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Wael Osman M, Kadziolka K, Peirot L. Optional Endovascular Therapy of Dissecting Posterior Cerebral Artery Aneurysm. INTERVENTIONAL NEUROLOGY 2017; 6:219-228. [PMID: 29118799 DOI: 10.1159/000477360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Posterior cerebral artery aneurysms are uncommon, with an occurrence rate of less than 1% of intracranial aneurysms. They have various shapes, including saccular and fusiform. Dissecting aneurysms may occur in distal posterior cerebral artery and they may affect the whole artery. Endovascular therapy is considered as a safe method of treatment and there are different techniques for endovascular therapy. SUMMARY Posterior cerebral artery aneurysms are uncommon. Endovascular therapy is considered as a safe method of treatment and there are different techniques for endovascular therapy. We present here three cases collected from Maison Blanche Hospital (Intervention Neuroradiology Department, CHU Reims, France) during 2011-2012; they were females, at a young age and the affected side was on the right. The first case was affected at the P2-P3 segment, the aneurysm was fusiform in shape and she presented with ischemic stroke, while the second and third cases were affected at the P2 segment, the aneurysms being saccular in shape; one of them presented with subarachnoid hemorrhage with a history of migraine and the other patient presented with ischemic stroke. All of them had no history of trauma, hypertension or other diseases. One patient was treated by coiling and sacrificing the parent artery, the second patient was treated with stent-assisted coils, and the third one was treated by coiling without sacrificing the parent artery.
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Affiliation(s)
| | | | - Laurent Peirot
- Intervention Neuroradiology Department, CHU Reims, Reims, France
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2
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de Andrade GC, Alves HP, Clímaco V, Pereira E, Lesczynsky A, Frudit ME. Two-stage reconstructive overlapping stent LEO+ and SILK for treatment of intracranial circumferential fusiform aneurysms in the posterior circulation. Interv Neuroradiol 2016; 22:516-23. [PMID: 27402799 DOI: 10.1177/1591019916656475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 06/02/2016] [Indexed: 11/16/2022] Open
Abstract
Intracranial circumferential fusiform aneurysms of the posterior circulation involving arterial branches or perforating vessels are difficult to treat. This article shows an endovascular reconstruction technique not yet described, using a telescoping self-expandable stent (LEO+) and flow-diverter device (SILK) at different surgical times. Two patients with circumferential fusiform aneurysm, one being an aneurysm of the segments P2 and P3 of the posterior cerebral artery, diagnosed after a headache, and the other a partially thrombosed aneurysm of the lower basilar artery, diagnosed following ischemia of the brain stem. Endovascular treatment was performed by means of a vascular reconstruction technique that used at different surgical times: overlapping; a telescoped self-expandable stent, LEO+; and a flow-diverter device, SILK. Angiographic control was carried out at 6 and 12 months, to evaluate arterial patency, flow maintenance in the arterial branches and perforating vessels, and thrombosis of the aneurysm. The combined use at different surgical times of the self-expandable stent and flow-diverter device was technically successful in both patients. There were no complications during the procedure, nor in the long-term follow-up with full arterial vascular reconstruction, maintenance of cerebral perfusion and complete aneurysm occlusion at the 6- and 12-month angiographic follow-up. There was no aneurysm recanalization nor intra-stent stenosis. Circumferential fusiform aneurysm of the posterior circulation involving arterial branches or perforating vessels to the brain stem may be treated with this arterial reconstruction technique at different surgical times, using the self-expandable stent called LEO+ and the flow-diverter device SILK, minimizing the risk of complications and failure of the endovascular technique, with the potential for arterial reconstruction with thrombosis of the aneurysmatic sac, as well as flow maintenance in the eloquent arteries, in this type of cerebral aneurysm.
