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Marsool Marsool MD, Bharadwaj HR, Ali SH, Aderinto N, Shah MH, Shing N, Dalal P, Huang H, Wellington J, Chaudri T, Awuah WA, Pacheco-Barrios N, Macha-Quillama L, Fernandez-Guzman D, Hussien Mohamed Ahmed KA. Exploring the Landscape of Intracranial Aneurysms in South America: A Comprehensive Narrative Review Intracranial Aneurysms in South America. World Neurosurg 2024; 185:3-25. [PMID: 38286319 DOI: 10.1016/j.wneu.2024.01.108] [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: 12/15/2023] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Abstract
Exploring the landscape of intracranial aneurysms in South America unravels a complex interplay of epidemiological factors, clinical manifestations, and therapeutic challenges. The study methodically conducts a comprehensive literature review spanning the years 2003 to 2023, focusing on English-language articles obtained from diverse databases to elucidate the multifaceted nature of intracranial aneurysms in the region. Results and discussions categorize outcomes into positive domains, emphasizing successful treatments, favorable recoveries, and high survival rates, while also shedding light on negative aspects such as residual aneurysms and complications. The research illuminates significant gaps in pathological typing of intracranial aneurysms and exposes challenges in healthcare accessibility, notably the disparities in neurosurgical resources. Management challenges, including constrained infrastructure access, a neurosurgeon shortage, and gender disparities, are underscored. Transitioning to future prospects, the study advocates for strategic interventions, proposing expanded neurosurgical training, multidisciplinary approaches, improved funding, enhanced access to care, and fostering international collaborations. The study concludes by emphasizing the pivotal role of collaborative efforts, intensified training programs, and global partnerships in propelling intracranial aneurysm management forward in South America, ultimately contributing to enhanced patient outcomes across the region.
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Affiliation(s)
| | | | - Syed Hasham Ali
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Nicholas Aderinto
- Internal Medicine Department, LAUTECH Teaching Hospital, Oyo, Nigeria
| | | | - Nathanael Shing
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Priyal Dalal
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Helen Huang
- University of Medicine and Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jack Wellington
- Department of Neurosurgery, Bradford Teaching Hospital NHS Foundation Trust, Bradford, United Kingdom
| | | | | | | | - Luis Macha-Quillama
- Alberto Hurtado Medical School, Cayetano Heredia Peruvian University, Lima, Peru
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Saal-Zapata G, Rodriguez-Calienes A, Malaga M, Velasquez-Rimachi V, Moran C, Bustamante-Paytan D, Pacheco-Barrios N, Pacheco-Barrios K, Alva-Diaz C, Walker M. Microsurgical and endovascular treatment of posterior inferior cerebellar artery aneurysms: a systematic review and meta-analysis. J Neurosurg Sci 2023; 67:638-652. [PMID: 35416457 DOI: 10.23736/s0390-5616.22.05710-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Posterior inferior cerebellar artery (PICA) aneurysms are uncommon vascular lesions of the posterior fossa. In addition to aneurysmal morphology, structural anatomic considerations may confer additional procedural risk, and as a result there is currently no consensus as to whether a surgical or endovascular approach offers greater safety and efficacy for patients. EVIDENCE ACQUISITION We systematically examined peer-reviewed literature describing PICA aneurysm treatment planning from January 2000 to May 2021 using the PRISMA methodology. A meta-analysis of proportions was performed. Certainty of the evidence was assessed using the GRADE approach. EVIDENCE SYNTHESIS Fifty-eight studies including 1673 PICA aneurysms were analyzed. Overall treatment occlusion rate was 97% (95% confidence interval [CI]: 93-100%) for surgery and 85% (95% CI: 78-92%) for endovascular therapy. The recurrence rate was 6% in the endovascular group and 1% for surgery. Overall morbidity and mortality were 16% and 7%, respectively. Intraoperative complications occurred in 9% of the surgical patients. CONCLUSIONS Despite a large body of literature, analysis indicates that 62% of studies had moderate or serious risk of bias, suggesting very-low certainty results. Therefore, treatment via either approach should be determined on a case-by-case basis and according to institutional experience.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Section of Endovascular Neurosurgery, Department of Neurosurgery, Guillermo Almenara Irigoyen-EsSalud National Hospital, Lima, Peru -
