Treatment of spontaneous arterial dissections with stent placement for preservation of the parent artery

Endovascular Management of Spontaneous Subclavian Artery Dissection

Spontaneous subclavian artery dissection (SCAD) is a rare clinical observation with very few cases reported in the medical literature. We describe a rare case of a 50-year-old female patient who presented with symptoms of critical limb ischemia of the right upper extremity. A digital subtraction angiogram (DSA) revealed a dissection in the proximal course of the subclavian artery (SCA). Prompt recanalization with endovascular therapy produced an excellent result.

Potential hemorrhagic risk of endovascular revascularization therapy due to recanalization of the dissected perforator in intracranial internal carotid artery dissection: A case report

Background:

Intracranial internal carotid artery (ICA) dissection manifesting as ischemic stroke is rare. Although endovascular revascularization therapy is effective in preventing the progression of stroke, little is known about the potential risk of this therapeutic approach.

Case Description:

We report a case of a 38-year-old woman who presented with acute ischemic infarcts in the territory of the left anterior choroidal artery (AChA) due to intracranial ICA dissection. She underwent balloon angioplasty, resulting in the complete resolution of the stenosis. The AChA, which was nearly occluded preoperatively, was unexpectedly recanalized after the procedure. Four hours later, she developed a parenchymal hemorrhage in the left basal ganglia without subarachnoid hemorrhage. The AChA, suspected as the hemorrhagic source during surgical hematoma removal, was revealed to have a disrupted internal elastic lamina on pathological examination, suggesting that the dissection of the ICA extended to the AChA.

Conclusion:

To the best of our knowledge, this is the first case report demonstrating that the intracranial ICA dissection extends to the associated perforator. Considering the potential risk of subsequent hemorrhagic complications by recanalization of the dissected perforator, prudent postoperative management, including strict blood pressure control, is advisable following endovascular revascularization therapy against intracranial artery dissection involving perforators.

Spinal Cord Infarction in the Region of the Posterior Spinal Artery After Embolization for Vertebral Artery Dissection

BACKGROUND

Endovascular surgery for vertebral artery dissections (VADs) carries the risk of spinal cord infarction (SCI). Although SCI in the region of the anterior spinal artery (ASA) has been reported, SCI in the region of the posterior spinal artery (PSA) is rare.

OBJECTIVE

To investigate PSA infarction after endovascular surgery for VAD.

METHODS

Infarction in the region of the PSA after endovascular surgery for VADs carried out in consecutive 21 cases was investigated. The variables of aneurysmal location, status, intra-aneurysmal thrombosis, antithrombotic therapy, and endovascular procedure were investigated in relation to the occurrence of spinal cord or brain stem infarction.

RESULTS

Thirteen cases were unruptured aneurysms, and 8, ruptured aneurysms. The endovascular surgical method was internal trapping in 10 cases, stent-assisted coil embolization in 8 cases, and proximal occlusion (PO) in 3 cases. Periprocedural symptomatic infarction was detected in 4 of the 21 cases (19%): 3 SCIs and 1 lower medulla infarction, after 1 stent-assisted coil embolization and 3 PO. All 3 symptomatic SCIs were PSA infarction. On univariate analysis, the variables of posterior inferior cerebellar artery-involved-type, PO, and intraprocedural proximal flow arrest were significantly correlated with occurrence of PSA infarction.

CONCLUSION

PSA infarction after endovascular surgery for VAD seems not to be a rare potential complication. Insufficiency of collateral blood flow and artery-to-artery embolism due to intraprocedural flow stagnation of the VA seem to be the possible mechanisms of PSA infarction in addition to previously reported mechanisms such as direct obliteration by the embolic materials and extended thrombosis of the VA stump.

Comparison of Endovascular Treatments of Ruptured Dissecting Aneurysms of the Intracranial Internal Carotid Artery and Vertebral Artery with a Review of the Literature

Objective

Subarachnoid hemorrhage (SAH) caused by rupture of an internal carotid artery (ICA) or vertebral artery (VA) dissecting aneuryesm is rare. Various treatment strategies have been used for ruptured intracranial dissections. The purpose of this study is to compare the clinical and angiographic characteristics and outcomes of endovascular treatment for ruptured dissecting aneurysms of the intracranial ICA and VA.

