Expanding the Indications for Flow Diversion: Treatment of Posterior Circulation Aneurysms

Neurosurgery ◽  
2019 ◽  
Vol 86 (Supplement_1) ◽  
pp. S76-S84
Author(s):  
Nimer Adeeb ◽  
Christopher S Ogilvy ◽  
Christoph J Griessenauer ◽  
Ajith J Thomas
Keyword(s):  
Antiplatelet Agents ◽  
Posterior Circulation ◽  
Flow Diversion ◽  
High Morbidity ◽  
Complication Rates ◽  
Anterior Circulation ◽  
Risk Of Rupture ◽  
Lower Complication ◽  
Ischemic Complications ◽  
Posterior Circulation Aneurysms

Abstract Posterior circulation aneurysms are often associated with a higher risk of rupture and compressive symptoms compared to their anterior circulation counterpart. Due to high morbidity and mortality associated with microsurgical treatment of those aneurysms, endovascular therapy gained ascendance as the preferred method of treatment. Flow diversion has emerged as a promising treatment option for posterior circulation aneurysms with a higher occlusion rate compared to other endovascular techniques and a lower complication rate compared to microsurgery. While treatment of saccular and dissecting aneurysms is often associated with comparatively good outcomes, fusiform and dolichoectatic aneurysms should be carefully selected prior to treatment to avoid devastating thromboembolic complications. Occlusion of covered posterior circulation branches showed no correlation with ischemic complications, and appropriate antiplatelet regimen and switching Clopidogrel nonresponders to different antiplatelet agents were associated with lower complication rates following flow diversion of posterior circulation aneurysms.

scholarly journals Surgical Treatment of Posterior Circulation Aneurysms – Anatomical Study and Surgical Technique

2018 ◽  
Vol 37 (01) ◽  
pp. 27-37
Author(s):  
Vitor Yamaki ◽  
Eric Paschoal ◽  
Manoel Teixeira ◽  
Eberval Figueiredo
Keyword(s):  
Surgical Treatment ◽  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Posterior Circulation ◽  
Surgical Approaches ◽  
Superior Cerebellar Artery ◽  
Anterior Circulation ◽  
Cerebellar Artery ◽  
Risk Of Rupture ◽  
Posterior Circulation Aneurysms

AbstractPosterior circulation aneurysms represent 10–15% of intracranial aneurysms. The diagnosis is usually secondary to subarachnoid hemorrhage due to its initial asymptomatic presentation and higher risk of rupture compared with aneurysms in the anterior circulation. The surgical treatment of posterior circulation aneurysms is complex and challenging for neurosurgeons because of the particular anatomy of the posterior circulation with its close relation to the brainstem and cranial nerves and also because of the depth and narrowness of the surgical approach. Aneurysms from different locations have specific anatomical relationships and surgical approaches for better visualization and dissection. Therefore, a detailed anatomy knowledge of the posterior circulation is mandatory for an individualized preoperative planning and good neurological and angiographic outcomes. We selected the main aneurysm sites on the posterior circulation, such as: posterior inferior cerebellar artery, basilar trunk, basilar bifurcation, posterior cerebral artery (PCA) and superior cerebellar artery for a detailed description of the relevant anatomy related to aneurysm, and the main surgical approaches for its surgical treatment. Furthermore, we performed a literature review with the most recent outcomes regarding to the surgical treatment of posterior circulation aneurysms.

Beware of Nihilism: Favorable Outcome despite Poor Admission Status in Posterior Circulation Aneurysms after Aneurysmal Subarachnoid Hemorrhage

2021 ◽  
Author(s):  
Nina Brawanski ◽  
Sepide Kashefiolasl ◽  
Sae-Yeon Won ◽  
Joachim Berkefeld ◽  
Elke Hattingen ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Mortality Rate ◽  
Cerebral Artery ◽  
Coil Embolization ◽  
Posterior Inferior Cerebellar Artery ◽  
Posterior Circulation ◽  
Anterior Circulation ◽  
Ruptured Aneurysms ◽  
Admission Status ◽  
Posterior Circulation Aneurysms