| | - Aaron Rodriguez-Calienes
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
| | - Marco Malaga
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
| | - Victor Velasquez-Rimachi
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
| | - Cristian Moran
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
- Scientific University of the South, Lima, Peru
| | | | - Niels Pacheco-Barrios
- Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru
- Faculty of Human Medicine, San Martin de Porres University, Lima, Peru
| | - Kevin Pacheco-Barrios
- Alberto Hurtado Faculty of Medicine, Cayetano Heredia Peruvian University, Lima, Peru
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, MA, USA
| | - Carlos Alva-Diaz
- Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú
| | - Melanie Walker
- Research Unit for the Generation and Synthesis of Health Evidence, San Ignacio de Loyola University, Lima, Perú
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Hou K, Lv X, Guo Y, Yu J. Endovascular treatment of posterior inferior cerebellar artery trunk aneurysm. Acta Neurol Belg 2022; 122:1405-1417. [PMID: 34677822 DOI: 10.1007/s13760-021-01826-8] [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: 08/08/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The posterior inferior cerebellar artery (PICA) generally originates from the vertebral artery (VA) and is the most complex cerebellar artery. Aneurysms can occur at any site along the PICA trunk. Although most PICA aneurysms are located at the VA-PICA junction, a small proportion is located at the PICA trunk. Endovascular treatment (EVT) of aneurysms in the PICA trunk may be difficult and complex. METHODS We performed a review to expound upon EVT of PICA trunk aneurysms. RESULTS The PICA can be divided into five segments (p1-5); the p1-3 segments are proximal segments, and the p4-5 segments are distal segments. Most PICA trunk aneurysms are dissecting aneurysms. Sometimes, the PICA can give rise to flow-related aneurysms in association with cerebellar arteriovenous malformations. Most aneurysms of the PICA trunk require aggressive treatment, especially those that have ruptured. Currently, the EVT mainly includes selective coiling with/without stent assistance and parent artery occlusion. Recently, some new devices, such as flow diversion and Barricade and Kaneka ED coils, can be used to treat PICA trunk aneurysms. The risk of complications with EVT seems to be higher; however, most complications are only transient or mild, and some are even clinically silent. In addition, open surgery is still an important option. CONCLUSION For PICA trunk aneurysms, the treatment choice should be assessed on a case-by-case basis. The rate of permanent morbidity of the EVT is low. EVT is an effective method for treating PICA trunk aneurysms.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Yunbao Guo
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China.
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Hou K, Yu J. Case Report: Can Ruptured Aneurysms in the Hypoplastic and Plexiform Posterior Inferior Cerebellar Arteries Be Safely Occluded? Front Neurol 2022; 13:904863. [PMID: 35812084 PMCID: PMC9263357 DOI: 10.3389/fneur.2022.904863] [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: 03/28/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022] Open
Abstract
Aneurysms arising from the posterior inferior cerebellar artery (PICA) are not rare and may originate from the proximal or peripheral segment of the PICA. However, when the affected PICA is hypoplastic and plexiform, it is difficult to occlude the aneurysm without sacrificing the parent vessel, the PICA. This type of aneurysm is rare, and whether it is safe to occlude the aneurysm and the parent artery, in cases of a ruptured aneurysm of the hypoplastic and plexiform PICA, has not been adequately studied and is still open to debate. In this report, two patients with ruptured aneurysms in the hypoplastic and plexiform PICA were presented. Both patients were admitted to our hospital for subarachnoid hemorrhage. After team discussions between the neurosurgeons and neurointerventionalists, the aneurysm and parent PICA had to be occluded via endovascular treatment under general anesthesia. One of the patients developed postprocedural brainstem infarction and exhibited favorable recovery. The other patient died of pulmonary infection, although improvement in the postoperative state was observed. Although rare, aneurysms can originate from the hypoplastic and plexiform PICA. Occluding the aneurysm and hypoplastic parent PICA via endovascular treatment might be a reasonable option.
