Management of Intracranial Vertebral Artery Dissections Initially Presenting without Subarachnoid Hemorrhage

Abstract OBJECTIVE The clinical and angiographic follow-up results for intracranial vertebral artery (VA) dissections that initially presented without subarachnoid hemorrhage (SAH) were retrospectively investigated, to clarify their management. METHODS Twenty-one patients with VA dissections that initially presented without SAH were studied. Initial angiography revealed aneurysmal dilation in 11 cases (typical pearl-and-string sign in 8 cases, aneurysmal dilation only in 2, and aneurysmal dilation with double-lumen sign in 1), occlusion in 7, double-lumen sign in 2, and string-like stenosis in 1. Nine patients (six with pearl-and-string sign, one with occlusion with aneurysmal dilations, and two with double-lumen sign), including three patients who experienced subsequent SAH, underwent endovascular proximal parent artery occlusion. The other 12 patients were treated conservatively. All patients were monitored with magnetic resonance angiography or digital subtraction angiography. RESULTS Three patients experienced subsequent SAH, 1 day (two patients) or 51 months after onset. Follow-up angiographic assessments of the 20 patients demonstrated complete resolution in five cases, reduction of aneurysmal dilation in one case, and partial recanalization in one case. However, enlargement or formation of an aneurysmal dilation was recognized in four cases and progression of dissection was observed in one case. Eighteen patients experienced good recoveries, and three patients demonstrated moderate disabilities as a result of the initial ischemic insult. CONCLUSION The risk of bleeding from unruptured VA dissections is higher than previously considered. Therefore, endovascular treatment should be considered for patients with VA dissections with relatively large or growing aneurysmal dilations.

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Treatment of Unruptured Vertebral Artery Aneurysm Involving Posterior Inferior Cerebellar Artery With Pipeline Embolization Device

Frontiers in Neurology ◽

10.3389/fneur.2021.622457 ◽

2021 ◽

Vol 12 ◽

Author(s):

Weiqi Fu ◽

Huijian Ge ◽

Gang Luo ◽

Xiangyu Meng ◽

Jiejun Wang ◽

...

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Artery Aneurysm ◽

Artery Occlusion ◽

Parent Artery ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Parent Artery Occlusion ◽

Cerebellar Artery

Background: Treatment of unruptured vertebral artery aneurysm involving posterior inferior cerebellar artery (PICA) is challenging. The experience of pipeline embolization device (PED) therapy for these lesions is still limited.Objective: To evaluate the safety and efficacy of the PED for unruptured vertebral artery aneurysm involving PICA.Methods: Thirty-two patients with unruptured vertebral artery aneurysm involving PICA underwent treatment with PED were retrospectively identified. Procedure-related complications, PICA patency, clinical, and angiographic outcomes were analyzed.Results: Thirty-two aneurysms were successfully treated without any procedure-related complications. Images were available in 30 patients (93.8%) during a period of 3–26 months follow-up (average 8.4 months), which confirmed complete occlusion in 17 patients (56.5%), near-complete occlusion in 9 patients (30%), and incomplete occlusion in one patient (3.3%). Parent artery occlusion (PAO) was occurred in 3 patients (10%). Twenty-eight of 30 PICA remained patent. The two occlusions of PICA were secondary to PAO. At a mean of 20.7 months (range 7–50 months) clinical follow-up, all the patients achieved a favorable outcome without any new neurological deficit.Conclusion: PED seems to be a safe and effective alternative endovascular option for patients with unruptured vertebral artery aneurysm involving PICA.

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Dissecting Aneurysm at the Proximal Anterior Cerebral Artery Treated by Parent Artery Occlusion

Interventional Neuroradiology ◽

10.1177/159101990901500121 ◽

2009 ◽

Vol 15 (1) ◽

pp. 123-126 ◽

Cited By ~ 11

Author(s):

M. Lv ◽

X. Lv ◽

Y. Li ◽

C. Jiang ◽

P. Jiang ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Artery Occlusion ◽

Dissecting Aneurysm ◽

Parent Artery ◽

Parent Artery Occlusion ◽

Proximal Anterior Cerebral Artery ◽

Neuroform Stent

Aneurysms of the A1 segment of the anterior cerebral artery (ACA) are rare. We described the first documented endovascular treatment of an A1 portion dissecting aneurysm by parent artery occlusion. A 43-year-old man patient presented with subarachnoid hemorrhage. Cerebral angiography demonstrated a dissecting aneurysm of the left anterior cerebral artery (ACA) at A1 portion. Because of the dissecting nature of the A1 portion aneurysm, a 2.5×15-mm Neuroform stent was placed in the left A1 portion. However, regrowth of the aneurysm was found on the three month follow-up angiogram, so the aneurysm and the left A1 portion of ACA were occluded completely.