Abstract Objective As shown in a previous study, aneurysm location seems to influence prognosis in patients with subarachnoid hemorrhage (SAH). We compared patients with ruptured aneurysms of anterior and posterior circulation, undergoing coil embolization, concerning differences in outcome and prognostic factors. Methods Patients with SAH were entered into a prospectively collected database. We retrospectively identified 307 patients with aneurysms of the anterior circulation (anterior cerebral artery, carotid bifurcation, and middle cerebral artery) and 244 patients with aneurysms of the posterior circulation (aneurysms of the basilar artery, posterior inferior cerebellar artery, posterior communicating artery and posterior cerebral artery). All patients underwent coil embolization. The outcome was assessed using the modified Rankin Scale (mRS; favorable [mRS 0–2] vs. unfavorable [mRS 3–6]) 6 months after SAH. Results In interventionally treated aneurysms of the anterior and posterior circulation, statistically significant risk factors for poor outcome were worse admission status and severe cerebral vasospasm. If compared with patients with ruptured aneurysms of the anterior circulation, patients with aneurysms of the posterior circulation had a significantly poorer admission status, and suffered significantly more often from an early hydrocephalus. Nonetheless, there were no differences in outcome or mortality rate between the two patient groups. Conclusion Patients with a ruptured aneurysm of the posterior circulation suffer more often from an early hydrocephalus and have a significantly worse admission status, possibly related to the untreated hydrocephalus. Nonetheless, the outcome and the mortality rate were comparable between ruptured anterior and posterior circulation aneurysms, treated by coil embolisation. Therefore, despite the poorer admission status of patients with ruptured posterior circulation aneurysms, treatment of these patients should be considered.

Stent-Assisted Coiling of Wide-Necked Aneurysms in the Setting of Acute Subarachnoid Hemorrhage

Neurosurgery ◽  
2011 ◽  
Vol 70 (6) ◽  
pp. 1415-1429 ◽  
Author(s):  
Peter S. Amenta ◽  
Richard T. Dalyai ◽  
David Kung ◽  
Amy Toporowski ◽  
Sid Chandela ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Antiplatelet Agents ◽  
Bleeding Complications ◽  
Anterior Circulation ◽  
Fatal Hemorrhage ◽  
Ischemic Complications ◽  
Acute Subarachnoid Hemorrhage ◽  
Grade Iii

Abstract BACKGROUND: Stent-assisted coiling in the setting of subarachnoid hemorrhage remains controversial. Currently, there is a paucity of data regarding the utility of this procedure and the risks of hemorrhagic and ischemic complications. OBJECTIVE: To assess the utility of stent-assisted coil embolization and pretreatment with antiplatelet agents in the management of ruptured wide-necked aneurysms. METHODS: A retrospective study of 65 patients with ruptured wide-necked aneurysms treated with stent-assisted coiling. Patients with hydrocephalus or a Hunt and Hess grade ≥ III received a ventriculostomy before endovascular intervention. Patients were treated intraoperatively with 600 mg of clopidogrel and maintained on daily doses of 75 mg of clopidogrel and 81 mg of aspirin. The Glasgow outcome scale (GOS) score was recorded at the time of discharge. We identified major bleeding complications secondary to antiplatelet therapy and cases of in-stent thrombosis that required periprocedural thrombolysis. RESULTS: Of the aneurysms, 66.2% arose within the anterior circulation; 69.2% of patients presented with hydrocephalus or a Hunt and Hess grade ≥ III and required a ventriculostomy. A good outcome (GOS of 4 or 5) was achieved in 63.1% of patients, and the overall mortality rate was 16.9%. There were 10 (15.38%) major complications associated with bleeding secondary to antiplatelet therapy (5 patients, 7.7%) or intraoperative in-stent thrombosis (5 patients, 7.7%). Three (4.6%) patients had a fatal hemorrhage. CONCLUSION: Our findings suggest that stent-assisted coiling and routine treatment with antiplatelet agents is a viable option in the management of ruptured wide-necked aneurysms.