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Isolated ruptured dissecting aneurysm of PICA with extremely narrow neck managed by a novel endovascular technique-a case report and review of literature. Childs Nerv Syst 2022; 38:673-676. [PMID: 34128120 DOI: 10.1007/s00381-021-05231-7] [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: 01/27/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
Dissecting aneurysms of posterior inferior cerebellar artery (PICA) are usually extensions of vertebral artery dissection. Isolated dissecting aneurysms of PICA are extremely rare. A 5-month-old female child presented with history of fall from a height of around 2 ft., followed by incessant crying and multiple episodes of vomiting. The anterior fontanelle was lax. Plain CT scan brain showed IVH in the fourth ventricle with no hydrocephalus. Twenty-four hours after admission, the child had one episode of vomiting and became unresponsive. The child was intubated, and a repeat CT scan brain showed thick acute SDH in the posterior fossa with hydrocephalus. Emergency suboccipital craniectomy and evacuation of thick acute subdural hematoma were done. Organized clot noted in the midline between the tonsils was not removed. Digital subtraction angiography (DSA) done 48 h after surgery showed ruptured dissecting aneurysm of left PICA. Endovascular temporary parent artery occlusion by coil deployment was performed, after which a check angiogram revealed complete exclusion of aneurysm from circulation. Endovascular proximal parent artery occlusion is the preferred treatment modality for dissecting aneurysms of PICA. Selective coil or Onyx embolization of the aneurysm with parent vessel preservation technique is a valid and increasingly used alternative. In this case, a novel technique of endovascular temporary parent artery occlusion by coil deployment was performed successfully. This technique may be recommended in select cases.
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Bypass Surgery Management of Complex Proximal and Distal Posterior Inferior Cerebellar Artery Aneurysms. J Craniofac Surg 2022; 33:2049-2054. [PMID: 35119411 DOI: 10.1097/scs.0000000000008507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/13/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND For the complex posterior inferior cerebellar artery (PICA) aneurysms, standard microsurgical or endovascular technical options were not feasible. To determine the efficacy and outcomes of bypass surgery for complex PICA aneurysms, the authors herein review our recent surgical experience for complex PICA aneurysms. METHODS The authors retrospectively reviewed our experience of extracranial-intracranial bypass and intracranial-intracranial bypass surgery in treatment of proximal and distal complex PICA aneurysms at our institution from 2016 to 2020. RESULTS Twelve patients harboring 12 complex PICA aneurysms received bypass surgery at our institution. Seven (58.3%) patients with proximal PICA aneurysms underwent extracranial-intracranial bypass. Five (41.7%) patients with distal PICA aneurysms accepted intracranial-intracranial bypass. The postoperative symptom improvement: Of the 6 patients with preoperative hypoperfusion or ischemic of the cerebellar hemisphere, the symptom resolved in 5 patients, improved in 1 patient, of 5 patients with preoperative mass effect, the symptom resolved in 5 patients. During the follow-up period, ten patients had a modified Rankin scale (mRS) score of 0 to 1, and 1 patient had an mRS score of 2. One patient had an mRS score of 3. The long-term graft patency rate was 91.7%. All patients had no recurrence of intracranial aneurysm. CONCLUSIONS Base on the complexity of anatomy structure and the vascular architecture, an individualized strategy was proposed for each patient. The use of different types of bypass procedures (occipital artery-PICA end-to-end bypass, PICA-PICA end-to-end anastomosis, and/or occipital artery graft) can safely and effectively manage these complex PICA aneurysms.