Methods

The authors retrospectively reviewed a series of patients with SAH caused by ruptured intracranial ICA and VA dissecting aneurysms from March 2009 to April 2014. The relevant demographic and angiographic data were collected, categorized and analyzed with respect to the outcome.

Results

Fifteen patients were identified (6 ICAs and 9 VAs). The percentage of patients showing unfavorable initial clinical condition and a history of hypertension was higher in the VA group. The initial aneurysm detection rate and the percentage of fusiform aneurysms were higher in the VA group. In the ICA group, all patients were treated with double stent-assisted coiling, and showed favorable outcomes. In the VA group, 2 patients were treated with double stent-assisted coiling and 7 with endovascular trapping. Two patients died and 1 patient developed severe disability.

Conclusion

Clinically, grave initial clinical condition and hypertension were more frequent in the VA group. Angiographically, bleb-like aneurysms were more frequent in the ICA group and fusiform aneurysms were more frequent in the VA group. Endovascular treatment of these aneurysms is feasible and the result is acceptable in most instances.

Stepwise stent deployment technique for tandem intracranial aneurysms: a review of 21 cases

OBJECTIVES

We performed this study to report our experience using a stepwise stent deployment technique for the treatment of tandem intracranial aneurysms.

METHODS

Patients with intracranial tandem aneurysms that were treated with a stepwise stent deployment technique between May 2009 and June 2013 were retrospectively reviewed.

RESULTS

Twenty-one patients with 42 tandem aneurysms were identified (11 men, 10 women), with a mean age of 53.7 years (range, 17-82 years). Subarachnoid haemorrhage was confirmed in 12 patients using computed tomography at onset. Complete occlusion was achieved in 20 of the aneurysms (47.6%) after the procedure, neck remnant in 9 (21.4%), and aneurysm remnant in 13 (31.0%). The perioperative complications included in-stent thrombosis in one case and vasospasm in two cases, none of which left a permanent neurological deficit. The modified Rankin Scale (mRS) score at discharge was 0-2 in 20 cases and 3 in one case. The follow-up angiograms available for 17 patients showed complete occlusion in 26 aneurysms, improved in 4, and stable in 4. All of the patients had mRS scores of 0-1 during the clinical follow-up period.

CONCLUSIONS

The stepwise stent deployment technique is feasible and helpful in the treatment of intracranial tandem aneurysms.

KEY POINTS

• Treating wide-necked intracranial aneurysms with stent-assisted coiling is preferable. • Tandem wide-necked intracranial aneurysms can be treated with a single stent. • Stepwise stent deployment is technically feasible for embolizing tandem intracranial aneurysms.

Discrepancy between preoperative imaging and postoperative pathological finding of ruptured intracranial dissecting aneurysm, and its surgical treatment: case report

The choice of therapeutic strategy for intracranial dissecting aneurysm is often based on radiographic features, including characteristic geometry (e.g., irregular stenosis, segmental stenosis, aneurysm formation [pearl-and-string sign]), irregular fusiform or aneurysmal dilation, double lumen, and tapering occlusion. However, there is often a discrepancy between preoperative radiographic data and actual dissecting length. The present report describes three cases in which there was a discrepancy between preoperative radiographic data and actual dissecting length in patients undergoing direct trapping with or without revascularization. All three cases experienced good outcomes, but these cases underscore the fact that open surgery is a good option for management of ruptured intracranial dissecting aneurysms for determination of the rupture point, dissecting length, and the relationship between dissecting area and small arteries arising from the associated vessel.

Endovascular treatment of intracranial artery dissection: clinical and angiographic follow-up