Transcirculation Silk Vista Baby-assisted coiling in half-T configuration for the treatment of posterior communicating artery aneurysms associated with a fetal posterior circulation: An alternative flow diversion strategy

2020 ◽  
pp. 159101992096188
Author(s):  
Mario Martínez-Galdámez ◽  
Miguel Schüller-Arteaga ◽  
Jorge Galván-Fernández ◽  
Vladimir Kalousek ◽  
Ezequiel Petra ◽  
...  
Keyword(s):  
Flow Diverter ◽  
Posterior Circulation ◽  
Flow Diversion ◽  
Anterior Communicating Artery ◽  
Anterior Circulation ◽  
Low Profile ◽  
Specific Subgroup ◽  
Flow Diverter Devices ◽  
Profile Flow ◽  
Incomplete Occlusion

Flow diverter devices have become a routine first-line option for treatment of an increasing population of intracranial aneurysms at many neurovascular centers.  Despite the promising results of flow diverter stents on anterior circulation, incomplete occlusion on the presence of fetal posterior circulation has been described on several reports.  Here we describe a novel technical alternative to conventional flow diversion approach for this specific subgroup of aneurysms using the low-profile flow diverter, Silk Vista Baby. The device was selectively placed into the fetal type posterior cerebral artery in half-T configuration for the treatment of a posterior communicating aneurysm using a transcirculation approach through the anterior communicating artery. This represents a useful and effective technique and should be considered when encountering the above-described situation.

Panacea or problem: flow diverters in the treatment of symptomatic large or giant fusiform vertebrobasilar aneurysms

2012 ◽  
Vol 116 (6) ◽  
pp. 1258-1266 ◽  
Author(s):  
Adnan H. Siddiqui ◽  
Adib A. Abla ◽  
Peter Kan ◽  
Travis M. Dumont ◽  
Shady Jahshan ◽  
...  
Keyword(s):  
Natural History ◽  
Intracranial Aneurysms ◽  
Neurological Status ◽  
Posterior Circulation ◽  
The Other ◽  
Flow Diversion ◽  
Morbidity And Mortality ◽  
Anterior Circulation ◽  
Subsequent Withdrawal ◽  
Vertebrobasilar Aneurysms

Object The use of flow-diverting stents has gained momentum as a curative approach in the treatment of complex proximal anterior circulation intracranial aneurysms. There have been some reported attempts of treating formidable lesions in the posterior circulation. Posterior circulation giant fusiform aneurysms have a particularly aggressive natural history. To date, no one approach has been shown to be comprehensively effective or low risk. The authors report the initial results, including the significant morbidity and mortality encountered, with flow diversion in the treatment of large or giant fusiform vertebrobasilar aneurysms at Millard Fillmore Gates Circle Hospital. Methods The authors retrospectively reviewed their prospectively collected endovascular database to identify patients with intracranial aneurysms who underwent treatment with flow-diverting devices and determined that 7 patients had presented with symptomatic large or giant fusiform vertebrobasilar aneurysms. The outcomes of these patients, based on the modified Rankin Scale (mRS), were tabulated, as were the complications experienced. Results Among the 7 patients, Pipeline devices were placed in 6 patients and Silk devices in 1 patient. At the last follow-up evaluation, 4 patients had died (mRS score of 6), all of whom were treated with the Pipeline device. The other 3 patients had mRS scores of 5 (severe disability), 1, and 0. The deaths included posttreatment aneurysm ruptures in 2 patients and lack of improvement in neurological status related to presenting brainstem infarcts and subsequent withdrawal of care in the other 2 patients. Conclusions Whether flow diversion will be an effective strategy for treatment of large or giant fusiform vertebrobasilar aneurysms remains to be seen. The authors' initial experience suggests substantial morbidity and mortality associated with the treatment and with the natural history. As outcomes data slowly become available for patients receiving these devices for fusiform posterior circulation aneurysms, practitioners should use these devices judiciously.

scholarly journals The safety of Pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center

2016 ◽  
Vol 125 (1) ◽  
pp. 111-119 ◽  
Author(s):  
Sabareesh K. Natarajan ◽  
Ning Lin ◽  
Ashish Sonig ◽  
Ansaar T. Rai ◽  
Jeffrey S. Carpenter ◽  
...  
Keyword(s):  
Case Series ◽  
Dissecting Aneurysm ◽  
Posterior Circulation ◽  
Flow Diversion ◽  
Single Center Experience ◽  
Vertebrobasilar Artery ◽  
Delayed Hemorrhage ◽  
Posterior Circulation Aneurysms ◽  
Previously Treated