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Chen X, Sun Z, Shi L, Xu L, Yu J, Fang B, Zheng J, Xu J, Zhang J. Endovascular management of ruptured distal posterior inferior cerebellar artery aneurysms: A retrospective cohort study. Medicine (Baltimore) 2018; 97:e13300. [PMID: 30544389 PMCID: PMC6310559 DOI: 10.1097/md.0000000000013300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Distal posterior inferior cerebellar artery (PICA) aneurysm is a kind of rare intracranial aneurysm with controversial evidence in managements. The main purposes of this research are to study the safety and effectiveness of parent artery occlusion (PAO) compared with selective aneurysm coiling (SAC) as well as figure out factors that affect the outcomes.All characteristics of patients that diagnosed with ruptured distal PICA aneurysm and treated with endovascular management in our hospital from July 2009 to February 2016 were retrospectively collected. Details include complete occlusion rate, procedure-related complications and Modified Rankin Scale (mRS) of 31 months (mean) follow-up.Total 36 patients finally met the criterions and were included in the present study. New imaging infarction was observed in 12 (33.33%) patients. And 10 of them showed no apparent neurological dysfunctions after 34 months (mean) follow-up; 1 remained coma status since the symptom onset; and 1 patient died. 27 (75%) patients got a mRS ≤ 2 at the discharge while 20 (86.96%) patients with 3-year follow-up after the operation. There is no significant difference between patients treated with SAC and PAO in both complications and functional recovery in 3-years follow-up period. Hunt&Hess classification (H&H), age, and hydrocephalus are risk factors for functional recovery at discharge.PAO is safe and efficient in the management of distal PICA aneurysms while complications and outcomes are similar with SAC. H&H, age, and hydrocephalus are predicting factors for the mRS at discharge. Further prospective study is still needed to confirm the results of present study.
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Affiliation(s)
- Xianyi Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Zeyu Sun
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Ligen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Liang Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jun Yu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Bing Fang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jingwei Zheng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jing Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
- Brain Research Institute
- Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, Zhejiang, China
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Bonda DJ, Labib M, Katz JM, Ortiz RA, Chalif D, Setton A, Langer DJ, Dehdashti AR. Intracranial Bypass of Posterior Inferior Cerebellar Artery Aneurysms: Indications, Technical Aspects, and Clinical Outcomes. Oper Neurosurg (Hagerstown) 2017; 13:586-595. [DOI: 10.1093/ons/opx064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 03/03/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: For some posterior inferior cerebellar artery (PICA) aneurysms, there is no constructive endovascular or direct surgical clipping option. Intracranial bypass is an alternative to a deconstructive technique.
OBJECTIVE: To evaluate the clinical features, surgical techniques, and outcome of PICA aneurysms treated with bypass and obliteration of the diseased segment.
METHODS: Retrospective review of PICA aneurysms treated via intracranial bypass was performed. Outcome measurements included postoperative stroke, cranial nerve deficits, gastrostomy/tracheostomy requirement, bypass patency, modified Rankin scale (mRS) at discharge, and mRS at 6 mo.
RESULTS: Seven patients with PICA aneurysms treated with intracranial bypass were identified. Five had fusiform aneurysms (4 ruptured, 1 unruptured), 1 had a giant partially thrombosed saccular aneurysm (unruptured), and 1 had a dissecting traumatic aneurysm (ruptured). Two aneurysms were at the anteromedullary segment, 4 at the lateral medullary segment, and 1 at the tonsillomedullary segment. Three patients underwent PICA-to-PICA side to side anastomoses, 2 PICA-to-PICA reanastomosis, 1 vertebral artery-to-PICA bypass, and 1 occipital artery-PICA bypass. Six out of 7 aneurysms were obliterated surgically and 1 with additional endovascular occlusion after the bypass. All bypasses were patent intraoperatively; 2 were later demonstrated occluded without radiological signs or symptoms of stroke. No patients had new cranial nerve deficit postoperatively. With the exception of 1 death due to pulmonary emboli 3 mo postoperatively, all others remain at a mRS ≤ 2.
CONCLUSION: Constructive bypass and aneurysm obliteration remains a viable alternative for treatment of PICA aneurysms not amenable to direct surgical clipping or to a vessel-preserving endovascular option.