Background. Intracranial artery dissections are rare and many controversies exist about treatment options. The aim of this study was to evaluate the efficacy and safety of the endovascular approach in patients with an intracranial dissection presenting with different symptoms. Methods. We prospectively evaluated the clinical features and treatment outcomes of 30 patients who had angiographically confirmed nontraumatic intracranial dissections over 4 years. Patients were followed up for 17 months, and their final outcomes were assessed by the modified Rankin Score (mRS) and angiography. Results. Sixteen (53.3%) patients had a dissection of the anterior circulation, whereas 14 (46.7%) had a posterior circulation dissection. Overall, 83.3% of the patients suffered a subarachnoid hemorrhage (SAH). Grade IV Hunt and Hess score was seen in 32% of the SAH presenting cases. Parent artery occlusion (PAO) with coil embolization was used in 70% of the cases. The prevalence of overall procedural complications was 23.3%, and all were completely resolved at the end of follow-up. No evidence of in-stent occlusion/stenosis or rebleeding was observed in our cases during follow-up. Angiography results improved more frequently in the PAO with coil embolization group (100%) than in the stent-only-treated group (88.9%) (P = 0.310) and the unruptured dissection group (5/5, 100%) in comparison with the group that presented with SAH (95.8%) (P = 0.833). Conclusion. Favorable outcomes were achieved following an endovascular approach for symptomatic ruptured or unruptured dissecting aneurysms. However, the long-term efficacy and durability of these procedures remain to be determined in a larger series.

Peri-stent aneurysm formation following a stent implant for stenotic intracranial vertebral artery dissection: a technical report of two cases successfully treated with coil embolization

INTRODUCTION

Although stenting for stenotic vertebral artery dissection (VAD) improves compromised blood flow, subsequent peri-stent aneurysm (PSA) formation is not well-known. We report two cases with PSA successfully treated with coil embolization.

METHODS

Three patients with stenotic intracranial VAD underwent endovascular angioplasty at our institution because they had acute infarction in posterior circulation territory and clinical evidence of hemodynamic insufficiency. In two of three patients balloon angioplasty at first session failed to relieve the stenosis, and a coronary stent was implanted. Angiography immediately after stenting showed no abnormality in case 1 and minimal slit-like projection at proximal portion of the stent in case 2.

RESULTS

Angiography obtained 16 months after the stenting revealed PSA in case 1. In case 2, angiography performed 3 months later showed that the projection at proximal portion enlarged and formed an aneurysm outside the stent. Because follow-up angiographies showed growth of the aneurysm in both cases, endovascular aneurysmal embolization was performed. We advanced a microcatheter into the aneurysm through the strut of existing stent and delivered detachable coils into the aneurysm lumen successfully in both cases. The post-procedural course was uneventful, and complete obliteration of aneurysm was confirmed on angiography in both cases.

CONCLUSION

Stenting for stenotic intracranial VAD may result in delayed PSA; therefore, follow-up angiographies would be necessary after stenting for stenotic intracranial arterial dissection. Coil embolization through the stent strut would be a solution for enlarging PSA.

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.

Long-term clinical and angiographic outcomes in patients with cervico-cranial dissections treated with stent placement: a meta-analysis of case series

Limited clinical and angiographic data exists for patients with spontaneous or traumatic cervico-cranial dissections treated with stent placement. We reviewed clinical and angiographic data on consecutive patients admitted to our hospital with spontaneous, traumatic, and iatrogenic cervico-cranial dissections treated with stent placement to study immediate and long-term clinical and angiographic outcomes. Additional patients were identified using pertinent studies published between 1980 and 2009, using a search of the PubMed, Cochrane, and Ovid libraries. Post-procedure complications and clinical outcomes were documented. Angiographic abnormalities collected at follow-up included presence of in-stent restenosis or pseudoaneurysm. After applying our strict search criteria, four studies including our series were used in the meta-analysis, representing 46 patients (mean age [standard deviation] 47 ± 14 years; 24 [52%] male) treated with stent placement for dissection. Overall, 72 stents were placed to treat 28 spontaneous, 11 traumatic, and 7 iatrogenic dissection patients with 51 dissections, involving 51 vessels; with a mean pre-stent stenosis of 71 ± 26% and mean post-stent stenosis of 6 ± 15%. The immediate and follow-up post-procedure complication rates per stent placed was 8 (11%) and 8 (11%), respectively. Among the 36 patients who underwent follow-up angiography, in-stent restenosis or pseudoaneurysms were present in 3 (8%) and 2 (6%) patients, respectively. A high rate of sustained resolution of angiographic abnormalities during long-term follow-up was noted, with a low rate of new transient ischemic attack, ischemic stroke, or death, supporting the feasibility, safety, and effectiveness of endovascular stent reconstruction.

