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Ji Z, He C, Li J, Geng J, Hu P, Li G, Zhang H. Safety and Efficacy of Low-Profile Braided Stents versus Flow Diverters in the Reconstructive Technique in the Treatment of Patients with Vertebrobasilar Dolichoectasia Aneurysms: A Cohort of 47 Patients with Long-Term Follow-Up. AJNR Am J Neuroradiol 2024; 45:176-182. [PMID: 38238095 DOI: 10.3174/ajnr.a8091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/02/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND PURPOSE Vertebrobasilar dolichoectasia aneurysm is a rare type of cerebrovascular disorder with a poor natural history, and endovascular treatment is widely accepted. Whether a high-profile braided stent (flow diverter) could promote occlusion of vertebrobasilar dolichoectasia aneurysm without increasing the complications rather than a low-profile braided stent remains uncertain. The aim of the study was to present a single-center experience of the safety and efficacy of a low-profile braided stent versus a flow diverter in treating patients with vertebrobasilar dolichoectasia aneurysms. MATERIALS AND METHODS The retrospective review was conducted on a total of 432 consecutive patients diagnosed with posterior circulation aneurysms who underwent endovascular treatment in our center from August 2013 to December 2021. Among these patients, 47 individuals with vertebrobasilar dolichoectasia aneurysms who were treated with low-profile braided stents or flow diverters were included. Vertebrobasilar dolichoectasia aneurysms involving only the vertebral artery were excluded. Patients were divided into 2 groups: the low-profile braided stent group and the flow diverter group based on the device used. Safety and efficacy outcomes were subsequently analyzed. RESULTS There were 25 total patients enrolled in low-profile braided stent group and 22 patients in flow diverter group. The safety of low-profile braided stents and flow diverters in the treatment of vertebrobasilar dolichoectasia aneurysms was evaluated by clinical outcome, a new neurologic deficit due to procedural complications, and neurologic death. The rates of good clinical outcome were similar between the 2 groups (low-profile braided stent, 56%, versus flow diverter, 59.1%; P = .831), and the rates of neurologic death were also similar (low-profile braided stent, 12%, versus flow diverter, 9.1%; P = .747). Higher rates of new neurologic deficits due to procedural complications were observed in the flow diverter group, but the difference was not significant (low-profile braided stent, 24%, versus flow diverter, 40.9%; P = .215). The efficacy was evaluated by angiographic occlusion of vertebrobasilar dolichoectasia aneurysms and progression of mass effect resulting from these aneurysms. Significantly higher rates of complete occlusion of vertebrobasilar dolichoectasia aneurysms were shown in the flow diverter group (41.2%; P = .028) than in the low-profile braided stent group (10%). CONCLUSIONS Both low-profile braided stents and flow diverters have similar high risks in reconstructive techniques in the treatment of vertebrobasilar dolichoectasia aneurysms, while a flow diverter is more effective in promoting complete occlusion of vertebrobasilar dolichoectasia aneurysm than a low-profile braided stent. A flow diverter may be a better alternative for carefully selected patients with vertebrobasilar dolichoectasia aneurysms.
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Affiliation(s)
- Zhe Ji
- From the Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Chuan He
- From the Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Jingwei Li
- From the Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Jiewen Geng
- From the Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Peng Hu
- From the Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Guilin Li
- From the Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Hongqi Zhang
- From the Department of Neurosurgery, China International Neuroscience Institute, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
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Matsukawa H, Uchida K, Shirakawa M, Kinjo N, Kuramoto Y, Sakakibara F, Shindo S, Yamada K, Yoshimura S. Prognostic Factors in Patients with Unruptured Vertebral and Basilar Fusiform Aneurysms Treated with Endovascular Procedures : A Single Center Retrospective Analysis. Clin Neuroradiol 2023; 33:1035-1044. [PMID: 37296346 DOI: 10.1007/s00062-023-01305-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/03/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Large vertebral and basilar fusiform aneurysms (VFA) are sometimes difficult to cure by endovascular treatment (EVT). We aimed to elucidate indicators of poor outcomes of EVT in patients with VFAs. METHODS Clinical data from 48 patients with 48 unruptured VFAs in the Hyogo Medical University were retrospectively analyzed. The primary outcome was defined as satisfactory aneurysm occlusion (SAO) according to Raymond-Roy grading scale. The secondary and safety outcomes were a modified Rankin scale (mRS) score of 0-2 at 90 days, retreatment, major stroke, and aneurysm-related death after EVT. RESULTS The EVT included stent-assisted coiling (n = 24; 50%), flow diverter (n = 19; 40%), and parent artery occlusion (n = 5; 10%). The SAO was less frequently observed in large or thrombosed VFAs at 12 months (64%, p = 0.021 and 62%, p = 0.014, respectively), especially when the aneurysms were both large and thrombosed (50%, p = 0.0030). Retreatment was more common in large aneurysms (29%, p = 0.034), thrombosed (32%, p = 0.011), and large thrombosed aneurysms (38%, p = 0.0036). Although the proportion of mRS 0-2 at 90 days and major stroke showed no significant differences, that of post-treatment rupture was significantly larger in large thrombosed VFAs (19%, p = 0.032). Aneurysm-related death occurred by aneurysm rupture and was more frequent in large thrombosed VFA (19%, p = 0.032). Multivariate analysis showed SAO at 12 months was less common (adjusted odds ratio, OR: 0.036, 95% confidence interval, CI 0.00091-0.57; p = 0.018), and retreatment was more common (adjusted OR 43, 95% CI 4.0-1381; p = 0.0012) in large thrombosed VFA. CONCLUSION The large thrombosed VFAs were associated with poor outcomes after EVT including flow diverter.
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Affiliation(s)
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawa, 663-8501, Nishinomiya, Hyogo, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawa, 663-8501, Nishinomiya, Hyogo, Japan
| | - Norito Kinjo
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawa, 663-8501, Nishinomiya, Hyogo, Japan
| | - Yoji Kuramoto
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawa, 663-8501, Nishinomiya, Hyogo, Japan
| | - Fumihiro Sakakibara
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawa, 663-8501, Nishinomiya, Hyogo, Japan
| | - Seigo Shindo
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kiyofumi Yamada
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, 1-1 Mukogawa, 663-8501, Nishinomiya, Hyogo, Japan.
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Chai JY, Chen L, Cheng L, Wu XB. Clinical prognosis and cerebrovascular imaging in patients with vertebrobasilar dolichoectasia. Asian J Surg 2023; 46:2574-2575. [PMID: 36681545 DOI: 10.1016/j.asjsur.2022.12.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Affiliation(s)
- Jing-Yan Chai
- Department of Neurology, The Affiliated Hospital of Jiujiang University, Jiujiang, 332000, Jiangxi Province, China.
| | - Liang Chen
- Department of Radiology, The Affiliated Hospital of Jiujiang University, Jiujiang, 332000, Jiangxi Province, China
| | - Lin Cheng
- Department of Neurology, The Affiliated Hospital of Jiujiang University, Jiujiang, 332000, Jiangxi Province, China
| | - Xiang-Bin Wu
- Department of Neurology, The Affiliated Hospital of Jiujiang University, Jiujiang, 332000, Jiangxi Province, China.
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Chen X, Peng F, Liu X, Xia J, Niu H, He X, Xu B, Bai X, Li Z, Xu P, Duan Y, Sui B, Zhao X, Liu A. Three-dimensional aneurysm wall enhancement in fusiform intracranial aneurysms is associated with aneurysmal symptoms. Front Neurosci 2023; 17:1171946. [PMID: 37214386 PMCID: PMC10196058 DOI: 10.3389/fnins.2023.1171946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Background and purpose Aneurysm wall enhancement (AWE) in high-resolution magnetic resonance imaging (HR-MRI) is a potential biomarker for evaluating unstable aneurysms. Fusiform intracranial aneurysms (FIAs) frequently have a complex and curved structure. We aimed to develop a new three-dimensional (3D) aneurysmal wall enhancement (AWE) characterization method to enable comprehensive FIA evaluation and to investigate the ability of 3D-AWE to predict symptomatic FIA. Methods We prospectively recruited patients with unruptured FIAs and received 3 T HR-MRI imaging from September 2017 to January 2019. 3D models of aneurysms and parent arteries were generated. Boundaries of the FIA were determined using 3D vessel diameter measurements. Dmax was the greatest diameter in the cross-section, while Lmax was the length of the centerline of the aneurysm. Signal intensity of the FIA was normalized to the pituitary stalk and then mapped onto the 3D model, then the average enhancement (3D-AWEavg), maximum enhancement (3D-AWEmax), enhancement area (AWEarea), and enhancement ratio (AWEratio) were calculated as AWE indicators, and the surface area of the entire aneurysm (Aarea) was also calculated. Areas with high AWE were defined as those with a value >0.9 times the signal intensity of the pituitary stalk. Multivariable logistic regression analyses were performed to determine independent predictors of aneurysm-related symptoms. FIA subtypes were defined as fusiform, dolichoectasia, and transitional. Differences between the three FIA subtypes were also examined. Results Forty-seven patients with 47 FIAs were included. Mean patient age was 55 ± 12.62 years and 74.5% were male. Twenty-nine patients (38.3%) were symptomatic. After adjusting for baseline differences in age, hypertension, Lmax, and FIA subtype, the multivariate logistics regression models showed that 3D-AWEavg (odds ratio [OR], 4.029; p = 0.019), 3D-AWEmax (OR, 3.437; p = 0.022), AWEarea (OR, 1.019; p = 0.008), and AWEratio (OR, 2.490; p = 0.045) were independent predictors of aneurysm-related symptoms. Dmax and Aarea were larger and 3D-AWEavg, 3D-AWEmax, AWEarea, and AWEratio were higher with the transitional subtype than the other two subtypes. Conclusion The new 3D AWE method, which enables the use of numerous new metrics, can predict symptomatic FIAs. Different 3D-AWE between the three FIA subtypes may be helpful in understanding the pathophysiology of FIAs.
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Affiliation(s)
- Xuge Chen
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital University, Beijing, China
| | - Fei Peng
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital University, Beijing, China
| | - Xinmin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiaxiang Xia
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital University, Beijing, China
| | - Hao Niu
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital University, Beijing, China
| | - Xiaoxin He
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital University, Beijing, China
| | - Boya Xu
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital University, Beijing, China
| | - Xiaoyan Bai
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhiye Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Xu
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yonghong Duan
- Department of Neurosurgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Binbin Sui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital University, Beijing, China
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Kim JH, Ko YS, Kwon SM, Kim CH, Lee CY. Predictive Factors of Recurrence after Endovascular Treatment of Unruptured Vertebrobasilar Fusiform Aneurysms. Clin Neuroradiol 2023; 33:73-86. [PMID: 35763061 DOI: 10.1007/s00062-022-01184-9] [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: 02/22/2022] [Accepted: 06/01/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to investigate the predictive factors of recurrence after endovascular treatment (EVT) for unruptured vertebrobasilar fusiform aneurysms (VBFA). METHODS This single-center retrospective study evaluated 36 patients who underwent EVT of unruptured VBFA between 2008 and 2020. Variables influencing recurrence, such as size, type, thrombus, preoperative symptoms, and treatment methods, were analyzed. All patients were followed up using vessel imaging. RESULTS In total, 7 of 36 patients (19.4%) developed recurrence. The mean time from EVT to recurrence was 9.2 months (range 2-26.9 months). Maximum aneurysmal diameter on magnetic resonance imaging was decreased, increased, and remained unchanged in 1, 7, and 28 patients, respectively. Transitional type VBFA, brain compression symptoms, large aneurysmal diameter and length, preoperative modified Rankin Scale (mRS) score ≥ 2, sole stenting technique, and intra-aneurysmal thrombus significantly influenced the risk of recurrence. Post-EVT, 7 (19.4%) patients showed complete occlusion of the aneurysm on the immediate postoperative angiogram, and 22 (61.1%) patients showed complete occlusion on the 1‑year follow-up imaging. Good outcomes were observed in 32 patients (88.9%) at the last follow-up, with a mRS score of 0-1 after EVT. CONCLUSION EVT achieves good outcomes in unruptured VBFA. Transitional type VBFA, brain compression symptoms, large aneurysmal diameter and length, preoperative mRS score ≥ 2, sole stenting technique, and intra-aneurysmal thrombus are risk factors for aneurysm recurrence after EVT.