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Treatment of Intracranial Aneurysm with Bare Stent Only

Interventional Neuroradiology ◽

10.1177/15910199080140s213 ◽

2008 ◽

Vol 14 (2_suppl) ◽

pp. 75-78 ◽

Cited By ~ 3

Author(s):

Michael Mu Huo Teng ◽

Chao-Bao Luo ◽

Feng-Chi Chang ◽

Harsan Harsan

Keyword(s):

Intracranial Aneurysm ◽

Artery Occlusion ◽

Dissecting Aneurysm ◽

Parent Artery ◽

Fusiform Aneurysm ◽

Surgical Clipping ◽

Parent Artery Occlusion ◽

Typical Treatment ◽

Dissecting Aneurysms

Typical treatment of intracranial aneurysm includes: surgical clipping, intrasacular packing, and parent artery occlusion. The treatment of a fusiform aneurysm is often parent artery occlusion, and keeping patency of the parent artery is difficult. We report our experience in the treatment of 3 cases of intracranial fusiform aneurysm with stent placement inside the parent artery only, without coil packing of the aneurysm lumen. All 3 patients had a non-hemorrhagic dissecting aneurysm in the vertebral artery. They were treated with 2 Helistents, 3 Neuroform stents, and 2 Neuroform stents, respectively. These aneurysms disappeared after treatment at their follow-up angiograms. Treatment with a bare stent may induce obliteration or reduction in the size of some aneurysms. This technique is useful in the treatment of non-hemorrhagic fusiform-shaped aneurysms or non-hemorrhagic dissecting aneurysms to preserve the patency of these parent arteries.

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Cerebral revascularization for the management of complex intracranial aneurysms: a single-center experience

Journal of Neurosurgery ◽

10.3171/2018.4.jns172752 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1297-1307 ◽

Cited By ~ 3

Author(s):

Eric S. Nussbaum ◽

Kevin M. Kallmes ◽

Jeffrey P. Lassig ◽

James K. Goddard ◽

Michael T. Madison ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Case Series ◽

Artery Occlusion ◽

High Flow ◽

Cerebral Revascularization ◽

Low Flow ◽

Parent Artery ◽

Team Approach ◽

Parent Artery Occlusion

OBJECTIVEBecause simple intracranial aneurysms (IAs) are increasingly treated endovascularly, neurovascular surgery has become focused on complex IAs that may require deconstructive aneurysm therapy with concomitant surgical bypass. The authors describe the decision-making process concerning cerebral revascularization and present outcomes that were achieved in a large case series of complex IAs managed with cerebral revascularization and parent artery occlusion.METHODSThe authors retrospectively reviewed the medical records, including neuroimaging studies, operative reports, and follow-up clinic notes, of all patients who were treated at the National Brain Aneurysm Center between July 1997 and June 2015 using cerebral revascularization as part of the management of an IA. They recorded the location, rupture status, and size of each IA, as well as neurological outcome using the modified Rankin Scale (mRS), aneurysm and bypass status at follow-up, and morbidity and mortality.RESULTSThe authors identified 126 patients who underwent revascularization surgery for 126 complex, atheromatous, calcified, or previously coiled aneurysms. Ninety-seven lesions (77.0%) were unruptured, and 99 (78.6%) were located in the anterior circulation. Aneurysm size was giant (≥ 25 mm) in 101 patients, large (10–24 mm) in 9, and small (≤ 9 mm) in 16 patients. Eighty-four low-flow bypasses were performed in 83 patients (65.9%). High-flow bypass was performed in 32 patients (25.4%). Eleven patients (8.7%) underwent in situ or intracranial-intracranial bypasses. Major morbidity (mRS score 4 or 5) occurred in 2 (2.4%) low-flow cases and 3 (9.1%) high-flow cases. Mortality occurred in 2 (2.4%) low-flow cases and 2 (6.1%) high-flow cases. At the 12-month follow-up, 83 (98.8%) low-flow and 30 (93.8%) high-flow bypasses were patent. Seventy-five patients (90.4%) undergoing low-flow and 28 (84.8%) high-flow bypasses had an mRS score ≤ 2. There were no statistically significant differences in patency rates or complications between low- and high-flow bypasses.CONCLUSIONSWhen treating challenging and complex IAs, incorporating revascularization strategies into the surgical repertoire may contribute to achieving favorable outcomes. In our series, low-flow bypass combined with isolated proximal or distal parent artery occlusion was associated with a low rate of ischemic complications while providing good long-term aneurysm control, potentially supporting its wider utilization in this setting. The authors suggest that consideration should be given to managing complex IAs at high-volume centers that offer a multidisciplinary team approach and the full spectrum of surgical and endovascular treatment options to optimize patient outcomes.

