Endovascular Treatment in Ruptured Middle Cerebral Artery Dissection Preservation of Arterial Continuity

Stent assisted coil embolization for a dissecting cerebral aneurysm of middle cerebral artery: A case report and the literature review

Background

Dissecting aneurysms of the middle cerebral artery (MCA) are very rare. We herein report a case of an unruptured dissecting aneurysm of the MCA treated by stent-assisted coil embolization.

Case Description

A 65-year-old man with no history of trauma presented with a headache. Time-of-flight imaging revealed a dissecting cerebral aneurysm in the right M1 segment of the MCA, and the aneurysm had increased in size within a short time. We treated the aneurysm by endovascular stenting with coils, and the patient developed no neurological deficits.

Conclusion

Because of the potential involvement of the lenticulostriate artery (LSA) in the area of dissection, choosing the best treatment (such as direct surgery or endovascular treatment) may be challenging. Treatment efficacy depends on whether the LSA is affected and on the length of the dissection. In our case, the dissection did not involve the LSA and could therefore be treated by stent-assisted coil embolization.

Spontaneous middle cerebral artery dissection: a series of six cases and literature review

Middle cerebral artery (MCA) dissection is rare, and various clinical presentations, including hemorrhage, ischemia, or comorbidities, and the changes in imaging findings over time hinder treatment decisions. The European Stroke Organization guidelines exclude MCA dissection. Few cases have been reported with no review of the relevant literature. Therefore, we reviewed the relevant literature and our own experience with non-traumatic MCA dissection cases to determine appropriate treatment strategies. At our institution and affiliated institutions, we encountered six cases of MCA dissection-five with infarction and one with hemorrhage. Two patients underwent revascularization, and one underwent an aneurysmectomy. We reviewed English and Japanese articles in PubMed and Medical Journal Web and summarized the results based on the relationships among age, sex, location, the presence of an aneurysm, the presence of angiography, history, treatment, and mode of onset. The clinical course, changes in imaging, treatment strategies, and prognosis were discussed. Eighty cases were included in the review. Cerebral aneurysms were more common distal to the M2 area (p = 0.00) and were correlated with hemorrhage (p < 0.001). Most hemorrhagic cases with aneurysms were treated surgically, while ischemic cases were treated with antithrombotic agents, and both had a similar neurological prognosis. There were some cases of rebleeding after antithrombotic therapy, especially in older adults.Surgical treatment is recommended in cases of hemorrhage and confirmed aneurysms, particularly for lesions distal to the M2 area. Patients with aneurysm-associated ischemia should be followed up, and antithrombotic treatment should be considered with particular care in older adults.

Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device

OBJECTIVE

Traumatic pseudoaneurysms of the proximal middle cerebral artery (MCA) segments are challenging to treat. We describe the management of traumatic internal carotid artery and MCA pseudoaneurysms with flow diversion.

CASE DESCRIPTION

A 19-year-old man had sustained a gunshot wound to the head. Delayed digital subtraction angiography showed de novo formation of the left internal carotid artery ophthalmic segment and left MCA M2 segment pseudoaneurysms. We had initially performed coil embolization of the left MCA pseudoaneurysm. However, it had recurred 2 weeks later. We treated both pseudoaneurysms with flow diversion using the Pipeline Flex embolization device. The patient has continued with dual antiplatelet therapy of aspirin and ticagrelor. Follow-up digital subtraction angiography at 6 months showed complete obliteration of both pseudoaneurysms with patent parent vessels. The patient remained neurologically intact.

CONCLUSIONS

Flow diversion can be an efficacious treatment of traumatic MCA pseudoaneurysms in appropriately selected cases. The risks versus benefits of dual antiplatelet therapy must be weighed in trauma settings.

Coil and Single-Stent Placement for Ruptured Dissecting Aneurysm of Middle Cerebral Artery: A Case Report

BACKGROUND

Ruptured dissecting aneurysms located at the middle cerebral artery (MCA) are rare, and their standard treatment has not been defined. Furthermore, lenticulostriate artery involvement in the dissecting segment makes treatment extremely difficult, and no previous reports have described successful treatment for such conditions.

CASE DESCRIPTION

We herein report the case of a 74-year-old woman who presented with sudden severe headache from subarachnoid hemorrhage due to dissection in the proximal M1 segment of left MCA involving lenticulostriate arteries. Digital subtraction angiography on day 6 showed that the dissecting aneurysm had enlarged despite strict blood pressure control. On day 8, the patient was treated successfully with a self-expanding closed cell stent and coil embolization, preserving blood flow in the lenticulostriate arteries as well as the MCA.

CONCLUSIONS

Follow-up digital subtraction angiography performed 5 weeks after endovascular therapy showed healing of the dissecting lesion, and the patient was discharged neurologically intact.

Endovascular Treatment of Middle Cerebral Artery Dissecting Aneurysms: A 7-Year Single-Center Study

OBJECTIVE

To evaluate safety and efficacy of endovascular treatment of middle cerebral artery dissecting aneurysms (MCADAs).

METHODS

Between July 2009 and April 2016, 14 patients with MCADAs received endovascular treatment. MCADAs were identified by their unique radiographic features on cerebral angiography. Baseline characteristics, angiographic features, and angiographic and clinical outcomes were analyzed retrospectively.

RESULTS

All 14 MCADAs (including 6 ruptured and 8 unruptured) were successfully treated with the endovascular approach. Stent-assisted coiling was used in 12 cases, coil alone in 1 case, and parent vessel occlusion in 1 case. Angiographic follow-up data were available for all patients at 6 months after treatment. Of 14 MCADAs, 10 were completely occluded, and 4 were improved (near occlusion). All parent arteries and covered perforators remained patent in the non-parent vessel occlusion group. No ischemic strokes or other complications were observed at 1-year clinical follow-up.

CONCLUSIONS

Our data suggest that endovascular treatment of MCADAs appears to be safe and effective. The choice of treatment method needs to be individualized. Larger studies are required to evaluate these promising results.