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Affiliation(s)
- Jae Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of)
| | - Young San Ko
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of)
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of)
| | - Chang Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of)
| | - Chang Young Lee
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of).
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Wei H, Yao K, Tian Q, Han S, Gao W, Han W, Liu S, Wang G, Chen Q, Li M. Low Wall Shear Stress and High Intra-aneurysmal Pressure are Associated with Ruptured Status of Vertebral Artery Dissecting Aneurysms. Cardiovasc Intervent Radiol 2023; 46:240-248. [PMID: 36653659 DOI: 10.1007/s00270-022-03353-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 12/26/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE The morphological and hemodynamic features of patients with vertebral artery dissecting aneurysms (VADAs) are yet unknown. This study sought to elucidate morphological and hemodynamic features of patients with ruptured and unruptured VADAs based on computed flow simulation. METHODS Fifty-two patients (31 unruptured and 21 ruptured VADAs) were admitted to two hospitals between March 2016 and October 2021. All VADAs were located in the intradural segment, and their clinical, morphological, and hemodynamic parameters were retrospectively analyzed. The hemodynamic parameters were determined through computational fluid dynamics simulations. Univariate statistical and multivariable logistic regression analyses were employed to select significantly different parameters and identify key factors. Receiver operating characteristic (ROC) analysis was used to assess the discrimination for each key factor. RESULTS Four hemodynamic parameters were observed to significantly differ between ruptured and unruptured VADAs, including wall shear stress (WSS), low shear area, intra-aneurysmal pressure (IAP), and relative residence time. However, no significant differences were observed in morphological parameters between ruptured and unruptured VADAs. Multivariable logistic regression analysis revealed that low WSS and high IAP were significantly observed in the ruptured VADAs and demonstrated adequate discrimination. CONCLUSIONS This research indicates significant hemodynamic differences, but no morphological differences were observed between ruptured and unruptured VADAs. The ruptured group had significantly lower WSS and higher IAP than the unruptured group. To further confirm the roles of low WSS and high IAP in the rupture of VADAs, large prospective studies and long-term follow-up of unruptured VADAs are required.
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Affiliation(s)
- Heng Wei
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Kun Yao
- Department of Neurosurgery, Jingzhou Central Hospital, Jingzhou, 434020, China
| | - Qi Tian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Shoumeng Han
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Wenhong Gao
- Department of Neurosurgery, Jingzhou Central Hospital, Jingzhou, 434020, China
| | - Wenrui Han
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Sheng Liu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Guijun Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Ziyang Road, Wuhan, 430060, Hubei Province, China.
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Cao S, Zhai M, He J, Cui P, Ge T, Wang J, Xu W, Wang R, Xia M. Prevalence and associated factors of basilar artery dolichosis in patients with acute cerebral infarction. Front Med (Lausanne) 2023; 10:832878. [PMID: 36910498 PMCID: PMC9995486 DOI: 10.3389/fmed.2023.832878] [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: 12/10/2021] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Little attention has been given to the factors associated with basilar artery (BA) dolichosis. This study aims to elucidate the prevalence and associated factors of BA dolichosis in patients with acute cerebral infarction (ACI). Methods We collected the clinical and laboratory data of 719 patients with ACI admitted to our department. Magnetic resonance angiography was used to evaluate the geometric parameters of the BA and intracranial vertebral arteries (VAs). A BA curve length > 29.5 mm or bending length (BL) > 10 mm was identified as BA dolichosis. Univariate and multivariate logistic regression were performed to determine the factors associated with BA dolichosis. Results Among 719 patients with ACI, 238 (33.1%) demonstrated BA dolichosis, including 226 (31.4%) with simple BA dolichosis and 12 (1.7%) with basilar artery dolichoectasia (BADE). Pearson correlation analyses showed that BA curve length was positively correlated with BL (r = 0.605). Multivariate logistic regression analysis demonstrated that current smoking (OR = 1.50, 95% CI: 1.02-2.21, p = 0.039), diabetes mellitus (OR = 1.66, 95% CI: 1.14-2.41, p = 0.008), BA diameter (OR = 3.04, 95% CI: 2.23-4.13, p < 0.001), BA bending (OR = 4.24, 95% CI: 2.91-6.17, p < 0.001) and BL (OR = 1.45, 95% CI: 1.36-1.55, p < 0.001) were significantly associated with BA dolichosis. Conclusion This study suggests that BA dolichosis was common in patients with ACI, and the morphological parameters of the vertebrobasilar artery and acquired risk factors (including smoking and diabetes) were risk factors for BA dolichosis.
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Affiliation(s)
- Shugang Cao
- Department of Neurology, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Mingfeng Zhai
- Department of Neurology, The People's Hospital of Fuyang, Fuyang, China
| | - Jun He
- Department of Neurology, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Ping Cui
- Department of Radiology, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Tingting Ge
- Department of Neurology, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Jian Wang
- Department of Neurology, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Wen'an Xu
- Department of Neurology, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Rongfeng Wang
- Department of Neurology, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Mingwu Xia
- Department of Neurology, Hefei Hospital Affiliated to Anhui Medical University, Hefei, China
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Peng F, Liu L, Niu H, Feng X, Zhang H, He X, Xia J, Xu B, Bai X, Li Z, Sui B, Liu A. Comparisons between cross-section and long-axis-section in the quantification of aneurysmal wall enhancement of fusiform intracranial aneurysms in identifying aneurysmal symptoms. Front Neurol 2022; 13:945526. [PMID: 35959406 PMCID: PMC9361002 DOI: 10.3389/fneur.2022.945526] [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: 05/16/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background To investigate the quantification of aneurysmal wall enhancement (AWE) in fusiform intracranial aneurysms (FIAs) and to compare AWE parameters based on different sections of FIAs in identifying aneurysm symptoms. Methods Consecutive patients were prospectively recruited from February 2017 to November 2019. Aneurysm-related symptoms were defined as sentinel headache and oculomotor nerve palsy. All patients underwent high resolution magnetic resonance imaging (HR-MRI) protocol, including both pre and post-contrast imaging. CRstalk (signal intensity of FIAs' wall divided by pituitary infundibulum) was evaluated both in the cross-section (CRstalk−cross) and the long-axis section (CRstalk−long) of FIAs. Aneurysm characteristics include the maximal diameter of the cross-section (Dmax), the maximal length of the long-axis section (Lmax), location, type, and mural thrombus. The performance of parameters for differentiating symptomatic and asymptomatic FIAs was obtained and compared by a receiver operating characteristic (ROC) curve. Results Forty-three FIAs were found in 43 patients. Eighteen (41.9%) patients who presented with aneurysmal symptoms were classified in the symptomatic group. In univariate analysis, male sex (P = 0.133), age (P = 0.013), FIAs type (P = 0.167), mural thrombus (P = 0.130), Lmax (P = 0.066), CRstalk−cross (P = 0.027), and CRstalk−long (P = 0.055) tended to be associated with aneurysmal symptoms. In the cross-section model of multivariate analysis, male (P = 0.038), age (P = 0.018), and CRstalk−cross (P = 0.048) were independently associated with aneurysmal symptoms. In the long-axis section model of multivariate analysis, male (P = 0.040), age (P = 0.010), CRstalk−long (P = 0.046), and Lmax (P = 0.019) were independently associated with aneurysmal symptoms. In the combination model of multivariate analysis, male (P = 0.027), age (P = 0.011), CRstalk−cross (P = 0.030), and Lmax (P = 0.020) were independently associated with aneurysmal symptoms. CRstalk−cross has the highest accuracy in predicting aneurysmal symptoms (AUC = 0.701). The combination of CRstalk−cross and Lmax exhibited the highest performance in discriminating symptomatic from asymptomatic FIAs (AUC = 0.780). Conclusion Aneurysmal wall enhancement is associated with symptomatic FIAs. CRstalk−cross and Lmax were independent risk factors for aneurysmal symptoms. The combination of these two factors may improve the predictive performance of aneurysmal symptoms and may also help to stratify the instability of FIAs in future studies.
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Affiliation(s)
- Fei Peng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lang Liu
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Hao Niu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Feng
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hong Zhang
- Operating Room, Heze Municipal Hospital, Heze, China
| | - Xiaoxin He
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiaxiang Xia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Boya Xu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Bai
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhiye Li
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Binbin Sui
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing, China
- *Correspondence: Binbin Sui
| | - Aihua Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
- Aihua Liu
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Bhat V, Kodapala S. Transient Ischemic Attack Due to Unruptured Basilar Artery Aneurysm. Cureus 2022; 14:e24102. [PMID: 35573510 PMCID: PMC9103616 DOI: 10.7759/cureus.24102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/08/2022] Open
Abstract
Intracranial aneurysms are typically asymptomatic. They are usually incidentally detected or detected only after rupture. Ischemic stroke or transient ischemic attack (TIA) due to unruptured intracranial aneurysms (UIAs) is rare. A 79-year-old male with well-controlled hypertension and hypothyroidism, presented with complaints of sudden-onset weakness of the right upper limb and lower limb, followed by altered sensorium and a fall. Two hours later, he had fully recovered. Neurologic examination was unremarkable. Computed tomography of the brain revealed a dilated and tortuous basilar artery, suggestive of an aneurysm compressing the left midbrain and pons, with no evidence of intracranial bleed. Further, magnetic resonance imaging with an angiogram revealed multiple lacunar infarcts in the posterior circulation, distal to the aneurysm. Finally, a cerebral angiogram confirmed a partially thrombosed, fusosaccular aneurysm, arising from the left vertebral and basilar arteries. In view of frailty and long vessel segment involvement, surgery was not advised. He was treated medically, with appropriate antiplatelets and prophylactic antiepileptics. On follow-up, he had no neurologic deficit and had suffered no later ischemic or hemorrhagic events. UIAs may cause brainstem strokes via thrombosis of the parent vessel, emboli from the thrombus, or compression of the parent artery. In our case, compression, the least common mechanism, appears to have caused the TIA, with emboli potentially responsible for the silent lacunar infarcts. Fusiform aneurysms of the vertebrobasilar system have a poor natural history. In elderly patients presenting with ischemic events due to UIAs of the vertebrobasilar system, surgical intervention can be risky. So, medical treatment with antiplatelets is recommended. UIAs should be considered in the differential diagnosis of patients with TIAs, and such patients should have a visualization of intracranial arteries.
