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Duangprasert G, Noiphithak R, Sukhor S, Tantongtip D. Efficacy and predicting factors of multimodal treatment for ruptured intracranial vertebral artery dissecting aneurysms. Neurosurg Rev 2023; 46:321. [PMID: 38040929 DOI: 10.1007/s10143-023-02226-7] [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: 10/11/2023] [Revised: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
We aimed to investigate the efficacy of our multimodal strategies and propose a treatment algorithm for ruptured vertebral artery dissecting aneurysms (VADAs). This study included 41 patients treated at a single institution between 2015 and 2022. The treatment modalities were justified based on the collateral circulation and aneurysm location related to the posterior inferior cerebellar artery (PICA). Treatment outcomes and complications of each treatment group were analyzed. The association between the collateral blood flow and the postoperative vertebrobasilar ischemia (VBI) was also investigated. There were 17 post-PICA, 10 PICA-involved, 7 pre-PICA, and 7 non-PICA types. Reconstruction techniques included flow diversion devices (n = 11) and stent-assisted coiling (n = 3). Deconstruction techniques included coil trapping (n=17) and microsurgical parent artery occlusion with (n = 8) or without PICA revascularization (n = 2). Five (18.5%) of the deconstruction group had postoperative VBI. Overall favorable outcomes in both groups were observed in 70.7% of patients with a mean follow-up time of 21.5 months. Poor World Federation of Neurosurgical Societies grade (IV-V) was identified as a predictor of unfavorable outcomes (p = 0.003). In addition, the VA4/BA4 ratio > 0.22, the presence of collateral blood flow from the posterior communicating artery (PcomA), and a contralateral VA diameter > 2.5 mm were associated with a lower risk of postoperative VBI. In summary, the proposed strategic treatment in this study is pragmatic, yielding satisfactory results where a deconstructive technique should be used with caution, particularly when there is a flow mismatch or the absence of collateral PcomA in the vertebrobasilar circulation.
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Affiliation(s)
- Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
| | - Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand.
| | - Sasikan Sukhor
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
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Zhou M, Wu Z, Maalim AA, Zeng Y, Guo X, Zhang Z, Yuan X, Enos ZM, Shu K, Lei T, Zhu M. Overlapping Stent Treatment for Ruptured Dissecting Aneurysms in Posterior Circulation. Brain Sci 2023; 13:1507. [PMID: 38002469 PMCID: PMC10669846 DOI: 10.3390/brainsci13111507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Ruptured dissecting aneurysms in posterior intracranial circulation present significant clinical challenges and often cause poor prognoses. Our cohort used overlapping stents as the primary treatment. We analyzed the medical records of 27 patients (18 men/nine women) with ruptured posterior circulation dissecting aneurysms (PCDAs). Their average age was 52 years. We selected 11 patients who used Enterprise (EP) and LVIS stents overlappingly and matched them 1:1 with counterparts who received either EP or LVIS stents individually. Overlapping stents was a feasible treatment in all 27 cases. We successfully followed up 26 patients for ≥6 months. Regrettably, one patient died from intracranial hypertension on Day 7 post-procedure. Immediate post-procedure angiographies indicated Raymond grade I, II, and III occlusions of PCDAs in 16 (59.3%), 7 (25.9%), and 4 (14.8%) cases, respectively. At an average follow-up duration of 16.2 months, 25 patients (96.2%) had modified Rankin Scale scores of 0-2, signifying positive outcomes. One patient (3.8%) had a score of 3-4. Recurrence rates for the EP and LVIS stent groups were higher than those of the overlapping stent group (45.45% vs. 9.09%, p = 0.15 and 27.27% vs. 9.09%, p = 0.59, respectively). No significant difference in recurrence rates existed between the overlapping and single-stent groups. Similarly, follow-up outcomes were consistent between the two groups. Overlapping stents could be an efficient method for treating ruptured PCDAs.
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Affiliation(s)
- Minghui Zhou
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zengbao Wu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ali Abdi Maalim
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ying Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiao Guo
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zhenhua Zhang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiaohong Yuan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zacharia Majaliwa Enos
- Department of Neurosurgery, Tongji Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430030, China;
| | - Kai Shu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Mingxin Zhu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
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Al-Ageely TA, Ismail M, Mohammed SA, Al-Delfi AH, Alshedidi MS, Al-Jaberi MB, Almufadhal MH, Abdulateef AA, Aljuboori Z, Al-Jehani H, Hoz SS. Failure of tandem flow diversion for intracranial aneurysms: Literature review and illustrative case. Surg Neurol Int 2022; 13:518. [DOI: 10.25259/sni_944_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background:
Flow diverters are becoming one of the main endovascular procedures used to treat aneurysms. Flow diverter devices (FDDs) have multiple types approved for endovascular procedure use. Although their indications are not well described, they are usually used for large or giant, wide-necked, and recurrent aneurysms. Multiple FDDs can be deployed to treat giant aneurysms to ensure and accelerate aneurysm occlusion and mitigate complications. We report a case of endovascular treatment of an intracranial aneurysm using three silk FDDs complicated by a delayed migration of the stents along the parent artery, along with a literature review of the related cases.
