Acute Treatment of Ruptured Fusiform Posterior Circulation Posterior Cerebral, Superior Cerebellar, and Posterior Inferior Cerebellar Artery Aneurysms With FRED Flow Diverter: Report of 5 Cases

2018 ◽  
Vol 16 (5) ◽  
pp. 549-556 ◽  
Author(s):  
Dan Laukka ◽  
Riitta Rautio ◽  
Melissa Rahi ◽  
Jaakko Rinne
Keyword(s):  
Treatment Time ◽  
Brain Infarction ◽  
Treatment Options ◽  
Posterior Inferior Cerebellar Artery ◽  
Flow Diverter ◽  
External Ventricular Drainage ◽  
Posterior Circulation ◽  
Superior Cerebellar Artery ◽  
Technical Success Rate ◽  
Cerebellar Artery

Abstract BACKGROUND Flow diverter (FD) treatment of ruptured fusiform posterior cerebral artery (PCA), posterior inferior cerebellar artery (PICA), and superior cerebellar artery (SCA) aneurysms are limited to single reports. OBJECTIVE To study the safety and efficacy of FD treatment for ruptured fusiform aneurysms of the PCA, SCA, and PICA. METHODS Five patients with ruptured posterior circulation fusiform aneurysms and treated with a Flow-Redirection Endoluminal Device (FRED/FRED Jr; Microvention, Tustin, California) stent in the acute phase of subarachnoid hemorrhage between 2013 and 2016 were included and reviewed retrospectively. RESULTS Two aneurysms located on the PICA, 2 on PCA, and 1 on the SCA. Mean treatment time with FD was 5.8 d (range, 0-11 d) from ictus. The technical success rate was 100%. On admission 2 patients were Hunt and Hess grade 1, 2 patients grade 3, and 1 patient grade 4. At discharge, 4 patients (80%) were independent (modified Ranking Scale (mRS) ≤2) and 1 patient had severe disability (mRS 4). None of the patients had aneurysmal rebleeding. All 5 aneurysms were completely occluded on angiographic follow-up (range, 3-22 mo). One patient had permanent intraprocedural in stent thrombosis and brain infarction. One patient had spontaneous nonaneurysmal intracerebral hemorrhage 1 mo after FD treatment. External ventricular drainage was inserted in 3 patients and ventriculoperitoneal shunt in 2 patients without hemorrhagic complications despite dual antiplatelet therapy. CONCLUSION FD could be considered as a treatment option for ruptured fusiform aneurysms located on PCA, PICA, or SCA when other treatment options are challenging.

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.

Embolization of Posterior Circulation Aneurysms with Detachable Coils

1998 ◽  
Vol 4 (1_suppl) ◽  
pp. 127-130 ◽  
Author(s):  
K. Kazekawa ◽  
T. Fukushima ◽  
M. Tomonaga ◽  
T. Kawano ◽  
T. Kawaguchi ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Posterior Circulation ◽  
Superior Cerebellar Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Cerebellar Artery ◽  
Long Term Follow Up ◽  
Detachable Coils ◽  
Posterior Circulation Aneurysms ◽  
Vertebrobasilar Junction

We evaluated the usefulness of endovascular treatment of posterior circulation aneurysms with GDCs and IDCs, Five cases were treated with IDCs, and 15 cases were treated with GDCs. In this study, 8 aneurysms were identified at the basilar bifurcation, 3 at the P1 segment of the pasterior cerebral artery, 1 at the origin of the superior cerebellar artery, 2 at the vertebrobasilar junction, 1 at the origin of the posterior inferior cerebellar artery, 1 at the distal anterior inferior cerebellar artery, and 4 dissecting aneurysms at the vertebral artery. Thirteen of the aneurysms were small (< 12 mm), 5 were large (13–24 mm), and 2 were giant (> 25 mm). Of the 20 patients, 14 patients returned to their previous occupation. Patients with permanent deficits included 2 patients with infarction caused by thromboembolic complications during the embolization procedure, and 2 with infarction caused by vasospasm. There were 2 deaths. The outcomes of the patients seemed favorable. However, long-term follow-up is necessary to determine the usefulness of detachable coils.

