Endovascular treatment of bilateral intracranial vertebral artery aneurysms: an algorithm based on a 10-year neurointerventional experience

Current status and prospects of endovascular treatment for intracranial vertebral artery aneurysms: A narrative review

Intracranial vertebral artery (VA) aneurysms are complex entities. Endovascular treatment (EVT) can be used to treat intracranial VA aneurysms. Nevertheless, managing these lesions with EVT remains challenging. Moreover, the suitability of EVT for every type of intracranial VA aneurysm has not been fully confirmed. Therefore, we conducted a needed review of the current literature and our experience summarizing the current status of and advancements in EVT in the management of intracranial VA aneurysms. In our review, several issues are discussed, including the anatomy and anomalies of the intracranial VA, the classification and natural history of intracranial VA aneurysms, indications and techniques for EVT in the management of intracranial VA aneurysms, and the outcomes of and complications experienced by patients who undergo EVT. A flowchart describing EVT options for dissecting intracranial VA aneurysms derived from the findings of this review and our experience is provided. The key to successful EVT is preservation of the posterior inferior cerebellar artery and avoidance of injury to any brainstem perforators. Currently, intracranial VA reconstruction via flow diverter deployment plays an important role in achieving successful treatment. For appropriate cases, both reconstructive and deconstructive EVT can result in good patient outcomes. However, EVT-related complications should be considered. If management of complex intracranial VA aneurysms with EVT would be expected to disproportionally harm the patient, extracranial-intracranial bypass and aneurysmectomy are often necessary. In addition, new products and techniques that show promise for achieving successful EVT in the management of intracranial VA aneurysms are described.

Stent-assisted coil embolization of ruptured vertebral artery dissected aneurysm with severe stenosis of bilateral vertebral artery V4 segment by the transmountain technique: a case report and review of the literatures

A 46-year-old woman presented with acute head and neck pain for 10 h. Head CT showed subarachnoid hemorrhage (SAH) and digital subtraction angiography (DSA) identified a ruptured dissected aneurysm of the right vertebral artery with severe artery stenosis. Moreover, an unruptured dissecting aneurysm and severe vascular stenosis were also found in the left vertebral artery. How to deal with ruptured bleeding aneurysm and prophylactically deal with contralateral unruptured dissecting aneurysm and the stenosis of the vertebral artery has become a thorny problem. By adopting the Transmountain technique, we used a single Enterprise-2 stent to cover the neck of the right ruptured vertebral artery dissection aneurysm and the severe stenosis of the distal vessel, while bypassing the vertebrobasilar artery junction to continue covering the severe stenosis and the unruptured dilated dissection of the contralateral vertebral artery. This new stent-assisted approach may provide a reference for clinicians in the treatment of complex dissection aneurysms.

Natural course of the acute unruptured intracranial vertebral artery dissections which show pearl-and-string sign

INTRODUCTION

Ruptured vertebral artery dissections frequently exhibit pearl-and-string signs, a characteristic also observed in many unruptured dissections. This study examines the natural course of 50 unruptured acute vertebral artery dissections presenting with pearl-and-string signs and compares them to 10 ruptured dissections of the same morphological pattern.

METHODS

We reviewed 633 radiology reports of head and neck imaging studies that included the keyword 'dissection'. From these, 60 cases displaying pearl-and-string signs were identified from a total of 322 vertebral artery dissections. These cases were classified based on morphological characteristics, including fusiform versus bulbous dilatation, symmetry, degree of expansion, and the severity of stenosis at both ends of the dilation. The relationships between these factors and favorable anatomical recovery were then analyzed.

RESULTS

Headaches were linked to subarachnoid hemorrhages in 10 cases with bulbous dilatations. In contrast, 50 unruptured cases had fusiform dilatations, with no subsequent hemorrhages except for two cases treated preventively. Most unruptured dissections (78.4%) improved on follow-up: 48.6% fully recovered, 29.7% retained smooth dilatation, 10.8% developed irregular stenotic segments, 8.1% became occluded, and 2.7% transformed into a saccular lesion. Smaller or hypoplastic vertebral arteries were more likely to occlude (p = 0.017). Mild distal stenosis was associated with improvement (p = 0.001).

CONCLUSION

Acute unruptured intracranial vertebral artery dissections with 'pearl-and-string' signs had benign courses, with most recovering spontaneously and no subsequent hemorrhages. Regular imaging follow-ups at one- to three-month intervals are recommended over immediate intervention.