Methods:
We conducted a PubMed Medline database search by the following combined formula of subjects headings: ((((((intracranial aneurysm[MeSH Terms]) AND (endovascular procedure[MeSH Terms])) OR (endovascular technique[MeSH Terms])) AND (endovascular[Title/Abstract]) AND (Flow diverter[Title/ Abstract])) OR (flow diversion[Title/Abstract])) OR (Pipeline[Title/Abstract])) AND (Multiple[Title/Abstract]).
Results:
The result was eight cases of endovascular treatment of intracranial aneurysms with multiple FDD. The male-to-female ratio in these cases was 5:3, and there is a wide age range from 22 months to 69 years old. The cases differed in the type and number of FDDs used, yet, they all had similar results with aneurysm occlusion and recovery of the patient with no observed complications.
Conclusion:
Tandem flow diverter deployment has technical challenges and complications such as complete obstruction can occur. Planning and learning from experience with those new technologies are the typical way to overcome such complications in the future.
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Affiliation(s)
- Teeba A. Al-Ageely
- Department of Neurosurgery, University of Baghdad, College of Medicine, Al Risafa, Baghdad, Iraq,
| | - Mustafa Ismail
- Department of Neurosurgery, University of Baghdad, College of Medicine, Al Risafa, Baghdad, Iraq,
| | - Sara A. Mohammed
- Department of Neurosurgery, University of Baghdad, College of Medicine, Al Risafa, Baghdad, Iraq,
| | - Ali H. Al-Delfi
- Department of Neurosurgery, University of Alameed, College of Medicine, Karbala, Iraq,
| | - Muhammed S. Alshedidi
- Department of Neurosurgery, University of Alameed, College of Medicine, Karbala, Iraq,
| | | | - Muntadher H. Almufadhal
- Department of Neurosurgery, University of Baghdad, College of Medicine, Al Risafa, Baghdad, Iraq,
| | | | - Zaid Aljuboori
- Department of Neurosurgery, University of Wisconsin-Madison, Wisconsin, United States,
| | - Hosam Al-Jehani
- Department of Neurosurgery, Imam Abdulrahman Alfaisal University, Dammam, Saudi Arabia,
| | - Samer S. Hoz
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, United States
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Zhao K, Zhao R, Yang X, Guan S, Liang G, Wang HL, Wang D, Feng W, Li Z, Wang W, Peng Y, Xu J, Wang L, Zhong M, Mao G, Li T, Zhang Y, Chen D, Cai C, Sun X, Shi H, Yu J, Wang Y, Gu Z, Zhu G, Zhu Q, Wan J, Li Q, Yang H, Li G, Chai E, Li Q, Yang P, Fang Y, Dai D, Hong B, Huang Q, Xu Y, Liu J, Xu J. Predictors of unfavorable outcome in stent-assisted coiling for symptomatic unruptured intracranial spontaneous vertebral artery dissecting aneurysms (uis-VADAs): results from a multicenter study. J Neurointerv Surg 2022; 14:1008-1013. [PMID: 34753811 DOI: 10.1136/neurintsurg-2021-017619] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/15/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate predictors of unfavorable outcome in stent-assisted coiling for symptomatic unruptured intracranial spontaneous vertebral artery dissecting aneurysms (uis-VADAs) based on 608 reconstructed lesions in 30 medical centres. METHODS A total of 608 patients (male:female=479:129; mean age, 53.26±10.26 years) with 608 symptomatic uis-VADAs underwent reconstructive treatments using stent(s) with coils between January 2009 and December 2015. Treatments and predictors of unfavorable outcomes were retrospectively analyzed. RESULTS Mainly, three methods were used to treat patients with uis-VADAs, including routine single-stent in 208 patients (such as Enterprise and others), new low-profile LVIS single stent in 107 patients, and multiple stents in 293 patients. During the median 66 months of clinical follow-up, 14 patients died, and 16 of the remaining 594 survivors had unfavorable outcomes (modified Rankin Scale score 3-5). The overall mortality rate was 2.3% (14/608), and the unfavorable outcome (mRS score 3-6) rate was 4.9% (30/608). Multivariate logistic regression analysis indicated that preprocedural ischemic infarctions (OR=3.78; 95% CI 1.52 to 9.40; p<0.01), diabetes mellitus (OR=3.74; 95% CI 1.31 to 10.68; p=0.01), and procedural complications (OR=14.18; 95% CI 5.47 to 36.80; p<0.01) were predictors of unfavorable outcome in the reconstructed VADAs. CONCLUSIONS This multicenter study indicated that preprocedural ischemic infarctions, diabetes mellitus, and procedural complications were related to unfavorable clinical outcomes in the reconstructed uis-VADAs.
