Subarachnoid hemorrhage from a dissecting aneurysm of the posterior cerebral artery in a child : rebleeding after stent-assisted coiling followed by stent-within-stent technique

Bypass surgery for ruptured dissecting aneurysms of the proximal posterior cerebral artery: illustrative case

BACKGROUND

Posterior cerebral artery (PCA) dissecting aneurysms commonly occur in the proximal PCA and are considered rare. The treatment of proximal PCA dissecting aneurysms is challenging because of the existence of perforators supplying the vital neural structures. Recently, endovascular intervention has been used; however, concerns for ischemic or hemorrhagic complications exist.

OBSERVATIONS

A 54-year-old woman presented with subarachnoid hemorrhage due to dissecting aneurysm rupture at the P1-P2 junction of the PCA. The thalamoperforating artery (TPA) and medial posterior choroidal artery (MPchA) originated from the proximal end and the distal end of the aneurysm, respectively. Additionally, the posterior communicating artery (PcomA) connected with the dissected segment. To preserve these perforators, we performed surgical trapping combined with superficial temporal artery (STA) PCA anastomosis. Clips were applied for trapping the proximal and distal end of the aneurysm, with preservation of the TPA and MPchA origin. PcomA was left open for blood flow preservation to the perforators directly arising from the aneurysm. The postoperative course was uneventful, and the patient was discharged.

LESSONS

Surgical trapping using STA-PCA bypass could be a treatment of choice for proximal PCA dissecting aneurysms, considering its potential for cure and prevention of ischemic complications.

Characteristics and Treatment Outcome of Intracranial Aneurysms in Children and Adolescents

Objective

Intracranial aneurysms are not common in young age patients. We sought to find the characteristics of the intracranial aneurysms in patients under 20 years of age.

Methods

We reviewed 23 consecutive patients ≤20 years of age treated for their intracranial aneurysms during the period from 1995 to 2017. From medical records and imaging studies, we gathered data on age, sex, presentation, associated medical condition, location and characteristics of aneurysms, treatment and clinical outcomes.

Results

The patients’ ages ranged from 13 months to 20 years (median, 14 years). There were 16 males and seven females (male to female ratio, 2.3 : 1) with 31 aneurysms. Clinical presentations included sudden severe headache in 61%, followed by altered mentality in 17% and seizure in 17%. More than one-fourth patients had specific medical conditions related to the development of the cerebral aneurysms. The majority of aneurysms occurred in the anterior circulation (71%), and were saccular (71%). There were each three patients with false aneurysms (13%) and giant aneurysms (13%), and only one patient with multiple aneurysms (4%). We treated 22 patients : 21 aneurysms with the endovascular methods, three with open surgery, and one with combined treatment. Good functional outcome could be achieved in 86% during the follow-up period.

Conclusion

In this series, the young-age patients with intracranial aneurysms were characterized by male predominance, related specific medical conditions, low incidence of multiple aneurysms, high incidence of giant aneurysms and good functional outcome after treatment.

Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases

BACKGROUND AND PURPOSE

There is very limited data concerning utilization of flow diverters in children. Our aim is to report results for the treatment of complex intracranial aneurysms and carotid cavernous fistulas by using flow diverters in children.

MATERIALS AND METHODS

Retrospective review of children (17 years of age or younger) treated with flow diverters between May 2011 and July 2014 was performed. Clinical and laboratory data and angiographic findings were extracted. Seven patients (6 males, 1 female; mean age, 12.7 years; range, 3-16 years) were included. Two presented with posttraumatic fistulas. The remaining patients presented with traumatic aneurysms of the cavernous carotid artery or fusiform aneurysms of the distal vertebral artery, M1, or A2 segments. All patients were premedicated with clopidogrel (75 mg daily for patients with body weights of >45 kg, 37.5 mg daily for 1 small child with a body weight of <45 kg) and aspirin (300 mg daily for ≥45 kg, 100 mg daily for smaller children).

RESULTS

VerifyNow and Multiplate Analyzer values were higher than expected. No clinical complications were noted. Imaging performed at 7-52 months after the procedure (mean/median, 22.3/14 months) revealed occlusions of all aneurysms and fistulas. One patient had an asymptomatic occlusion of the parent artery; otherwise, no hemodynamically significant parent artery restenosis was observed. There were no clinically significant neurologic events during follow-up.