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Affiliation(s)
- Vivek Bhat
- Internal Medicine, St. John's Medical College, Bangalore, IND
| | - Suresha Kodapala
- Neurology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
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Saalfeld S, Stahl J, Korte J, Miller Marsh LM, Preim B, Beuing O, Cherednychenko Y, Behme D, Berg P. Can Endovascular Treatment of Fusiform Intracranial Aneurysms Restore the Healthy Hemodynamic Environment?–A Virtual Pilot Study. Front Neurol 2022; 12:771694. [PMID: 35140672 PMCID: PMC8818669 DOI: 10.3389/fneur.2021.771694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
Numerous studies assess intracranial aneurysm rupture risk based on morphological and hemodynamic parameter analysis in addition to clinical information such as aneurysm localization, age, and sex. However, intracranial aneurysms mostly occur with a saccular shape located either lateral to the parent artery or at a bifurcation. In contrast, fusiform intracranial aneurysms (FIAs), i.e., aneurysms with a non-saccular, dilated form, occur in approximately 3–13% of all cases and therefore have not yet been as thoroughly studied. To improve the understanding of FIA hemodynamics, this pilot study contains morphological analyses and image-based blood flow simulations in three patient-specific cases. For a precise and realistic comparison to the pre-pathological state, each dilation was manually removed and the time-dependent blood flow simulations were repeated. Additionally, a validated fast virtual stenting approach was applied to evaluate the effect of virtual endovascular flow-diverter deployment focusing on relevant hemodynamic quantities. For two of the three patients, post-interventional information was available and included in the analysis. The results of this numerical pilot study indicate that complex flow structures, i.e., helical flow phenomena and the presence of high oscillating flow features, predominantly occur in FIAs with morphologically differing appearances. Due to the investigation of the individual healthy states, the original flow environment could be restored which serves as a reference for the virtual treatment target. It was shown that the realistic deployment led to a considerable stabilization of the individual hemodynamics in all cases. Furthermore, a quantification of the stent-induced therapy effect became feasible for the treating physician. The results of the morphological and hemodynamic analyses in this pilot study show that virtual stenting can be used in FIAs to quantify the effect of the planned endovascular treatment.
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Affiliation(s)
- Sylvia Saalfeld
- Research Campus STIMULATE, University of Magdeburg, Magdeburg, Germany
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
- *Correspondence: Sylvia Saalfeld
| | - Janneck Stahl
- Research Campus STIMULATE, University of Magdeburg, Magdeburg, Germany
- Department of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany
| | - Jana Korte
- Research Campus STIMULATE, University of Magdeburg, Magdeburg, Germany
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Laurel Morgan Miller Marsh
- Research Campus STIMULATE, University of Magdeburg, Magdeburg, Germany
- Department of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany
- Department of Mechanical Engineering, University of Washington, Seattle, WA, United States
| | - Bernhard Preim
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Oliver Beuing
- Department of Radiology, AMEOS Hospital Bernburg, Bernburg, Germany
| | - Yurii Cherednychenko
- Endovascular Centre, Dnipropetrovsk Regional Clinical Hospital named after I.I. Mechnikov, Dnipro, Ukraine
| | - Daniel Behme
- Research Campus STIMULATE, University of Magdeburg, Magdeburg, Germany
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Philipp Berg
- Research Campus STIMULATE, University of Magdeburg, Magdeburg, Germany
- Department of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany
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11
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Goroshchenko SA. [Diagnosis and treatment of non-saccular vertebrobasilar aneurysms]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:109-114. [PMID: 35758086 DOI: 10.17116/neiro202286031109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To systematize the data on diagnosis and treatment of non-saccular vertebrobasilar aneurysms. MATERIAL AND METHODS We have analyzed modern and fundamental studies in the PubMed database for the period 1969-2020. The following keywords were used: non-saccular aneurysm, dolichoectasia, vertebrobasilar pool. Fifty-nine studies including 1 meta-analysis, 9 case reports, 24 reviews and 25 original articles were selected. RESULTS Analysis of literature data indicates various unresolved problems associated with difficult diagnosis and choice of treatment that results high rates of disability and mortality. CONCLUSION Data on anatomical features of non-saccular aneurysms, such as presence or absence of perforating arteries within the affected arterial segment, analysis of electrophysiological changes following brainstem compression by aneurysm can serve as factors that will improve treatment outcomes in these patients.
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Affiliation(s)
- S A Goroshchenko
- Polenov Russian Research Neurosurgical Institute - Branch of the Almazov National Medical Research Center, St. Petersburg, Russia
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12
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Cao S, Zhu X, Wu Q, Ni X, He J, Cui P, Ge T, Wang J, Xu W, Xia M. Basilar Artery Dolichosis Increases the Risk of Long-Term Recurrence in Patients With Pontine Infarction: A Prospective Cohort Study. Front Neurol 2021; 12:788145. [PMID: 34966351 PMCID: PMC8710450 DOI: 10.3389/fneur.2021.788145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
Background and Purpose: Patients with basilar artery (BA) dolichosis are at high risk of acute pontine infarction (API), but the association between BA dolichosis and long–term stroke recurrence has received little attention. We aimed to identify the effect of BA dolichosis on the risk of long–term brainstem infarction recurrence in patients with API. Methods: In this prospective cohort study, we enrolled 113 patients with API admitted to our department. BA dolichosis was diagnosed by a BA curve length >29.5 mm or bending length (BL) >10 mm on magnetic resonance angiography. The primary outcome was the occurrence of diffusion–weighted imaging (DWI)–confirmed brainstem infarction. The Cox proportional hazard model was used to detect possible predictors of brainstem infarction recurrence. Results: Among 113 patients with API, 39 (34.5%) patients had BA dolichosis, and DWI–confirmed brainstem infarction recurred in 15 (13.3%) patients with a mean follow–up time of 31.2 months; the estimated 5–year incidence of brainstem infarction recurrence was 23.1% in patients with BA dolichosis, which was significantly higher than the incidence of 8.1% in patients without BA dolichosis. Cox proportional hazard analysis showed that age ≥65 years (hazard ratio (HR) = 3.341, 95% confidence interval (CI): 1.079–10.348, P = 0.036) and BA dolichosis (HR = 3.048, 95% CI: 1.069–8.693, P = 0.037) were significantly associated with a higher risk of brainstem infarction recurrence. In a subgroup analysis stratified by age, the patients aged ≥65 years with BA dolichosis had a higher risk of brainstem infarction recurrence (HR = 7.319, 95% CI: 1.525–35.123, P = 0.013). Conclusions: This study indicates that BA dolichosis may increase the risk of long–term brainstem infarction recurrence in patients with API, especially in elderly patients, and therefore warrants more attention in clinical practice.
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Affiliation(s)
- Shugang Cao
- Department of Neurology, The Second People's Hospital of Hefei, Hefei, China
| | - Xiaoxia Zhu
- Department of Geriatrics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qian Wu
- Department of Neurology, The Second People's Hospital of Hefei, Hefei, China
| | - Xiaoxing Ni
- Department of Neurology, The Second People's Hospital of Hefei, Hefei, China
| | - Jun He
- Department of Neurology, The Second People's Hospital of Hefei, Hefei, China
| | - Ping Cui
- Department of Radiology, The Second People's Hospital of Hefei, Hefei, China
| | - Tingting Ge
- Department of Neurology, The Second People's Hospital of Hefei, Hefei, China
| | - Jian Wang
- Department of Neurology, The Second People's Hospital of Hefei, Hefei, China
| | - Wen'an Xu
- Department of Neurology, The Second People's Hospital of Hefei, Hefei, China
| | - Mingwu Xia
- Department of Neurology, The Second People's Hospital of Hefei, Hefei, China
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13
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Rinaldo L, Nasr DM, Flemming KD, Lanzino G, Brinjikji W. Relationship of brainstem infarction to rupture of nonsaccular vertebrobasilar aneurysms. J Neurosurg 2021; 135:1591-1597. [PMID: 33892472 DOI: 10.3171/2020.9.jns201937] [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: 05/23/2020] [Accepted: 09/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Symptomatic nonsaccular vertebrobasilar aneurysms (NSVBAs) are associated with high rates of aneurysm-related death. Anecdotal evidence suggests that brainstem infarction may be a harbinger of aneurysm rupture. The authors aimed to investigate the association between brainstem infarction and subsequent NSVBA rupture. METHODS The clinical records and radiographic imaging studies of patients presenting to the authors' institution between 1996 and 2019 for evaluation and management of an NSVBA were retrospectively reviewed to determine the effect of perforating artery infarction on the natural history of NSVBAs. Kaplan-Meier curves for patients with and patients without perforator infarction were constructed, and predictors of aneurysm rupture were identified using a multivariate Cox proportional hazards model. RESULTS There were 98 patients with 591.3 person-years of follow-up who met the inclusion criteria for analysis. There were 20 patients who experienced perforator infarction during follow-up. Ten patients (10.2%) experienced aneurysm rupture during follow-up and 26 patients (26.5%) died due to aneurysm-related complications, with annual rates of rupture and aneurysm-related death of 1.7% and 4.4%, respectively. Five patients with a perforator infarction later experienced aneurysm rupture, with a median time between infarction and rupture of 3 months (range 0-35 months). On multivariate analysis, the presence of intraaneurysmal thrombus (risk ratio [RR] 4.01, 95% confidence interval [CI] 1.12-14.44, p = 0.033) and perforator infarction (RR 6.37, 95% CI 1.07-37.95, p = 0.042) were independently associated with risk of aneurysm rupture. CONCLUSIONS NSVBAs continue to be extremely challenging clinical entities with a poor prognosis. These results suggest that brainstem infarction due to perforating artery occlusion may be a harbinger of near-term aneurysm rupture.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- Departments of1Neurosurgery
- 3Radiology, Mayo Clinic, Rochester, Minnesota
| | - Waleed Brinjikji
- Departments of1Neurosurgery
- 3Radiology, Mayo Clinic, Rochester, Minnesota
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14
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Tsunoda S, Inoue T. Microsurgical Treatment Strategy of Vertebral Artery Fusiform Aneurysm-From the Standpoint of Hemodynamic Integrity and Perforator Preservation. Front Neurol 2021; 12:728176. [PMID: 34616354 PMCID: PMC8488355 DOI: 10.3389/fneur.2021.728176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/10/2021] [Indexed: 11/13/2022] Open
Abstract
During treatment of vertebral artery (VA) fusiform aneurysms, it is critical to preserve peripheral perforators and anterograde blood flow of the VA and to reduce hemodynamic load to the contralateral VA. Even in the era of endovascular treatment, there are still many benefits to using microsurgical treatments with appropriate clip application and preservation of the perforators around the aneurysm, in conjunction with various bypass techniques. The ideal microsurgical technique involves reconstructive clipping that obliterates the aneurysm but preserves anterograde blood flow of the VA, followed by isolation of the aneurysm and VA reconstruction. If these two methods are unavailable, proximal clipping of the aneurysm combined with flow-augmentation bypass to the distal branch can be considered as an alternative surgical management. We discuss the microsurgical treatment of unruptured VA fusiform aneurysms in our surgical cases on the basis of a review of the current literature.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
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15
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Church EW, Bigder MG, Sussman ES, Gummidipundi SE, Han SS, Heit JJ, Do HM, Dodd RL, Marks MP, Steinberg GK. Treatment of posterior circulation fusiform aneurysms. J Neurosurg 2021; 134:1894-1900. [PMID: 32707547 DOI: 10.3171/2020.4.jns192838] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Perforator arteries, the absence of an aneurysm discrete neck, and the often-extensive nature of posterior circulation fusiform aneurysms present treatment challenges. There have been advances in microsurgical and endovascular approaches, including flow diversion, and the authors sought to review these treatments in a long-term series at their neurovascular referral center. METHODS The authors performed a retrospective chart review from 1990 to 2018. Primary outcomes were modified Rankin Scale (mRS) scores and Glasgow Outcome Scale (GOS) scores at follow-up. The authors also examined neurological complication rates. Using regression techniques, they reviewed independent and dependent variables, including presenting features, aneurysm location and size, surgical approach, and pretreatment and posttreatment thrombosis. RESULTS Eighty-four patients met the inclusion criteria. Their mean age was 53 years, and 49 (58%) were female. Forty-one (49%) patients presented with subarachnoid hemorrhage. Aneurysms were located on the vertebral artery (VA) or posterior inferior cerebellar artery (PICA) in 50 (60%) patients, basilar artery (BA) or vertebrobasilar junction (VBJ) in 22 (26%), and posterior cerebral artery (PCA) in 12 (14%). Thirty-one (37%) patients were treated with microsurgical and 53 (63%) with endovascular approaches. Six aneurysms were treated with endovascular flow diversion. The authors found moderate disability or better (mRS score ≤ 3) in 85% of the patients at a mean 14-month follow-up. The GOS score was ≥ 4 in 82% of the patients. The overall neurological complication rate was 12%. In the regression analysis, patients with VA or PICA aneurysms had better functional outcomes than the other groups (p < 0.001). Endovascular strategies were associated with better outcomes for BA-VBJ aneurysms (p < 0.01), but microsurgery was associated with better outcomes for VA-PICA and PCA aneurysms (p < 0.05). There were no other significant associations between patient, aneurysm characteristics, or treatment features and neurological complications (p > 0.05). Patients treated with flow diversion had more complications than those who underwent other endovascular and microsurgical strategies, but the difference was not significant in regression models. CONCLUSIONS Posterior circulation fusiform aneurysms remain a challenging aneurysm subtype, but an interdisciplinary treatment approach can result in good outcomes. While flow diversion is a useful addition to the armamentarium, traditional endovascular and microsurgical techniques continue to offer effective options.