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Affiliation(s)
- Guilherme Cabral de Andrade
- Integrated Center of Neurology and Neurosurgery (CINN), Maringa, Brazil Department of Neurointervention, Paraná Hospital, Maringa, Brazil
| | - Helvercio P Alves
- Integrated Center of Neurology and Neurosurgery (CINN), Maringa, Brazil Department of Neurointervention, Paraná Hospital, Maringa, Brazil
| | - Valter Clímaco
- Integrated Center of Neurology and Neurosurgery (CINN), Maringa, Brazil
| | - Eduardo Pereira
- Integrated Center of Neurology and Neurosurgery (CINN), Maringa, Brazil
| | | | - Michel E Frudit
- Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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Galal A, Bahrassa F, Dalfino JC, Boulos AS. Stent-assisted treatment of unruptured and ruptured intracranial aneurysms: clinical and angiographic outcome. Br J Neurosurg 2013; 27:607-16. [DOI: 10.3109/02688697.2012.757292] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ali MS, Amenta PS, Starke RM, Jabbour PM, Gonzalez LF, Tjoumakaris SI, Flanders AE, Rosenwasser RH, Dumont AS. Intracranial vertebral artery dissections: evolving perspectives. Interv Neuroradiol 2012; 18:469-83. [PMID: 23217643 DOI: 10.1177/159101991201800414] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 08/25/2012] [Indexed: 11/16/2022] Open
Abstract
Intracranial vertebral artery dissection (VAD) represents the underlying etiology in a significant percentage of posterior circulation ischemic strokes and subarachnoid hemorrhages. These lesions are particularly challenging in their diagnosis, management, and in the prediction of long-term outcome. Advances in the understanding of underlying processes leading to dissection, as well as the evolution of modern imaging techniques are discussed. The data pertaining to medical management of intracranial VADs, with emphasis on anticoagulants and antiplatelet agents, is reviewed. Surgical intervention is discussed, including, the selection of operative candidates, open and endovascular procedures, and potential complications. The evolution of endovascular technology and techniques is highlighted.
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Affiliation(s)
- M S Ali
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Baran B, Kornafel O, Guziński M, Sąsiadek M. Dolichoectasia of the circle of Willis arteries and fusiform aneurysm of basilar artery - case report and review of the literature. Pol J Radiol 2012; 77:54-9. [PMID: 22844310 PMCID: PMC3403802 DOI: 10.12659/pjr.882971] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/21/2012] [Indexed: 12/01/2022] Open
Abstract
Background: Dolichoectasia of intracranial arteries is a rare arteriopathy characterized by elongation and widening of the arteries and disturbance of the laminar blood flow. It involves mostly vertebral and basilar arteries. In advanced cases, formation of a fusiform aneurysm is possible. Case Report: A sixty-four-year-old female with hypertension was admitted to the hospital with severe non-systemic vertigo and dysarthria, which had lasted for a couple of weeks. Imaging of the brain revealed dolichoectasia of arteries of the circle of Willis coexisting with a fusiform aneurysm of the basilar artery. Conclusions: Intracranial arterial dolichoectasia may be asymptomatic for a long time. However, in many cases it leads to neurological symptoms associated with haemodynamic disturbance (due to unstable wall clots) and mass effect caused by the widened vessel.
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Affiliation(s)
- Bogusława Baran
- Department of General and Interventional Radiology and Neuroradiology, Wrocław Medical University, Wrocław, Poland
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Nakiri GS, Al-Khawaldeh M, Parente B, Kessler I, Gory B, Riva R, Mounayer C. Treatment of ruptured intra-cranial internal carotid artery dissection using a flow-diverter stent. J Neuroradiol 2012; 39:271-5. [PMID: 22226815 DOI: 10.1016/j.neurad.2011.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 10/12/2011] [Accepted: 10/20/2011] [Indexed: 11/26/2022]
Abstract
In the presence of associated subarachnoid hemorrhage, the treatment of arterial dissection can be classified as either deconstructive (involving occlusion or sacrifice of the parent vessel) or reconstructive (preserving blood-flow through the parent vessel). In both treatment strategies, the main goal is to prevent any further risk of rebleeding. However, reconstructive treatment is reserved only for those patients in whom occlusion of the parent vessel is not feasible due to an insufficient collateral supply. This report is of a case of intra-cranial carotid artery dissection treated by a reconstructive endovascular approach, with deployment of a flow-diverter stent, for the management of an associated subarachnoid hemorrhage. This is, to the authors' knowledge, the first report of the use of a flow-diverter device as the main treatment of a ruptured supraclinoid carotid artery dissection.