CONCLUSIONS

Although flow-diverter placement appears to be safe and effective on midterm follow-up in children, longer follow-up is critical. The current sizes of flow diverter devices and delivery systems cover the pediatric size range, obviating developing flow diverters specific to children.

Endovascular treatment of posterior cerebral artery aneurysms: a single center's experience of 55 cases

OBJECTIVE Aneurysms of the posterior cerebral artery (PCA) are uncommon. To date, a limited number of studies have examined the outcomes of endovascular treatment for PCA aneurysms. The authors' aim in this study is to report their experience with the endovascular treatment of PCA aneurysms. METHODS Between January 2007 and December 2014, 55 patients with 59 PCA aneurysms were treated using the endovascular approach at the authors' institution. Twenty-three patients had 25 saccular aneurysms, and 32 patients had 34 fusiform/dissecting aneurysms. The endovascular modalities included the following: 1) selective occlusion of the aneurysm (n = 22); 2) complete occlusion of the aneurysm and the parent artery (n = 20); 3) parent artery occlusion (n = 6); 4) partial coiling of the aneurysm and the parent artery (n = 5); and 5) occlusion of the dissecting aneurysm sac (n = 2). RESULTS The immediate angiographic results included 45 complete occlusions (82%), 2 nearly complete occlusions (4%), and 8 incomplete occlusions (14%). The mean follow-up period of 21.8 months in 46 patients showed 37 stable results, 6 further thromboses, and 3 recurrences. The final results included 41 complete occlusions (89%), 2 nearly complete occlusions (4%), and 3 incomplete occlusions (7%). Procedure-related complications included the following: 1) rebleeding (n = 1); 2) infarction (n = 4); and 3) perforation (n = 1). There was 1 (1.8%) procedure-related death due to rebleeding, and 2 (3.6%) non-procedure-related deaths due to severe subarachnoid hemorrhage. Clinical outcomes were excellent (Glasgow Outcome Scale 5) in 47 of 49 patients at the long-term follow-up. CONCLUSIONS PCA aneurysms may be effectively treated by different endovascular approaches with favorable clinical and radiological outcomes. However, patients who present with severe SAH still have an overall poor prognosis. Partial coiling of the aneurysm and the parent artery is an attractive alternative treatment for patients who may not tolerate parent artery occlusion. Further study with a larger case series is necessary for validation of the durability and efficacy of this treatment.

Endoluminal Reconstruction for Nonsaccular Aneurysms of the Proximal Posterior Cerebral Artery with the Pipeline Embolization Device

BACKGROUND AND PURPOSE

Treatment options for nonsaccular posterior cerebral artery aneurysms include a range of surgical and endovascular reconstructive and deconstructive methods. However, no truly satisfactory treatment option is available to date for lesions arising from the P1 and P2 segments. The purpose of the present case series is to investigate both the efficacy and safety of the Pipeline Embolization Device in treating these challenging aneurysms.

MATERIALS AND METHODS

We present a series of 6 consecutive patients who underwent endoluminal reconstruction with the Pipeline Embolization Device for nonsaccular P1 or P2 segment aneurysms between January 2009 and June 2013.

RESULTS

Aneurysm location included the P1 segment in 2 patients and the P2 segment in 4 patients. Mean aneurysm diameter was 23 mm (range, 5-44 mm). Mean length of the arterial segment involved was 10 mm (range, 6-19 mm). Clinical presentation included mass effect in 4 patients and perforator stroke and subacute aneurysmal subarachnoid hemorrhage in 1 patient each. Endovascular reconstruction was performed by using 1 Pipeline Embolization Device in 5 patients and 2 overlapping Pipeline Embolization Devices in the remaining patient. Angiographic aneurysm occlusion was immediate in 1 patient, within 6 months in 4 patients, and within 1 year in the remaining patient. Index symptoms resolved in 4 patients and stabilized in the remaining 2. No new permanent neurologic sequelae and no aneurysm recurrence were recorded during the mean follow-up period of 613 days (range, 540-725 days).