Treatment of unruptured intracranial vertebral artery dissection aneurysms with Flow Diverter compared with conventional stent-assisted coiling-a single-center study

AIM

Flow diverters (FDs) are being increasingly used off-label for treatment of intracranial vertebral artery dissection aneurysms (IVADAs). However, the safety and efficacy of FDs for unruptured IVADAs remain unclear. This study was performed to investigate whether FDs-alone are safer and more effective than conventional stent-asisted coiling.

METHODS

We retrospectively analyzed 152 patients who underwent endovascular stenting from December 2011 to December 2022. The baseline data, aneurysm characteristics, surgical details, perioperative complications, follow-up angiography, and clinical outcomes were collected and compared between patients who underwent stenting with FD-alone versus conventional stent-asisted coiling. Propensity score matching was also conducted.

RESULTS

All 152 patients underwent successful endovascular therapy. Forty patients were treated with FDs-alone, and 112 were treated with conventional stent-asisted coiling (including 62 with double stents). The complete occlusion rate was 93.75% in the FD group and 93.61% in the conventional stent group (p = 0.979). The complication rate was 5.00% in the FD group and 8.93% in the conventional stent group (p = 0.653). The in-stent restenosis rate was 3.13% in the FD group and 5.32% in the conventional stent group (p = 0.615). The procedure duration was significantly shorter in the FD than conventional stent group (p = 0.034). After propensity score matching, 37 patients with FDs were successfully matched, and the procedure duration was still significantly shorter in the FD group (p = 0.042).

CONCLUSION

FD placement is a safe and effective treatment for IVADAs. It is also a simpler procedure with a shorter operation time than conventional stent placement.

TRIAL REGISTRATION NUMBER

ChiCTR2300074171 ClinicalTrials.gov ID:NCT06134557.

Flow diverter versus stent-assisted coiling treatment for managing dissecting intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

Dissecting intracranial aneurysms (DIAs) have been treated through endovascular reconstructive manners, such as flow diverters (FDs) and stent-assisted coiling (SAC). Notably, no robust evidence has compared both approaches. Hence, the authors conducted a meta-analysis to compare their outcomes.

METHODS

PubMed, Embase and Web of Science were searched for studies employing SAC and FD treatment for DIAs. The following outcomes were considered for extraction: procedure-related mortality, total mortality, postoperative and follow-up complete aneurysm occlusion, complications, good clinical outcomes, recurrence, and retreatment. Odds ratio (OR) with random effects was employed for statistical comparison.

RESULTS

The meta-analysis included 10 studies. A total of 195 and 222 patients were included in the FD and the SAC group, respectively. Stent-assisted coiling had higher postoperative complete aneurysm occlusion rates (OR 0.03; 95% CI 0.01-0.08). Flow diverter retreatment rate was lower, but without statistical significance (OR 0.35; 95% CI 0.11-1.10). No significant differences were found in follow-up complete aneurysm occlusion (OR 1.18; 95% CI 0.35-3.99); total mortality (OR 0.44; 95% CI 0.09-2.08); intraoperative complications (OR 0.30; 95% CI 0.06-1.45); postoperative complication (OR 0.77; 95% CI 0.35-1.70); good clinical outcomes (OR 0.97; 95% CI 0.43-2.20); and recurrence (OR 0.38; 95% CI 0.13-1.10) between the two groups.

CONCLUSION

Stent-assisted coiling shows higher postoperative complete aneurysmal occlusion rates, but both techniques achieve similar rates in angiographic follow-up. Flow diverter has lower, but not statistically significant, retreatment rates than SAC. Both techniques have similar complication rates. Future randomized, multicenter, and prospective studies with larger sample sizes are needed for more conclusive findings.

A case of bilateral vertebral artery dissection treated by bilateral surgical occlusion and low-flow bypass

Background

Bilateral vertebral artery dissection aneurysm (VADA) is a rare condition that leads to severe stroke. However, the surgical strategy for its treatment is controversial because the pathology is very complicated and varies in each case. Here, we report a case of bilateral VADA that was successfully treated with staged bilateral VADA occlusion and low-flow bypass.