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Affiliation(s)
- Guilherme S Nakiri
- Department of Interventional Neuroradiology, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France
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Yoon WK, Kim YW, Kim SR, Park IS, Kim SD, Jo KW, Baik MW. Angiographic and clinical outcomes of stent-alone treatment for spontaneous vertebrobasilar dissecting aneurysm. Acta Neurochir (Wien) 2010; 152:1477-86; discussion 1486. [PMID: 20508955 DOI: 10.1007/s00701-010-0693-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Accepted: 05/10/2010] [Indexed: 12/15/2022]
Abstract
PURPOSE Spontaneous vertebrobasilar dissecting aneurysm (VBD) is a very challenging disease with an unpredictable clinical course and controversies on treatment strategy. The present study reports radiological and clinical outcomes of stent-alone treatment (SAT) for VBD. METHODS Twenty-four VBDs treated with SAT are included in the present study. Clinical and angiographic data were reviewed retrospectively. RESULTS A total of 24 lesions in 22 patients with a mean follow-up period of 16.21 months were included. Of the 24 individual lesions, 23 were intracranial vertebral artery lesions and 1 lesion was located in the basilar artery. There were six cases of ruptured dissections with the other cases having various symptoms. The immediate post-SAT angiographic outcomes included 5 lesions with good remodeling over 90% recovery and 19 poorly remodeled lesions. The latest angiographic outcomes included 17 cases of good remodeling (remodeling rate over 90%), 6 cases of poor remodeling (remodeling rate below 70%), and 1 case with morphological aggravation. The overlapping stent technique was used in seven cases and it was significantly associated with good angiographic results. None of the rupture cases underwent re-rupture post SAT. There was one case of a symptomatic complication of a femoral arteriovenous fistula. CONCLUSIONS The SAT could be a feasible alternative for the treatment of VBD. The overlapping technique was significantly associated with good angiographic outcome. We expect that technological development of the intracranial stent will allow better procedural outcomes of SAT.
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Affiliation(s)
- Won Ki Yoon
- Department of Neurosurgery, Holy Family Hospital, The Catholic University of Korea, Sosa-dong, Wonmi-gu, Bucheon, Gyeonggi-do 429-717, Republic of Korea
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Park SI, Kim BM, Kim DI, Shin YS, Suh SH, Chung EC, Kim SY, Kim SH, Won YS. Clinical and angiographic follow-up of stent-only therapy for acute intracranial vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 2009; 30:1351-6. [PMID: 19342544 DOI: 10.3174/ajnr.a1561] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Little has been known about the clinical and angiographic follow-up results of stent-only therapy for intracranial vertebrobasilar dissecting aneurysms (VBDA). The purpose of this study was to evaluate the feasibility, safety, clinical, and angiographic follow-up of stent-only therapy for VBDA. MATERIALS AND METHODS Twenty-seven patients with 29 VBDAs (11 ruptured, 18 unruptured), not suitable for deconstructive treatment, underwent stent-only therapy. Feasibility, safety, clinical, and angiographic follow-up were retrospectively evaluated. Angiographic outcomes were compared between single-stent and multiple-stent groups. RESULTS All attempted stent placements were successfully accomplished without any treatment-related complication. Of the 11 ruptured VBDAs, 4 were treated by single stents, 6 by double overlapping stents, and 1 by triple overlapping stents. Of the 18 unruptured VBDAs, 6 were treated by stents, and 12 by double overlapping stents. One patient with a ruptured VBDA, treated by single stent, had rebleeding and died. None of the remaining patients had posttreatment bleeding during follow-up (mean, 28 months; range, 7-50 months). Eight patients with ruptured VBDA and all patients with unruptured VBDA had excellent outcomes (modified Rankin Scale, 0-1). The remaining 2 patients with ruptured VBDA were moderately disabled because of the initial damage. Angiographic follow-up was available in 27 VBDAs, 4 to 42 months (mean, 12 months) after treatment. Follow-up angiograms revealed complete obliteration of the dissecting aneurysm in 12, partial obliteration in 12, stable in 1, enlargement in 1, and in-stent occlusion in 1. Angiographic improvement (complete or partial obliteration) was more frequent in the multiple-stent group (17/17) than in the single-stent group (7/9; P < .05). CONCLUSIONS In this small series, stent-only therapy was safe and effective in the treatment of VBDAs that were not deemed suitable for treatment with parent-artery occlusion.