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Affiliation(s)
| | | | | | - Santosh E Gummidipundi
- 3Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Summer S Han
- Departments of1Neurosurgery and
- 3Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Jeremy J Heit
- Departments of1Neurosurgery and
- 2Radiology, and Stanford Stroke Center; and
| | - Huy M Do
- Departments of1Neurosurgery and
- 2Radiology, and Stanford Stroke Center; and
| | - Robert L Dodd
- Departments of1Neurosurgery and
- 2Radiology, and Stanford Stroke Center; and
| | - Michael P Marks
- Departments of1Neurosurgery and
- 2Radiology, and Stanford Stroke Center; and
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16
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Nakatomi H, Kiyofuji S, Ono H, Tanaka M, Kamiyama H, Takizawa K, Imai H, Saito N, Shiokawa Y, Morita A, Flemming KD, Link MJ. Giant Fusiform and Dolichoectatic Aneurysms of the Basilar Trunk and Vertebrobasilar Junction-Clinicopathological and Surgical Outcome. Neurosurgery 2021; 88:82-95. [PMID: 32745190 PMCID: PMC7891276 DOI: 10.1093/neuros/nyaa317] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 05/24/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Giant fusiform and dolichoectatic aneurysms of the basilar trunk and
vertebrobasilar junction (BTVBJ-GFDA) are extremely difficult to treat. OBJECTIVE To evaluate factors influencing survival and outcome of BTVBJ-GFDA by
performing a retrospective multicenter cohort study. METHODS A total of 32 patients with BTVBJ-GFDA were included in this study.
Clinicopathological characteristics, treatment measures, and outcomes were
collected from medical records and imaging studies. Autopsy and histological
findings of the aneurysm and adjacent brain tissue were also obtained in 9
cases. RESULTS A total of 11 patients did not undergo surgery, of whom 10 died; 3 from
progressive brainstem compression, 4 from subarachnoid hemorrhage, 2 from
brainstem infarction, and 1 from associated atherosclerotic disease. The
remaining 21 patients underwent a surgical treatment, consisting of
immediately proximal parent artery occlusion, remotely proximal parent
artery occlusion, clip reconstruction, and distal bypass and achieved
significantly longer overall survival compared with those who received
conservative therapy (adjusted hazard ratio 1.508, 95% CI
1.058-2.148, P = .02). Histological
examination of the aneurysms demonstrated staged clots, open lumen, and
intrathrombotic channels with endothelial lining. The patients younger than
45 yr of age showed statistically longer survival than those equal and older
than 45 yr (P = .03). CONCLUSION Surgical intervention achieved greater survival than conservative management
in BTVBJ-GFDA. Narrow ideal treatment window of the blood flow within the
aneurysm to maintain sufficient but not excess supply should be targeted
based on the hemodynamics of both the posterior communicating arteries and
perforating vessel collaterals.
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Affiliation(s)
- Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.,Division of Collaborative Laboratory for Medical Science of Neural Dynamics, RIKEN Center for Brain Science, Saitama, Japan
| | - Satoshi Kiyofuji
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hideaki Ono
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Minoru Tanaka
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery and Stroke, Teishinkai Hospital, Hokkaido, Japan
| | - Katsumi Takizawa
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Hokkaido, Japan
| | - Hideaki Imai
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Akio Morita
- Department of Neurosurgery, Nippon Medical University, Tokyo, Japan
| | | | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Cao L, Zhu C, Eisenmenger L, Du X, Liu J, Yang Q, Lu J, Li K, Saloner D. Wall enhancement characteristics of vertebrobasilar nonsaccular aneurysms and their relationship to symptoms. Eur J Radiol 2020; 129:109064. [DOI: 10.1016/j.ejrad.2020.109064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/18/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022]
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18
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Patil AS, Iratwar S, Rathod C, Korde P. Target Sign of Third Ventricle in Basilar Dolichoectasia with Multiple Clinical Presentations: A Case Report. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0039-3402536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractBasilar dolichoectasia (BDE) is an uncommon anatomical variant usually detected incidentally or during stroke evaluation. BDE can occasionally become symptomatic and may present with stroke (infarct or hemorrhage), raised intracranial pressure due to obstructive hydrocephalus, or with cranial nerve palsies. We present a unique case of BDE presenting with obstructive hydrocephalus, stroke, and cranial nerve palsy in single patient and propose a radiological sign (target sign of third ventricle), which could aid in imaging diagnosis and further management.
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Affiliation(s)
- Akshay S. Patil
- Department of Neurosurgery, Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, India
| | - Sandeep Iratwar
- Department of Neurosurgery, Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, India
| | - Chetan Rathod
- Department of Neurosurgery, Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, India
| | - Paresh Korde
- Department of Neurosurgery, Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, India
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19
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Lenga P, Hohaus C, Hong B, Kursumovic A, Maldaner N, Burkhardt JK, Bijlenga P, Rüfenacht DA, Schmidt NO, Vajkoczy P, Dengler J. Giant intracranial aneurysms of the posterior circulation and their relation to the brainstem: analysis of risk factors for neurological deficits. J Neurosurg 2019; 131:403-409. [PMID: 30095339 DOI: 10.3171/2018.4.jns172343] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Giant posterior circulation aneurysms (GPCirAs) usually cause substantial mass effect on the brainstem, which may lead to neurological deficits. So far, there has been no systematic investigation of factors associated with such deficits in GPCirA. The authors aim to examine the risk factors for cranial nerve deficit (CND), motor deficit, and disability in patients with GPCirA. METHODS Using MR images obtained in 30 patients with unruptured GPCirA, the authors examined GPCirA volume, presence of hydrocephalus or partial thrombosis (PT) of the aneurysm, and the degree of brainstem displacement measured by the distance between the McRae line and the tip of the GPCirA (∆MT). They evaluated associations between these factors and neurological deficits. RESULTS Thirty GPCirAs in 30 patients were included. The prevalence of CNDs was 50%. Patients with CNDs significantly differed from those without CNDs in terms of age (mean 51.0 years [SD 15.0 years] vs 69.0 years [SD 21.0 years], p = 0.01) and in ∆MT (median 50.7 mm [IQR 39.2-53.9 mm] vs 39.0 mm [IQR 32.3-45.9 mm], p = 0.02). The prevalence of motor deficits was 33.3%. Patients with motor deficits showed a larger ∆MT (median 50.5 mm [IQR 40.8-54.6 mm]) compared with those without (∆MT: median 39.1 mm [IQR 32.8-50.5 mm], p = 0.04). GPCirA volume was larger in patients with poor modified Rankin Scale (mRS) scores (median 14.9 cm3 [IQR 8.6-18.7 cm3]) than in those with mRS scores of 0-2 (median 6.8 cm3 [IQR 4.4-11.7 cm3], p = 0.03). After adjusting for patient age and the occurrence of hydrocephalus or PT, the authors found that higher degrees of disability were significantly associated with aneurysm volume (OR 1.13, 95% CI 1.0-1.3; p = 0.04), but not with ∆MT. The occurrence of CND or motor deficit was not associated with any of the examined variables. There was no correlation between GPCirA volume and ∆MT (rs = 0.01, p = 0.96). The prevalence of neurological deficits did not differ between GPCirA at the basilar apex, the basilar trunk, the vertebrobasilar junction, or the vertebral artery. CONCLUSIONS In this study, the neurological condition of the patients was associated only with GPCirA volume and not with the degree of brainstem displacement, the occurrence of PT or hydrocephalus, or the exact location of the GPCirA. These findings highlight the clinical relevance of GPCirA volume and suggest that factors such as brainstem displacement or PT should play less of a role when finding arguments for or against treatment of GPCirA.Clinical trial registration no.: NCT02066493 (clinicaltrials.gov).
