously progressive stenosis in the PICA bifurcation region. A 36-year-old woman was examined at the authors’ hospital for persistent pain in the left posterior neck. Left vertebral arteriography revealed stenosis due to dissection around the PICA bifurcation and aneurysm formation at the distal position. Due to the progression of stenosis, there were concerns about PICA occlusion, and stent implantation in the vertebral artery was performed via the PICA. Neck pain ceased immediately after surgery, and 3 months later, cerebral angiography showed favorable patency of the PICA and decreased aneurysm size. This case suggests that stent implantation in the PICA might be a useful treatment option for non-hemorrhagic vertebral artery dissection with associated severe stenosis in the PICA bifurcation region.
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Kim CH, Lee CH, Kim YH, Sung SK, Son DW, Lee SW, Song GS. Flow Diverter Devices for the Treatment of Unruptured Vertebral Artery Dissecting Aneurysm. J Korean Neurosurg Soc 2021; 64:891-900. [PMID: 34689473 PMCID: PMC8590915 DOI: 10.3340/jkns.2021.0181] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/27/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Chang Hyeun Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Chi Hyung Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Young Ha Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Soon Ki Sung
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Dong Wuk Son
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Sang Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Geun Sung Song
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
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7
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Chen J, Tao M, Han J, Feng X, Peng F, Tong X, Niu H, Ma N, Liu A. Pipeline Embolization Device for the Treatment of Unruptured Intracranial Dissecting Aneurysms. Front Neurol 2021; 12:691897. [PMID: 34594292 PMCID: PMC8476866 DOI: 10.3389/fneur.2021.691897] [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: 04/07/2021] [Accepted: 06/07/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Intracranial dissecting aneurysms (IDAs) are rare but pose significant challenges to treatment. The pipeline embolization device (PED) has been demonstrated to be an effective treatment option with excellent outcomes. Herein, we report our experience with patients treated with the PED for unruptured IDAs. Methods: We retrospectively reviewed our hospital database and identified patients who were treated with PEDs for unruptured IDAs between March 2016 and September 2020. Data including demographics, clinical presentation, aneurysm characteristics, procedural details, intra- or peri-procedural complications, and follow-up details were collected. Results: Eighty patients (61 men, 76.25%) were treated with PED for unruptured IDAs. The most common symptoms were headache (34, 42.5%), dizziness (29, 36.25%), and nausea or vomiting (15, 18.75%). Of these patients, 73 had one aneurysm, and seven harbored two aneurysms. All of them achieved successful PED deployment. Six patients experienced intra- or peri-procedural complications including perforator artery occlusion, thromboembolic, hemorrhagic events, and falling of the stent into the aneurysm sac. Follow-up with digital subtractive angiography was available for 29 patients with a median of 6 months, and 28 (96.56%) patients had aneurysm occlusion. Late thrombosis occurred in four patients, and two of them had unfavorable outcomes. Clinical follow-up showed that a favorable clinical outcome was achieved in 76 (95%) patients, and the mortality rate was 3.75%. Conclusion: Treating unruptured IDAs is safe and effective with long-term favorable clinical and angiographic outcomes. However, the complications of this treatment should be noted. Careful selection of appropriate patients and individualized antiplatelet therapy might be needed.
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Affiliation(s)
- Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mushun Tao
- Department of Neurosurgery, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Jiangli Han
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xin Feng
- Department of Neurosurgery Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Fei Peng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Niu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Neurosurgery, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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8
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Fu W, Ge H, Luo G, Meng X, Wang J, Jin H, Li Y. Treatment of Unruptured Vertebral Artery Aneurysm Involving Posterior Inferior Cerebellar Artery With Pipeline Embolization Device. Front Neurol 2021; 12:622457. [PMID: 34177754 PMCID: PMC8222993 DOI: 10.3389/fneur.2021.622457] [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: 10/28/2020] [Accepted: 04/20/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Treatment of unruptured vertebral artery aneurysm involving posterior inferior cerebellar artery (PICA) is challenging. The experience of pipeline embolization device (PED) therapy for these lesions is still limited. Objective: To evaluate the safety and efficacy of the PED for unruptured vertebral artery aneurysm involving PICA. Methods: Thirty-two patients with unruptured vertebral artery aneurysm involving PICA underwent treatment with PED were retrospectively identified. Procedure-related complications, PICA patency, clinical, and angiographic outcomes were analyzed. Results: Thirty-two aneurysms were successfully treated without any procedure-related complications. Images were available in 30 patients (93.8%) during a period of 3–26 months follow-up (average 8.4 months), which confirmed complete occlusion in 17 patients (56.5%), near-complete occlusion in 9 patients (30%), and incomplete occlusion in one patient (3.3%). Parent artery occlusion (PAO) was occurred in 3 patients (10%). Twenty-eight of 30 PICA remained patent. The two occlusions of PICA were secondary to PAO. At a mean of 20.7 months (range 7–50 months) clinical follow-up, all the patients achieved a favorable outcome without any new neurological deficit. Conclusion: PED seems to be a safe and effective alternative endovascular option for patients with unruptured vertebral artery aneurysm involving PICA.
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Affiliation(s)
- Weiqi Fu
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Fushun Central Hospital, Fushun, China
| | - Huijian Ge
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiejun Wang
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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9
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Catapano JS, Ducruet AF, Cadigan MS, Farhadi DS, Majmundar N, Nguyen CL, Baranoski JF, Cole TS, Wilkinson DA, Fredrickson VL, Srinivasan VM, Albuquerque FC. Endovascular treatment of vertebral artery dissecting aneurysms : a 20-year institutional experience. J Neurointerv Surg 2021; 14:257-261. [PMID: 33906940 DOI: 10.1136/neurintsurg-2020-017089] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The ideal treatment for unruptured vertebral artery dissecting aneurysms (VADAs) and ruptured dominant VADAs remains controversial. We report our experience in the management and endovascular treatment of patients with VADAs. METHODS Patients treated endovascularly for intradural VADAs at a single institution from January 1, 1999, to December 31, 2019, were retrospectively reviewed. Primary neurological outcomes were assessed using modified Rankin Scale (mRS) scores, with mRS >2 considered a poor neurological outcome. Additionally, any worsening (increase) in the mRS score from the preoperative neurological examination was considered a poor outcome. RESULTS Ninety-one patients of mean (SD) age 53 (11.6) years (48 (53%) men) underwent endovascular treatment for VADAs. Fifty-four patients (59%) presented with ruptured VADAs and 44 VADAs (48%) involved the dominant vertebral artery. Forty-seven patients (51%) were treated with vessel sacrifice of the parent artery, 29 (32%) with flow diversion devices (FDDs), and 15 (17%) with stent-assisted coil embolization (stent/coil). Rates of procedural complications and retreatment were significantly higher with stent/coil treatment (complications 4/15; retreatment 6/15) than with vessel sacrifice (complications 1/47; retreatment 2/47) or FDD (complications 2/29; retreatment 4/29) (p=0.008 and p=0.002, respectively). Of 37 patients with unruptured VADAs treated, only two (5%) had mRS scores >2 on follow-up. CONCLUSION Endovascular FDD treatment of VADAs appears to be associated with lower retreatment and complication rates than stenting/coiling, although further study is required for confirmation. Endovascular treatment of unruptured VADAs was safe and was associated with favorable angiographic and neurological outcomes.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Megan S Cadigan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Neil Majmundar
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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10
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Takeuchi M, Uyama A, Matsumoto T, Tsuto K, Konishi Y, Iwabuchi S. Experimental Safety Evaluation of Inflated Assisting Balloons for Endovascular Surgery. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:707-711. [PMID: 37502270 PMCID: PMC10371007 DOI: 10.5797/jnet.oa.2020-0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/01/2021] [Indexed: 07/29/2023]
Abstract
Objective The balloon-assisted technique is one of the methods used for cerebral aneurysm embolization. There are several applications of assisting balloons such as remodeling the neck of cerebral aneurysms, protecting blood vessel branches, and stabilizing the microcatheter. In this study, we measured the pressure inside inflated assisting balloons to assess safety or procedure. Methods A T-junction silicone model was used. The pressure inside the balloon inflated to the set herniation levels in the T-junction model was measured using a fiber pressure sensor. We compared the pressure and difference between each assisting balloon. Results The pressure required for inflating the balloon to the set herniation level in the T-junction model varied depending on the type of assisting balloon. The results suggest that differences in pressure among inflated balloons are likely attributable to differences in the materials used in the lumens of the balloons. Conclusion The pressure inside various inflated assisting balloons was measured for comparison and differences were found. This experiment contributes to the safety of the balloon-assisted technique.
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Affiliation(s)
- Masataka Takeuchi
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
- Department of Neurosurgery, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Atsushi Uyama
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
| | - Takashi Matsumoto
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
| | - Kazuma Tsuto
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
| | - Yoshifumi Konishi
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
| | - Satoshi Iwabuchi
- Department of Neurosurgery (Ohashi), School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
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11
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Chung J, Cheol Lim Y, Sam Shin Y. Endovascular Treatment of Intracranial Vertebral Artery Dissection. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:265-280. [PMID: 37501904 PMCID: PMC10370974 DOI: 10.5797/jnet.ra.2020-0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/23/2020] [Indexed: 07/29/2023]
Abstract
Intracranial vertebral artery dissection (VAD) is the most common arterial dissection in intracranial arteries. Some types of VAD can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis, whereas others can progress to stroke that needs treatment. Recently, endovascular treatment (EVT) has emerged and is suggested as a treatment option for VADs due to perceived low rates of procedure-related morbidity with good efficacy. In the last decade, we have accumulated our strategies to treat those VADs. Here, we try to share our experiences about VADs, including indications and methods of treatment of VADs using EVT. We perform EVT for ruptured VADs presenting with SAH and some of unruptured VADs such as VAD with recurrent or progressive ischemia, dissecting aneurysm larger than 7 mm or with mass effect, early ugly change of VADs in shape and size during follow-up period, involving the basilar artery (BA) and bilateral VADs. We present how we have done in our real practice for the last decade for treating VADs by EVT rather than reviewing and organizing so-far-published literature. We tended to occlude the rupture point by vertebral artery (VA) occlusion in non-dominant VA or stent-assisted coiling in dominant VA for ruptured VADs. We tended to reconstruct original hemodynamics using various stents for unruptured VADs. To decide what to treat and how to treat are very complicated for VADs. However, we believe that EVT is the current mainstay for treating VADs. Each technique of EVT should be determined on a case-by-case basis at the discretion of endovascular neurosurgeons and/or interventional neuroradiologists according to presenting symptoms, hemodynamic status, including sufficiency of the collateral supply and anatomic features of the vertebrobasilar artery as well as the posterior inferior cerebellar artery, anterior spinal artery, and medullary perforators.