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Affiliation(s)
- David J. Bonda
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Mohamad Labib
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Jeffrey M. Katz
- Department of Neurology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Rafael A. Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - David Chalif
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Avi Setton
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - David J. Langer
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
- Department of Neurosurgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Amir R. Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
- Department of Neurosurgery, Lenox Hill Hospital, Northwell Health, New York, New York
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Management of posterior inferior cerebellar artery aneurysms: What factors play the most important role in outcome? Acta Neurochir (Wien) 2017; 159:549-558. [PMID: 28066873 DOI: 10.1007/s00701-016-3058-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Posterior inferior cerebellar artery (PICA) aneurysms are an uncommon, heterogeneous group of aneurysms with poorer clinical outcomes compared to other intracranial aneurysms. We performed a multicenter retrospective study to analyze the outcome in a large series of patients treated with modern microsurgical and endovascular techniques. METHODS Records of 94 patients treated for PICA aneurysms between 2000 and 2015 at three large tertiary referral centers were retrospectively reviewed. RESULTS Eighty-three patients met inclusion criteria and of these, two died before treatment, leaving 81 treated patients (43 underwent endovascular and 38 surgical treatment). Among patients treated endovascularly, procedure-related complications occurred in four cases (11.8%). Six patients (19.4%) suffered from complications directly associated with surgery. Recurrences occurred in 0% of surgical and in 16.3% of endovascularly treated patients, requiring treatment. Patients with unruptured asymptomatic aneurysms had good outcomes. In the group of 67 ruptured aneurysms, 16 endovascularly (47.1%) and 15 surgically (48.4%) treated patients had modified Rankin scale (mRS) scores of 3-6. Of patients in poor neurological condition (Hunt & Hess (H&H) IV-V at admission), 84.6% suffered a poor clinical outcome. Fifty percent of patients with distal and 31.9% patients with proximal ruptured PICA aneurysms suffered a poor neurological outcome. CONCLUSIONS This study of PICA aneurysms demonstrates that results of both treatment modalities are comparable. However, endovascular treatment is associated with higher risks of recurrence, requiring additional treatment. Outcomes were mostly impacted by clinical state at admission.
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Safety and efficacy of treatment strategies for posterior inferior cerebellar artery aneurysms: a systematic review and meta-analysis. Acta Neurochir (Wien) 2016; 158:2415-2428. [PMID: 27718027 DOI: 10.1007/s00701-016-2965-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION We conducted a systematic review of the literature to evaluate the safety and efficacy of treatment strategies for PICA aneurysms. METHODS A systematic search of Medline, EMBASE, Scopus, and Web of Science was done for studies published through November 2015. We included studies that described treatment of PICA aneurysms with ≥10 patients. Random-effects meta-analysis was used to pool the following outcomes: complete occlusion, technical success, periprocedural morbidity/mortality, stroke rates, aneurysm recurrence/rebleed, CN palsies rates, and long-term neurological morbidity/mortality. RESULTS We included 29 studies with 796 PICA aneurysms. When considering all ruptured PICA aneurysms, complete occlusion rates were 97.1 % (95 % CI = 94.5-99.0 %) in the surgical group and 84.3 % (95 % CI = 73.8-92.6 %) in the endovascular group. Aneurysm recurrence occurred in 1.4 % (95 % CI = 0.3-3.3 %) after surgery and in 6.9 % (95 % CI = 3.6-10.9 %) after endovascular treatment. Overall neurological morbidity and mortality were 14.4 % (95 % CI = 8.7-21.2 %) and 9.8 % (95 % CI = 5.8-14.8 %) after surgery and 15.1 % (95 % CI = 10.5-20.2 %) and 17.1 % (95 % CI = 11.5-23.7 %) after endovascular treatment, respectively. When considering all unruptured PICA aneurysms, complete occlusion rates were 92.9 % (95 % CI = 79.5-100 %) in the surgical group and 75.7 % (95 % CI = 45.4-97.1 %) in the endovascular group. Overall long-term good neurological outcome rates were 91.5 % (95 % CI = 74.4-100 %) in the surgical series and 93.3 % (95 % CI = 82.7-99.5 %) in the endovascular group. CONCLUSIONS Our meta-analysis demonstrated that both treatment modalities are technically feasible with high rates of technical success and effective with sufficient long-term aneurysm occlusion rates. Our data suggest that surgery is associated with superior angiographic outcomes. While endovascular therapy could be a reasonable first-line treatment option for proximal PICA aneurysms, surgery remains a highly effective first-line choice for distal PICA aneurysms. These findings should be considered when deciding the best therapeutic strategy.