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Affiliation(s)
- Pavlina Lenga
- 1Department of Neurosurgery, Charité-Universitaetsmedizin Berlin
| | | | - Bujung Hong
- 3Department of Neurosurgery, Hannover Medical School, Hannover
| | - Adisa Kursumovic
- 4Department of Neurosurgery and Interventional Neuroradiology, DONAUISAR Klinikum Deggendorf, Germany
| | | | | | | | - Daniel A Rüfenacht
- 7Department of Neuroradiology, Clinic Hirslanden, Zurich, Switzerland; and
| | - Nils O Schmidt
- 8Department of Neurosurgery, University Medical Center, Hamburg Eppendorf, Germany
| | - Peter Vajkoczy
- 1Department of Neurosurgery, Charité-Universitaetsmedizin Berlin
| | - Julius Dengler
- 1Department of Neurosurgery, Charité-Universitaetsmedizin Berlin
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20
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Wang J, Jia L, Yang X, Jia X, Liu J, Liu P, Miao Z, Zhang Y, Tian Z, Wang K, Wang Z, Zhang Y, Lv M. Outcomes in Symptomatic Patients With Vertebrobasilar Dolichoectasia Following Endovascular Treatment. Front Neurol 2019; 10:610. [PMID: 31263445 PMCID: PMC6585389 DOI: 10.3389/fneur.2019.00610] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/23/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate whether the presenting symptoms of VBD predict outcomes following endovascular treatment. Methods: We retrospectively reviewed our institutional clinical database and identified 22 patients (all men; mean age: 52.6 years, range: 11-73 years) with a diagnosis of VBD, who underwent endovascular treatment from January 2010 to December 2017. Results: After analyzing the clinical and imaging data, we evaluated data for 22 symptomatic patients with VBD. At the time of VBD diagnosis, 13 patients (59%) had compressive symptoms, four (18%) had hemorrhagic symptoms, and five (23%) had ischemic symptoms. Nine of the 22 patients (41%), who presented with hemorrhagic and ischemic symptoms, achieved a satisfactory clinical and/or digital subtraction angiography imaging outcome after endovascular treatment. However, of the 13 patients who presented with compressive symptoms, seven (54%, 7/13) died from severe brainstem compression during follow-up; furthermore, magnetic resonance imaging showed worsening of the mass effect in eight patients with compressive symptoms (62%, 8/13). Conclusions: VBD is considered a challenging lesion without an ideal treatment modality. Endovascular treatment of VBD in patients presenting with compressive symptoms at diagnosis may not be beneficial. However, long-term outcomes following endovascular treatment may be acceptable in patients with non-compressive symptoms at diagnosis compared with those with compressive symptoms.
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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
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuecang Jia
- Taian Hospital of Traditional Chinese, Taian, China
| | - Jian Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zefeng Miao
- Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Ying Zhang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongbin Tian
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kun Wang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongxiao Wang
- 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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21
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Growth of Asymptomatic Intracranial Fusiform Aneurysms. Clin Neuroradiol 2018; 29:717-723. [DOI: 10.1007/s00062-018-0695-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/26/2018] [Indexed: 10/16/2022]
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22
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Lehman VT, Brinjikji W, Mossa-Basha M, Lanzino G, Rabinstein AA, Kallmes DF, Huston J. Conventional and high-resolution vessel wall MRI of intracranial aneurysms: current concepts and new horizons. J Neurosurg 2018; 128:969-981. [DOI: 10.3171/2016.12.jns162262] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial aneurysms are heterogeneous in histopathology and imaging appearance. The biological behavior of different types of aneurysms is now known to depend on the structure and physiology of the aneurysm wall itself in addition to intraluminal flow and other luminal features. Aneurysm wall structure and imaging markers of physiology such as aneurysm wall enhancement have been assessed in many prior investigations using conventional-resolution MRI. Recently, high-resolution vessel wall imaging (HR-VWI) techniques with MRI have been introduced. Reports of findings on high-resolution imaging have already emerged for many types of aneurysms demonstrating detailed characterization of wall enhancement, thickness, and components, but many questions remain unexplored. This review discusses the key HR-VWI literature to date. Aneurysm wall findings on conventional-resolution MRI are also discussed as these may help one understand the potential utility and findings on HR-VWI for various aneurysm types. The authors have illustrated these points with several examples demonstrating both features already described in the literature and novel cases demonstrating the potential for future clinical and research applications.
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Affiliation(s)
| | | | - Mahmud Mossa-Basha
- 2Department of Radiology, University of Washington Medical Center, Seattle, Washington
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23
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Nasr D, Flemming K, Lanzino G, Cloft H, Kallmes D, Murad M, Brinjikji W. Natural History of Vertebrobasilar Dolichoectatic and Fusiform Aneurysms: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2018; 45:68-77. [DOI: 10.1159/000486866] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 01/11/2018] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose: Vertebrobasilar non-saccular and dolichoectatic aneurysms (VBDA) are a rare type of aneurysm and are generally associated with poor prognosis. In order to better characterize the natural history of VBDAs, we performed a systematic review and meta-analysis of the literature to determine rates of mortality, growth, rupture, ischemia, and intraparenchymal hemorrhage. Materials and Methods: We searched the literature for longitudinal natural history studies of VBDA patients reporting clinical and imaging outcomes. Studied outcomes included annualized rates of growth, rupture, ischemic stroke, intracerebral hemorrhage (ICH), and mortality. We also studied the association between aneurysm morphology (dolichoectatic versus fusiform) and natural history. Meta-analysis was performed using a random-effects model using summary statistics from included studies. Results: Fifteen studies with 827 patients and 5,093 patient-years were included. The overall annual mortality rate among patients with VBDAs was 13%/year (95% CI 8–19). Patients with fusiform aneurysms had a higher mortality rate than those with dolichoectatic aneurysms, but this did not reach statistical significance (12 vs. 8%, p = 0.11). The overall growth rate was 6%/year (95% CI 4–13). Patients with fusiform aneurysms had higher growth rates than those with dolichoectatic aneurysms (12 vs. 3%, p < 0.0001). The overall rupture rate was 3%/year (95% CI 1–5). Patients with fusiform aneurysms had higher rupture rates than those with dolichoectatic aneurysms (3 vs. 0%, p < 0.0001). The overall rate of ischemic stroke was 6%/year (95% CI 4–9). Patients with dolichoectatic aneurysms had higher ischemic stroke rates than those with fusiform aneurysms, but this did not reach statistical significance (8 vs. 4%, p = 0.13). The overall rate of ICH was 2%/year (95% CI 0–8) with no difference in rates between dolichoectatic and fusiform aneurysms (2 vs. 2%, p = 0.65). Conclusion: In general, the natural history of VBDAs is poor. However, dolichoectatic and fusiform VBDAs appear to have distinct natural histories with substantially higher growth and rupture associated with fusiform aneurysms. These findings suggest that these aneurysms should be considered separate entities. Further studies on the natural history of vertebrobasilar dolichoectatic and fusiform aneurysms with more complete follow-up are needed to better understand the risk factors for progression of these aneurysms.
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24
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Del Brutto VJ, Ortiz JG, Biller J. Intracranial Arterial Dolichoectasia. Front Neurol 2017; 8:344. [PMID: 28769872 PMCID: PMC5511833 DOI: 10.3389/fneur.2017.00344] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/03/2017] [Indexed: 11/13/2022] Open
Abstract
An increased diameter (ectasis) and/or long and tortuous course (dolichosis) of at least one cerebral artery define intracranial arterial dolichoectasia (IADE). IADE could be detected incidentally or may give rise to an array of neurological complications including ischemic stroke, intracranial hemorrhage, or compression of surrounding neural structures. The basilar artery is preferentially affected and has been studied in more detail, mainly due to the presence of accepted diagnostic criteria proposed by Smoker and colleagues in 1986 (1). Criteria for the diagnoses of dolichoectasia in other cerebral arteries have been suggested. However, they lack validation across studies. The prevalence of IADE is approximately 0.08–6.5% in the general population, while in patients with stroke, the prevalence ranges from 3 to 17%. Variations among case series depend on the characteristics of the studied population, diagnostic tests used, and diagnostic criteria applied. In rare instances, an underlying hereditary condition, connective tissue disorder, or infection predispose to the development of IADE. However, most cases are sporadic and associated with traditional vascular risk factors including advanced age, male gender, and arterial hypertension. The link between this dilative arteriopathy and other vascular abnormalities, such as abdominal aortic aneurysm, coronary artery ectasia, and cerebral small vessel disease, suggests the underlying diffuse vascular process. Further understanding is needed on the physiopathology of IADE and how to prevent its progression and clinical complications.
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Affiliation(s)
- Victor J Del Brutto
- Department of Neurology, Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - Jorge G Ortiz
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
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25
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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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26
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Moriyoshi H, Furukawa S, Iwata M, Suzuki J, Nakai N, Nishida S, Ito Y. A case of intracranial arterial dolichoectasia with 4 repeated cerebral infarctions in 6 months and enlargement of basilar artery. Rinsho Shinkeigaku 2017; 57:124-129. [PMID: 28228620 DOI: 10.5692/clinicalneurol.cn-000989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 78-year-old man was admitted to our hospital because of sudden right hemiparesis and dysarthria. His cranial MRI showed an area of hyperintensity in left pons on DWI and MRA revealed dilated, elongated and tortuous intracranial artery. We diagnosed as acute phase ischemic stroke and intracranial arterial dolichoectasia (IADE). Intravenous infusion of rt-PA was performed 157 minutes after the onset of symptoms, and his hemiparesis improved. However, he subsequently suffered from cerebral infarction 4 times in 6 months, and we treated him twice with thrombolytic therapy. Although thrombolytic therapy was effective in the short term and antithrombotic therapy was continued, he had bilateral hemiplegia and severe dysphagia because of repeated cerebral infarctions. Hence basilar artery was dilated with intramural hemorrhage over 6 months, and we discontinued antithrombolytic therapy. It is possible that antithrombolytic therapy affects enlargement of IADE. Antithrombolytic therapy for IADE should be done carefully.
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27
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Bhogal P, Pérez MA, Ganslandt O, Bäzner H, Henkes H, Fischer S. Treatment of posterior circulation non-saccular aneurysms with flow diverters: a single-center experience and review of 56 patients. J Neurointerv Surg 2016; 9:471-481. [PMID: 27836994 PMCID: PMC5520279 DOI: 10.1136/neurintsurg-2016-012781] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Non-saccular aneurysms of the posterior fossa are an uncommon pathology with no clear treatment strategy. The use of flow-diverting stents (FDS) has had mixed results. We sought to evaluate our experience of FDS for the treatment of this pathology. METHODS We retrospectively reviewed our database of prospectively collected information for all patients treated only with flow diversion for an unruptured non-saccular aneurysm of the posterior circulation between February 2009 and April 2016. The aneurysms were classified as dolichoectasia, fusiform or transitional, and imaging characteristics including maximal diameter, disease vessel segment, MRI features (intra-aneurysmal thrombus, T1 hyperintensity in the aneurysmal wall, infarctions in the territory of the posterior circulation, and mass effect) were recorded alongside clinical and follow-up data. RESULTS We identified 56 patients (45 men) with 58 aneurysms. The average age of the patients was 63.5 years. Twenty-two patients were symptomatic from the aneurysms at presentation. The majority of the lesions were vertebrobasilar in location (44.8%) with isolated vertebral lesions representing 29.3% of aneurysms. Transitional aneurysms were the most common (48.2%). The mean maximal diameter of the aneurysms was 11 mm. Angiographic exclusion of the aneurysms was seen in 57.4% of aneurysms with follow-up (n=47). During the follow-up period nine patients died. CONCLUSIONS Treatment of non-saccular aneurysms of the posterior fossa is technically possible. Early treatment, particularly of the fusiform and transitional subtypes, is recognized, as is treatment prior to the development of symptoms. A 'watch and wait' strategy with regular imaging follow-up could be employed for asymptomatic dolichoectasia.