Treatment of ruptured intra-cranial internal carotid artery dissection using a flow-diverter stent

In the presence of associated subarachnoid hemorrhage, the treatment of arterial dissection can be classified as either deconstructive (involving occlusion or sacrifice of the parent vessel) or reconstructive (preserving blood-flow through the parent vessel). In both treatment strategies, the main goal is to prevent any further risk of rebleeding. However, reconstructive treatment is reserved only for those patients in whom occlusion of the parent vessel is not feasible due to an insufficient collateral supply. This report is of a case of intra-cranial carotid artery dissection treated by a reconstructive endovascular approach, with deployment of a flow-diverter stent, for the management of an associated subarachnoid hemorrhage. This is, to the authors' knowledge, the first report of the use of a flow-diverter device as the main treatment of a ruptured supraclinoid carotid artery dissection.

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.

Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

BACKGROUND:

Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.

OBJECTIVE:

To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.

METHODS:

We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.

RESULTS:

For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).

CONCLUSION:

Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

Treatment of ruptured intracranial dissecting aneurysms in Hong Kong

Background:

Data suggests that hemorrhagic presentations occur in 20% of internal carotid artery dissections and 50% of vertebral artery dissections. A Finnish study has reported favorable outcomes in only 32% of patients.

We aimed to review the epidemiology and management outcomes in a Chinese population.

Methods:

We reviewed the aneurysmal subarachnoid hemorrhage registry of patients who presented with intracranial dissecting aneurysms at a neurosurgical center in Hong Kong over a five-year period.

Results:

A total of 23 patients with intracranial dissecting aneurysms were identified, accounting for 8% of all spontaneous subarachnoid hemorrhage patients. Forty-eight percent of the patients identified were treated by main trunk occlusion and 39% were treated by embolization or stent-assisted embolization or stent alone. Thirteen percent were managed by craniotomy and trapping or wrapping. Favorable outcomes at six months were achieved in 67%.

Conclusions:

Patients with intracranial dissecting aneurysms account for a significant proportion of the cases of spontaneous subarachnoid hemorrhage in our population. Carefully selected endovascular and microsurgical treatments can lead to management outcomes similar to patients with saccular aneurysms.

Angiographic and clinical outcomes of stent-alone treatment for spontaneous vertebrobasilar dissecting aneurysm

PURPOSE

Spontaneous vertebrobasilar dissecting aneurysm (VBD) is a very challenging disease with an unpredictable clinical course and controversies on treatment strategy. The present study reports radiological and clinical outcomes of stent-alone treatment (SAT) for VBD.

METHODS

Twenty-four VBDs treated with SAT are included in the present study. Clinical and angiographic data were reviewed retrospectively.

RESULTS

A total of 24 lesions in 22 patients with a mean follow-up period of 16.21 months were included. Of the 24 individual lesions, 23 were intracranial vertebral artery lesions and 1 lesion was located in the basilar artery. There were six cases of ruptured dissections with the other cases having various symptoms. The immediate post-SAT angiographic outcomes included 5 lesions with good remodeling over 90% recovery and 19 poorly remodeled lesions. The latest angiographic outcomes included 17 cases of good remodeling (remodeling rate over 90%), 6 cases of poor remodeling (remodeling rate below 70%), and 1 case with morphological aggravation. The overlapping stent technique was used in seven cases and it was significantly associated with good angiographic results. None of the rupture cases underwent re-rupture post SAT. There was one case of a symptomatic complication of a femoral arteriovenous fistula.

CONCLUSIONS

The SAT could be a feasible alternative for the treatment of VBD. The overlapping technique was significantly associated with good angiographic outcome. We expect that technological development of the intracranial stent will allow better procedural outcomes of SAT.