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Chung Y, Ryu J, Choi SK, Kim EJ, Choi JH, Lee SH. Treatment Strategy for Isolated Posterior Inferior Cerebellar Artery Dissection. World Neurosurg 2016; 98:644-653. [PMID: 27890746 DOI: 10.1016/j.wneu.2016.11.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Isolated dissections that develop on the posterior inferior cerebellar artery (PICA) require intensive treatment because of their potential fatality. However, because of the rarity of these dissections, the optimal treatment has not yet been established. METHODS We retrospectively reviewed the clinical records of all patients who underwent any PICA dissection treatment in our institute over the last 4 years. Ten patients were enrolled, including 7 patients with subarachnoid hemorrhage (SAH) and 3 with PICA territory infarction. Dissection was seen at the proximal portion in 8 patients, whereas the remaining 2 patients showed distal PICA dissecting aneurysms. RESULTS Among the 7 patients with hemorrhage, 5 were actively treated (trapping and bypass, 2 patients; surgical clipping, 1 patient; coil embolization, 2 patients). Conservative management was performed in the other 2 patients. Among the 3 patients with infarction, 2 received conservative treatment. Endovascular treatment was performed in 1 patient, who showed rapid progression, aneurysm formation, and conversion to massive SAH within 10 days after the initial attack. Although 7 patients showed relatively good outcomes (modified Rankin Scale score, ≤2) after 30 days of follow-up, 1 patient had a final modified Rankin Scale score of 3. In addition, the other 2 patients (1 in each group) died as a result of major SAH. CONCLUSIONS Given the dynamic clinical course and potential fatality of PICA dissection, meticulous evaluation, intensive treatment with a diverse range of modalities, and proper follow-up are required for patients with PICA dissection to achieve favorable outcomes.
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Affiliation(s)
- Yeongu Chung
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Kyung Hee University Hospital, Seoul, Korea
| | - Jiwook Ryu
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Kyung Hee University Hospital, Seoul, Korea
| | - Seok Keun Choi
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Kyung Hee University Hospital, Seoul, Korea
| | - Eui Jong Kim
- Department of Radiology, College of Medicine, Kyung Hee University, Kyung Hee University Hospital, Seoul, Korea
| | - Joon Ho Choi
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Kyung Hee University Hospital, Seoul, Korea.
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Ganesh Kumar N, Ladner TR, Kahn IS, Zuckerman SL, Baker CB, Skaletsky M, Cushing D, Sanborn MR, Mocco J, Ecker RD. Parent vessel occlusion for treatment of cerebral aneurysms: Is there still an indication? A series of 17 patients. J Neurol Sci 2016; 372:250-255. [PMID: 28017223 DOI: 10.1016/j.jns.2016.11.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 10/27/2016] [Accepted: 11/22/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION/PURPOSE Flow diversion has allowed cerebrovascular neurosurgeons and neurointerventionalists to treat complex, large aneurysms, previously treated with trapping, bypass, and/or parent vessel sacrifice. However, a minority of aneurysms remain that cannot be treated endovascularly, and microsurgical treatment is too dangerous. However, balloon test occlusion (macro and micro), micro WADA testing, ICG, intra-angiography and intra-operative monitoring are all available to clinically test the hypothesis that vessel sacrifice is safe. We describe a dual-institution series of aneurysms successfully treated with parent vessel occlusion (PVO). MATERIALS/METHODS Prospectively collected databases of all endovascular and open cerebrovascular cases performed at Maine Medical Center and Vanderbilt University Medical Center from 2011 to 2013 were screened for patients treated with primary vessel sacrifice. A total of 817 patients were screened and 17 patients were identified who underwent parent vessel sacrifice as primary treatment. RESULTS All 17 patients primarily treated with PVO are described below. Nine patients presented with SAH, and 3/17 involved anterior circulation. Complete occlusion was achieved in 15/17 patients. In the remaining 2 patients, significant reduction in the aneurysm occurred. Modified Rankin Score (mRS) of 0, signifying complete independence, was achieved for 16/17 patients. One patient died due to an extracranial process. CONCLUSIONS Parent vessel sacrifice remains a viable and durable solution in select ruptured and unruptured intracranial aneurysms. Many adjuncts are available to aid in the decision making. In this small series, patients naturally divided into vertebral dissecting aneurysms, giant aneurysms and small distal aneurysms. Outcomes were favorable in this highly selected group.