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Affiliation(s)
- Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Cheol Lim
- Department of Neurosurgery, Ajou University College of Medicine and Hospital, Suwon, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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12
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Pipeline embolization for recurrent vertebral artery thromboembolic events secondary to a misplaced pedicle screw. Neurol Sci 2020; 42:1555-1558. [DOI: 10.1007/s10072-020-04943-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
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13
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Endo H, Tanoue S, Hiramatsu M, Matsumoto Y, Sato K, Sato M, Matsumaru Y, Tsuruta W, Kiyosue H. Risk factors for medullary infarction after endovascular trapping of vertebral artery dissecting aneurysms. Neurosurg Rev 2020; 44:2283-2290. [PMID: 33083928 DOI: 10.1007/s10143-020-01424-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/22/2020] [Accepted: 10/15/2020] [Indexed: 11/25/2022]
Abstract
Internal trapping (IT) is a treatment option for intracranial vertebral artery dissecting aneurysms (VADAs). Medullary infarction (MI) is a complication linked to this treatment. This study aims to clarify the outcomes of IT for VADAs and the risk factors for MIs. We retrospectively reviewed the databases from 2010 to 2017 to identify patients with VADAs treated by IT at seven collaborating institutions. Radiological findings, clinical courses, and outcomes were analyzed. Perforating arteries were classified into terminal or longitudinal types using preoperative angiography. IT was completed in 90 patients (74 ruptured and 16 unruptured VADA). Postoperative rebleeding did not occur in any ruptured VADA patients. Postoperative MRI detected MIs in 26 patients (28.9%). The incidence of MIs in the ruptured VADA (32%) was higher compared with that in the unruptured VADA (13%), though it was not significant. In the MI group, the occlusion or blind alley of the terminal-type and longitudinal-type perforator was confirmed in 23 patients (88%) and 11 patients (42%), respectively. The occlusion or blind alley of the terminal-type perforator was an independent risk factor for MIs in the logistic regression analysis (OR 5.81; 95% CI 1.34-25.11; p = 0.018). In ruptured VADA, postoperative MI (OR 12.2; 95% CI 3.19-64.55; p = 0.0001) and high-grade SAH (OR 8.02; 95% CI 2.32-37.70; p = 0.0006) were independent risk factors of an unfavorable clinical outcome. In conclusion, MIs were an independent risk factor for unfavorable outcomes after IT, especially for a ruptured VADA. The occlusion or blind alley of the terminal-type perforator caused by the IT was associated with postoperative MIs.
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Affiliation(s)
- Hidenori Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Shuichi Tanoue
- Department of Radiology, Kurume University School of Medicine, Kurume, Japan
| | - Masafumi Hiramatsu
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Masayuki Sato
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Hiro Kiyosue
- Department of Radiology, Oita University Faculty of Medicine, Oita, Japan
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14
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Gupta G, Eckstein DA, Narayan V, Jumah F, DePalma AA, Sozio SJ, Prendergast N, Schonfeld S, Keller I, Al-Mufti F, Nosko M, Nanda A, Roychowdhury S. Endovascular Management of Intracranial Vertebral Artery Dissection: Technical Nuances for the Preservation of Posterior Inferior Cerebellar Artery and Basilar Artery. Oper Neurosurg (Hagerstown) 2020; 19:241-248. [PMID: 32526018 DOI: 10.1093/ons/opaa174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 04/06/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The treatment of intracranial vertebral artery dissection (VAD) can be challenging. OBJECTIVE To evaluate the clinical presentation, endovascular treatment techniques, and prognostic outcome of patients diagnosed with intracranial VAD at our institution. METHODS A retrospective analysis of 35 patients who were diagnosed with VAD at our institution over 17-yr period (2001-2017) is presented. A total of 27 patients with a total of 30 affected arteries underwent endovascular treatment, and their outcome was evaluated. RESULTS Of the 35 total patients with VAD, 15 presented with headache, 12 with focal neurological deficits, 2 with neck pain, 2 with dizziness, 1 with syncope, and 3 after trauma. Of the 30 dissected arteries, 18 were treated with deconstruction and 12 were treated with stent reconstruction. Treatment method was determined by the dominance of the affected artery and location relative to the ipsilateral posterior inferior cerebellar artery (PICA) and the basilar artery. Deconstructive techniques were utilized in all cases of hypoplastic artery dissection and the majority of codominant artery dissections, whereas reconstruction was performed on the majority of dominant artery dissections. Rupture did not impact treatment technique. Four patients demonstrated post-treatment infarcts, and another 1 patient died because of intraparenchymal bleed. The remaining 22 patients demonstrated favorable clinical outcome. None of the patients developed recanalization or needed retreatment till the last follow-up. CONCLUSION This study suggests that endovascular treatment of intracranial VAD with deconstruction or stent reconstruction based on the patients anatomy, particularly vessel dominance and location with respect to PICA, is feasible and effective though the revascularization procedures still has its role in selected cases.
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Affiliation(s)
- Gaurav Gupta
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Donna A Eckstein
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Vinayak Narayan
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Fareed Jumah
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anthony A DePalma
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Stephen J Sozio
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Nancy Prendergast
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Steven Schonfeld
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Irwin Keller
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Fawaz Al-Mufti
- Department of Neurology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Michael Nosko
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anil Nanda
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sudipta Roychowdhury
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Department of Neurology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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15
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Gu Y, Chen L, Zhang Y, Chen M, Li Y, Zhu Y, Lu H, Wei L, Zhang P, Li M, Gu B, You J, Wang W. Reconstructive treatment of symptomatic vertebral artery dissecting aneurysms with Willis covered stent: Initial experience. J Interv Med 2020; 3:184-191. [PMID: 34805932 PMCID: PMC8562248 DOI: 10.1016/j.jimed.2020.08.003] [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: 04/24/2020] [Revised: 07/10/2020] [Accepted: 08/03/2020] [Indexed: 11/23/2022] Open
Abstract
Background Symptomatic vertebral artery dissecting aneurysm (VADA) is a challenging disease with controversy on treatment strategy due to anatomic configuration and their nature. Moreover, the outcomes of reconstructive treatment have not been well established. Objective To evaluate the safety and efficacy of reconstructive endovascular treatment (EVT) for symptomatic VADAs with Willis covered stent. Methods We evaluated retrospectively 13 patients with symptomatic VADAs who treated with Willis covered stent, compared with stent-assisted coiling (SAC) on the characteristics, posttreatment course, angiographic and clinical follow-up outcomes at an average of 14.4 months (range, 3–48 months). Results A total of 33 patients with symptomatic VADAs were reviewed, 23 of these patients with ruptured VADAs. The technical successful rate is 100% respectively in Willis covered stent (Group A) and SAC (Group B, n = 20). The initial complete occlusion rate was significant higher in group A (100%) than group B (30%) (p < 0.01). Major procedure-related complications were not significant different in the two groups. Serial follow-up angiograms revealed 5 recurrent VADAs in group B and no recurrence in group A (p > 0.05). No obvious in-stent stenosis and no re-hemorrhage and delayed ischemic symptoms during the follow-up period. The final angiograms of all survived patients demonstrated the complete occlusion rate was higher in group A (100%) than group B (80%), but no significant statistical difference (p > 0.05). Clinical outcomes were favorable in 31 (93.9%), severe disability occurred in one in group B, and only one death in group A. The final clinical outcomes were also not significant difference in the two groups (p > 0.05). Conclusions Our initial result demonstrated reconstructive EVT with Willis covered stent provides a viable approach for selected symptomatic VADAs involving the intracranial and extracranial segments, which is similar to favorable results with SAC. However, an expanded clinical experiences and larger cohort studies are needed.
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Affiliation(s)
- Yi Gu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - Li Chen
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - Yang Zhang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - Mo Chen
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - YongDong Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - YueQi Zhu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - HaiTao Lu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - LiMing Wei
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - PeiLei Zhang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - MinHua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - BinXian Gu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
| | - Jin You
- Zhejiang Shin-an International Hospital, 314031, China
- Corresponding author. Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 yishan road, xuhui district, Shanghai, 200233, China.
| | - Wu Wang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, China
- Corresponding author. Interventional Radiology, Zhejiang Shin-an International Hospital, 314031, China.
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16
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Edaki H, Itami H, Ikushima K, Shinji Y, Otsuka S, Kusaka N, Nishiura T, Ogihara K. A Case of Brainstem Infarction That Was Found to Be Vertebral Artery Dissection in a Short Period after the Diagnosis of Atherothrombotic Infarction. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:428-434. [PMID: 37502663 PMCID: PMC10370534 DOI: 10.5797/jnet.cr.2019-0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 05/15/2020] [Indexed: 07/29/2023]
Abstract
Objective We report a case of vertebral artery dissecting aneurysm that caused right lateral medullary infarction, which was treated by endovascular therapy. Case Presentations A 57-year-old man developed right-side headache and dysarthria on the day before presentation, and exhibited mouth dropping and dysphagia the following day. Initial MRI demonstrated right lateral medullary infarction with atherothrombotic change with no vessel lesion, and we started infusion and medication administration. Later MRI revealed bilateral vertebral artery dissection, and we treated the growing right vertebral artery dissecting aneurysm by stenting and coils. Conclusion The possibility of dissecting lesions should be considered in cases of medullary infarction. Stenting and coil treatment is a useful option for bilateral dissecting vertebral aneurysms.