A study of vertebrobasilar artery dissection with subarachnoid hemorrhage

We retrospectively studied clinical characteristics of 368 patients with cerebral artery dissections who were diagnosed in 172 Japanese hospitals. Of these patients, 130 (35%) presented with subarachnoid hemorrhage, 217 (59%) with cerebral infarctions, and 21 (6%) with transient ischemic attacks. We analyzed 109 (84%) subarachnoid hemorrhage cases caused by vertebrobasilar artery dissection to evaluate conservative and surgical treatment from the viewpoint of postoperative rerupture and infarction.Subsequent ruptures were observed in 14% of the 21 cases with nonsurgical treatment. For the preventive purpose of rerupture, 88 patients received surgical interventions: 68 trappings, 13 proximal occlusions, 6 aneurysmal sac occlusions and 1 stenting. Rerupture was experienced in 33% of the aneurysmal sac occlusion patients while not occurring in the other three surgical interventions. In the group without vascular anastomosis, postoperative cerebral infarction was observed in 25% of the trapping, none of the proximal occlusion and 33% of the aneurysmal sac occlusion cases.In this study, aneurysmal sac occlusion treatments were more frequently complicated by rerupture or cerebral infarction postoperatively than the other treatment methods. It was difficult to determine which surgical treatment can achieve better surgical outcome among the proximal occlusion and trapping with or without vascular anastomosis.

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.

Endovascular strategies for vertebrobasilar dissecting aneurysms

BACKGROUND AND PURPOSE

Dissecting vertebrobasilar aneurysms are challenging to treat, and standard treatment modalities remain controversial. We retrospectively evaluated our experience using endovascular techniques to treat these aneurysms.

MATERIALS AND METHODS

From February 1997 to December 2007, 42 patients with intradural vertebrobasilar dissecting aneurysms underwent endovascular treatment. Twenty-nine patients had ruptured aneurysms, and 13 patients had unruptured dissecting aneurysms. The endovascular modalities for vertebrobasilar dissecting aneurysms were the following: 1) trapping (n = 30), 2) proximal occlusion (n = 3), 3) stent with coil (n = 6), and 4) stent alone (n = 3).

RESULTS

Seventeen of the 29 patients with ruptured vertebrobasilar dissecting aneurysms had successful outcomes without procedural complications following endovascular treatment. Procedure-related complications were the following: 1) rebleeding (n = 3), 2) posterior inferior cerebellar artery (PICA) territory infarction (n = 6), 3) brain stem infarction (n = 2), and 4) thromboembolism-related multiple infarctions (n = 1). Clinical outcomes were favorable in 32 patients (76.1%). There were 3 (7.1%) procedure-related mortalities due to rebleeding, and 1 (2.4%) non-procedure-related mortality due to pneumonia sepsis. All 13 patients with unruptured vertebrobasilar dissecting aneurysms had favorable clinical and radiologic outcomes without procedure-related complications.

CONCLUSIONS

Endovascular procedures for treatment of unruptured symptomatic dissecting aneurysms resulted in favorable outcomes. Ruptured vertebrobasilar dissecting aneurysms are associated with a high risk of periprocedural complications. Risks can be managed by using appropriate endovascular techniques according to aneurysm location, configuration, and relationship with the PICA.

Intravascular ultrasonography-guided stent angioplasty of an extracranial vertebral artery dissection

The authors report on a case of intravascular ultrasonography (IVUS)-guided stent angioplasty for iatrogenic extracranial vertebral artery (VA) dissection in a 49-year-old man after coil embolization for an unruptured aneurysm of the right posterior inferior cerebellar artery. Insignificant dissections occurred during the procedure. Postoperatively, the patient experienced gradually worsening posterior neck pain and headache, and follow-up angiography 8 months after the coil embolization revealed expansion of the dissection. The patient underwent stent angioplasty with IVUS guidance and his symptoms improved.

To the authors' knowledge, this is the first report of IVUS-guided stent angioplasty of an extracranial VA dissection. It was safe and feasible to treat extracranial VA dissections with stent placement under IVUS guidance. Intravascular environments are in real time with IVUS, and this technique is useful in the confirmation of a true lumen and evaluation of appropriate stent apposition. More clinical experience with this technique is necessary and mandatory, and devices with smaller diameters with improved trackability are essential for further introduction of IVUS into the field of endovascular neurosurgery.

Endovascular treatment of giant intracranial aneurysms with willis covered stents: technical case report

OBJECTIVE

To evaluate the efficacy of endovascular treatment of giant intracranial aneurysms with Willis covered stents (Micro-Port, Shanghai, China).

CLINICAL PRESENTATION

The endovascular treatment of two cases of giant intracranial aneurysm was successfully accomplished by the placement of Willis covered stents specially designed for intracranial use. Both patients presented with symptoms of cavernous mass effect that resulted from a giant aneurysm in the cavernous segment of the internal carotid artery.