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Parent artery occlusion is not obsolete in giant aneurysms of the ICA. Experience with very-long-term follow-up

Neuroradiology ◽

10.1007/s00234-010-0800-8 ◽

2010 ◽

Vol 53 (12) ◽

pp. 973-982 ◽

Cited By ~ 34

Author(s):

Frédéric Clarençon ◽

Fabrice Bonneville ◽

Anne-Laure Boch ◽

Lise Lejean ◽

Alessandra Biondi

Keyword(s):

Artery Occlusion ◽

Parent Artery ◽

Giant Aneurysms ◽

Parent Artery Occlusion ◽

Long Term Follow Up

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Antegrade recanalization of a completely embolized vertebral artery after endovascular treatment of a ruptured intracranial dissecting aneurysm

Journal of Neurosurgery ◽

10.3171/jns.2005.102.1.0161 ◽

2005 ◽

Vol 102 (1) ◽

pp. 161-166 ◽

Cited By ~ 23

Author(s):

Motoshi Sawada ◽

Yasuhiko Kaku ◽

Shinichi Yoshimura ◽

Masahiro Kawaguchi ◽

Takashi Matsuhisa ◽

...

Keyword(s):

Vertebral Artery ◽

Cerebral Aneurysms ◽

Systemic Circulation ◽

Parent Artery ◽

Content Type ◽

Endovascular Occlusion ◽

Aneurysmal Dilation ◽

Dissecting Aneurysms ◽

Fine Print

✓ Occlusion of the parent artery is a traditional method of treatment of unclippable cerebral aneurysms. Surgical or endovascular occlusion of the parent artery proximal to the aneurysm has been recommended for the treatment of dissecting aneurysms located in the vertebrobasilar circulation. Nevertheless, occlusion of the parent artery may not result in permanent exclusion of the aneurysm from the systemic circulation because, occasionally, postoperative rebleeding occurs after proximal occlusion. Alternatively, endovascular occlusion of the affected site, including the aneurysmal dilation, and parent artery, is a safe and reliable treatment for dissecting aneurysms. The authors present two rare cases of ruptured vertebral artery (VA) dissecting aneurysms that were treated by endovascular occlusion of the affected site including the aneurysm and parent artery by using Guglielmi detachable coils. In both cases the VA recanalized in an antegrade fashion during the follow-up period. Based on these unique cases, the authors suggest that a careful angiographic follow up of dissecting aneurysms is required, even in patients successfully treated with endovascular occlusion of the affected artery and aneurysm.

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Endovascular treatment of posterior cerebral artery aneurysms: a single center's experience of 55 cases

Journal of Neurosurgery ◽

10.3171/2016.1.jns152447 ◽

2017 ◽

Vol 126 (4) ◽

pp. 1094-1105 ◽

Cited By ~ 6

Author(s):

Xuanfeng Qin ◽

Feng Xu ◽

Yashengjiang Maimaiti ◽

Yongtao Zheng ◽

Bin Xu ◽

...

