Coil embolisation for ruptured vertebral artery dissection distal to the origin of the posterior inferior cerebellar artery

Endovascular treatments of intracranial vertebral and internal carotid arteries dissections: An interactive systematic review and meta-analysis

INTRODUCTION

Management of intracranial artery dissection (IAD) remains elusive in medical practice. Intracranially, vertebral artery dissection (VAD) is more commonly encountered than internal carotid artery dissection (ICAD). Deconstructive (EVT-d) and reconstructive (EVT-r) endovascular techniques have been utilized to treat VAD and ICAD. This meta-analysis investigates the safety and efficacy of EVT-r and EVT-d in the management of VAD and ICAD.

METHODS

The literature was searched for all studies with consecutive patient series evaluating EVT-d or EVT-r for VAD or ICAD management. Baseline characteristics and outcomes were compared between EVT-r and EVT-d groups using the random-effect model and meta-regression approaches.

RESULTS

Overall, 1095 cases pooled from 56 studies were included. There was no statistically significant difference in baseline characteristics between VAD and ICAD. EVT-r was applied in 647 cases (59.1%) and EVT-d in the rest There was no statistical difference in the rate of procedural complications between EVT-r and EVT-d. Although EVT-d was significantly associated with higher rates of complete aneurysm occlusion (86.4%), lower rates of good clinical outcomes (72.1%) and higher mortality (15.1%) were achieved compared to EVT-r (70.2%, 83.3%, and 9.5%; respectively). The mortality rate was higher, and good clinical outcomes were less common in ruptured aneurysms. Ischemic presentation was statistically associated with poor outcomes (mRS 3-5) but low mortality. ICAD often tended to grow following treatment and resulted in poor neurological outcomes.

CONCLUSIONS

IAD has favorable outcomes when treated appropriately. Novel reconstructive endovascular techniques are promising and should be integrated well in endovascular practice. Further studies are warranted.

Internal Trapping of an Acutely Ruptured Dissecting Aneurysm of a Dominant Vertebral Artery Following Balloon Test Occlusion: A Case Report

Objective

To report a case of an acutely ruptured vertebral artery dissecting aneurysm (VADA) with a hypoplastic contralateral vertebral artery (VA) successfully treated with internal trapping following the estimation of the collateral flow from anterior circulation.

Case Presentation

A 46-year-old woman was diagnosed with subarachnoid hemorrhage and acute hydrocephalus. Ventriculostomy was performed under general anesthesia. CTA revealed a left VADA distal to the origin of the left posterior inferior cerebellar artery (PICA). The right VA was hypoplastic, and the right posterior communicating artery (Pcom) was fetal type. We performed balloon test occlusion (BTO) of the VA proximal to the origin of the left PICA and estimated sufficient collateral blood flow via the right Pcom and basilar artery (BA) to the anterior spinal artery (ASA) and the left PICA. Internal trapping of the left VADA was then performed. The angiograms after internal trapping revealed collateral flow from the right Pcom to the BA, and the hypoplastic right VA perfused the proximal BA and ASA. She recovered without any neurological deficits following antiplatelet therapy and vasospasm treatment. She was followed up for 6 years without any neurological events occurring.

Conclusion

When BTO indicates sufficient collateral flow, internal trapping could be a useful treatment for acutely ruptured VADAs on the dominant side, given a complete understanding of the angioarchitecture and the risk of vasospasm due to subarachnoid hemorrhage.

Subarachnoid Hemorrhage Due to Rupture of Vertebral Artery Dissecting Aneurysms: Treatments, Outcomes, and Prognostic Factors

BACKGROUND

Mortality rate after subarachnoid hemorrhage due to rupture of vertebral artery dissecting aneurysms (VADAs) is high; endovascular coil trapping is the first-line therapy to prevent rerupture. To select optimal treatments, the positional relationship between the VADA and posterior inferior cerebellar artery (PICA) and the morphology of the contralateral vertebral artery must be considered, and outcome predictors of different treatment methods and their possible complications must be identified.

METHODS

We retrospectively studied 44 patients with ruptured VADAs who had undergone endovascular or surgical treatment. VADA morphology was assessed on conventional preoperative angiograms, and VADAs were categorized based on their site in relation to the PICA. VADA site, treatment method, and complications were used to identify prognostic factors.