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Affiliation(s)
- Hisanori Edaki
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Yamaguchi, Japan
| | - Hisakazu Itami
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Yamaguchi, Japan
| | - Kenta Ikushima
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Yamaguchi, Japan
| | - Yukei Shinji
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Yamaguchi, Japan
| | - Shinji Otsuka
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Yamaguchi, Japan
| | - Noboru Kusaka
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Yamaguchi, Japan
| | - Tsukasa Nishiura
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Yamaguchi, Japan
| | - Kotaro Ogihara
- Department of Neurosurgery, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Yamaguchi, Japan
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17
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Wagner KM, Srinivasan VM, Srivatsan A, Ghali MGZ, Thomas AJ, Enriquez-Marulanda A, Alturki AY, Ogilvy CS, Mokin M, Kuhn AL, Puri A, Grandhi R, Chen S, Johnson J, Kan P. Outcomes after coverage of lenticulostriate vessels by flow diverters: a multicenter experience. J Neurosurg 2020; 132:473-480. [PMID: 30641842 DOI: 10.3171/2018.8.jns18755] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE With the increasing use of flow diversion as treatment for intracranial aneurysms, there is a concomitant increased vigilance in monitoring complications. The low porosity of flow diverters is concerning when the origins of vessels are covered, whether large circle of Willis branches or critical perforators. In this study, the authors report their experience with flow diverter coverage of the lenticulostriate vessels and evaluate their safety and outcomes. METHODS The authors retrospectively reviewed 5 institutional databases of all flow diversion cases from August 2012 to June 2018. Information regarding patient presentation, aneurysm location, treatment, and outcomes were recorded. Patients who were treated with flow diverters placed in the proximal middle cerebral artery (MCA), proximal anterior cerebral artery, or distal internal carotid artery leading to coverage of the medial and lateral lenticulostriate vessels were included. Clinical outcomes according to the modified Rankin Scale were reviewed. Univariate and multivariate analyses were performed to establish risk factors for lenticulostriate infarct. RESULTS Fifty-two patients were included in the analysis. Postprocedure cross-sectional images were available in 30 patients. Two patients experienced transient occlusion of the MCA during the procedure; one was asymptomatic, and the other had a clinical and radiographic ipsilateral internal capsule stroke. Five patients had transient symptoms without radiographic infarct in the lenticulostriate territory. Two patients experienced in-stent thrombosis, leading to clinical MCA infarcts (one in the ipsilateral caudate) after discontinuing antiplatelet therapy. Discontinuation of dual antiplatelet therapy prior to 6 months was the only variable that was significantly correlated with stroke outcome (p < 0.01, OR 0.3, 95% CI 0-0.43), and this significance persisted when controlled for other risk factors, including age, smoking status, and aneurysm location. CONCLUSIONS The use and versatility of flow diversion is increasing, and safety data are continuing to accumulate. Here, the authors provide early data on the safety of covering lenticulostriate vessels with flow diverters. The authors concluded that the coverage of these perforators does not routinely lead to clinically significant ischemia when dual antiplatelet therapy is continued for 6 months. Further evaluation is needed in larger cohorts and with imaging follow-up as experience develops in using these devices in more distal circulation.
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Affiliation(s)
| | | | | | | | - Ajith J Thomas
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alejandro Enriquez-Marulanda
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Abdulrahman Y Alturki
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Maxim Mokin
- 3Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Anna L Kuhn
- 4Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts; and
| | - Ajit Puri
- 5Department of Neurosurgery, University of Texas at San Antonio, Texas
| | - Ramesh Grandhi
- 5Department of Neurosurgery, University of Texas at San Antonio, Texas
| | - Stephen Chen
- 6Radiology, Baylor College of Medicine, Houston, Texas
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18
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Kan P, Sweid A, Srivatsan A, Jabbour P. Expanding Indications for Flow Diverters: Ruptured Aneurysms, Blister Aneurysms, and Dissecting Aneurysms. Neurosurgery 2019; 86:S96-S103. [DOI: 10.1093/neuros/nyz304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The safety and efficacy of flow diversion (FD) in the treatment of cerebral aneurysms have been reported by many studies. FD has enabled the treatment of complex aneurysms and aneurysms that were previously untreatable by conventional means. It has achieved high rates of obliteration with essentially no recanalization, and its indications have continued to expand, now including ruptured aneurysms, blister aneurysms, and dissecting aneurysms.
OBJECTIVE
To provide a review on the outcomes of studies covering the use of FD in the settings of ruptured, blister, and dissecting aneurysms. In addition, to discuss dual antiplatelet therapy (DAPT) used in preparation for FD deployment in these scenarios, including associated complications with DAPT use in the acute rupture setting.
METHODS
References for this topical review were identified by PubMed searches between January 2000 and January 2019. The search terms “aneurysm”, “flow diverter”, “stent”, “pipeline”, “ruptured”, “blister”, and “dissecting aneurysms” were used.
RESULTS
FD carries a higher complication rate in the acute rupture setting than for unruptured aneurysms. Patient selection is of paramount importance for achieving good functional and angiographic outcomes. DAPT still remains challenging, especially in ruptured aneurysms. Advancements in surface modification of flow diverters can reduce the risk of thromboembolism and perhaps lead to a safer antiplatelet regimen.
CONCLUSION
In summary, FD shows promise to be an effective treatment for ruptured, blister, and dissecting aneurysms.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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19
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Wang J, Jia L, Duan Z, Wang Z, Yang X, Zhang Y, Lv M. Endovascular Treatment of Large or Giant Non-saccular Vertebrobasilar Aneurysms: Pipeline Embolization Devices Versus Conventional Stents. Front Neurosci 2019; 13:1253. [PMID: 31849580 PMCID: PMC6892827 DOI: 10.3389/fnins.2019.01253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/05/2019] [Indexed: 12/04/2022] Open
Abstract
Background Endovascular treatment of large or giant non-saccular vertebrobasilar aneurysms (VBAs) by conventional stents is difficult and has unsatisfactory outcomes. Object This study was performed to retrospectively analyze the safety and efficacy of a flow diverter in treating large and giant non-saccular VBAs. Methods We identified 78 patients with 83 large or giant non-saccular VBAs who accepted endovascular treatment with a pipeline embolization device (PED) or conventional stent from January 2014 to June 2018. The technical details of the procedure, procedure-associated complications, angiographic outcomes, and clinical outcomes were evaluated. Results Forty-two patients (53.8%, 42/78) with 44 aneurysms (53.0%, 44/83) underwent endovascular treatment with PEDs. Thirty-six patients (46.2%, 36/78) with 39 aneurysms (47.0%, 39/83) underwent endovascular treatment with conventional stents. The complication rate of PED group and conventional stent group was 7.1% (3/42) and 5.6% (2/36), respectively (odds ratio, 0.765; 95% confidence interval, 0.121–4.851; P = 0.776). During a median follow-up time of 28.8 months, the complete occlusion rate in the PED group and conventional stent group was 90.2% (37/41) and 70.3% (26/37), respectively (odds ratio, 3.913; 95% confidence interval, 1.122–13.652; P = 0.032). Conclusion Endovascular treatment with a PED is a promising and safe modality for large and giant non-saccular VBAs, and the complication rate is acceptable, compared with conventional endovascular treatment.
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Affiliation(s)
- Jiejun Wang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Luqiong Jia
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhibin Duan
- Department of Neurosurgery, Jincheng People's Hospital, Jincheng, China
| | - Zhongxiao Wang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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20
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Meybodi AT, Lawton MT, Benet A. Sequential Extradural Release of the V3 Vertebral Artery to Facilitate Intradural V4 Vertebral Artery Reanastomosis: Feasibility of a Novel Revascularization Technique. Oper Neurosurg (Hagerstown) 2019; 13:345-351. [PMID: 28521347 DOI: 10.1093/ons/opw015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 01/03/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Revascularization of the intradural vertebral artery (VA) usually involves V3-V4 bypass using an interposition graft. The interposition of a graft increases surgical time, adds risks, and requires 2 suture lines. OBJECTIVE To assess the feasibility of an excision-reanastomosis of V4 by sequentially releasing V3. METHODS Twenty specimens were prepared for surgical simulation of a far-lateral approach. The third and fourth segments of the VA were exposed through the far-lateral approach bilaterally. The V3 segment was divided into three subsegments: (1) V3 f : from entry to C1 transverse foramen to the point of exit from C1 transverse foramen; (2) V3 s : from V3 f to the distal point of V3 within the sulcus arteriosus; and (3) V3 d : from point V3 leaves the sulcus arteriosus to its dural entrance. After transecting the VA 2 mm proximal to the posterior inferior cerebellar artery origin, each subsegment was released sequentially. We measured the lengths obtained before and after releasing each segment by pulling the VA along its main axis to recreate a V3-V4 excision-reanastomosis. RESULTS The V3 could not be effectively mobilized without release. When totally released, an average length of 13.15 mm was available for completing V3-V4 reanastomosis. CONCLUSION Complete release of V3 from all its adhesions in its extracranial course can provide an average length of 13.15 mm for excision-reanastomosis. The present study shows the anatomic feasibility of the use of V3 segment in primary anastomosis after excision of a diseased segment of the intradural VA, laying the basis for future clinical application.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California
| | - Arnau Benet
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California
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21
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Kyeung Ko J, Weon Lee S, Hwa Choi C, Lee TH. Endovascular reconstructive treatment using a fill-and-tunnel technique for a fusiform vertebral artery dissecting aneurysm with ipsilateral dominance. Interv Neuroradiol 2019; 25:539-547. [PMID: 31088243 DOI: 10.1177/1591019919846616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Fusiform dissecting aneurysms involving the dominant vertebral artery with poor collaterals are challenging to treat. The purpose of this study was to present an initial experience with a fill and tunnel technique for reconstructive endovascular treatment of these conditions. METHODS A total of 13 patients, 11 men and 2 women, each with a fusiform vertebral artery dissecting aneurysm not amenable to internal trapping of the parent artery, underwent reconstructive endovascular treatment using a fill and tunnel technique between January 2012 and December 2015. The safety, feasibility, and clinical and angiographic outcomes of these procedures were retrospectively evaluated. RESULTS The average maximum diameter of the fusiform aneurysms was 12.1 mm. Five were ruptured. Three aneurysms were treated with a single stent and the remaining 10 aneurysms required double-stent placement. Treatment was technically successful in all 13 patients, achieving complete occlusion (n = 10, 76.9%) and near-complete occlusion (n = 3, 23.1%). No procedure-related complications occurred in any patient. There were no delayed thromboembolic or hemorrhagic complications during the follow-up period (mean, 19.0 months). Angiographic follow-ups (mean, 9.1 months) showed stable occlusion in 90.9% (10/11) and asymptomatic in-stent occlusion in one patient (9.1%, 1/11). At the end of the observation period (mean, 19.0 months), all patients had excellent clinical outcomes (modified Rankin Scale (mRS) 0, 92.3%, 12/13), except one (mRS 4), resulting from poor preoperative status. CONCLUSIONS This retrospective study demonstrated that endovascular reconstruction using a fill-and-tunnel technique was a technically safe, feasible, and clinically effective treatment method for fusiform vertebral artery dissecting aneurysms with ipsilateral dominance.