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Affiliation(s)
- P Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
| | - S Fischer
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie, Nuklearmedizin, Knappschaftskrankenhaus Bochum-Langendreer Universtätsklinik, Bochum, Germany
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28
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Intracranial vessel wall imaging for evaluation of steno-occlusive diseases and intracranial aneurysms. J Neuroradiol 2016; 44:123-134. [PMID: 27836652 DOI: 10.1016/j.neurad.2016.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 07/18/2016] [Accepted: 10/04/2016] [Indexed: 01/23/2023]
Abstract
Cerebrovascular diseases have traditionally been classified, diagnosed and managed based on their luminal characteristics. However, over the past several years, several advancements in MRI techniques have ushered in high-resolution vessel wall imaging (HR-VWI), enabling evaluation of intracranial vessel wall pathology. These advancements now allow us to differentiate diseases which have a common angiographic appearance but vastly different natural histories (i.e. moyamoya versus atherosclerosis, reversible cerebral vasoconstriction syndrome versus vasculitis, stable versus unstable intracranial aneurysms). In this review, we detail the anatomical, histopathological and imaging characteristics of various intracranial steno-occlusive diseases and types of intracranial aneurysms and describe the role that HR-VWI can play in diagnosis, risk stratification and treatment.
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29
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J-O'Shanahan A, Noda K, Tsuboi T, Ota N, Kamiyama H, Tokuda S, Tanikawa R. Radical surgical treatment for recurrent giant fusiform thrombosed vertebral artery aneurysm previously coiled. Surg Neurol Int 2016; 7:S237-42. [PMID: 27127714 PMCID: PMC4828954 DOI: 10.4103/2152-7806.179581] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 01/28/2016] [Indexed: 11/29/2022] Open
Abstract
Background: Fusiform aneurysms are rare (<1%) and the underlying pathophysiology is not well known. Endovascular coiling is the standard of treatment; however, a surgical procedure with vascular reconstruction by excluding the pathological segment of the vessel and restoring the blood flow, seems to be the most effective and definitive treatment. Case Description: We report a patient who presented a fusiform vertebral artery aneurysm previously coiled which developed a giant enlargement and a new contralateral fusiform aneurysm. Hemodynamic changes resulting in the formation of contralateral aneurysm might be the result of aneurysm occlusion without revascularization. In addition, continued blood flow to the aneurysmal wall through the vasa vasorum might result in aneurysm recanalization or regrowth. In order to account for these possible sources of complications, we performed a vascular reconstruction with high and low flow bypasses after trapping the aneurysm. Conclusions: We hypothesize that, in this and similar cases, surgical vascular reconstruction should be the first and definitive treatment under experienced cerebrovascular surgeons.
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Affiliation(s)
- Aruma J-O'Shanahan
- Department of Neurosurgery, University Hospital Dr. Negrín, Gran Canaria, Canary Islands, Spain
| | - Kosumo Noda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Toshiyuki Tsuboi
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Sadahisa Tokuda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Hokkaido, Japan
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30
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George E, Settler A, Connors S, Greenfield JP. Pediatric Gliomatosis Cerebri: A Review of 15 Years. J Child Neurol 2016; 31:378-87. [PMID: 26239491 DOI: 10.1177/0883073815596612] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 06/17/2015] [Indexed: 01/22/2023]
Abstract
Gliomatosis cerebri is a rare glial tumor that carries a poor prognosis. Seen in both adults and children, gliomatosis cerebri appears to differ in these populations as with adult versus pediatric glioblastoma. We present 10 children who either presented to the Weill Cornell Medical College or enrolled in the institution's Gliomatosis Cerebri International Registry alongside a cohort of 89 pediatric patients reported in the literature between 2000 and 2014. Age ranged from 4 months to 21 years, with a male to female ratio of 1.71. Median overall survival for patients in the registry cohort was 17 months (n = 10) and for the historic cohort was 13 months (n = 52). Overall survival was analyzed for the combined cohort and was significantly longer when presenting at age ≥ 10 (20 vs 10 months), for boys (18 vs 11 months), and with low-grade pathology (26.5 vs 12 months) but did not vary significantly by treatment approach.
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Affiliation(s)
- Emilie George
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Allison Settler
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Scott Connors
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA
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31
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Nasr DM, Brinjikji W, Rouchaud A, Kadirvel R, Flemming KD, Kallmes DF. Imaging Characteristics of Growing and Ruptured Vertebrobasilar Non-Saccular and Dolichoectatic Aneurysms. Stroke 2016; 47:106-12. [DOI: 10.1161/strokeaha.115.011671] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/22/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Vertebrobasilar, nonsaccular, and dolichoectatic aneurysms generally have a poor natural history. We performed a study examining the natural history of vertebrobasilar, nonsaccular, and dolichoectatic aneurysms receiving serial imaging and studied imaging characteristics associated with growth and rupture.
Methods—
We included all vertebrobasilar dolichoectatic, fusiform, and transitional aneurysms with serial imaging follow-up seen at our institution over a 15-year period. Two radiologists and a neurologist evaluated aneurysms for size, type, mural T1 signal, mural thrombus, daughter sac, mass effect, and tortuosity. Primary outcomes were aneurysm growth or rupture. Univariate analysis was performed with chi-squared tests for categorical variables and Student’s
t
test or analysis of variance for continuous variables. Multivariate logistic regression analysis was performed to identify variables independently associated with aneurysm growth or rupture.
Results—
One hundred and fifty-two patients with 542 patient-years (mean 3.6±3.5 years) of imaging follow-up were included. Aneurysms were fusiform in 45 cases (29.6%), dolichoectatic in 75 cases (49.3%), and transitional in 32 cases (21.1%). Thirty-five aneurysms (23.0%) grew (growth rate=6.5%/year). Eight aneurysms (5.3%) ruptured (rupture rate=1.5%/year). Variables associated with growth and rupture on univariate analysis were size >10 mm (57.6% versus 16.0%,
P
<0.0001), mural T1 signal (39.7% versus 16.3%,
P
=0.001), daughter sac (56.3% versus 21.3%), and mural thrombus (45.5% versus 13.4%,
P
<0.0001). 26.7% of fusiform aneurysms, 9.3% of dolichoectatic aneurysms, and 59.4% of transitional aneurysms grew or ruptured (
P
<0.0001). The only variable independently associated with rupture was transitional morphology (
P
=0.003).
Conclusions—
Vertebrobasilar, nonsaccular, and dolichoectatic aneurysms are associated with a poor natural history with high growth and rupture rates. Further research is needed to determine the best treatments for this disease.
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Affiliation(s)
- Deena M. Nasr
- From the Department of Neurology, Mayo Clinic, Rochester, MN (D.M.N., K.D.F.); and Department of Radiology, Mayo Clinic, Rochester, MN (W.B., A.R., R.K., D.F.K.)
| | - Waleed Brinjikji
- From the Department of Neurology, Mayo Clinic, Rochester, MN (D.M.N., K.D.F.); and Department of Radiology, Mayo Clinic, Rochester, MN (W.B., A.R., R.K., D.F.K.)
| | - Aymeric Rouchaud
- From the Department of Neurology, Mayo Clinic, Rochester, MN (D.M.N., K.D.F.); and Department of Radiology, Mayo Clinic, Rochester, MN (W.B., A.R., R.K., D.F.K.)
| | - Ramanathan Kadirvel
- From the Department of Neurology, Mayo Clinic, Rochester, MN (D.M.N., K.D.F.); and Department of Radiology, Mayo Clinic, Rochester, MN (W.B., A.R., R.K., D.F.K.)
| | - Kelly D. Flemming
- From the Department of Neurology, Mayo Clinic, Rochester, MN (D.M.N., K.D.F.); and Department of Radiology, Mayo Clinic, Rochester, MN (W.B., A.R., R.K., D.F.K.)
| | - David F. Kallmes
- From the Department of Neurology, Mayo Clinic, Rochester, MN (D.M.N., K.D.F.); and Department of Radiology, Mayo Clinic, Rochester, MN (W.B., A.R., R.K., D.F.K.)
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32
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Pico F, Labreuche J, Amarenco P. Pathophysiology, presentation, prognosis, and management of intracranial arterial dolichoectasia. Lancet Neurol 2015. [PMID: 26194931 DOI: 10.1016/s1474-4422(15)00089-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Up to 12% of patients with stroke have intracranial arterial dolichoectasia (IADE) and the basilar artery is affected in 80% of these cases. Diagnostic criteria and prognosis studies of IADE are based on basilar artery diameter, which is a good quantitative marker for the severity of the disease. The pathophysiology is largely unknown, but IADE can be viewed as a common final pathway of arterial wall response or damage in the tunica media due to various mechanisms, such as matrix metalloproteinase dysfunction or muscle cell or elastic fibre injury. No randomised controlled trials have been undertaken in IADE and thus little high-level evidence is available on which to base treatment guidelines. IADE management depends on clinical presentation and disease severity, and includes blood pressure control, antithrombotic treatments, endovascular procedures, and surgery. Further studies are needed to better define IADE in the general population, to establish its prevalence and pathophysiology, to identify subgroups at risk of life-threatening complications, and to offer effective treatment options.
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Affiliation(s)
- Fernando Pico
- Neurology Department and Stroke Centre, Centre Hospitalier de Versailles, Le Chesnay and Université de Versailles Saint-Quentin-en-Yvelines, Île-de-France, France; INSERM Laboratory for Vascular Translational Science, Paris, France
| | - Julien Labreuche
- Department of Neurology and Stroke Centre, Paris, France; AP-HP Bichat University Hospital, Paris-Diderot University and Medical School, Paris, France
| | - Pierre Amarenco
- INSERM Laboratory for Vascular Translational Science, Paris, France; Department of Neurology and Stroke Centre, Paris, France; AP-HP Bichat University Hospital, Paris-Diderot University and Medical School, Paris, France.
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Abstract
Dolichoectasia (DE) in cerebral arteries is a poorly understood arteriopathy that has been associated with increased risk of vascular morbidity and mortality. Dolichoectasia tends to affects older individuals with vascular risk factors, but it can also be secondary to specific conditions related with extracellular matrix health. The range of methods used to study DE and the biases inherent to hospital-based samples weaken the generalizability of DE study results to the general population. Within the context of these limitations, there is growing evidence that DE is a serious condition that can increase the risk of vascular death. Recurrent strokes and compressive symptoms are among the major causes of morbidity, but cardiac ischemic disease and aortic aneurysms are not uncommon in populations with DE. The devastating outcomes of patients with DE are a call to action aimed at improving the quality of research on the topic and discovering therapies that can palliate the burden of DE in the population.