RESULTS

The sites of the 44 VADAs were PICA-proximal (n = 3), PICA-distal (n = 22), PICA-absent (n = 7), and PICA-involved (n = 12). Treatments included internal coil trapping (n = 30), proximal coil occlusion (n = 5), and stent placement (n = 3); surgical flow alteration via an occipital artery-PICA bypass and ligation at the proximal vertebral artery and the PICA origin was performed in 6 patients. Periprocedural rebleeding was associated with a poor outcome. Internal coil trapping prevented the rerupture of PICA-proximal and PICA-absent VADAs, and flow alteration prevented rerupture of PICA-involved VADAs; there were no complications directly attributable to these procedures.

CONCLUSIONS

Periprocedural rebleeding was a poor prognostic factor. Internal trapping of PICA-proximal and PICA-absent VADAs and flow alteration in PICA-involved VADAs prevented rerupture.

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

Rupture of spontaneous dissecting aneurysms of the middle cerebral artery (MCA) is rare and its etiology remains obscure, although the risk of rebleeding is greater than with saccular aneurysms. Most reports concerning the treatment of a ruptured dissecting aneurysm of the anterior circulation involve surgical trapping or wrapping. Here, we report on a case of an MCA dissecting rupture treated with endovascular procedures. A 22-year-old female presented with sudden stuporous mental change following severe headache and left side hemiparesis. A computed tomography scan showed a diffuse subarachnoid hemorrhage and diffusion MR showed diffusion restriction at the right putamen and internal capsule. A 3-hour follow-up digital subtraction angiography (DSA) showed a dissecting aneurysm, which was not seen on an initial DSA. A stent assisted coil embolization was performed and double stents were applied to achieve flow diversion effects. A small remnant area of the dissecting aneurysm had disappeared at 60-day and was not observed on 12-month follow-up DSA.

Long-term outcome of endovascular reconstruction with the Pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery

Object

Use of a flow-diverting device has shown promising short-term results in the management of vertebral artery (VA) dissecting aneurysms, but there is still uncertainty regarding its long-term efficacy and safety. The authors report their initial experience with respect to the potential utility and long-term clinical outcomes of using a flow-diverting device in the treatment of unruptured dissecting VA aneurysms.

Methods

The authors conducted a retrospective review of all cases of unruptured intracranial VA dissecting aneurysms treated at their institution (Tuen Mun Hospital) with a flow-diverting device. They describe the clinical presentations and angiographic features of the cases and report the clinical outcome (with modified Rankin Scale [mRS] scores) at most recent follow-up, as well as results of the latest angiographic assessment, with particular focus on in-stent patency and side-branch occlusion.

Results

A total of 4 aneurysms were successfully obliterated by using flow-diverting devices alone. Two devices were deployed in a telescoping fashion in each of 2 aneurysms, whereas only 1 device was inserted in each of the other 2 aneurysms. No periprocedural complication was encountered. No patient showed any angiographic evidence of recurrence, in-stent thrombosis, or side-branch occlusion in angiographic reassessment at a mean of 22 months after treatment (range 18–24 months). As of the most recent clinical follow-up (mean 30 months after treatment, range 24–37 months), all patients had favorable outcomes (mRS Score 0).

Conclusions

Reconstruction using a flow-diverting device is an attractive alternative in definitive treatment of dissecting VA aneurysms, demonstrating favorable long-term clinical and angiographic outcomes and the ability to maintain parent artery and side-branch patency. It is particularly useful in cases with eloquent side-branch or dominant VA involvement.

Spontaneous intradural vertebral artery dissection: a single-center experience and review of the literature

OBJECTIVES

To define the natural history of spontaneous intracranial vertebral artery dissections (VADs) and to review current treatment strategies.

MATERIAL AND METHODS

We searched the MEDLINE database for all existing English and French literature on VADs through January 2008. Keywords employed were intradural/intracranial vertebral artery dissection, vertebral artery dissection, and vertebral artery dissection treatment. We also reviewed our series of patients with spontaneous VAD treated in the past 5 years. Data were collected, categorized, and analyzed.

RESULTS

In our sample of 457 patients, men were more frequently affected than women, and the mean age was 51.8 years. The majority of patients (79%) presented with subarachnoid hemorrhage (SAH). We experienced a high incidence (37%) of recurrent SAH, particularly within the first 24 hours after SAH first occurred. Angiographic fusiform dilatation and pearl-and-string lesions were the most common finding. Patients who presented with SAH fared worse than those who presented with ischemia.