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Affiliation(s)
- S I Park
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Korea
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Hopkins LN, Ecker RD. CEREBRAL ENDOVASCULAR NEUROSURGERY. Neurosurgery 2008; 62:SHC1483-SHC1502. [DOI: 10.1227/01.neu.0000315304.66122.f0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 03/05/2008] [Indexed: 11/19/2022] Open
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Zenteno MA, Santos-Franco JA, Freitas-Modenesi JM, Gómez C, Murillo-Bonilla L, Aburto-Murrieta Y, Díaz-Romero R, Nathal E, Gómez-Llata S, Lee A. Use of the sole stenting technique for the management of aneurysms in the posterior circulation in a prospective series of 20 patients. J Neurosurg 2008; 108:1104-18. [PMID: 18518712 DOI: 10.3171/jns/2008/108/6/1104] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The use of intracranial stents in stent-assisted coil embolization is now a current neurosurgical practice worldwide. The clinical utility of these stents in the sole stenting (SS) technique, however, has not been thoroughly described, and the published reports of this experience are scarce. This study was designed to evaluate SS treatment of dissecting and nondissecting aneurysms of the posterior circulation.
Methods
This prospective and descriptive study was conducted in 20 consecutive patients who harbored single aneurysms of the posterior circulation and who were treated using the SS approach in the last 3 years. The clinical and radiological assessment and follow-up of the patients were evaluated using the modified Rankin scale as well as with computed tomography angiography and digital subtraction angiography at discharge and at 1, 3, 6, and 12 months.
Results
Eleven of the 20 patients had subarachnoid hemorrhages, 3 presented with ischemia, 1 presented with brainstem compression, and the remaining 5 patients had incidentally discovered, asymptomatic lesions. Only 1 patient had a complication (occipital infarction) attributable to the SS procedure. One patient died of rebleeding 2 weeks after the procedure. At 1 month, 40% of the patients had a subtotal or total occlusion, which increased to 55% at 3 months and 85% at 6 months, with a final subtotal or total occlusion rate of 80% at 1 year. The SS procedure in 1 case was considered a failure at 6 months because no change had been noted since the 1-month follow-up. One case showed partial occlusion and 1 case showed recanalization.
Conclusions
Use of SS for aneurysms in the posterior circulation complex is a safe and effective technique, demonstrating an occlusion rate of 80% at the 1-year follow up.