CONCLUSIONS

Endovascular reconstruction with the Pipeline Embolization Device for nonsaccular aneurysms arising from the P1 and P2 segments compares favorably with historical treatment options in terms of occlusion rate, margin of safety, and neurologic outcome.

The safety and efficacy of stenting in the treatment of complex posterior cerebral artery aneurysms: a seven-case report and literature review

OBJECTIVE

To investigate the safety and efficacy of stenting with coil in the endovascular treatment of complex posterior cerebral artery (PCA) aneurysms.

METHODS

The data on PCA aneurysms treated with stents were retrospectively reviewed from a prospectively collected intervention database. The literature was reviewed concerning the use of stents for PCA aneurysms.

RESULTS

Seven cases with complex PCA aneurysms (male: female = 6:1; ruptured: unruptured = 4:3) were retrieved from our database. Three aneurysms were localized at the junction of P1 and P2 segments (P1-2), two at P1, and two at P2A. Four were wide-necked saccular aneurysms, while the other three were dissecting ones. A total of nine stents (one Neuroform and eight Enterprise stents) were successfully deployed. Two aneurysms were totally eliminated, three were with neck residues and two were partially occluded. No procedure-related complications occurred. All patients recovered well. Angiographic follow-ups (FU) showed that three aneurysms achieved total obliterations, one got improved, two remained stable, and one recurred. The recurred aneurysm caused no symptom and was treated with two stents. Clinical FU demonstrated no neurological deterioration or bleeding. In literature review, the procedure-related mortality is 5.3 % (2/38). The incidence of permanent neurologic deficit is 2.6 % (1/38). Three (3/23) aneurysms recurred, of which one caused rebleeding. Four (4/23) in-stent stenoses were all asymptomatic. No other hemorrhagic or ischemic event occurred in clinical FU.

CONCLUSION

Stent offers a therapeutic alternative for complex PCA aneurysms especially when PVO cannot be tolerated. Long-term therapeutic efficacy requires further observations in clinical series with larger case numbers.

Traumatic pseudoaneurysms of the common carotid and vertebral artery in a four-year-old child

Pseudoaneurysms of the neck arteries are rare lesions usually traumatic and less frequently infectious in origin. They are often described as case reports. We describe here an unusual occurrence of pseudoaneurysms in the common carotid and vertebral artery in a four-year-old child victim of a stab wound in the neck treated by parent artery occlusion of the vertebral and common carotid arteries.

Potential proneness of fetal-type posterior cerebral artery to vascular insufficiency in parent vessel occlusion of distal posterior cerebral artery aneurysms

OBJECT

The purpose of this study was to report the potential proneness of a fetal-type posterior cerebral artery (PCA) to develop vascular insufficiency in parent vessel occlusion of distal PCA aneurysms.

METHODS

Between January 2005 and January 2011, 19 patients (9 females and 10 males) with 20 distal PCA aneurysms (16 dissecting and 4 saccular) were treated with endovascular parent vessel occlusion. The ages of the patients ranged from 5 to 71 years, with a mean age of 40.2 years. Of the 20 aneurysms, 4 were ruptured and 16 were unruptured. One of the unruptured aneurysms was additional to another ruptured aneurysm, and 15 were incidentally discovered. Five aneurysms were smaller than 10 mm, and the other 15 were 10 mm or larger.

RESULTS

All aneurysms were successfully treated with simultaneous coil occlusion of the aneurysm and the parent PCA. One patient had hemianopia at the initial presentation, and 2 patients had new persistent hemianopia due to insufficient leptomeningeal collateral circulation; in 16 patients with an intact visual field, no hemianopia developed because there was sufficient leptomeningeal collateral circulation. A fetal-type PCA was involved in all 3 patients with hemianopia, which was initially presented or caused by parent vessel occlusion. However, in the patients without hemianopia, an adult-type PCA was involved in all cases.

CONCLUSIONS

Endovascular treatment via coil occlusion of the aneurysm as well as the parent artery can be used to cure distal PCA aneurysms. A fetal-type PCA could be an important predictive factor for vascular insufficiency in parent vessel occlusion treatment.