Skull base approaches to the basilar artery

2005 ◽  
Vol 19 (2) ◽  
pp. 1-12 ◽  
Author(s):  
L. Fernando Gonzalez ◽  
Sepideh Amin-Hanjani ◽  
Nicholas C. Bambakidis ◽  
Robert F. Spetzler
Keyword(s):  
Skull Base ◽  
Basilar Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Free Edge ◽  
Posterior Circulation ◽  
Surgical Instruments ◽  
Petrous Apex ◽  
Superior Cerebellar Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Cerebellar Artery

Posterior circulation lesions constitute approximately 10% of all intracranial aneurysms. Their distribution includes the basilar artery (BA) bifurcation, superior cerebellar artery, posterior inferior cerebellar artery, and anterior inferior cerebellar artery. The specific features of a patient's aneurysm and superb anatomical knowledge help the surgeon to choose the most appropriate approach and to tailor it to the patient's situation. The main principle that must be applied is maximization of bone resection. This allows the surgeon to work within a wider corridor, which facilitates the use of surgical instruments and minimizes retraction of the brain. The management of aneurysms within the posterior circulation requires expertise in skull base and vascular surgery. Endovascular treatments have become increasingly important, but in this paper the authors focus on the surgical management of these difficult aneurysms. The paper is divided into three parts: the first section is a brief review of the anatomy of the BA; the second part is a review of the techniques associated with the management of posterior fossa aneurysms; and in the third section the authors describe the different approaches, their nuances and indications based on the location of the aneurysm, and its relationship to the surrounding bone (especially the clivus, dorsum sellae, and the free edge of the petrous apex).

scholarly journals Posterior circulation aneurysms: A 10-year institutional analysis

2012 ◽  
Vol 01 (02) ◽  
pp. 119-123
Author(s):  
Saurabh Sharma ◽  
Ansari Abuzer ◽  
Ashish Suri ◽  
Shailesh Gaikwad ◽  
N.K. Mishra ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Posterior Circulation ◽  
Superior Cerebellar Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Poor Grade ◽  
Cranial Nerve Palsies ◽  
Cerebellar Artery ◽  
Posterior Circulation Aneurysms ◽  
Grade Ii ◽  
Multimodality Approach

Abstract Aneurysms are uncommon and challenging to manage. A retrospective study was designed to report 53 patients who are treated from June 2002 to June 2011. The mean age at presentation was 46.34 ± 13.67 years (males, 26). Clinical features included subarachnoid hemorrhage (median Hunt and Hess Grade II, n = 42), cranial nerve palsies (9), hydrocephalus (5), and incidentally diagnosed (5). Locations included superior cerebellar artery (3), posterior cerebral artery (2), basilar trunk (4), vertebral (8), anterior inferior cerebellar artery (AICA) (5), posterior inferior cerebellar artery (PICA) (13), vertebrobasilar junction (6), and basilar top (13). Management included both endovascular intervention (26) and surgery (19), and both (2). Five patients presented as poor grade and underwent only extraventricular drain placement while one patient had thrombosed aneurysm and was managed conservatively. Mortality was 26.4% (n = 14) and morbidity included vasospasm (10), meningitis (2), pseudomeningocele (2), pneumonitis (2), and myocardial infarction (1). Posterior circulation aneurysms are highly challenging. They require the multimodality approach, and decision regarding surgery or embolization has to be individualized.

scholarly journals Thrombectomy in posterior circulation stroke through persistent primitive trigeminal artery: A case report

2015 ◽  
Vol 21 (6) ◽  
pp. 715-718 ◽  
Author(s):  
MJHL Mulder ◽  
GJ Lycklama à Nijeholt ◽  
W Dinkelaar ◽  
TPW de Rooij ◽  
ACGM van Es ◽  
...  
Keyword(s):  
Posterior Circulation ◽  
Superior Cerebellar Artery ◽  
Trigeminal Artery ◽  
Left Hand ◽  
Persistent Primitive Trigeminal Artery ◽  
Cerebellar Artery ◽  
Intervention Patient ◽  
Primitive Trigeminal Artery ◽  
The Right ◽  
Neurovascular Anatomy

We describe a case of intra-arterial treatment (IAT) of acute posterior circulation occlusion in a patient with a persistent primitive trigeminal artery (PPTA). The patient presented with an acute left sided hemiparesis and loss of consciousness (Glasgow coma score of 5). Computed tomography angiography showed an acute occlusion of the right internal carotid artery (ICA), the PPTA, distal basilar artery (BA), right posterior cerebral artery (PCA), and right superior cerebellar artery (SCA). Stent-retriever assisted thrombectomy was not considered possible through the hypoplastic proximal BA. After passage of the proximal ICA occlusion, the right PCA and SCA were recanalized through the PPTA, with a single thrombectomy procedure. Ten days after intervention patient was discharged scoring optimal EMV with only a mild facial and left hand paresis remaining. PPTA is a persistent embryological carotid–basilar connection. Knowledge of existing (embryonic) variants in neurovascular anatomy is essential when planning and performing acute neurointerventional procedures.