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Affiliation(s)
- Jun Kyeung Ko
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sang Weon Lee
- Department of Neurosurgery, Medical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chang Hwa Choi
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Tae Hong Lee
- Department of Diagnostic Radiology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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22
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Zhang Y, Liang F, Zhang Y, Yan P, Liang S, Ma C, Jiang C. Exploring the Feasibility of Pipeline Embolization Device Compared With Stent-Assisted Coiling to Treat Non-saccular, Unruptured, Intradural Vertebral Artery Aneurysms. Front Neurol 2019; 10:275. [PMID: 30972007 PMCID: PMC6443633 DOI: 10.3389/fneur.2019.00275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 03/04/2019] [Indexed: 11/15/2022] Open
Abstract
Object: The pipeline embolization device (PED) has been used to treat non-saccular, unruptured, intradural vertebral artery aneurysms at some institutions. However, there is an absence of large controlled studies validating the feasibility of this treatment. This study aimed to explore the therapeutic feasibility of PED by comparing PED treatment with controlled stent-assisted coiling (SAC). Materials and Methods: Thirty-two PED procedures were matched in a 1:2 manner with 64 SAC procedures based on patient age, sex, aneurysm size, and aneurysm location. Technical factors, procedural complications, angiographic results, and clinical outcomes were analyzed and compared. Results: There was no statistically significant difference in technical factors and procedural complications between the two groups (PED vs. SAC, 9.4 vs. 4.7%, P = 0.397). In multivariate analysis, smoking and therapeutic modality were identified as independent predictors of occlusion. Smoking was a risk factor for aneurysm obliteration [hazard ratio (HR) 0.53; 95% confidence interval (CI), 0.31–0.89; P = 0.018]. Aneurysms treated with PED were more likely to achieve obliteration over time compared with aneurysms treated with SAC (HR 2.97; 95% CI, 1.79–4.93; P < 0.001). The rate of favorable clinical outcomes (modified Rankin Scale (mRS), 0–2) was similar between the two groups (PED vs. SAC, 100 vs. 96.9%, P = 0.551). In the SAC group, one patient had neurological deficit with an mRS of four at the latest follow-up. There was no mortality in either group. Conclusions: The PED and SAC groups showed similar technical factors, procedural complications, angiographic results, and favorable clinical outcomes. Aneurysms treated with PED were more prone to obliteration over time than aneurysms treated with SAC. These outcomes suggest, based on short-term follow-up, PED is a safe and feasible strategy for the treatment of non-saccular, unruptured, intradural vertebral artery aneurysms.
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Affiliation(s)
- Yupeng Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fei Liang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuxiang Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Yan
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Chao Ma
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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23
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Kanematsu Y, Satomi J, Korai M, Okazaki T, Yamaguchi I, Tada Y, Uno M, Nagahiro S, Takagi Y. Flow Alteration Therapy for Ruptured Vertebral Artery Dissecting Aneurysms Involving the Posterior Inferior Cerebellar Artery. Neurol Med Chir (Tokyo) 2018; 58:341-349. [PMID: 29998934 PMCID: PMC6092607 DOI: 10.2176/nmc.oa.2018-0076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Surgery for- and endovascular treatment of vertebral artery (VA) dissecting aneurysms involving the origin of the posterior inferior cerebellar artery (PICA) remain challenging. Their ideal treatment is complete isolation of the aneurysm by surgical or endovascular trapping plus PICA reconstruction. However, postoperative lower cranial nerve palsy and medullary infarction are potential complications. We report four patients with VA dissecting aneurysms involving the PICA origin who were treated by occipital artery (OA)-PICA bypass followed by proximal occlusion of the VA and clip ligation of the PICA origin instead of trapping. There were no procedural or ischemic complications. In all patients, angiography performed 2–3 weeks later showed good patency of the bypass graft and complete obliteration of the aneurysm. During the follow-up period ranging from 1 to 14 years, none experienced bleeding. Although retrograde blood flow to the dissecting aneurysm persisted in the absence of trapping, iatrogenic lower cranial nerve injury could be avoided. The decrease in aneurysmal flow might elicit spontaneous thrombosis and prevent aneurysmal rerupture. Our technique might be less invasive than aneurysmal trapping and help to prevent rebleeding.
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Affiliation(s)
| | | | | | | | | | | | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
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24
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Giorgianni A, Pellegrino C, Minotto R, Mercuri A, Frattini L, Baruzzi F, Valvassori L. Flow-diverter stenting of post-traumatic bilateral anterior cerebral artery pseudoaneurysm: A case report. Interv Neuroradiol 2018; 21:23-8. [PMID: 25934771 DOI: 10.1177/1591019915575441] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The use of flow-diverter (FD) stents in recent years has positively changed the therapeutic approach to some vascular diseases, especially of certain types of aneurysms. This paper describes the case of a young patient after a major head trauma causing multiple skull fractures. The trauma occasioned two pseudoaneurysms from the A1 segment of the right anterior cerebral artery and from the A2 segment of the left anterior cerebral artery. Both lesions were treated with two Pipeline devices (ev3, Irvine, CA, USA) in two different sessions. The CT study and angiographic investigations performed in the following month showed a complete resolution of the post-traumatic pseudoaneurysmal lesions. Although the use of FD stents is described in the literature, particularly in the treatment of selected aneurysms, this paper shows good technical results in the use of these stents in cases of intracranial post-traumatic pseudoaneurysms with clinical improvement.
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Affiliation(s)
| | - Carlo Pellegrino
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Renzo Minotto
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Anna Mercuri
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Lara Frattini
- Departement of Anesthesiology, Ospedale di Circolo, Varese, Italy
| | - Fabio Baruzzi
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Luca Valvassori
- Departement of Neuroradiology, Ospedale Niguarda Ca' Granda, Milan, Italy
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25
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Wang CC, Fang YB, Zhang P, Zhu X, Hong B, Xu Y, Liu JM, Huang QH. Reconstructive endovascular treatment of vertebral artery dissecting aneurysms with the Low-profile Visualized Intraluminal Support (LVIS) device. PLoS One 2017; 12:e0180079. [PMID: 28662097 PMCID: PMC5491116 DOI: 10.1371/journal.pone.0180079] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/11/2017] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Chuan-Chuan Wang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi-Bin Fang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ping Zhang
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xuan Zhu
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian-Min Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (QHH); (JML)
| | - Qing-Hai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (QHH); (JML)
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26
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Awad AJ, Mascitelli JR, Haroun RR, De Leacy RA, Fifi JT, Mocco J. Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion. Neurosurg Focus 2017; 42:E14. [DOI: 10.3171/2017.3.focus1748] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fusiform aneurysms are uncommon compared with their saccular counterparts, yet they remain very challenging to treat and are associated with high rates of rebleeding and morbidity. Lack of a true aneurysm neck renders simple clip reconstruction or coil embolization usually impossible, and more advanced techniques are required, including bypass, stent-assisted coiling, and, more recently, flow diversion. In this article, the authors review posterior circulation fusiform aneurysms, including pathogenesis, natural history, and endovascular treatment, including the role of flow diversion. In addition, the authors propose an algorithm for treatment based on their practice.
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Affiliation(s)
- Ahmed J. Awad
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
- 2Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Justin R. Mascitelli
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| | - Reham R. Haroun
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| | - Reade A. De Leacy
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| | - Johanna T. Fifi
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| | - J Mocco
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
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27
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Patel PD, Chalouhi N, Atallah E, Tjoumakaris S, Hasan D, Zarzour H, Rosenwasser R, Jabbour P. Off-label uses of the Pipeline embolization device: a review of the literature. Neurosurg Focus 2017; 42:E4. [DOI: 10.3171/2017.3.focus1742] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.
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Affiliation(s)
- Purvee D. Patel
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- 2Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Elias Atallah
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 3Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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28
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Cerejo R, Bain M, Moore N, Hardman J, Bauer A, Hussain MS, Masaryk T, Rasmussen P, Toth G. Flow diverter treatment of intracranial vertebral artery dissecting pseudoaneurysms. J Neurointerv Surg 2017; 9:1064-1068. [PMID: 28438894 DOI: 10.1136/neurintsurg-2017-013020] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/19/2017] [Accepted: 03/27/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Intracranial vertebral dissecting pseudoaneurysms are a rare, but increasingly recognized, cause of subarachnoid hemorrhage and ischemic stroke. The risks of aneurysm re-rupture and associated morbidity are high. The use of flow diverter stents for the treatment of these aneurysms has not been well studied. OBJECTIVE To report our data and provide a summarized review of literature using flow diverter stents for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. METHODS We performed a retrospective analysis of flow diverter stents used for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. Clinical, imaging, procedural, and follow-up data were collected. RESULTS We identified eight vertebral dissecting pseudoaneurysms in seven patients (5 (71.4%) female; median age 47 years (IQR 46-52)) who had undergone treatment with flow diverter stents. In 4/7 patients (57.1%) the aneurysm had ruptured; however, only one was treated in the acute phase. Median size of the largest diameter of the aneurysm was 6.3 mm (IQR 4.2-8.8), and 7/8 aneurysms (87.5%) were treated with a single flow diverter device. Three aneurysms were concurrently coiled. Angiographic complete occlusion was seen in 6/8 (75%) aneurysms at a median follow-up of 14 months (IQR 7.7-20.2). Two patients had periprocedural strokes with transient neurologic deficits. All patients had a good clinical outcome (modified Rankin Scale score ≤2). There were no re-treatments or aneurysm ruptures during the follow-up period. CONCLUSIONS Our experience suggests that flow diverter stent treatment of intracranial vertebral artery dissecting pseudoaneurysms is safe, and associated with good occlusion rates and favorable clinical outcomes.