Case Description

A Japanese man in his 40s presented with bilateral VADA with subarachnoid hemorrhage. He had only mild headaches without any other neurological deficits. Subsequently, the ruptured left VADA was surgically trapped. However, on postoperative day 11, the contralateral VADA enlarged. The right VADA was then proximally clipped via a lateral suboccipital approach. Furthermore, a superficial temporal artery-superior cerebellar artery bypass was performed through a subtemporal approach in advance to preserve cerebral flow in the posterior circulation. The bilateral VADA was obliterated, and the patient had an uneventful postoperative course during the 1-year and 6-month follow-up period.

Conclusion

Bilateral VADA can be successfully treated with staged bilateral VADA obstruction and low-flow bypass. In this case, as the posterior communicating arteries were the fetal type and the precommunicating segments of the posterior cerebral arteries (P1) were hypoplastic, a low-flow bypass was used to supply the basilar and cerebellar arteries, except the posterior cerebral and posterior inferior cerebellar arteries. Furthermore, low-flow bypass is a less invasive option than high-flow bypass.

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.

Endovascular treatment of intracranial vertebral artery dissecting aneurysm, a case series study with two years follow up on complications

Background

This study is aimed to analyze the clinical outcomes of endovascular treatments for patients with intracranial vertebral artery dissecting aneurysms.

Methods

Clinical data of 32 patients with vertebral artery dissecting aneurysms who underwent endovascular procedures in the Department of Neurosurgery of our University from January 2016 to December 2019 were retrospectively analyzed. Nine cases were treated with endovascular occlusion; 23 cases received reconstructive treatment, including 20 cases of stent combined with coil embolization, and 3 cases of stent implantation. The angiography taken at 3-22 months after surgery was reviewed.

Results

The endovascular treatments for all 32 cases were successful. Thirty-one cases had no postoperative complications during index hospital. Mid-term follow-up showed that: 27 cases (84%) had embolism; 5 cases (16%) had recurrence, of which 4 cases were treated again with endovascular procedures followed with no further complications and no recurrence, and 1 case received closely monitor but no reoperation. During an average follow-up of 10.5 months, except for one case that was self-discharged due to end-stage brainstem compression and respiratory failure, the rest of the patients were in stable conditions without bleeding or infarction.

Conclusion

Endovascular treatment of intracranial vertebral artery dissecting aneurysms is safe and effective. Recurrent vertebral artery dissecting aneurysms can be treated with endovascular reoperations with satisfactory outcomes.

Endovascular treatment of intracranial vertebral artery unruptured dissecting aneurysms: Comparison of flow diversion and stent-assisted coiling or stenting alone

Purpose

To investigate the effect and safety of flow diverters in the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery in comparison with stent-assisted coiling or stenting alone.

Materials and methods

Patients with unruptured dissecting intracranial aneurysms of the vertebral artery treated with the flow diverter, stent-assisted coiling, or stenting alone were retrospectively enrolled. The clinical data were analyzed and compared.

Results

Twenty-five patients were enrolled in the flow diversion group and 42 patients in the stenting group. Twenty-six flow diverters were deployed in the flow diversion group. Immediate angiography revealed contrast agent retention within the aneurysm cavity in all patients. In the stenting group, 48 stents were deployed, and immediate angiographic outcome showed O'Kelly-Marotta (OKM) grade D in 18 (42.9%) aneurysms, grade C in 16 (38.1%), and grade B in 8 (19.0%). Periprocedural ischemic complications of thrombosis occurred in two (4.8%) patients and were treated with thrombolysis. In the flow diversion group, 19 (76%) patients underwent angiographic follow-up 3–46 (median 24) months after the procedure, with the OKM grade D in 11 (57.9%) patients, C in two (10.5%), and B in six (31.6%). The aneurysm recurrence rate was zero, and all diverters remained patent. Asymptomatic instent stenosis occurred in two (10.5%) patients. In seven of the ten patients with mild or moderate parent artery stenosis before the procedure who experienced angiographic follow-up, the stenosis was improved in five (71.4%) patients. In the stenting group, angiographic follow-up was carried out in 33 (78.6%) patients 6–58 months (median 34) after the procedure, with OKM grade D in 22 (66.7%) patients, grade C in five (15.2%), grade B in three (9.1%), and aneurysm recurrence (grade B, with increased contrast agent into the aneurysm cavity) in three (9.1%). Five (16.7%) patients experienced asymptomatic instent stenosis, and six of the 12 patients (50%) with parent artery stenosis were improved.

Conclusion

Flow diverters with or without selective adjunctive coiling for the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery may be safe and effective with good occlusion effects not inferior to those of stent-assisted coiling and stenting alone even though the long-term effect still warrants confirmation.