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Affiliation(s)
- Nishant Ganesh Kumar
- Vanderbilt University Medical Center, Department of Neurosurgery, Nashville, Tenessee, USA.
| | - Travis R Ladner
- Vanderbilt University Medical Center, Department of Neurosurgery, Nashville, Tenessee, USA
| | - Imad S Kahn
- Dartmouth Hitchcock Medical Center, Department of Neurosurgery, Hanover, New Hampshire, USA
| | - Scott L Zuckerman
- Vanderbilt University Medical Center, Department of Neurosurgery, Nashville, Tenessee, USA
| | - Christopher B Baker
- Maine Medical Center, Neuroscience Institute, Portland, Maine, USA; Maine Medical Center, Department of Radiology, Portland, ME, USA
| | | | - Deborah Cushing
- Maine Medical Center, Neuroscience Institute, Portland, Maine, USA
| | | | - J Mocco
- Mt. Sinai Medical Center, Department of Neurosurgery, New York, New York, USA
| | - Robert D Ecker
- Maine Medical Center, Neuroscience Institute, Portland, Maine, USA; Maine Medical Center, Department of Surgery, Portland, ME, USA
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13
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Juszkat R, Kram P, Stanisławska K, Jankowski R, Stachowska-Tomczak B, Nowak S, Liebert W. Ten years of experience in endovascular treatment of ruptured aneurysms of the posterior inferior cerebellar artery. Interv Neuroradiol 2016; 22:129-37. [PMID: 26825074 DOI: 10.1177/1591019915622164] [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: 08/16/2015] [Accepted: 10/29/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this study is to present our 10 years of experience in endovascular treatment of ruptured posterior inferior cerebellar artery (PICA) saccular aneurysms and to compare clinical presentation and outcome after endovascular treatment between patients with PICA aneurysms and patients with aneurysms in different locations. METHODS AND FINDINGS Out of 932 patients with a ruptured intracranial aneurysm treated endovascularly in our institution, 38 aneurysms were located at the posterior inferior cerebellar artery. Clinical presentation, mean aneurysm diameter and outcome of the therapy in this group were compared with the same for ruptured aneurysms in other locations. Patients discharged with favourable outcomes were checked angiographically in the follow-up period. Thirty-four patients with ruptured PICA aneurysms were treated by selective endovascular coiling. Two patients with wide-necked aneurysms had endovascular stents implanted. In two cases, the parent vessel was occluded due to failure to catheterise the target aneurysm. The evaluated variables did not differ significantly between two groups, but significantly more ruptured aneurysms in the PICA group were under 6 mm in diameter. 29.4% of controlled aneurysms needed additional reembolisation in the follow-up period. CONCLUSIONS Clinical presentation, extension of subarachnoid haemorrhage and outcome after endovascular treatment did not differ significantly between patients with ruptured aneurysms located on the PICA and patients with aneurysms located elsewhere intracranially. Endovascular treatment is an effective method of therapy in patients with ruptured PICA aneurysms. In our experience, even when sacrificing of the PICA is required, the results of treatment are favourable.