Intracranial Vertebral Endarterectomy

Neurosurgery ◽  
1990 ◽  
Vol 26 (3) ◽  
pp. 465-471 ◽  
Author(s):  
James I. Ausman ◽  
Fernando G. Diaz ◽  
Balaji Sadasivan ◽  
Manuel Dujovny
Keyword(s):  
Vertebral Artery ◽  
Medical Therapy ◽  
Superficial Temporal Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Temporal Artery ◽  
Superior Cerebellar Artery ◽  
Focal Lesion ◽  
Cerebellar Infarction ◽  
Vertebrobasilar Insufficiency ◽  
Cerebellar Artery

Abstract Intracranial vertebral endarterectomy was performed on six patients with vertebrobasilar insufficiency in whom medical therapy failed. The patients underwent operations for stenotic plaque in the intracranial vertebral artery with the opposite vertebral artery being occluded, hypoplastic, or severely stenosed. In four of the patients, the stenosis was mainly proximal to the posterior inferior cerebellar artery (PICA). In this group, after endarterectomy, the vertebral artery was patent in two patients, and their symptoms resolved: in one patient the endarterectomy occluded, but the patient's symptoms improved; and in one patient the endarterectomy was unsuccessful, and he continued to have symptoms. In one patient, the plaque was at the origin of the PICA. The operation appeared technically to be successful, but the patient developed a cerebellar infarction and died. In one patient the stenosis was distal to the PICA. During endarterectomy, the plaque was found to invade the posterior wall of the vertebral artery. The vertebral artery was ligated, and the patient developed a Wallenburg syndrome. The results of superficial temporal artery to superior cerebellar artery anastomosis are better than those for intracranial vertebral endarterectomy for patients with symptomatic intracranial vertebral artery stenosis. The use of intracranial vertebral endarterectomy should be limited to patients who have disabling symptoms despite medical therapy, a focal lesion proximal to the PICA, and a patent posterior circulation collateral or bypass.

Deep Bypasses to the Distal Posterior Circulation

Neurosurgery ◽  
2010 ◽  
Vol 66 (1) ◽  
pp. 92-101 ◽  
Author(s):  
Zsolt Zador ◽  
Daniel C. Lu ◽  
Christine M. Arnold ◽  
Michael T. Lawton
Keyword(s):  
Temporal Lobe ◽  
Artery Bypass ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Posterior Circulation ◽  
Superior Cerebellar Artery ◽  
Brain Shift ◽  
Morphometric Measurements ◽  
Subtemporal Approach ◽  
Cerebellar Artery

Abstract OBJECTIVE The subtemporal approach for a superficial temporal artery–to–superior cerebellar artery bypass requires significant superior retraction that can injure the temporal lobe, compromise veins, and cause edema postoperatively. In contrast, the pretemporal approach requires posterolateral retraction that seems to be less injurious to the temporal lobe and better tolerated clinically. We hypothesized that the pretemporal approach provides ample exposure, more gentle retraction, and better clinical results than the subtemporal approach. METHODS Standard orbitozygomatic-pterional and subtemporal approaches were performed on both sides of 4 formalin-fixed cadaver heads for morphometric measurements. Temporal lobe retraction was quantified for each approach in terms of brain shift and retraction pressure by using both sides of 3 fresh, unfixed cadaver heads. Similar morphometric measurements were made in 14 patients in whom bypasses to the distal posterior circulation were performed. The effect of temporal lobe retraction was assessed with edema volumes on postoperative computed tomography scans. RESULTS In cadaver heads and in patients, the pretemporal approach optimized exposure of the P2A segment of the posterior cerebral artery (PCA) and the subtemporal approach optimized exposure of the lateral pontomesencephalic segment of the superior cerebellar artery (SCA). Working depths and lengths of exposed artery were similar with these 2 approaches, but the PCA was a larger recipient than the SCA. Brain shift was 42% less with pretemporal than with subtemporal retraction, and retraction pressure was 43% less with pretemporal than with subtemporal retraction. The volume of temporal lobe edema was 56% less in patients with bypasses performed with the pretemporal approach as compared with the subtemporal approach. CONCLUSION Pretemporal exposure of the PCA is equivalent to subtemporal exposure of the SCA, but the pretemporal approach is facilitated by a larger recipient artery. Posterolateral temporal lobe retraction associated with the pretemporal approach is gentler than superior retraction with the subtemporal approach. These results validate our preference for the pretemporal approach over the subtemporal approach when performing deep bypasses to the posterior circulation.