INTERVENTION

Three Willis covered stents were successfully placed in two patients. Immediate postprocedure angiograms demonstrated some endoleak of the aneurysms. In one patient, the endoleak was eliminated and complete exclusion of the aneurysms was confirmed with follow-up angiography. However, the other patient required the placement of a new Willis covered stent.

CONCLUSION

The use of covered stents in intracranial vascular structures is a feasible method to treat selected cases of intracranial giant aneurysms. It is suggested that patients who present with compressive mass effect caused by large or giant aneurysms are the best candidates for covered stent placement, but potential complications should be considered carefully before the stenting procedure.

Symptomatic spontaneous intracranial carotid artery dissection treated with a self-expanding intracranial nitinol stent: a case report

BACKGROUND

Although extracranial carotid dissection with stroke is common, intracranial dissection with stroke is rare. Stenting has been used to treat extracranial carotid dissections. Intracranially, however, it is only recently that stents have become a feasible option for this disease. We present a case of a spontaneous intracranial CAD with progressive symptoms despite medical management treated with a self-expanding intracranial micronitinol stent.

CASE DESCRIPTION

A 47-year-old, right-handed woman presented to the emergency department after noticing left-sided face and arm weakness and numbness, along with slurred speech. The patient was started on aspirin 325 mg/d orally and lovenox 40 mg/d subcutaneously. On hospital day 2, the patient was noted to have repeated episodes of weakness and numbness on the left side and MRI evidence of a new stroke. A diagnostic cerebral angiogram from a selective right internal carotid injection revealed a flow-limiting stenosis secondary to a dissection of the supraclinoid internal carotid artery with severe flow limitation to the hemisphere. Endovascular management was decided on, and a Neuroform stent measuring 4.5 x 20 mm (Boston Scientific Corporation, Natick, Mass) was deployed across the dissection with significant improvement of flow to that hemisphere on the poststent angiogram.

CONCLUSIONS

This case illustrates the successful off-label use of a self-expanding intracranial nitinol stent to treat a symptomatic intracranial internal CAD in the setting of failure of traditional medical management. This is a promising application of novel endovascular technology.

ENDOVASCULAR TREATMENT OF DISTAL CERVICAL AND INTRACRANIAL DISSECTIONS WITH THE NEUROFORM STENT

OBJECTIVE

Endovascular stent reconstruction is the primary intervention for cervical and intracranial dissections in symptomatic patients refractory to medical management. Advancement of traditional balloon-expanding stents into the distal internal carotid artery and vertebrobasilar artery can be technically challenging and potentially traumatic.

METHODS

On retrospective review, nine patients at our institution with distal cervical and/or intracranial dissections were alternatively treated with the self-expanding, dedicated intracranial Neuroform stent. Three patients with dissecting aneurysms also required stent-assisted coil embolization. Seven patients were followed with imaging and clinical assessment for a mean of 16.3 months.

RESULTS

All patients (five men, four women; mean age, 50 yr) were symptomatic. Spontaneous (n = 4) or traumatic and/or iatrogenic (n = 5) dissections involved the internal carotid artery (n = 2), vertebral artery (n = 5), and vertebrobasilar artery (n = 2). Indications for treatment included transient ischemic attacks, impending infarcts, antiplatelet failure, enlarging or ruptured dissecting aneurysms, intracranial dissections, or subarachnoid hemorrhages. Dissections were treated with single (n = 4), overlapping (n = 2), or tandem (n = 3) Neuroform stents. Dissection-related mean stenosis improved from 76% preprocedure to 23% postprocedure, with further reduction to 8% at follow-up imaging. Stent-assisted coil embolization of large dissecting aneurysms (n = 3) resulted in retreatment of a neck remnant (n = 1). Small dissecting aneurysms (n = 5) underwent spontaneous stent-induced thrombosis. There were no procedure-related complications. Mortality was limited to the presenting sequelae of vertebrobasilar artery thrombosis (n = 2). Suboptimal technical outcomes were related to delayed in-stent stenosis (n = 2). All surviving patients (n = 7) reported clinical improvement or resolution of symptoms.

CONCLUSION

The Neuroform stent seems to be safe and technically effective in the endovascular management of distal cervical and intracranial dissections, with favorable clinical outcomes.