CONCLUSIONS

Due to a high rate of recurrent bleeding, we concluded that early treatment by either surgical or endovascular route is indicated in patients who present with SAH secondary to spontaneous intradural VADs. Treatment decisions should take into account the site and type of dissection, vertebral artery dominance, and involvement of posterior inferior cerebellar artery.

Successful endovascular reconstruction of acutely ruptured pseudoaneurysm of the vertebral artery, complicated by isolated vertebrobasilar circulation and symptomatic vasospasm

The management of a ruptured pseudoaneurysm of intracranial vertebral artery (VA), which is the sole supplier to an isolated vertebrobasilar system, is challenging. The authors report on such a case in a 49-year-old man who suffered a grade III subarachnoid hemorrhage (SAH) caused by a dissecting fusiform pseudoaneurysm of the left VA. The right VA terminated in the posterior inferior cerebellar artery and posterior communicating arteries were absent. The patient developed symptoms consistent with vasospasm on day 9 after SAH, which was treated by intra-arterial vasolytic therapy, followed by stent placement and "in-stent" balloon angioplasty. Angiography 2 weeks later showed near-complete resolution of the pseudoaneurysm. At discharge, the patient's modified Rankin score was one. In this complicated case in which an isolated vertebrobasilar circulation precluded parent vessel sacrifice, we detail the successful management using a combination of intra-arterial vasolytic therapy, stent reconstruction, and balloon angioplasty.

Incidence of Ischemic Complications after Endovascular Treatment for Ruptured Dissecting Vertebral Artery Aneurysms. Comparison between Those Arising Proximal to and Distal to the Origin of the Posterior Inferior Cerebellar Artery

SUMMARY

We analyzed the incidence of ischemic complications after internal trapping for ruptured VA dissecting aneurysms. Between April 2001 and August 2005, nine cases of ruptured VA dissecting aneurysms, five in women, "proximal" or distal (distal type) to the origin of the PICA, were treated by internal trapping in the acute stage after SAH. There were four cases of proximal type and five of distal type. The demographics of the patients were reviewed in the medical charts and radiological findings were evaluated by neuroradiologists. The dissected site was completely obliterated and PICA was preserved in all cases. Follow-up angiography performed five to 19 days after treatment revealed complete obliteration of the aneurysm and patency of the PICA. The incidence of perioprocedural ischemic complications for the PICA-distal type (75%) was higher than that for the PICA-proximal type (20%). Here we retrospectively analyzed and discussed the incidence and mechanisms of ischemic complications.

Proximal Flow Arrest With Temporary Subclavian Steal for Internal Trapping of a Ruptured Vertebral Artery Dissecting Aneurysm-Case Report-

A 48-year-old woman presented with subarachnoid hemorrhage originating from a dissecting aneurysm of the left vertebral artery (VA). Internal trapping with proximal flow arrest was planned. The origin of the left VA was too tortuous to allow positioning of an occlusion balloon catheter and a microcatheter in the left VA via the femoral artery. Therefore, the temporary subclavian steal technique was used for proximal flow arrest, by placing an occlusion balloon catheter in the subclavian artery proximal to the VA origin via the femoral artery. Thereafter, coil embolization was achieved through the left axillary artery. The patient recovered well after the procedure.

Vertebrobasilar dissection with subarachnoid hemorrhage: a retrospective study of 29 patients

We have reviewed initial diagnostic features, treatment, and outcome in 29 patients with acute subarachnoid hemorrhage due to non-traumatic vertebrobasilar artery dissection diagnosed in our hospital between 1993 and 2003. The dissections occurred in the vertebral artery in 19 patients, the posterior inferior cerebellar artery (PICA) in two patients, the basilar artery in four patients, and in the vertebral artery extending into the PICA in four patients. A pseudoaneurysm was found in 20 patients. Clinical manifestations typically included sudden onset of moderate to severe headache, nuchal rigidity, and drowsiness. Fourteen patients were treated conservatively. Fifteen patients underwent endovascular treatment with either parent artery occlusion (13 patients) or aneurysmal coil occlusion with preservation of the parent artery (2 patients). Re-bleeding occurred within 12 days and before treatment in nine patients. Eight of these had a pseudoaneurysm. No patient bled after endovascular treatment. Poor grade and early re-bleeding were associated with less favorable outcome. Outcome at 6 months did not differ significantly between endovascular and conservative treatment. Altogether, good recovery was achieved for 16 patients, moderate disability was seen in one, severe disability in four, and eight patients (27%) died. The absence of bleeding subsequent to endovascular treatment in this study suggests that endovascular treatment may be a rational approach in these patients at high risk of re-bleeding, especially those with a pseudoaneurysm.