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Affiliation(s)
- Russell Cerejo
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Bain
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Moore
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Julian Hardman
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrew Bauer
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Thomas Masaryk
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter Rasmussen
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
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29
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Chung Y, Lee SH, Choi SK, Kim BJ, Lee KM, Kim EJ. Triple Stent Therapy for the Treatment of Vertebral Dissecting Aneurysms: Efficacy and Safety. World Neurosurg 2017; 99:79-88. [DOI: 10.1016/j.wneu.2016.11.118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
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30
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Wang A, Santarelli J, Stiefel MF. Pipeline embolization device as primary treatment for cervical internal carotid artery pseudoaneurysms. Surg Neurol Int 2017; 8:3. [PMID: 28217382 PMCID: PMC5288989 DOI: 10.4103/2152-7806.198730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 11/15/2016] [Indexed: 12/16/2022] Open
Abstract
Background: Limited data exists on the durability and occlusion rate of treating extracranial cervical internal carotid artery pseudoaneurysms using the pipeline embolization device (PED) flow-diverting stent. Methods: Three patients presenting with dissecting cervical internal carotid artery pseudoaneurysms were treated with the PED as the sole treatment modality. Results: In all three patients, successful aneurysmal occlusion and parent vessel reconstruction occurred on immediate angiography and continued on 6-month follow-up. No immediate or delayed complications were seen, and all patients remained neurologically intact. Conclusion: Complete aneurysmal occlusion and long-term angiographic occlusion can occur after PED treatment of cervical carotid pseudoaneurysms. In select patients, the PED can be a suitable primary treatment modality with good neurological outcome for cervical carotid pseudoaneurysms.
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Affiliation(s)
- Arthur Wang
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA
| | - Justin Santarelli
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA; NeuroVascular Institute, Westchester Medical Center, Valhalla, New York, USA
| | - Michael F Stiefel
- Capital Institute for Neurosciences, Stroke and Cerebrovascular Center, Capital Health System, Trenton, NJ, USA
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Zhang YS, Wang S, Wang Y, Tian ZB, Liu J, Wang K, Chen JF, Yang XJ. Treatment for Spontaneous Intracranial Dissecting Aneurysms in Childhood: A Retrospective Study of 26 Cases. Front Neurol 2016; 7:224. [PMID: 27999562 PMCID: PMC5138241 DOI: 10.3389/fneur.2016.00224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 11/23/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study aimed to assess the clinicoradiological features and treatment outcomes of intracranial dissecting aneurysms (IDAs) in childhood. METHODS We conducted a retrospective study of pediatric patients who were treated for spontaneous IDAs in our institute between January 2010 and December 2015. The clinical presentation, aneurysm characteristics, treatment modality, and outcome were studied. RESULTS We studied 26 pediatric patients (mean age, 13.4 years; range, 4-18 years) with 31 IDAs who comprised 6.9% of all IDA patients treated during the same period. Seventeen (65.4%) patients were males, and nine (34.6%) were females. The incidence of large (≥10 mm in size) or giant aneurysms (≥25 mm in size) was 65.5%. Twenty-one (80.8%) patients underwent endovascular or surgical treatment and five (19.2%) received conservative treatment. Perioperative complications occurred in three patients, in whom two eventually recovered completely with a Glasgow Outcome Scale (GOS) score of 5 and one partially recovered with a GOS score 4. Overall, 25 (96.2%) patients had a favorable outcome and one (3.8%) had an unfavorable outcome at a mean follow-up of 22.8 months (range, 6-60 months). CONCLUSION Pediatric IDAs are rare. In this series, endovascular management was a relatively safe and effective method of treatment for pediatric IDAs. However, continued follow-up is required because of the possibility of aneurysm recurrence and de novo aneurysm formation after treatment.
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Affiliation(s)
- Yi-Sen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Yang Wang
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University , Nanchang , China
| | - Zhong-Bin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Jun-Fan Chen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Xin-Jian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University , Beijing , China
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Zhang Y, Tian Z, Sui B, Wang Y, Liu J, Li M, Li Y, Jiang C, Yang X. Endovascular Treatment of Spontaneous Intracranial Fusiform and Dissecting Aneurysms: Outcomes Related to Imaging Classification of 309 Cases. World Neurosurg 2016; 98:444-455. [PMID: 27890754 DOI: 10.1016/j.wneu.2016.11.074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/14/2016] [Accepted: 11/15/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To propose a modified classification system for spontaneous intracranial dissecting aneurysms (IDAs) that can guide treatment decisions. METHODS Between January 2010 and December 2015, 3183 consecutive patients were referred to our department for endovascular treatment of a cerebral aneurysm. Among this group, 309 patients harboring a total of 323 spontaneous IDAs were identified. Based on a modified imaging classification system, spontaneous IDAs were classified into 4 subtypes: classic dissecting aneurysm, segmental ectasia, dolichoectatic dissecting aneurysm, and large mural bleeding ectasia. A logistic regression analysis was conducted to identify predictors of clinical outcomes. RESULTS Of the 323 IDAs, 216 (66.87%) were treated with stent-assisted coiling, 47 (14.55%) with internal trapping, and 60 (18.58%) with sole stenting. Of the 309 patients, 8 (2.59%) suffered intraoperative complications, 40 (12.94%) experienced postoperative complications, 9 died (2.79%), and 1 (0.32%) had severe disability. The mean duration of clinical follow-up of the 309 patients was 10.40 months (range, 3-72 months). Imaging follow-up was available for 262 patients (274 IDAs), with a mean duration of 7.10 months (range, 3-60 months), and 24 aneurysm recurrences (9.16%) were noted. Aneurysm type was the sole independent predictor of different outcomes on logistic regression analysis (P = 0.004). CONCLUSIONS There was a strong relationship between the subtypes of spontaneous IDAs and clinical course. Our classification system is confirmed to be helpful in assessing patients' prognosis and guiding their treatment.
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Affiliation(s)
- Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Binbin Sui
- Department of Neuroimaging, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, First Affiliated Hospital, Nanchang University, Nanchang, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Miao Li
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Ota N, Tanikawa R, Eda H, Matsumoto T, Miyazaki T, Matsukawa H, Yanagisawa T, Suzuki G, Miyata S, Oda J, Noda K, Tsuboi T, Takeda R, Kamiyama H, Tokuda S. Radical treatment for bilateral vertebral artery dissecting aneurysms by reconstruction of the vertebral artery. J Neurosurg 2016; 125:953-963. [DOI: 10.3171/2015.8.jns15362] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Bilateral vertebral artery dissecting aneurysms (VADAs) have a poor prognosis because progressive enlargement of the aneurysms compresses the brainstem or causes subarachnoid hemorrhage. The trapping of 1 vertebral artery (VA) places increased hemodynamic stress on the contralateral VA and may lead to enlargement and rupture. Therefore, management strategies are controversial. This study describes a radical treatment for bilateral VADAs using bypass surgery.
METHODS
Seven patients with bilateral VADAs were included. Three patients were treated by trapping of 1 VA via coiling or clipping at another hospital; the previously treated VA in 1 patient and the contralateral untreated VA in 2 patients subsequently enlarged. The other 4 patients presented without previous intervention and progressive enlargement of the aneurysms.
RESULTS
The post–coil embolization patients underwent V3–posterior cerebral artery (PCA) bypass and trapping. The other 4 patients underwent VA reconstruction via V3–V4 or V4–V4 bypass, with contralateral trapping on a separate day in 3 patients and observation in 1 patient. Perioperative complications included 1 case of cerebrospinal fluid leakage for which the patient required an additional operation, 1 case of dysphagia and facial palsy due to sigmoid sinus thrombosis, and 1 case of dysphagia. The long-term outcomes of these patients were favorable.
CONCLUSIONS
Patients with bilateral VADAs require treatment on both sides. If VA trapping is performed first, the treatment options for the other side are limited to V3-PCA bypass and trapping. This procedure is effective; however, it is also invasive and technically difficult. In cases of bilateral VADAs in which it is feasible to reconstruct 1 side, the best approach is to begin by reconstructing the VA that appears technically easiest, followed by trapping of the contralateral VADA. This strategy allows enough time to suture vessels because contralateral reverse flow is maintained.
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Magnetic Resonance Imaging Follow-Up of Large or Giant Vertebrobasilar Dissecting Aneurysms After Total Embolization on Angiography. World Neurosurg 2016; 91:218-27. [DOI: 10.1016/j.wneu.2016.04.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 04/06/2016] [Accepted: 04/06/2016] [Indexed: 02/05/2023]
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Kim SO, Chung YG, Won YS, Rho MH. Delayed Ischemic Stroke after Flow Diversion of Large Posterior Communicating Artery Aneurysm. J Cerebrovasc Endovasc Neurosurg 2016; 18:19-26. [PMID: 27114962 PMCID: PMC4842904 DOI: 10.7461/jcen.2016.18.1.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 12/21/2015] [Accepted: 03/09/2016] [Indexed: 11/23/2022] Open
Abstract
For securing large, giant, and wide-neck aneurysms, conventional coil embolization has substantial limitations, such as incomplete occlusion, recanalization, and a high recurrence rate. To overcome these limitations, a novel paradigm was suggested and, as a result, flow-diverting device was developed. The flow-diverting device is an innovative and effective technique to allow securing of large, giant, and wide-neck aneurysms. In numerous studies, the flow-diverting device has shown better outcomes than coil embolization. However, the flow-diverting device has also some risks, including rupture of aneurysm, intracerebral hemorrhage, and ischemic stroke. In addition, with more experience, unexpected complications are also reported.5)7) In the present case, we experienced a delayed ischemic stroke at 27 days after endovascular treatment. The patient had multiple aneurysms and, among them, we treated a large posterior communicating artery aneurysm using Pipeline™ Embolization Device. The patient was tolerable for 25 days, but then suddenly presented intermittent right hemiparesis. In the initial diffusion magnetic resonance imaging (MRI), there was no acute lesion; however, in the follow-up MRI, an acute ischemic stroke was found in the territory of anterior choroidal artery which was covered by Pipeline Embolization Device. We suspect that neo-intimal overgrowth or a tiny thrombus have led to this delayed complication. Through our case, we learned that the neurosurgeon should be aware of the possibility of delayed ischemic stroke after flow diversion, as well as, long-term close observation and follow-up angiography are necessary even in the event of no acute complications.