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Affiliation(s)
- Jose Gutierrez
- Department of Neurology, Columbia University Medical Center, 710 W 168th Street, 6th floor, Suite 639, New York, NY, 10032, USA,
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Kobayashi N, Murayama Y, Yuki I, Ishibashi T, Ebara M, Arakawa H, Irie K, Takao H, Kajiwara I, Nishimura K, Karagiozov K, Urashima M. Natural course of dissecting vertebrobasilar artery aneurysms without stroke. AJNR Am J Neuroradiol 2014; 35:1371-5. [PMID: 24610902 DOI: 10.3174/ajnr.a3873] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The natural history and therapeutic management of dissecting vertebrobasilar aneurysms without ischemic or hemorrhagic stroke (nonstroke dissecting vertebrobasilar aneurysms) are not well-established. We conservatively followed patients with nonstroke dissecting vertebrobasilar aneurysms and evaluated the factors related to clinical and morphologic deterioration. MATERIALS AND METHODS One hundred thirteen patients were enrolled and divided by clinical presentation at diagnosis: asymptomatic (group 1, n = 52), pain only (group 2, n = 56), and mass effect (group 3, n = 5). Patients were conservatively managed without intervention and antithrombotic therapy. Clinical outcomes and morphologic changes were analyzed. RESULTS A total of 113 patients who were diagnosed with nonstroke dissecting vertebrobasilar aneurysm had a mean follow-up of 2.9 years (range, 27 days to 8 years). Throughout that period, 1 patient in group 1 (1.9%) and 1 patient in group 2 (1.8%) showed clinical deterioration due to mass effect, and 1 patient in group 3 (20%) developed ischemic stroke followed by subarachnoid hemorrhage. Most patients (97.3%) were clinically unchanged. Three patients who had clinical deterioration showed aneurysm enlargement (P < .001). Aneurysms remained morphologically unchanged in 91 patients (80.5%). Aneurysm enlargement was seen in 5 patients (4.4%); risk of enlargement was significantly associated with either maximum diameter (hazard ratio = 1.30; 95% CI, 1.11-11.52; P = .001) or aneurysm ≥10 mm (hazard ratio = 18.0; 95% CI, 1.95-167; P = .011). CONCLUSIONS The natural course of these lesions suggests that acute intervention is not always required and close follow-up without antithrombotic therapy is reasonable. Patients with symptoms due to mass effect or aneurysms of >10 mm may require treatment.
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Affiliation(s)
- N Kobayashi
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - Y Murayama
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - I Yuki
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - T Ishibashi
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - M Ebara
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - H Arakawa
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - K Irie
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - H Takao
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - I Kajiwara
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - K Nishimura
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - K Karagiozov
- From the Department of Neurosurgery (N.K., Y.M., I.Y., T.I., M.E., H.A., K.I., H.T., I.K., K.N., K.K.)
| | - M Urashima
- Division of Molecular Epidemiology (M.U.), The Jikei University School of Medicine, Tokyo, Japan
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Abstract
OPINION STATEMENT Gliomatosis cerebri (GC) is an intriguing disease for several reasons. First, it is difficult to draw the border between GC and diffuse gliomas. In this regard, GC could represent the most invasive form of diffuse gliomas. Second, both in terms of histologic grading and clinical course, GC is a heterogeneous disease, ranging from rapidly evolving to slowly and somewhat indolent forms. Because of the extensive spread of the disease, surgery-outside a biopsy for diagnosis-is rarely indicated in gliomatosis cerebri. Therapeutic options include radiotherapy, generally involving the whole brain, and chemotherapy with temozolomide or nitrosoureas. Because of the rarity of the disease, no trial comparing these two modalities has been undertaken so far. Decision is, therefore, based on small retrospective noncomparative studies and expert opinions. On one hand, there is a rationale to postpone the whole brain radiotherapy because of late neurotoxicity, but on the other hand, there is also the risk that an aggressive disease evolves to intracranial hypertension making the radiotherapy hazardous or even impossible. As a consequence, the patient would lose the opportunity to receive a potentially effective treatment. In this decision, the evaluation of histologic data together with clinical and radiologic features, performance status, and molecular profile may be of help. Because radiotherapy usually involves large volumes of the brain, chemotherapy is generally preferred up front in patients with a slowly evolving disease. Conversely, in patients with rapidly (ie, over few weeks) evolving disease with neurologic deficits or when histologic features of glioblastoma are evident, whole brain radiotherapy (45 Gy with 1.8 Gy fractions), alone or associated with concomitant temozolomide, is often preferred. The value of advanced of magnetic resonance imaging and positron emission tomography techniques to predict outcome and monitoring the treatment still remains to be defined.
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Yuh SJ, Alkherayf F, Lesiuk H. Dolichoectasia of the vertebral basilar and internal carotid arteries: A case report and literature review. Surg Neurol Int 2013; 4:153. [PMID: 24381796 PMCID: PMC3872646 DOI: 10.4103/2152-7806.122397] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Accepted: 09/17/2013] [Indexed: 11/14/2022] Open
Abstract
Background: Dolichoectasia is a rare disorder of the cerebral vasculature consisting of vascular elongation, widening, and tortuosity, usually involving the vertebral and basilar arteries. Its neurological symptoms and signs are highly variable. Case Description: We present a case of dolichoectasia of the vertebrobasilar system in a patient with a long standing history of multiple falls. Repeat neuroimaging revealed an increase in size of the dolichoectatic segment. In addition, a new fusiform dilatation of the contralateral petrous segment of the internal carotid artery and isolated ventriculomegaly had developed. Conclusion: Vertebrobasilar dolichoectasia can cause multiple clinical manifestations, with hydrocephalus being less common. In addition, having dolichoectasia of both posterior and anterior circulation is extremely rare.
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Affiliation(s)
- Sung-Joo Yuh
- Division of Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Fahad Alkherayf
- Division of Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Howard Lesiuk
- Division of Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
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Gutierrez J, Sultan S, Bagci A, Rundek T, Alperin N, Elkind MSV, Sacco RL, Wright CB. Circle of Willis configuration as a determinant of intracranial dolichoectasia. Cerebrovasc Dis 2013; 36:446-53. [PMID: 24281350 DOI: 10.1159/000356347] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 10/14/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Circle of Willis (COW) variants might influence arterial caliber in the brain. We hypothesized that these variants would be associated with the prevalence of intracranial dolichoectasia (DE). METHODS We examined COW variants and DE in a sample of stroke-free participants (n = 436) undergoing magnetic resonance angiography (MRA) as part of a population-based study. Large intracranial arterial diameters were obtained when available; if not, the artery was defined as hypoplastic or absent according to its visibility on MRA. Subscores for the anterior and the posterior circulations were created. DE was defined as arterial diameters ≥2 SD above the population mean for that artery, adjusting for intracranial volume. Generalized linear models with a Poisson distribution were used to evaluate predictors of both absent and hypoplastic vessels, and logistic regression was used to assess the odds ratio (OR) and 95% confidence interval (95% CI) of DE depending on COW variants. RESULTS Only 44% of the sample had all 14 arteries present, 32% lacked 1 artery, 18% lacked 2 and 6% lacked 3 or more. DE of at least 1 artery was not associated with the total number of hypoplastic or absent arteries, but DE in a posterior circulation artery was weakly associated with the number of absent arteries in the posterior circulation (β coefficient = 0.36, p = 0.06). DE of at least 1 artery was more frequent in those with 1 or more absent arteries (OR 1.27, 95% CI 1.03-1.57). Posterior circulation DE was more frequent in participants with at least 1 or more absent arteries at any location (OR 1.35, 95% CI 1.02-1.78). Participants with an incomplete posterior COW were more likely to have DE in the anterior circulation (OR 1.52, 95% CI 1.01-2.33). Having an absent left anterior cerebral artery (ACA) A1 segment was associated with right ACA DE (OR 34.1, 95% CI 3.16-368.2); an absent right ACA was associated with left ACA DE (OR 14.1, 95% CI 1.69-118.28). Absence of 1 (OR 1.9, 95% CI 1.1-3.4) or 2 (OR 3.0, 95% CI 1.4-6.6) of the 2 arteries connecting the anterior to the posterior circulation was associated with basilar artery DE. CONCLUSION The COW is a pleomorphic structure that allows collateral flow to compensate for an insufficient or absent arterial component at the base of the skull. By presumed flow diversion, arteries might undergo outward remodeling. Whether this compensatory arterial dilatation is beneficial or not remains unknown.
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Affiliation(s)
- Jose Gutierrez
- Department of Neurology, Columbia University Medical Center, New York, N.Y., USA
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Wolters FJ, Rinkel GJE, Vergouwen MDI. Clinical course and treatment of vertebrobasilar dolichoectasia: a systematic review of the literature. Neurol Res 2013; 35:131-7. [DOI: 10.1179/1743132812y.0000000149] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Franciscus J Wolters
- UMC Utrecht Stroke CenterDepartment of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gabriël J E Rinkel
- UMC Utrecht Stroke CenterDepartment of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mervyn D I Vergouwen
- UMC Utrecht Stroke CenterDepartment of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands
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Shapiro M, Becske T, Riina HA, Raz E, Zumofen D, Nelson PK. Non-saccular vertebrobasilar aneurysms and dolichoectasia: a systematic literature review. J Neurointerv Surg 2013; 6:389-93. [PMID: 23843444 DOI: 10.1136/neurintsurg-2013-010793] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Maksim Shapiro
- Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York, USA
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Gutierrez J, Bagci A, Gardener H, Rundek T, Ekind MSV, Alperin N, Sacco RL, Wright CB. Dolichoectasia diagnostic methods in a multi-ethnic, stroke-free cohort: results from the northern Manhattan study. J Neuroimaging 2013; 24:226-31. [PMID: 23317292 DOI: 10.1111/j.1552-6569.2012.00781.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 10/06/2012] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Dolichoectasia (DE) is a vasculopathy that consists of abnormal elongation and dilatation of arteries. The objective of this study is to evaluate the frequency of DE in an unselected population and assess different diagnostic methods. METHODS The Northern Manhattan Study is a multiethnic population based cohort of stroke-free participants. The definition proposed for DE was total cranial volume (TCV)-adjusted arterial diameter ≥2 SD. Other methods studied included visual assessment, unadjusted arterial diameters cutoff, Smoker's criteria and basilar artery (BA) volume. RESULTS A total of 718 subjects were included in the analysis (mean age 71.6 ± 8.0 years, 40% men, 61% Hispanic). Using the TCV-adjusted DE definition, 19% of the sample had at least one dolichoectatic artery. In 7% of the subjects, two or more arteries were affected. The BA was the most common dolichoectatic artery. Reproducibility for arterial diameter measurements was good to excellent (.70-.95), while for visual assessment ranged from fair to good (.49-.79). CONCLUSIONS A TCV-adjusted intracranial arterial diameter ≥2 SD is proposed as a useful DE definition. The variability in the prevalence of DE depending on the methods used underscores the need to agree on a reliable, universal definition of DE.
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Affiliation(s)
- Jose Gutierrez
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
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41
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Lin YW, Chen CH, Lai ML. The dilemma of treating vertebrobasilar dolichoectasia. Clin Pract 2012; 2:e84. [PMID: 24765483 PMCID: PMC3981198 DOI: 10.4081/cp.2012.e84] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 07/02/2012] [Accepted: 08/30/2012] [Indexed: 11/23/2022] Open
Abstract
Vertebrobasilar dolichoectasia (VBD) is a common phenomenon among people over 50 years old, and the related clinical expressions are varied. One of our VBD patients presented with brainstem infarction initially, received low molecular weight heparin treatment, and developed rupture of the dolichoectasia segment. Another patient with a similar-sized VBD experienced recurrent brainstem infarction three times over 2 years, despite higher bleeding tendency and long-term antiplatelet treatment. The third patient with a smallersized VBD, had left hemiplegia and received intravenous recombinant tissue plasminogen activator within 3 h, totally recovered with no lesions detected on brain Magnetic Resonance Imaging (MRI). The pathophysiology of VBD is unique, its prevalence and risks of ischemic stroke and intracranial hemorrhage both increase as the degree of arterial dolichoectasia extends, making the strategy of management quite a challenge. The best management of VBD is controlling arterial hypertension and following up with image studies regularly to detect the early extension of VBD degree.