Emergent endovascular treatment of ruptured vertebral artery dissecting aneurysms

The goal of this study was to evaluate the results of endovascular and surgical treatments for ruptured vertebral artery dissecting aneurysms (VADAs) to determine which treatment is preferable. We evaluated the cases of 25 consecutive patients with ruptured VADAs treated in our institution. From 1992 to 1997, five patients were treated surgically. Since 1998, 20 patients with VADAs have been treated with endovascular therapy. The goal of the treatment was to exclude the aneurysm from the circulation. Among the five patients undergoing surgery, three aneurysms were treated with proximal clipping, one with trapping, and one with dome clipping. None of the patients were treated during the acute stage of rupture. Transient complications occurred in two patients. Of the 20 patients treated through the endovascular approach, 15 were treated within 24 h of rupture, but 12 had rebleeding before treatment. Eighteen aneurysms were occluded, along with the affected vertebral artery (VA), by using detachable coils (internal trapping), and one was occluded with the VA preserved. A stent-assisted occlusion of one aneurysm was done in a patient who had a contralateral hypoplastic VA. In both groups, the outcome of each patient depended greatly on the patient's condition before treatment and whether there was rebleeding. No posttreatment bleeding occurred. All procedures were effective, but endovascular treatment was less invasive and easier to use during the acute stage of subarachnoid hemorrhage. Although this report does not describe a controlled study, we found that endovascular treatment is preferable for treating ruptured VADAs in the acute stage.

Rebleeding and ischemia after acute endovascular treatment of ruptured dissecting subarachnoid vertebral artery aneurysms

SUMMARY

Dissection aneurysms of the vertebral artery represent 3.2% of all cerebral aneurysms and 28% of intracranial dissection aneurysms. Dissection of the vertebral artery in its intracranial segment (V4) usually causes a subarachnoid hemorrhage (SAH) from subadventiatial extension of the vessel wall hematoma. Rarely (one case in seven), the symptomatology is characterized by brain stem ischemia from the vertebral artery and/or postero-inferior cerebellar artery occlusive dissection. The high rebleeding (18-33% with a 10+/-5 day interval between the first and the second bleeding) and mortality (> 45%) rates 1, 13 of this disease prompt emergency treatment usually consisting in endovascular coiling of the dissection aneurysm and/or the dissected segment of the parent vessel. Herein we report our experience in endovascular coiling of acutely ruptured dissecting aneurysms of the vertebral artery dissection in V4 segment. We focus the discussion on the risk of rebleeding and the ischemic complications that my occur after endovascular or surgical treatment.

Rebleeding of a vertebral artery dissecting aneurysm during stent-assisted coil embolization: a pitfall of the “stent and coil” technique

BACKGROUND

A stent-assisted coil embolization has been applied as a novel choice of treatment for vertebral artery dissecting aneurysms (VADAs).

CLINICAL PRESENTATION

A 45-year-old man suffered from subarachnoid hemorrhage three times within 2 hours. The left vertebral angiogram showed a VADA at the distal origin of the posterior inferior cerebellar artery. The right vertebral artery was hypoplastic, and collateral circulation to the posterior fossa was poor.

INTERVENTION

Stent-assisted coil embolization was performed under general anesthesia. The aneurysm was excluded from the circulation with good patency of the vertebral artery, although the fourth coil caused rebleeding from the aneurysmal dome during the procedure.

CONCLUSION

This is the first case report that demonstrates rebleeding from VADA during stent-assisted coil embolization in the acute stage of its rupture. We have to be aware of the risks and be ready to prevent fatal complications with this novel technique.

Treatment of hemorrhagic intracranial dissections

OBJECTIVE

To analyze the treatment options in hemorrhagic intracranial dissections.

METHODS

This study involved a retrospective review of 27 patients with 29 dissections treated during a 16-year period, mainly by endovascular treatment (EVT).