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Affiliation(s)
- Si On Kim
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Yeon Gu Chung
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Yu Sam Won
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Myung Ho Rho
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
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Zhou G, Su M, Zhu YQ, Li MH. Efficacy of Flow-Diverting Devices for Cerebral Aneurysms: A Systematic Review and Meta-analysis. World Neurosurg 2016; 85:252-62. [DOI: 10.1016/j.wneu.2015.09.088] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 09/26/2015] [Accepted: 09/26/2015] [Indexed: 11/30/2022]
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Kühn AL, Kan P, Massari F, Lozano JD, Hou SY, Howk M, Gounis MJ, Wakhloo AK, Puri AS. Endovascular reconstruction of unruptured intradural vertebral artery dissecting aneurysms with the Pipeline embolization device. J Neurointerv Surg 2015; 8:1048-51. [DOI: 10.1136/neurintsurg-2015-012028] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/16/2015] [Indexed: 11/04/2022]
Abstract
BackgroundDissecting aneurysms of the vertebral artery (VA) are difficult to treat using current surgical and endovascular techniques.ObjectiveTo analyze retrospectively the efficacy and safety of flow diverters in the treatment of dissecting aneurysms of the vertebral artery.MethodsWe identified six patients with six unruptured VA dissecting aneurysms either arising from the V4 or V3–V4 junction that were treated with the Pipeline embolization device (PED) at our institution between July 2012 and February 2015. Among other parameters, technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated.ResultsPED placement was achieved in all cases and immediate angiography follow-up demonstrated intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of dysarthria was noted in one patient. Major procedure-related complications were not observed. The 6-month follow-up (n=6) demonstrated complete/near-complete aneurysm obliteration in five patients and partial obliteration in one. At the 1-year follow-up (n=5) stable complete aneurysm occlusion was seen in two patients. Two cases showed progression from near complete occlusion and partial occlusion at 6 months to complete occlusion and near complete occlusion. One cases showed unchanged near complete occlusion. No aneurysmal bleeding, in-stent stenosis or thromboembolic complication was seen. National Institutes of Health Stroke Scale and modified Rankin scale scores remained unchanged from admission to discharge.ConclusionsOur preliminary experience with the use of PED for the treatment of intradural VA dissecting aneurysms shows promising short-term results, making this technique a feasible and safe treatment option in patients suitable for this approach. However, long-term and larger cohort studies are needed to validate these results.
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Gölitz P, Struffert T, Hoelter P, Eyüpoglu I, Knossalla F, Doerfler A. Flow-diverting stents allow efficient treatment of unruptured, intradural dissecting aneurysms of the vertebral artery: An explanatory approach using in vivo flow analysis. Interv Neuroradiol 2015; 22:76-83. [PMID: 26515700 DOI: 10.1177/1591019915609166] [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: 06/15/2015] [Accepted: 08/09/2015] [Indexed: 12/26/2022] Open
Abstract
OBJECT Our study aimed to evaluate the efficiency of flow-diverting stents (FDS) in treating unruptured, intradural dissecting aneurysms of the vertebral artery (VADAs). Additionally, the effect of FDS on the aneurysmal flow pattern was investigated by performing in vivo flow analysis using parametric color coding (PCC). METHODS We evaluated 11 patients with unruptured, intradural VADAs, treated with FDS. Pre- and postinterventional DSA-series were postprocessed by PCC, and time-density curves were calculated. The parameters aneurysmal inflow-velocity, outflow-velocity and relative time-to-peak (rTTP) were calculated. Pre- and postinterventional values were compared and correlated with the occlusion rate after six months. RESULTS Follow-up DSA detected 10 aneurysms occluded, meaning an occlusion rate of 91%. No procedure-related morbidity and mortality was found. Flow analyses revealed a significant reduction of aneurysmal inflow- velocity and prolongation of rTTP after FDS deployment. Concerning aneurysm occlusion, the postinterventional outflow-velocity turned out to be a marginally statistically significant predictor. A definite threshold value (-0.7 density change/s) could be determined for the outflow-velocity that allows prediction of complete aneurysm occlusion with high sensitivity and specificity (100%). CONCLUSIONS Using FDS can be considered an efficient and safe therapy option in treating unruptured, intradural VADA. From in vivo flow analyses the postinterventional aneurysmal outflow-velocity turned out to be a potential predictor for later complete aneurysm occlusion. Here, it might be possible to determine a threshold value that allows prediction of aneurysm occlusion with high specificity and sensitivity. As fast, applicable and easy-to-handle tool, PCC could be used for procedural monitoring and might contribute to further treatment optimization.
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Affiliation(s)
- Philipp Gölitz
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | - Tobias Struffert
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | - Philip Hoelter
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | - Ilker Eyüpoglu
- Department of Neurosurgery, University of Erlangen-Nuremberg, Germany
| | - Frauke Knossalla
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
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Mazur MD, Kilburg C, Wang V, Taussky P. Pipeline embolization device for the treatment of vertebral artery aneurysms: the fate of covered branch vessels. J Neurointerv Surg 2015; 8:1041-7. [DOI: 10.1136/neurintsurg-2015-012040] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 09/29/2015] [Indexed: 11/04/2022]
Abstract
IntroductionPreliminary studies suggest that flow-diverting stents may be suitable for the treatment of aneurysms of the posterior circulation. The safety and efficacy of using flow-diverting stents for vertebral artery (VA) aneurysms is not well defined.ObjectiveTo examine the fate of covering the posterior inferior cerebellar artery (PICA) in patients undergoing placement of a flow-diverting stent for VA aneurysm.MethodsConsecutive patients who underwent placement of a Pipeline Embolization Device (PED) for treatment of an aneurysm of the V4 segment of the VA between April 2012 and June 2015 at our institution were retrospectively evaluated. Angiograms were reviewed to determine the patency of the PICA when the vessel origin was covered by the PED.Results11 patients with VA aneurysms who underwent treatment with the PED were identified. In each case the device covered the origin of the PICA. Follow-up angiography in eight patients demonstrated thrombosis of the aneurysm with patency of the PICA.ConclusionsFlow-diverting stents can be used for the treatment of VA aneurysms. When appropriately sized to the vessel wall and positioned in the VA, the device may cover the origin of the PICA without impairing flow through the branching artery.
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40
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Treatment strategies for dissecting aneurysms of the posterior cerebral artery. Acta Neurochir (Wien) 2015; 157:1633-43. [PMID: 26259621 DOI: 10.1007/s00701-015-2526-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/28/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Dissecting aneurysms of the posterior cerebral artery (PCA) are rare and difficult to treat because of their deep and unfamiliar locations and unusual shapes. Although several treatment modalities have been proposed, none have generated satisfying results. Our experiences with PCA-dissecting aneurysms are reviewed and the treatment strategies discussed. METHODS All consecutive patients with PCA-dissecting aneurysm who were treated in a tertiary referral hospital between January 1998 and March 2014 were identified by retrospective review. Their clinical characteristics, radiological findings, treatment modalities and outcomes were documented. RESULTS Of the 21 patients with 21 PCA-dissecting aneurysms, 9 had subarachnoid hemorrhage and 3 had acute infarction of the thalamus at presentation. The aneurysms involved P1 (n = 4), the P1-2 junction (n = 3), mid-P2 (n = 6), P2A (n = 3), P2P (n = 1) and the P2-3 junction (n = 4). The aneurysm shapes were as follows: fusiform (n = 12), partially thrombosed (n = 8) and blood blister-like aneurysms (n = 1). The mean size was 16.6 ± 9.7 mm. Parent artery occlusion (PAO) without bypass (n = 15), PAO with bypass (n = 2), stent-assisted endosaccular coiling (n = 3) and stent placement only (n = 1) were performed. All three patients who underwent stent-assisted endosaccular coiling and the single patient who underwent PAO without bypass developed aneurysm recurrence. Six of the ten patients who received a PAO without a balloon test occlusion (BTO) experienced PCA territory infarction, whereas only one of the five patients who received a PAO after passing the BTO experienced an infarction. CONCLUSIONS PAO for PCA-dissecting aneurysm was effective in preventing recurrence. In addition, BTO before PAO was helpful in identifying candidates who truly needed surgical revascularization.
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Debette S, Compter A, Labeyrie MA, Uyttenboogaart M, Metso TM, Majersik JJ, Goeggel-Simonetti B, Engelter ST, Pezzini A, Bijlenga P, Southerland AM, Naggara O, Béjot Y, Cole JW, Ducros A, Giacalone G, Schilling S, Reiner P, Sarikaya H, Welleweerd JC, Kappelle LJ, de Borst GJ, Bonati LH, Jung S, Thijs V, Martin JJ, Brandt T, Grond-Ginsbach C, Kloss M, Mizutani T, Minematsu K, Meschia JF, Pereira VM, Bersano A, Touzé E, Lyrer PA, Leys D, Chabriat H, Markus HS, Worrall BB, Chabrier S, Baumgartner R, Stapf C, Tatlisumak T, Arnold M, Bousser MG. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol 2015; 14:640-54. [PMID: 25987283 DOI: 10.1016/s1474-4422(15)00009-5] [Citation(s) in RCA: 264] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 02/26/2015] [Accepted: 03/20/2015] [Indexed: 12/27/2022]
Abstract
Spontaneous intracranial artery dissection is an uncommon and probably underdiagnosed cause of stroke that is defined by the occurrence of a haematoma in the wall of an intracranial artery. Patients can present with headache, ischaemic stroke, subarachnoid haemorrhage, or symptoms associated with mass effect, mostly on the brainstem. Although intracranial artery dissection is less common than cervical artery dissection in adults of European ethnic origin, intracranial artery dissection is reportedly more common in children and in Asian populations. Risk factors and mechanisms are poorly understood, and diagnosis is challenging because characteristic imaging features can be difficult to detect in view of the small size of intracranial arteries. Therefore, multimodal follow-up imaging is often needed to confirm the diagnosis. Treatment of intracranial artery dissections is empirical in the absence of data from randomised controlled trials. Most patients with subarachnoid haemorrhage undergo surgical or endovascular treatment to prevent rebleeding, whereas patients with intracranial artery dissection and cerebral ischaemia are treated with antithrombotics. Prognosis seems worse in patients with subarachnoid haemorrhage than in those without.