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Affiliation(s)
- Kaijun Zhao
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
- Department of Neurosurgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rui Zhao
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Sheng Guan
- Department of Interventional Neuroradiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, Henan, China
| | - Guobiao Liang
- Department of Neurosurgery, General Hospital of Shenyang Military Command, Shenyang, Liaoning, China
| | - Hong-Lei Wang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Donghai Wang
- Department of Neurosurgery, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Wenfeng Feng
- Department of Neurosurgery, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Zhenbao Li
- Department of Neurosurgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Weiwei Wang
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Ya Peng
- Cerebral Vascular Disease Center, Changzhou First People's Hospital, Changzhou, Jiangsu, China
- Cerebral Vascular Disease Center, Changzhou First People's Hospital, Changzhou, Jiangsu, China
| | - Jing Xu
- Department of Neurosurgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Lei Wang
- Department of Neurosurgery, Yichang Central People's Hospital, Yichang, Hubei, China
| | - Ming Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guohua Mao
- Department of Neurosurgery, Nanchang University Second Affiliated Hospital, Nanchang, Jiangxi, China
| | - Tianxiao Li
- Department of Radiology, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yang Zhang
- Department of Neurosurgery, Anhui Provincial Hospital, Hefei, Anhui, China
| | - Dong Chen
- Department of Neurosurgery, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Chuwei Cai
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaochuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, Sichuan, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Jianjun Yu
- Department of Cerebrovascular Disease, Linyi People's Hospital, Linyi, Shandong, China
| | - Yang Wang
- Department of Interventional Neuroradiology, Beijing Chaoyang Hospital, Beijing, China
| | - Zhen Gu
- Department of Neurosurgery, Kunming Medical College Fourth Affiliated Hospital, Kunming, Yunnan, China
| | - Gang Zhu
- Department of Neurosurgery, Third Military Medical University Southwest Hospital, Chongqing, China
| | - Qing Zhu
- Department of Neurosurgery, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jieqing Wan
- Department of Neurosurgery, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, Shanghai, China
| | - Qiuping Li
- Department of Neurosurgery, Zhongshan Hospital Fudan University, Shanghai, Shanghai, China
| | - Hua Yang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Gang Li
- Department of Cerebrovascular Disease, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Erqing Chai
- Department of Neurosurgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Qiang Li
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Yibin Fang
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Dongwei Dai
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Bo Hong
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Yi Xu
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital，Naval Medical University, Shanghai, China
| | - Jinyu Xu
- Department of Neurosurgery, Changhai Hospital，Naval Medical University, Shanghai, China
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Sasaki N, Imamura H, Shigeyasu M, Sakai N. Radical treatment of ruptured dissecting aneurysm on the P1 segment with monotherapy using multiple LVIS stents. BMJ Case Rep 2021; 14:e244950. [PMID: 34521744 PMCID: PMC8442063 DOI: 10.1136/bcr-2021-244950] [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] [Accepted: 09/02/2021] [Indexed: 11/03/2022] Open
Abstract
The standard endovascular treatment for ruptured dissecting aneurysm is a parent artery occlusion. However, this treatment is unsuitable when the artery of the lesion gives off perforating vessels that supply blood to critical regions or when the collateral flow cannot be expected due to the sacrifice of the parent artery. Here, we present an infrequent case of ruptured dissecting aneurysm on P1 segment of the posterior cerebral artery. The aneurysm had little sac for coiling and the artery of the lesion had some perforator branches; thus, we selected the monotherapy with three overlapping low-profile visualised intraluminal support stents as radical treatment, which resulted in prompt obliteration of the aneurysm. The patient was fully recovered at 3 months after the procedure. Previous studies have reported the effectiveness of multiple stents alone for dissecting aneurysms, whereas this case showed that overlapping stents may also be effective on the P1 segment.
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Affiliation(s)
- Natsuhi Sasaki
- Neurosurgery, Kobe City Medical Center General Hospital Department of Neurosurgery, Kobe, Hyogo, Japan
- Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
| | - Hirotoshi Imamura
- Neurosurgery, Kobe City Medical Center General Hospital Department of Neurosurgery, Kobe, Hyogo, Japan
| | - Masashi Shigeyasu
- Neurosurgery, Kobe City Medical Center General Hospital Department of Neurosurgery, Kobe, Hyogo, Japan
| | - Nobuyuki Sakai
- Neurosurgery, Kobe City Medical Center General Hospital Department of Neurosurgery, Kobe, Hyogo, Japan
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