Keyword(s):

Endovascular Treatment ◽

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Case Series ◽

Artery Occlusion ◽

Dissecting Aneurysm ◽

Attractive Alternative ◽

Parent Artery ◽

Parent Artery Occlusion

OBJECTIVE Aneurysms of the posterior cerebral artery (PCA) are uncommon. To date, a limited number of studies have examined the outcomes of endovascular treatment for PCA aneurysms. The authors' aim in this study is to report their experience with the endovascular treatment of PCA aneurysms. METHODS Between January 2007 and December 2014, 55 patients with 59 PCA aneurysms were treated using the endovascular approach at the authors' institution. Twenty-three patients had 25 saccular aneurysms, and 32 patients had 34 fusiform/dissecting aneurysms. The endovascular modalities included the following: 1) selective occlusion of the aneurysm (n = 22); 2) complete occlusion of the aneurysm and the parent artery (n = 20); 3) parent artery occlusion (n = 6); 4) partial coiling of the aneurysm and the parent artery (n = 5); and 5) occlusion of the dissecting aneurysm sac (n = 2). RESULTS The immediate angiographic results included 45 complete occlusions (82%), 2 nearly complete occlusions (4%), and 8 incomplete occlusions (14%). The mean follow-up period of 21.8 months in 46 patients showed 37 stable results, 6 further thromboses, and 3 recurrences. The final results included 41 complete occlusions (89%), 2 nearly complete occlusions (4%), and 3 incomplete occlusions (7%). Procedure-related complications included the following: 1) rebleeding (n = 1); 2) infarction (n = 4); and 3) perforation (n = 1). There was 1 (1.8%) procedure-related death due to rebleeding, and 2 (3.6%) non–procedure-related deaths due to severe subarachnoid hemorrhage. Clinical outcomes were excellent (Glasgow Outcome Scale 5) in 47 of 49 patients at the long-term follow-up. CONCLUSIONS PCA aneurysms may be effectively treated by different endovascular approaches with favorable clinical and radiological outcomes. However, patients who present with severe SAH still have an overall poor prognosis. Partial coiling of the aneurysm and the parent artery is an attractive alternative treatment for patients who may not tolerate parent artery occlusion. Further study with a larger case series is necessary for validation of the durability and efficacy of this treatment.

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Treatment of vertebral artery aneurysms with transposition of the posterior inferior cerebellar artery to the vertebral artery combined with parent artery occlusion

Journal of Neurosurgery ◽

10.3171/jns.2006.105.5.781 ◽

2006 ◽

Vol 105 (5) ◽

pp. 781-784 ◽

Cited By ~ 11

Author(s):

Kuniaki Ogasawara ◽

Yoshitaka Kubo ◽

Nobuhiko Tomitsuka ◽

Masayuki Sasoh ◽

Yasunari Otawara ◽

...

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Artery Occlusion ◽

The Other ◽

Parent Artery ◽

Pica Pica ◽

Suboccipital Craniectomy ◽

Parent Artery Occlusion ◽

Cerebellar Artery ◽

Good Patency

✓ The authors describe transposition of the posterior inferior cerebellar artery (PICA) to the vertebral artery (VA) combined with parent artery occlusion for the treatment of VA aneurysms in cases in which a clip could not be applied because of the origin of the ipsilateral PICA. The aneurysm is trapped through a lower lateral suboccipital craniectomy. The PICA is then cut just distal to the aneurysm, and the PICA and VA proximal to the aneurysm are anastomosed in an end-to-end or end-to-side fashion. The surgical procedure was successfully performed in two patients, each of whom had hypoplastic occipital arteries (OAs). The PICA contralateral to the lesion was hypoplastic in one patient and distant to the ipsilateral PICA in the other patient. Mild transient dysphagia developed postoperatively in one patient due to glossopharyngeal and vagus nerve palsy, and the other patient had an uneventful postoperative course. In both patients, postoperative cerebral angiography demonstrated good patency of the transposed PICA. These results show that transposition of the PICA to the VA is a useful procedure for the reconstruction of the PICA when parent artery occlusion is necessary to exclude a VA aneurysm involving the origin of the PICA and when OA–PICA anastomosis or PICA–PICA anastomosis cannot be performed.

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