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Affiliation(s)
- Stéphanie Debette
- Department of Neurology, Lariboisière Hospital, Paris 7 University, DHU Neurovasc Sorbonne Paris Cité, Paris, France; Inserm U897, Bordeaux University, France.
| | - Annette Compter
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc-Antoine Labeyrie
- Department of Neuroradiology, Lariboisière Hospital, Paris 7 University, DHU Neurovasc Sorbonne Paris Cité, Paris, France
| | - Maarten Uyttenboogaart
- Departments of Neurology and Radiology, University Medical Centre Groningen, Groningen, Netherlands
| | - Tina M Metso
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital of Basel, Basel, Switzerland; Neurorehabilitation Unit, University Centre for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, Basel, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, Brescia University Hospital, Brescia, Italy
| | - Philippe Bijlenga
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Medical Center, Geneva, Switzerland
| | - Andrew M Southerland
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Olivier Naggara
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Center Hospitalier Sainte-Anne, DHU Neurovasc Paris Sorbonne, Paris, France
| | - Yannick Béjot
- Department of Neurology, Dijon University Hospital, Dijon, France
| | - John W Cole
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anne Ducros
- Department of Neurology, Gui de Chauliac Hospital, Montpellier I University, Montpellier, France
| | - Giacomo Giacalone
- Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele, Milano, Italy
| | | | - Peggy Reiner
- Department of Neurology, Lariboisière Hospital, Paris 7 University, DHU Neurovasc Sorbonne Paris Cité, Paris, France
| | - Hakan Sarikaya
- Department of Neurology, University Hospital Inselspital and University of Bern, Bern, Switzerland; Department of Neurology, University Hospital of Zürich, Zürich, Switzerland
| | - Janna C Welleweerd
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Gert Jan de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Leo H Bonati
- Department of Neurology and Stroke Centre, University Hospital of Basel, Basel, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Vincent Thijs
- Department of Neurosciences, Experimental Neurology, Laboratory of Neurobiology, KU Leuven University of Leuven, Leuven, Belgium; VIB-Vesalius Research Center, Leuven, Belgium; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Juan J Martin
- Department of Neurology, Sanatorio Allende, Cordoba, Argentina
| | - Tobias Brandt
- Clinics for Neurologic Rehabilitation, Kliniken Schmieder, Heidelberg, Germany
| | | | - Manja Kloss
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Tohru Mizutani
- Department of Neurosurgery, Showa University, Tokyo, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | | | - Vitor M Pereira
- Division of Neuroradiology, Department of Medical Imaging, and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Anna Bersano
- Cerebrovascular Disease Unit, IRCCS Foundation C Besta Neurological Institute, Milan, Italy
| | - Emmanuel Touzé
- Université Caen Basse Normandie, Inserm U919, Department of Neurology, CHU Côte de Nacre, Caen, France
| | - Philippe A Lyrer
- Department of Neurology and Stroke Centre, University Hospital of Basel, Basel, Switzerland
| | - Didier Leys
- Department of Neurology, Lille University Hospital, Lille, France
| | - Hugues Chabriat
- Department of Neurology, Lariboisière Hospital, Paris 7 University, DHU Neurovasc Sorbonne Paris Cité, Paris, France
| | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Bradford B Worrall
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Stéphane Chabrier
- French Centre for Paediatric Stroke and EA3065, Saint-Etienne University Hospital, Saint-Etienne, France
| | | | - Christian Stapf
- Department of Neurology, Lariboisière Hospital, Paris 7 University, DHU Neurovasc Sorbonne Paris Cité, Paris, France
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Marcel Arnold
- Department of Neurology, University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Marie-Germaine Bousser
- Department of Neurology, Lariboisière Hospital, Paris 7 University, DHU Neurovasc Sorbonne Paris Cité, Paris, France
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Daou B, Starke RM, Chalouhi N, Tjoumakaris S, Khoury J, Hasan D, Rosenwasser RH, Jabbour PM. The Use of the Pipeline Embolization Device in the Management of Recurrent Previously Coiled Cerebral Aneurysms. Neurosurgery 2015; 77:692-7; discission 697. [DOI: 10.1227/neu.0000000000000901] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The biggest downside of cerebral aneurysm coiling is the high rates of recurrence and retreatments. With the increasing number of aneurysm recurrences after failed coiling procedures, the best retreatment strategy remains unknown.
OBJECTIVE:
To assess the efficacy and safety of the Pipeline Embolization Device (PED) in the treatment of recurrent previously coiled aneurysms.
METHODS:
Thirty-three patients who underwent treatment with the PED of a recurrent previously coiled aneurysm were retrospectively identified. Efficacy was assessed in terms of angiographic occlusion at the latest cerebral angiogram, recurrence and retreatment rates after PED placement, and clinical outcome at the latest follow-up. Safety was assessed by looking at the complications, morbidity, and mortality after PED treatment.
RESULTS:
The mean patient age was 53 years. The mean percent recurrence from coiling to PED placement was 34%. The mean time from coiling to PED placement was 40 months. PED treatment resulted in complete aneurysm occlusion in 76.7% of patients and near-complete aneurysm occlusion (≥90%) in 10%, for a total rate of complete and near-complete aneurysm occlusion of 86.7%. All patients, including those with incomplete aneurysm occlusion, had a significant reduction in aneurysm size. Two aneurysms required another retreatment after PED placement (6.2%). Ninety-seven percent of patients had a good clinical outcome. Complications were observed in 1 patient (3%), who suffered an intracerebral hemorrhage. There were no mortalities.
CONCLUSION:
The use of the PED in the management of recurrent, previously coiled aneurysms is safe and effective in achieving aneurysm occlusion.
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Affiliation(s)
- Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Jean Khoury
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | | | - Pascal M. Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Li H, Li XF, Zhang X, He XY, Duan CZ, Liu YC. Treatment of unruptured vertebral dissecting aneurysms: internal trapping or stent-assisted coiling. Int J Neurosci 2015; 126:243-8. [PMID: 26001201 DOI: 10.3109/00207454.2015.1010648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Endovascular treatment is an attractive approach for the treatment of unruptured vertebral dissecting aneurysms, and includes internal trapping and stent-assisted coil embolization. However, the optimal therapy remains debatable. We reviewed our experience with both endovascular treatment modalities and compared the safety, efficacy, and short-term outcomes for each approach. MATERIALS AND METHODS We retrospectively reviewed 65 consecutive patients with unruptured vertebral dissecting aneurysms who underwent endovascular treatment between January 2003 and January 2014. 24 patients underwent endovascular internal trapping (group A) while 41 patients underwent stent-assisted coiling (group B). Thirteen patients underwent single stent with coiling while 28 patients underwent double or three stent-assisted coiling. Short-term outcomes were evaluated using the modified Rankin Scale. RESULTS A favorable clinical outcome was achieved in 58 of 65 patients. Procedure-related complications included ischemic symptoms (n = 6) and recurrence (n = 4). There was no statistical difference in modified Rankin Scale scoring between groups. Group A patients had more ischemia symptoms compared with group B patients (p = 0.043), Group B patients had higher recurrence rates compared with group A patients, but the difference had no statistical significance (p = 1.00). However, recurrence only occurred in patients who underwent stent-assisted coiling alone (p = 0.046). CONCLUSION Stent-assisted coiling for unruptured vertebral dissecting aneurysms may maintain artery patency. Multilayer disposition of stents with coils may decrease complications and facilitate aneurysm occlusion. Larger, prospective studies are necessary to determine the long-term outcomes of reconstructive therapy.
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Affiliation(s)
- Hui Li
- a Department of Neurosurgery , Southern Medical University , Zhujiang Hospital, 253# Industry Road, Guangzhou , Guangdong , RP China
| | - Xi-Feng Li
- a Department of Neurosurgery , Southern Medical University , Zhujiang Hospital, 253# Industry Road, Guangzhou , Guangdong , RP China
| | - Xin Zhang
- a Department of Neurosurgery , Southern Medical University , Zhujiang Hospital, 253# Industry Road, Guangzhou , Guangdong , RP China
| | - Xu-Ying He
- a Department of Neurosurgery , Southern Medical University , Zhujiang Hospital, 253# Industry Road, Guangzhou , Guangdong , RP China
| | - Chuan-Zhi Duan
- a Department of Neurosurgery , Southern Medical University , Zhujiang Hospital, 253# Industry Road, Guangzhou , Guangdong , RP China
| | - Yan-Chao Liu
- a Department of Neurosurgery , Southern Medical University , Zhujiang Hospital, 253# Industry Road, Guangzhou , Guangdong , RP China
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Bhogal P, Brouwer PA, Söderqvist ÅK, Ohlsson M, Andersson T, Holmin S, Söderman M. Patients with subarachnoid haemorrhage from vertebrobasilar dissection: treatment with stent-in-stent technique. Neuroradiology 2015; 57:605-14. [PMID: 25740790 DOI: 10.1007/s00234-015-1505-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/20/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Vertebrobasilar dissection is an uncommon cause of subarachnoid haemorrhage (SAH) that carries a high risk for early repeat haemorrhage. The need for rapid treatment of this disease entity is without question; however, the best method for treatment is still undetermined. Here, we present our results using the stent-in-stent technique, without coiling, for these patients and propose that it is a viable treatment strategy. METHODS We identified in our local database for neurointerventional therapy, between 1st October 2000 and 1st January 2014, 93 patients with potential subarachnoid haemorrhage secondary to vertebrobasilar pathology. After review of the clinical notes and imaging, 15 were found to have presented with subarachnoid haemorrhage and treated with stents alone. All dissections were spontaneous with no history of preceding trauma. The ages ranged between 46 and 71 years (mean 61 years). RESULTS All patients presented with Fischer grade 4 SAH and had a visible pseudoaneurysm. The pre-operative GCS varied with two patients scoring 3, one patient scoring 6 and the remaining 12 patients scoring 8 or above. All cases were subjected to stent-in-stent treatment alone. We did not experience any intra-procedural complications. In our series, eight patients had full recovery with a Glasgow Outcome Scale (GOS) of 5, three had moderate disability (GOS 4), one had severe disability (GOS 3), and three patents died, one patient from stent thrombosis or re-bleeding and two from their initial SAH. CONCLUSION The stent-in-stent technique represents a viable reconstructive endovascular surgical technique with a low risk of intra-procedural complication and post-operative repeat haemorrhage.