OBJECT Pessimism exists regarding flow diversion for posterior circulation aneurysms because of reports of perforator territory infarcts and delayed ruptures. The authors report the results of patients who underwent Pipeline Embolization Device (PED) flow diversion using novel strategies for treatment of fusiform posterior circulation aneurysms, and compare these results with those from previously reported series. METHODS The authors conducted a retrospective review of data from consecutive patients with fusiform vertebrobasilar artery aneurysms treated with the PED. RESULTS This review resulted in the identification of 12 such patients (mean [± SD] age 55.1 ± 14.1 years). Eleven patients had symptoms; 1 had a dissecting aneurysm identified on imaging for neck pain. The average aneurysm size was 13.25 ± 4.5 mm. None of the aneurysms were ruptured or previously treated. The average clinical follow-up duration was 22.1 ± 10.7 months and radiological follow-up was 14.5 ± 11.1 months from the index PED treatment. One patient suffered a perforator stroke and had a modified Rankin Scale (mRS) score of 4 at last follow-up. Another patient had a retained stent pusher requiring retrieval via surgical cut-down but recovered to an mRS score of 0 at last follow-up. Eleven (91.7%) of 12 patients recovered to an mRS score of 0 or 1. Two patients had aneurysmal remnants at 7 and 10 months, respectively, after the index PED, which were retreated with PEDs. At last follow-up, all 12 aneurysms were occluded and PEDs were patent. The minimum follow-up duration was 12 months from the index PED treatment; no patient experienced delayed hemorrhage, stroke, or in-stent stenosis. CONCLUSIONS Flow diversion with selective adjunctive techniques is evolving to become a safer treatment option for posterior circulation aneurysms. This is the longest clinical follow-up duration reported for a single-center experience of flow-diversion treatment of these aneurysms.

Flow diverters for ruptured posterior circulation perforator aneurysms: multicenter experience and literature review

2020 ◽  
Vol 12 (7) ◽  
pp. 688-694
Author(s):  
Valerio Da Ros ◽  
Francesco Diana ◽  
Federico Sabuzi ◽  
Emanuele Malatesta ◽  
Antioco Sanna ◽  
...  
Keyword(s):  
Perioperative Complications ◽  
Treatment Options ◽  
Flow Diverter ◽  
Posterior Circulation ◽  
Complication Rates ◽  
Lower Complication ◽  
Long Term Follow Up ◽  
Ischemic Complication

BackgroundThe management of ruptured posterior circulation perforator aneurysms (rPCPAs) remains unclear. We present our experience in treating rPCPAs with flow diverter stents (FDs) and evaluate their safety and efficacy at mid- to long-term follow-up. A diagnostic and therapeutic algorithm for rPCPAs is also proposed.MethodsWe retrospectively analyzed data from all consecutive patients with rPCPAs treated with FDs at our institutions between January 2013 and July 2019. Clinical presentations, time of treatments, intra- and perioperative complications, and clinical and angiographic outcomes were recorded, with a mid- to long-term follow-up. A systematic review of the literature on rPCPAs treated with FDs was also performed.ResultsSeven patients with seven rPCPAs were treated with FDs. All patients presented with an atypical subarachnoid hemorrhage distribution and a low to medium Hunt–Hess grade. In 29% of cases rPCPAs were identified on the initial angiogram. In 57% of cases, FDs were inserted within 2 days of the diagnosis. Immediate aneurysm occlusion was observed in 14% of the cases and in 71% at the first follow-up (mean 2.4 months). At mean follow-up of 33 months (range 3–72 months) one case of delayed ischemic complication occurred. Six patients had a modified Rankin Scale (mRS) score of 0 and one patient had an mRS score of 4 at the latest follow-up.ConclusionsThe best management for rPCPAs remains unclear, but FDs seem to have lower complication rates than other treatment options. Further studies with larger series are needed to confirm the role of FDs in rPCPA.

Clinical and Radiographic Outcome in the Management of Posterior Circulation Aneurysms by Use of Direct Surgical or Endovascular Techniques

Neurosurgery ◽  
2002 ◽  
Vol 51 (1) ◽  
pp. 14-22 ◽  
Author(s):  
Christopher S. Ogilvy ◽  
Brian L. Hoh ◽  
Robert J. Singer ◽  
Christopher M. Putman
Keyword(s):  
Surgical Treatment ◽  
High Risk ◽  
Endovascular Treatment ◽  
Posterior Circulation ◽  
Endovascular Coiling ◽  
High Morbidity ◽  
Surgical Clipping ◽  
Fisher Grade ◽  
Posterior Circulation Aneurysms ◽  
History Of