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Affiliation(s)
- Yu-Wei Lin
- Department of Neurology, Mackay Memorial Hospital, Taipei
| | - Chih-Hung Chen
- Stroke Center and Department of Neurology, National Cheng Kung University Hospital, Tainan; ; College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Liang Lai
- Stroke Center and Department of Neurology, National Cheng Kung University Hospital, Tainan; ; College of Medicine, National Cheng Kung University, Tainan, Taiwan
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42
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Abstract
This article outlines the roles of the anesthesiologist in the management of patients undergoing invasive endovascular procedures to treat vascular diseases, primarily of the central nervous system. This practice is usually termed interventional neuroradiology or endovascular neurosurgery. The article emphasizes perioperative and anesthetic management strategies to prevent complications and minimize their effects if they occur. Planning the anesthetic and perioperative management is predicated on understanding the goals of the therapeutic intervention and anticipating potential problems.
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43
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Chadarévian JPD, Legido A, Halligan GE, Faerber EN, Piatt JH, Morrissette JD, Ara J, Grant ML, Katsetos CD. Cerebellar gliomatosis in a toddler: case report of a challenging condition and review of the literature. J Child Neurol 2012; 27:511-20. [PMID: 21940698 DOI: 10.1177/0883073811419315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Gliomatosis confined to the cerebellum is most unusual. We report such a case in a 20-month-old male who presented with unsteadiness. Magnetic resonance imaging revealed a diffuse area of abnormal signal intensity within both cerebellar hemispheres, which did not enhance after contrast administration. The patient underwent a biopsy, which revealed a diffuse glioma infiltrating the cerebellum. Overall, the tumor cells had oligodendroglioma-like features and exhibited only focal vimentin immunoreactivity. They were negative for glial fibrillary acidic protein, synaptophysin, βIII-tubulin, and neurofilament protein. Immunofluorescence, performed on primary biopsy explants maintained in cell culture without exposure to growth factors or differentiation-promoting agents, revealed widespread nestin immunoreactivity and immunolabeling of occasional cells with antibodies to platelet-derived growth factor-α and O1/O4, markers of oligodendrocyte precursor-cells and immature oligodendrocytes, respectively. Fluorescent in situ hybridization performed on explants, touch preparations, and paraffin sections failed to reveal loss of heterozygosity for either 1p36 or 19q13. The patient was treated with temozolomide and remains stable, albeit with residual quiescent tumor, more than 3 years after surgery. This report calls attention to an unusual presentation of gliomatosis confined to the cerebellum of a toddler and addresses salient aspects of clinical and radiological differential diagnosis, as well as therapeutic challenges encountered.
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Affiliation(s)
- Jean-Pierre de Chadarévian
- Department of Pathology and Laboratory Medicine, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, PA, USA.
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Kwon HM, Lee YS. Dolichoectasia of the Intracranial Arteries. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 13:261-7. [DOI: 10.1007/s11936-011-0123-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nakamura Y, Hirayama T, Ikeda K. Clinicoradiologic features of vertebrobasilar dolichoectasia in stroke patients. J Stroke Cerebrovasc Dis 2010; 21:5-10. [PMID: 20833564 DOI: 10.1016/j.jstrokecerebrovasdis.2010.04.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 03/26/2010] [Accepted: 04/04/2010] [Indexed: 11/17/2022] Open
Abstract
The prevalence and implications of vertebrobasilar dolichoectasia (VBD), a causative arteriopathy of stroke are unclear in Asian stroke patients. Through a comparative study of VBD and non-VBD stroke patients, we aimed to elucidate the clinicoradiologic features of VBD patients in Japan. A total of 481 consecutive patients (302 men and 179 women) with acute stroke were admitted to our department between 2007 and 2008. Of these 481 inpatients, 374 (231 men and 143 women) had brain infarct (BI), and 107 (71 men and 36 women) had brain hemorrhage (BH). We reviewed medical records, and VBD was diagnosed by magnetic resonance angiography. Cardiovascular disease (CVD) risk profile, modified Rankin scale score at 30 days poststroke, and stroke lesions were compared among 4 groups: the VBD BI group, the VBD BH group, the non-VBD BI group, and the non-VBD BH group. The diameter, height, and lateral displacement of the basilar artery (BA) were analyzed in the VBD patients. Statistical analyses used multivariate logistic regression analysis. VBD was found in 37 patients (34 men and 3 women). Mean age (± SD) was 64.4 ± 14.7 years (63.4 ± 14.6 years in men and 65.3 ± 6.1 years in women). Twenty-four patients (21 men and 3 women) had BI, and 13 men had BH. There were significant male preferences in VBD BI (P < .01) and VBD BH patients (P < .01). Mean age (± SD) was 67.7 ± 14.3 years in BI patients and 56.7 ± 12.7 years in BH patients. The VBD BH men were significantly younger than the non-VBD BH men (P < .05) and VBD BI men (P < .01). Frequency of current smoking was significantly greater in VBD BI patients compared with non-VBD BI patients (P < .05). Other CVD risk factors did not differ among the 4 groups. Mean modified Rankin Scale score was significantly higher in VBD BH men compared with non-VBD BH men and VBD BI men (P < .01). The height and lateral displacement of the BA were scored more severely in BH patients than in BI patients (P < .01), but BA diameter did not differ between BH and BI patients. The frequency of pontine infarct and hemorrhage was 3-fold greater in VBD BI (P < .05) and VBD BH patients (P < .005) compared with non-VBD BI and BH patients. Our findings indicate a VBD prevalence of 7.7% in stroke patients, 6.4% in BI patients, and 12.1% in BH patients. Our clinicoradiologic analyses suggest male predominance, younger onset of BH, and higher frequency of pontine lesions in VBD patients. Significant BA changes and poor outcome of stroke were found in patients with hemorrhagic VBD rather than ischemic VBD. Thus, more attention should be paid to risk and care of BH in VBD patients, in addition to those of BI.
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Affiliation(s)
- Yoshikazu Nakamura
- Department of Neurology, Toho University Omori Medical Center, Tokyo, Japan
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Ishihara H, Sakai N, Kuroiwa T, Kunieda T, Osaka N, Morizane A, Sakai C, Yano T, Kajikawa R, Kikuchi H. Endovascular trapping for vertebral artery fusiform aneurysm in a patient with idiopathic thrombocytopenic purpura. Neurol Med Chir (Tokyo) 2009; 49:514-7. [PMID: 19940399 DOI: 10.2176/nmc.49.514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 56-year-old woman with adult idiopathic thrombocytopenic purpura (ITP) diagnosed 17 years previously presented with a fusiform aneurysm manifesting as chronic headache. She had suffered no major hemorrhagic complications, although her platelet counts were between 3.0 x 10(9)/l and 50.0 x 10(9)/l. Magnetic resonance angiography identified a fusiform aneurysm of the right vertebral artery. Endovascular trapping after high-dose gammaglobulin with steroid therapy was performed. The patient received antiplatelet therapy to prevent thromboembolic events. The parent artery and aneurysm were completely occluded with no hemorrhagic complications. Endovascular treatment is considered safe in patients with ITP, although careful periprocedural management of platelet count is required.
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Affiliation(s)
- Hideyuki Ishihara
- Department of Neurosurgery, Kobe City General Hospital, Kobe, Hyogo.
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48
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Iihara K, Murao K, Yamada N, Takahashi JC, Nakajima N, Satow T, Hishikawa T, Nagata I, Miyamoto S. Growth potential and response to multimodality treatment of partially thrombosed large or giant aneurysms in the posterior circulation. Neurosurgery 2008; 63:832-42; discussion 842-4. [PMID: 19005372 DOI: 10.1227/01.neu.0000313625.15571.1b] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study examined the growth potential and response to multimodality treatment of partially thrombosed large or giant aneurysms in the posterior circulation. METHODS The 17 aneurysms arose from nonbranching sites of the vertebral artery (VA) in 6 patients and from branching sites in 11 patients (the VA-posteroinferior cerebellar artery [PICA], 3 cases; basilar artery [BA] fenestration, 1 case; BA-superior cerebellar artery [SCA], 5 cases; and BA tip, 2 cases). RESULTS Endovascular trapping was performed in 5 VA aneurysms at nonbranching sites, 2 VA-PICA cases with or without revascularization of the PICA, and 1 BA fenestration case. Endosaccular embolization was performed in 2 BA-SCA aneurysms as the sole treatment or after superficial temporal artery-SCA bypass for a broad-necked lesion. Surgical proximal occlusion (PO) with or without revascularization of the PICA was performed in 2 VA cases. Endovascular treatment failed to prevent growth in 1 VA-PICA case and the broad-necked BA-SCA case. Simple flow alteration by PO of 3 BA aneurysms, with gadolinium enhancement on T1-weighted images, did not prevent growth. Maximum flow reduction by various combinations of bypass (superficial temporal artery-posterior cerebral artery or superficial temporal artery-SCA) and BA PO, aimed at reducing hemodynamic stress on the neck, was tailored to 5 cases, including those refractory to PO; it achieved marked shrinkage in 2 cases and stabilization of the aneurysms in 3 cases. The aneurysms harboring neither gadolinium enhancement nor hyperintensity on fluid-attenuated inversion recovery images showed significantly lower growth potential before treatment and a lesser degree of shrinkage after tailored treatment than the remaining cases (P = 0.03 and P = 0.01, respectively). Overall, marked shrinkage was achieved in 27%, moderate shrinkage in 20%, stabilization in 47%, enlargement in 7%, and favorable outcome in 71%. Maximum flow reduction strategy for BA aneurysms tended to show higher shrinking efficacy than endovascular trapping for VA and BA aneurysms (P = 0.08). CONCLUSION For aneurysms at nonbranching sites, endovascular trapping may be effective, although its shrinking efficacy may be moderate. For the most formidable BA aneurysms at branching sites, maximum flow reduction may cause marked shrinkage, even of aggressive lesions.
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Affiliation(s)
- Koji Iihara
- Department of Neurosurgery, National Cardiovascular Center, Suita, Japan.
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49
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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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Abstract
This review outlines the roles of anesthesiologists in the management of patients undergoing invasive endovascular procedures to treat vascular diseases, primarily of the central nervous system. This practice usually is termed interventional neuroradiology or endovascular neurosurgery. The discussion emphasizes perioperative and anesthetic management strategies to prevent complications and minimize their effects if they occur. Planning anesthetic and perioperative management is predicated on understanding the goals of the therapeutic intervention and anticipating potential problems.
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Affiliation(s)
- William L Young
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 1001 Potrero Avenue, Room 3C-38, San Francisco, CA 94110, USA.
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