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Affiliation(s)
- Robert Juszkat
- Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poland
| | - Paweł Kram
- Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poland
| | - Katarzyna Stanisławska
- Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poland
| | - Roman Jankowski
- Department of Neurosurgery and Neurotraumatology, Poznan University of Medical Sciences, Poland
| | | | - Stanisław Nowak
- Department of Neurosurgery and Neurotraumatology, Poznan University of Medical Sciences, Poland
| | - Włodzimierz Liebert
- Department of Neurosurgery and Neurotraumatology, Poznan University of Medical Sciences, Poland
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14
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Sejkorová A, Cihlář F, Hejčl A, Lodin J, Vachata P, Sameš M. Microsurgery and endovascular treatment of posterior inferior cerebellar artery aneurysms. Neurosurg Rev 2015; 39:159-68; discussion 168. [DOI: 10.1007/s10143-015-0659-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 05/01/2015] [Accepted: 06/27/2015] [Indexed: 11/28/2022]
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15
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Li H, Li XF, He XY, Zhang X, Zhu GH, Fang QR, Wang ZQ, Duan CZ. Endovascular Treatment of Dissecting Aneurysms of the Posterior Inferior Cerebellar Artery and Predictors of Outcome. J Stroke Cerebrovasc Dis 2015; 24:2134-42. [PMID: 26150084 DOI: 10.1016/j.jstrokecerebrovasdis.2015.05.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Isolated dissecting aneurysms of the posterior inferior cerebellar artery (PICA) are rare lesions, which carry high risk of rebleeding and mortality. However, the existing literature concerning predictors of outcome after endovascular treatment is limited and controversial. Our present study retrospectively reviewed and analyzed the clinical outcome of endovascular treatment-ruptured PICA-dissecting aneurysms and explored the predictors of outcome. METHODS We retrospectively reviewed 17 consecutive patients with ruptured PICA dissecting aneurysms that underwent endovascular treatment from January 2003 to January 2014. Nine patients underwent selective coiling, whereas 7 patients underwent parent artery occlusion and 1 patient underwent stent-assisted coiling. Follow-up outcomes were evaluated using the modified Rankin Scale. The clinical outcomes of patients were categorized as favorable (modified Rankin Scale [mRS] score 0-1) or unfavorable (mRS score 2-6). RESULTS Favorable outcomes (mRS score 0-1) were obtained in 13 of 17 patients. Post-treatment recurrence occurred in 1 patient with selective coiling in the 15-month follow-up, and the patient received stent-assisted coiling. The only patients with stent-assisted coiling developed PICA occlusion during follow-up. Aneurysm located in distal segment usually presented with intraventricular hemorrhage (P = .015). Hypertension, coexisting hydrocephalus, and time to operation (latter than 2 weeks) were associated with unfavorable outcome. CONCLUSIONS Endovascular treatment of isolated dissecting aneurysm of PICA had excellent clinical outcomes, hypertension, coexisting hydrocephalus, and time to operation (latter than 2 weeks), which were associated with unfavorable outcome. Long-term follow-ups are necessary to provide stronger conclusions.
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Affiliation(s)
- Hui Li
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, 510282, Guangzhou, Guangdong, China
| | - Xi-Feng Li
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, 510282, Guangzhou, Guangdong, China
| | - Xu-Ying He
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, 510282, Guangzhou, Guangdong, China
| | - Xin Zhang
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, 510282, Guangzhou, Guangdong, China
| | - Guo-Hui Zhu
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, 510282, Guangzhou, Guangdong, China
| | - Qin-Rui Fang
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, 510282, Guangzhou, Guangdong, China
| | - Ze-Qun Wang
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, 510282, Guangzhou, Guangdong, China
| | - Chuan-Zhi Duan
- Department of Neurosurgery/Neurosurgery Institute/Key Laboratory on Brain Function Repair and Regeneration of Guangdong, Southern Medical University, Zhujiang Hospital, 510282, Guangzhou, Guangdong, China.
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