RESULTS

EVT was performed in the acute stage in 12 of the 29 dissections, and occlusion was performed using coils at the dissection site in six dissections and with proximal balloon occlusion in six dissections. Wrapping was performed in one case. In the remaining 16 dissections, which were not treated, mainly for anatomic reasons, three patients died, one from rebleeding. Angiographic follow-up performed in the 13 surviving patients demonstrated an initially misdiagnosed lesion in one and worsening lesions in five that led to delayed EVT in five and surgical clipping in one. One of these dissections, which was located on a dominant vertebral artery, was treated after subsequent rupture using a stent and coils to preserve the patency of the parent vessel. Four ischemic complications related to EVT resulted in a moderate disability in two patients. No rebleeding occurred after EVT, but one patient died because of a poor initial clinical status; the other patients improved. In the 10 patients treated conservatively, four died, three from a poor initial clinical status and one from rebleeding, and six patients had a good clinical outcome. Of the 27 patients, three had rebleeding and one died as a result of that rebleeding. Seventeen patients (63%) had a good recovery, six (22%) had a moderate disability, and four (15%) died.

CONCLUSION

EVT provides effective protection against rebleeding. When possible, occlusion with coils at the dissection site is the current method of choice. Another option is parent artery occlusion with balloons, and the use of a stent may preserve vessel permeability in specific cases.

Endovascular Treatment of Cerebral Aneurysms

Balloon occlusion of parent vessel and direct coiling are the two endovascular techniques routinely used and commonly accepted as alternatives to surgery for treatment of the cerebral aneurysm in many patients. Based on our experience and what is reported in the literature, the various aspects concerning techniques, difficulties, risks, are described. In comparison to surgery, the endovascular approach is a relatively new technique, which is still in evolution. To date, there is no objective indication regarding the method to be used in a given case. The experience and attitude of the involved team still play an essential role.

Dissecting aneurysms of the vertebral artery: a management strategy

OBJECT

The authors present a retrospective analysis of their experience in the treatment of vertebral artery (VA) dissecting aneurysms and propose a management strategy for such aneurysms, with special emphasis on the most formidable VA dissecting aneurysms, which involve the origin of the posterior inferior cerebellar artery (PICA).

METHODS

Since 1998, 18 patients with VA dissecting aneurysms, 11 of whom presented with subarachnoid hemorrhage (SAH), have been treated by endovascular surgery at the authors' institution. Obliteration of the entire segment of the dissected site with coils (internal trapping) was performed for aneurysms without involvement of the origin of the PICA (12 cases; among these the treatment-related morbidity rate was 16.7%). The treatment strategy applied to PICA-involved VA dissecting aneurysms presenting with SAH (three cases) included proximal occlusion of the parent artery followed by internal trapping of the aneurysm (one case), proximal occlusion of the parent artery followed by occipital artery (OA)-PICA bypass (one case), and two-staged internal trapping of the aneurysm involving double PICAs (one case). For PICA-involved VA dissecting aneurysms that were not associated with SAH at presentation (three cases), OA-PICA bypass was performed and followed by internal trapping of the aneurysm (two cases). In the remaining case in which a fetal-type posterior communicating artery was present, internal trapping was performed following successful balloon test occlusion (BTO). Overall, there was no sign of infarction in the PICA territory, despite complete occlusion of aneurysms involving the PICA. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. The overall treatment-related morbidity rate for the VA dissecting aneurysms involving the PICA was 16.7%.

CONCLUSIONS

Dissecting VA aneurysms that do not involve the PICA can be safely treated by internal trapping. For those lesions that do involve the PICA, a decision-making algorithm is advocated to maximize the efficacy of the treatment as well as to minimize the risks of treatment-related morbidity based on BTO.

A dissecting aneurysm of the posterior inferior cerebellar artery. A case report

SUMMARY

Dissecting aneurysms occur when blood extrudes into the wall of a vessel. Posterior circulation dissections are recognised as an important cause of cerbral infarction and subarachnoid haemorrhage(SAH), however posterior inferior cerebellar artery (PICA) aneurysmal dissections are rare. A 49-year-old man who presented with SAH was found to have a left PICA dissection on cerebral angiography. The lesion was treated with surgical clipping proximal to the dissection and a distal PICA to PICA anastomosis. The pathology, diagnosis, presentation and treatment of these difficult lesions is discussed.