Endovascular treatment of huge dissecting aneurysms involving the basilar artery. Experience and lessons from two cases

SUMMARY

Dissecting aneurysms involving the basilar artery (BA) are lesions with significant morbidity and mortality. Their management is controversial and often difficult. There is no generally approved strategy. Two cases of huge dissections involving the BA presented with subarachnoid hemorrhage in one case and mass effect in both cases. The dissection of case 1 involved the upper two thirds of the BA distal to the anterior inferior cerebellar arteries (AICA). Another dissection of case 2 involved the bilateral vertebral arteries (VA) distal to bilateral PICA and extended to upper third of the BA. After making a basket with coils inside the pseudoaneursym, proximal dissection was totally occluded in case 1. Dissection on the bilateral VA distal to the bilateral PICA and proximal BA was occluded in case 2 with a small residual dissection on the left VA. Case 1 had an excellent recovery with a durable image and clinical result. But recanalization and regrowth occurred in case 2, which might have originated from the residual dissection on the left VA, induced acute mass effect and sudden coma six weeks after the initial treatment. The residual and regrown dissection had to be occluded in a second intervention. The patient died two days later. BA occlusion is safe and efficient for dissections involving the BA as in our case and the literature. Proximal occlusion might be enough for huge and long lesions like ours. It seems that completely dense packing of proximal dissection is the key point to prevent recanalization.

Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases

INTRODUCTION

The aim of this retrospective study was to evaluate the clinical efficacy and limitations of different endovascular modalities in the treatment of very large and giant intracranial aneurysms.

METHODS

A group of 20 patients with very large and giant intracranial aneurysms treated by endovascular approaches were retrospectively analyzed. Of the 20 patients, 9 had been treated by parent artery occlusion, 8 by coil embolization, and 3 with an intracranial covered stent. Two recurrent aneurysms initially treated with coil embolization were retreated with an intracranial covered stent. Patients were followed for 9-83 months after the procedure.

RESULTS

Endovascular treatment was technically feasible in all 20 patients. One patient died 7 days after the procedure from rebleeding caused by incomplete aneurysmal occlusion. Immediate postprocedural angiograms showed that complete occlusion was achieved in 11 aneurysms, subtotal occlusion in 7, and incomplete occlusion in 2. The final angiographic results in the other 19 surviving patients confirmed complete occlusion of 15 aneurysms, subtotal occlusion in 3, and incomplete occlusion in 1. Clinical evaluations performed at the final follow-up visit showed an excellent outcome in 11 patients and a good outcome in 8.

CONCLUSION

Endovascular treatment of giant intracranial aneurysms with coil embolization is often associated with a low complete occlusion rate and a high recanalization rate, and parent artery occlusion remains a practical option in selected patients. Based on our limited experience, the use of an intracranial covered stent appears to be a relatively simple and safe procedure for occluding very large and giant aneurysms while still maintaining the patency of the parent artery.

Dissection of the V4 segment of the vertebral artery: clinicoradiologic manifestations and endovascular treatment

Intracranial vertebral artery (VA) dissection has three clinical presentations: ischemia, hemorrhage, and mass effect. Imaging findings of intracranial VA dissections vary according to clinical presentation. Irregular stenosis or occlusion of the VA is the most common finding in patients with posterior fossa infarction, whereas a dissecting aneurysm is the main feature in those with acute subarachnoid hemorrhage. A chronic, giant, dissecting aneurysm can cause mass effect on the brain stem or cranial nerves, as well as distal embolism. Magnetic resonance imaging is useful for detection of intramural hematomas and intimal flaps, both of which are diagnostic of VA dissection. Multidetector computed tomography angiography is increasingly used for diagnosis of VA dissection. Catheter angiography is still beneficial for evaluation of precise endoluminal morphology of the dissection before surgical or endovascular intervention. Endovascular treatment is now considered a major therapeutic option for patients with a ruptured dissecting aneurysm or a chronic dissecting aneurysm. Anticoagulation therapy is currently considered the initial treatment of choice in patients with posterior circulation ischemic symptoms. Endovascular treatment, such as stent-assisted angioplasty or coil occlusion at the dissection site, can be performed in selected patients with posterior fossa ischemic symptoms.