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Affiliation(s)
- Pervinder Bhogal
- Department of Neuroradiology, The Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden,
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Song Y, Wang Y, Li C, Wang Y, Mu S, Yang X. Retreatment and outcomes of recurrent intracranial vertebral artery dissecting aneurysms after stent assisted coiling: a single center experience. PLoS One 2014; 9:e113027. [PMID: 25393341 PMCID: PMC4231114 DOI: 10.1371/journal.pone.0113027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 10/22/2014] [Indexed: 01/04/2023] Open
Abstract
Background and purpose The retreatment of recurrent intracranial vertebral artery dissecting aneurysms (VADAs) after stent assisted coiling (SAC) has not yet been studied. The purpose of this study was to evaluate the strategies and outcomes for retreatment of recurrent VADAs after SAC. Methods Between September 2009 and November 2013, six consecutive patients presenting with recurrent intracranial VADAs after SAC were enrolled in this study. They were all male with age ranging from 29 to 54 years (mean age, 46.2 years). The procedures of treatments and angiographic and clinical follow-up were reviewed retrospectively. Retreatment modalities were selected individually according to the characteristics of recurrence. The outcomes of retreatment were evaluated by angiographic and clinical follow-up. Results Six patients with recurrent intracranial VADAs after SAC were retreated, with second SAC in three patients, coil embolization, double overlapping stents placement and endovascular occlusion with aneurysm trapping in one patient, respectively. Immediate angiographic outcomes of retreatment were: complete occlusion in three patients, nearly complete occlusion in two patients, and contrast medium retention in dissecting aneurysm in one patient. All cases were technically successful. No complications related to endovascular procedures occurred. Angiographic follow-up was available in all five patients treated with second SAC or double overlapping stents, which was complete occlusion in four patients, obliteration of parent artery in one patient, showing no recurrence at 4–11 months (mean: 8.6 months). Clinical follow-up was performed in all six patients at 11–51 months after initial endovascular treatment and at 9–43 months after retreatment. The mRS of last clinical follow-up was excellent in five patients and mild disability in only one patient. Conclusions Endovascular retreatment is feasible and effective for recurrent intracranial VADAs after SAC. Individualized strategies of retreatment should be enacted according to the characteristics and reasons for the recurrence.
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Affiliation(s)
- Ying Song
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanmin Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shiqing Mu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- * E-mail:
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Nam KH, Ko JK, Cha SH, Choi CH, Lee TH, Lee JI. Endovascular treatment of acute intracranial vertebral artery dissection: long-term follow-up results of internal trapping and reconstructive treatment using coils and stents. J Neurointerv Surg 2014; 7:829-34. [PMID: 25237069 DOI: 10.1136/neurintsurg-2014-011366] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 08/30/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular internal trapping is an effective procedure for the treatment of acute vertebral artery dissection (VAD). However, the outcomes of reconstructive treatment have not been well established. The aim of our study is to evaluate the long-term clinical and angiographic results of endovascular internal trapping or reconstructive treatment of acute VAD. METHODS Between 2005 and 2013, 26 patients with acute VAD were managed with internal coil trapping (n=10), stent-assisted coiling (n=14), stent only (n=1), and proximal occlusion (n=1). Stent-assisted coiling included the modified stent-assisted semi-jailing technique (n=10), balloon-in-stent technique (n=2), and coiling followed by balloon mounted stent (n=2). Digital subtraction angiography (DSA) was performed in all patients except for three who died during the acute stage. RESULTS Of 26 patients with VAD, 14 and 12 presented with hemorrhagic and non-hemorrhagic types, respectively. The dominancy of the relevant artery was defined as dominant (n=9), even (n=12), and non-dominant (n=5). Reconstructive treatment was performed in six patients with ruptured VADs which failed balloon test occlusion and nine with non-hemorrhagic VADs. Clinical outcomes were favorable in 22 (84.6%), severe disability occurred in one, and there were three deaths (11.5%). All patients except the three who died had angiographic follow-up at 6-32 months (mean 10.4 months). The angiographic results of nine cases of internal trapping and one of proximal occlusion all showed a stable occlusion state. Among the 15 cases of reconstructive treatment, follow-up DSAs were available for the 13 surviving patients, 10 of which demonstrated stable occlusion of aneurysmal dilation and patent parent artery. CONCLUSIONS This study suggests that internal trapping is a stable and effective treatment for acute VAD. Reconstructive treatment using stent and coils could also be a feasible alternative modality for hemorrhagic type VAD. However, serial DSA follow-up is essential.
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Affiliation(s)
- Kyoung Hyup Nam
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jun Kyeung Ko
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Seung Heon Cha
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Chang Hwa Choi
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Tae Hong Lee
- Department of Diagnostic Radiology, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Successful Treatment of Growing Basilar Artery Dissecting Aneurysm by Pipeline Flow Diversion Embolization Device. J Stroke Cerebrovasc Dis 2014; 23:1713-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 10/06/2013] [Accepted: 11/20/2013] [Indexed: 11/24/2022] Open
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Use of concentric Solitaire stent to anchor Pipeline flow diverter constructs in treatment of shallow cervical carotid dissecting pseudoaneurysms. J Clin Neurosci 2014; 21:1024-8. [DOI: 10.1016/j.jocn.2013.10.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 10/19/2013] [Indexed: 11/17/2022]
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Zhou Y, Yang PF, Fang YB, Xu Y, Hong B, Zhao WY, Li Q, Zhao R, Huang QH, Liu JM. Parent artery reconstruction for large or giant cerebral aneurysms using a Tubridge flow diverter (PARAT): study protocol for a multicenter, randomized, controlled clinical trial. BMC Neurol 2014; 14:97. [PMID: 24885396 PMCID: PMC4016793 DOI: 10.1186/1471-2377-14-97] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 04/11/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The treatment of large (10-25 mm) or giant (≥25 mm) cerebral aneurysms remains technically challenging, with a much higher complication and recanalization rate than that is observed for smaller aneurysms. The use of a flow diverter seems to facilitate the treatment of this special entity. In a previous single-center prospective study approved by the Ethics Committee and China Food and Drug Administration (CFDA), we obtained promising results, showing remarkable safety and effectiveness for the Tubridge flow diverter. Nevertheless, the previous study may have been limited by biases due to its single-center design and limited number of subjects. Furthermore, although various articles have reported durable results from treating aneurysms using flow diverters, increasing questions have arisen about this form of treatment. Thus, prospective, multiple-center, randomized trials containing more subjects are needed. METHODS/DESIGN This study is a multicenter, randomized, controlled clinical trial comparing clinical outcomes for patients with unruptured large/giant intracranial aneurysms treated with either conventional stent-assisted coiling or flow diverter implantation. A total of 124 patients who fulfill the inclusion and exclusion criteria will be randomized into either a treatment group or a control group in the ratio of 1:1. The treatment group will receive Tubridge implantation alone or combined with bared coils, and the control group will be treated with stent-assisted coiling (bare coils). The primary endpoint will be the complete occlusion rate at 6-month follow-up. Secondary endpoints include the immediate technique success rate, overall mortality, adverse events (ischemic stroke or intracranial bleeding) within 30 days, 90 days and 1 year post-operation, and the rate of intra-stent stenosis and thrombosis 6 months post-operation. DISCUSSION This prospective trial may provide more information on the safety and efficacy of the Tubridge flow diverter and may potentially change the strategy for treatment of large or giant aneurysms. TRIAL REGISTRATION The trial is registered on the Chinese Clinical Trial Registry: ChiCTR-TRC-13003127.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Qing-Hai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai 200433, P,R, China.
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Zhou Y, Yang PF, Fang YB, Xu Y, Hong B, Zhao WY, Li Q, Zhao R, Huang QH, Liu JM. A novel flow-diverting device (Tubridge) for the treatment of 28 large or giant intracranial aneurysms: a single-center experience. AJNR Am J Neuroradiol 2014; 35:2326-33. [PMID: 24722307 DOI: 10.3174/ajnr.a3925] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Tubridge flow diverter is a novel device developed in China and aimed at reconstructing the parent artery and occluding the aneurysm. We conducted this study to evaluate its feasibility, safety, and efficacy for the treatment of large or giant internal carotid artery aneurysms, which are still challenging with conventional therapy. MATERIALS AND METHODS The clinical and angiographic data of 28 patients with 28 large or giant internal carotid artery aneurysms treated with Tubridge flow diverters were prospectively collected and analyzed. RESULTS Thirty-three Tubridge flow diverters were successfully implanted except for 1 poor midstent opening; the result was a technical success rate of 97.0% (32/33). Follow-up angiographies were available for 25 aneurysms; the mean follow-up was 9.9 months (5-24 months). Of the 25 aneurysms, 18 (72.0%) were completely occluded, 6 (24.0%) were improved, and 1 (4.0%) was unchanged. All of the visible covered branches and parent arteries were patent, with no stenosis or obliteration. During a follow-up of 6-30 months (mean, 19 months), symptoms were resolved in 13 patients, improved in 6 patients, and unchanged in 4 patients. Five patients experienced transient clinical deterioration due to a postoperative increased mass effect. Procedure-related morbidity and mortality were both zero. CONCLUSIONS Our preliminary experience shows that the Tubridge flow diverter is a safe and effective tool for treating large and giant internal carotid artery aneurysms. However, multicenter randomized trials and studies involving a long-term follow-up are necessary.
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Affiliation(s)
- Y Zhou
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - P-F Yang
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Y-B Fang
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Y Xu
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - B Hong
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - W-Y Zhao
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Q Li
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - R Zhao
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Q-H Huang
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China.
| | - J-M Liu
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China.
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