Abstract OBJECTIVE Posterior circulation aneurysms can be difficult lesions to treat surgically, and they have potential for high morbidity and mortality, particularly in elderly patients or those in poor neurological condition. In an effort to improve outcomes, our combined neurosurgical and neuroendovascular unit has used both surgical clipping and endovascular coiling techniques to treat posterior circulation aneurysms. Patients considered at high risk for surgery were managed with endovascular treatment. METHODS From 1990 to 1998, 197 posterior circulation aneurysms in 189 patients were treated in our combined neurovascular unit. Of these aneurysms, 128 were ruptured, 63 were unruptured, and 6 had a distant history of rupture in patients who came to our center for delayed or repeat treatment. A total of 132 aneurysms were treated with surgical clipping (85 ruptured, 46 unruptured, and 1 with distant history of rupture) and 65 aneurysms were treated with endovascular coiling (43 ruptured, 17 unruptured, and 5 with distant history of rupture). Dissecting aneurysms of the vertebral or posteroinferior cerebellar arteries or aneurysms treated with proximal (Hunterian) occlusion were excluded from this analysis. Surgical risk was assessed using a previously described system (Massachusetts General Hospital [MGH] grade), which incorporates age, Hunt and Hess grade, size of lesion, and Fisher grade. RESULTS Overall clinical outcomes at 1 year of follow-up were 77.2% excellent or good, 10.2% fair, 4.1% poor, and 8.6% dead. Surgical treatment resulted in 95.6% complete aneurysm occlusion and 4.4% with residual aneurysm after surgical treatment, whereas endovascular treatment resulted in 32.3% complete occlusion, 26.2% with residual aneurysm, and 41.5% with partial occlusion. In most cases, however, treatment with Guglielmi detachable coils (Boston Scientific/Target, Fremont, CA) was performed for palliation rather than complete radiographic occlusion. Outcome was closely associated with MGH grade with either treatment modality. Excellent/good outcomes were achieved in 96, 92.3, 82.9, 46.2, and 0% of surgically treated patients with MGH Grades of 0, 1, 2, 3, and 4, respectively. In comparison, excellent/good outcomes were achieved in 100, 84.2, 61.9, 0, and 50% of endovascularly treated patients with MGH Grades of 0, 1, 2, 3, and 4, respectively. CONCLUSION A combined surgical and endovascular approach to posterior circulation aneurysms can achieve good outcomes in high-risk surgical patients treated by use of coiling techniques.

The poor prognosis of ruptured intracranial aneurysms of the posterior circulation

1995 ◽  
Vol 82 (5) ◽  
pp. 791-795 ◽  
Author(s):  
Wouter I. Schievink ◽  
Eelco F. M. Wijdicks ◽  
David G. Piepgras ◽  
Chu-Pin Chu ◽  
W. Michael O'Fallon ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Initial Period ◽  
Posterior Circulation ◽  
Medical Record Linkage ◽  
Anterior Circulation ◽  
Content Type ◽  
Clinical Series ◽  
Posterior Circulation Aneurysms ◽  
Fine Print

✓ The first 48 hours after aneurysmal subarachnoid hemorrhage are critical in determining final outcome. However, most patients who die during this initial period are not included in hospital-based studies. We investigated the occurrence of subarachnoid hemorrhage in a population-based study to evaluate possible predictors of poor outcome. All patients diagnosed with aneurysmal subarachnoid hemorrhage between 1955 and 1984 were selected for analysis of mortality in the first 30 days using the medical record—linkage system employed for epidemiological studies in Rochester, Minnesota. One hundred and thirty-six patients were identified. The mean age of these 99 women and 37 men was 55 years. Rates for survival to 48 hours were 32% for the 19 patients with posterior circulation aneurysms, 77% for the 87 patients with anterior circulation aneurysms, and 70% for the 30 patients with a presumed aneurysm (p < 0.0001). Rates for survival to 30 days were 11%, 57%, and 53%, respectively, in these three patient groups (p < 0.0001). Clinical grade on admission to the hospital, the main variable predictive of death within 48 hours, was significantly worse in patients with posterior circulation aneurysms than in others (p < 0.0001). The prognosis of ruptured posterior circulation aneurysms is poor. The high early mortality explains why posterior circulation aneurysms are uncommon in most clinical series of patients with subarachnoid hemorrhage. The management of incidentally discovered intact posterior circulation aneurysms may be influenced by these findings.

Sign in / Sign up

Export Citation Format

Share Document