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Affiliation(s)
- Marco Antonio Zenteno
- 1Departments of Neurological Endovascular Therapy and
- 3Comprehensive Stroke Center, Hospital Ángeles del Pedregal, México City
- 7Universidad Nacional Autónoma de México, México City, México
| | | | | | - Camilo Gómez
- 6Alabama Neurological Institute, Birmingham, Alabama; and
| | - Luis Murillo-Bonilla
- 4Comprehensive Vascular Institute, Hospital Ángeles del Carmen, Guadalajara, México
| | - Yolanda Aburto-Murrieta
- 1Departments of Neurological Endovascular Therapy and
- 3Comprehensive Stroke Center, Hospital Ángeles del Pedregal, México City
| | | | - Edgar Nathal
- 2Neurosurgery, Instituto Nacional de Neurología y Neurocirugía, México City
- 7Universidad Nacional Autónoma de México, México City, México
| | - Sergio Gómez-Llata
- 2Neurosurgery, Instituto Nacional de Neurología y Neurocirugía, México City
- 7Universidad Nacional Autónoma de México, México City, México
| | - Angel Lee
- 3Comprehensive Stroke Center, Hospital Ángeles del Pedregal, México City
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Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options. Neurosurg Rev 2008; 31:131-40; discussion 140. [DOI: 10.1007/s10143-008-0124-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 12/05/2007] [Accepted: 01/01/2008] [Indexed: 11/27/2022]
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Zhao WY, Krings T, Alvarez H, Ozanne A, Holmin S, Lasjaunias P. Management of spontaneous haemorrhagic intracranial vertebrobasilar dissection: review of 21 consecutive cases. Acta Neurochir (Wien) 2007; 149:585-96; discussion 596. [PMID: 17514349 DOI: 10.1007/s00701-007-1161-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Accepted: 04/11/2007] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Haemorrhagic intracranial vertebrobasilar dissection is an uncommon cause of nontraumatic subarachnoid haemorrhage (SAH) and accounts for only 1-10% of non-traumatic SAH. Treatment in the acute phase is considered to be essential because of the high risk of rebleeding and the consequent unfavourable outcome. However, the location, the potential for involvement of eloquent vessels and the histopathological characteristics of the vessel wall make treatment demanding from both a technical and anatomical point of view. We report our experience in the management of this disease. PATIENTS AND TREATMENTS: From 1989 to June 2006, we managed 21 patients with spontaneous haemorrhagic dissection located in the intracranial vertebrobasilar system, 13 patients were treated using an endovascular approach, 1 by surgical clipping, and 7 were managed conservatively. RESULTS Among the 13 patients treated endovascularly, 7 underwent proximal occlusion, 4 underwent parent artery embolization at the site of dissection, and 2 underwent endovascular trapping. Severe, treatment-related complications due to dislodgement of the thrombus during the procedure occurred in 1 patient, who then died from brainstem ischaemia. One patient died from severe pneumonia and one patient was left disabled from vasospastic ischaemia resulting from severe initial SAH. The remaining 10 patients had satisfactory outcomes: none rebled after treatment and when discharged they had Karnovsky scores of 80-100. Of the 7 conservatively treated patients, three died of rebleeding and four were discharged with Karnovsky scores of 50-100. One patient, who was treated surgically, was discharged with a Karnovsky of 90. CONCLUSION The high rate of rebleeding and consequent mortality among the patients treated conservatively argues for treatment in the acute phase. Treatment should be guided by each patient's angiomorphology, clinical condition and the experience of the neurosurgical/neuroradiological team. Options include endovascular or surgical trapping of the dissection and proximal occlusion and embolisation of the parent artery at the site of the dissection.
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MESH Headings
- Acute Disease
- Aortic Dissection/diagnosis
- Aortic Dissection/mortality
- Aortic Dissection/therapy
- Aneurysm, Ruptured/diagnosis
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/mortality
- Aneurysm, Ruptured/therapy
- Angiography, Digital Subtraction
- Cause of Death
- Cerebellum/blood supply
- Cerebral Angiography
- Cooperative Behavior
- Embolization, Therapeutic
- Glasgow Coma Scale
- Humans
- Image Processing, Computer-Assisted
- Imaging, Three-Dimensional
- Intracranial Aneurysm/diagnosis
- Intracranial Aneurysm/mortality
- Intracranial Aneurysm/therapy
- Karnofsky Performance Status
- Magnetic Resonance Imaging
- Neurologic Examination
- Outcome and Process Assessment, Health Care
- Patient Care Team
- Recurrence
- Retrospective Studies
- Subarachnoid Hemorrhage/diagnosis
- Subarachnoid Hemorrhage/mortality
- Subarachnoid Hemorrhage/therapy
- Surgical Instruments
- Survival Rate
- Tomography, X-Ray Computed
- Vertebral Artery Dissection/diagnosis
- Vertebral Artery Dissection/mortality
- Vertebral Artery Dissection/therapy
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Affiliation(s)
- W Y Zhao
- Neuroradiologie Vasculaire Diagnostique et Thérapeutique, Hôpital Bicêtre, Le Kremlin Bicêtre, France.
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