LVIS Blue as a low porosity stent and coil adjuvant

2018 ◽  
Vol 10 (7) ◽  
pp. 682-686 ◽  
Author(s):  
Matthew J Koch ◽  
Christopher J Stapleton ◽  
Scott B Raymond ◽  
Susan Williams ◽  
Thabele M Leslie-Mazwi ◽  
...  
Keyword(s):  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Posterior Inferior Cerebellar Artery ◽  
Endovascular Embolization ◽  
Superior Cerebellar Artery ◽  
Anterior Communicating Artery ◽  
Aneurysm Neck ◽  
Proximal Internal Carotid Artery ◽  
Cerebellar Artery

IntroductionThe LVIS Blue is an FDA-approved stent with 28% metallic coverage that is indicated for use in conjunction with coil embolization for the treatment of intracranial aneurysms. Given a porosity similar to approved flow diverters and higher than currently available intracranial stents, we sought to evaluate the effectiveness of this device for the treatment of intracranial aneurysms.MethodsWe performed an observational single-center study to evaluate initial occlusion and occlusion at 6-month follow-up for patients treated with the LVIS Blue in conjunction with coil embolization at our institution using the modified Raymond–Roy classification (mRRC), where mRRC 1 indicates complete embolization, mRRC 2 persistent opacification of the aneurysm neck, mRRC 3a filling of the aneurysm dome within coil interstices, and mRRC 3b filling of the aneurysm dome.ResultsSixteen aneurysms were treated with the LVIS Blue device in conjunction with coil embolization with 6-month angiographic follow-up. Aneurysms were treated throughout the intracranial circulation: five proximal internal carotid artery (ICA) (ophthalmic or communicating segments), two superior cerebellar artery, two ICA terminus, two anterior communicating artery, two distal middle cerebral artery, one posterior inferior cerebellar artery, and two basilar tip aneurysms. Post-procedurally, there was one mRRC 1 closure, five mRRC 2 closures, and 10 mRRC 3a or 3b occlusion. At follow-up, all the mRRC 1 and mRRC 3a closures, 85% of the mRRC 3b closures and 75% of the mRRC 2 closures were stable or improved to an mRRC 1 or 2 at follow-up.ConclusionsThe LVIS Blue represents a safe option as a coil adjunct for endovascular embolization within both the proximal and distal anterior and posterior circulation.

Revascularization and Aneurysm Surgery

Neurosurgery ◽  
2014 ◽  
Vol 74 (5) ◽  
pp. 482-498 ◽  
Author(s):  
M. Yashar S. Kalani ◽  
Wyatt Ramey ◽  
Felipe C. Albuquerque ◽  
Cameron G. McDougall ◽  
Peter Nakaji ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Superior Cerebellar Artery ◽  
External Carotid ◽  
Occipital Artery ◽  
Aneurysm Surgery ◽  
Cerebellar Artery

Abstract BACKGROUND: Given advances in endovascular technique, the indications for revascularization in aneurysm surgery have declined. OBJECTIVE: We sought to define indications, outline technical strategies, and evaluate the outcomes of patients treated with bypass in the endovascular era. METHODS: We retrospectively reviewed all aneurysms treated between September 2006 and February 2013. RESULTS: We identified 54 consecutive patients (16 males and 39 females) with 56 aneurysms. Aneurysms were located along the cervical internal carotid artery (ICA) (n = 1), petrous/cavernous ICA (n = 1), cavernous ICA (n = 16), supraclinoid ICA (n = 7), posterior communicating artery (n = 2), anterior cerebral artery (n = 4), middle cerebral artery (MCA) (n = 13), posterior cerebral artery (PCA) (n = 3), posterior inferior cerebellar artery (n = 4), and vertebrobasilar arteries (n = 5). Revascularization was performed with superficial temporal artery (STA) to MCA bypass (n = 25), STA to superior cerebellar artery (SCA) (n = 3), STA to PCA (n = 1), STA-SCA/STA-PCA (n = 1), occipital artery (OA) to PCA (n = 2), external carotid artery/ICA to MCA (n = 15), OA to MCA (n = 1), OA to posterior inferior cerebellar artery (n = 1), and in situ bypasses (n = 8). At a mean clinical follow-up of 18.5 months, 45 patients (81.8%) had a good outcome (Glasgow Outcome Scale 4 or 5). There were 7 cases of mortality (12.7%) and an additional 9 cases of morbidity (15.8%). At a mean angiographic follow-up of 17.8 months, 14 bypasses were occluded. Excluding the 7 cases of mortality, the majority of aneurysms (n = 42) were obliterated. We identified 7 cases of residual aneurysm and recurrence in 6 patients at follow-up. CONCLUSION: Given current limitations with existing treatments, cerebral revascularization remains an essential technique for aneurysm surgery.

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