Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies

2017 ◽  
Vol 10 (7) ◽  
pp. 663-668 ◽  
Author(s):  
Visish M Srinivasan ◽  
Michael George Zaki Ghali ◽  
Oleg E Reznik ◽  
Jacob Cherian ◽  
Maxim Mokin ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Flow Diversion ◽  
Partial Reduction ◽  
Anterior Circulation ◽  
Cerebellar Artery ◽  
Institutional Experience ◽  
Pica Aneurysms ◽  
Anterior Circulation Aneurysms ◽  
Direct Placement

BackgroundThe pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA.MethodsInstitutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study.Results10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up.ConclusionsThe PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection.

scholarly journals Treatment of posterior inferior cerebellar artery aneurysms using flow-diverter stents: A single-center experience

2019 ◽  
Vol 25 (4) ◽  
pp. 407-413 ◽  
Author(s):  
Şükrü Oğuz ◽  
Hasan Dinc
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Proximal Part ◽  
Flow Diverter ◽  
Dissecting Aneurysm ◽  
High Rate ◽  
Single Center ◽  
Anterior Circulation ◽  
Cerebellar Artery ◽  
Pica Aneurysms

Introduction The effectiveness and reliability of flow-diverter stents, which are commonly used in aneurysms of the anterior circulation, have been demonstrated previously. However, the use of these devices is associated with higher rates of perforator and branch ischemia following the treatment of aneurysms of the posterior circulation. Methods This work involved a single-center; retrospective study reviewing eight patients who had aneurysms related to the posterior inferior cerebellar artery (PICA) and who were treated with flow-diverter stents from September 2013 to May 2017. Results The mean aneurysm diameter was 7.6 mm (range, 5 to 11 mm). The types of aneurysm included five aneurysms that were saccular, two that were fusiform, and one that was dissecting. All saccular aneurysms in the neck involved the PICA origin, and one dissecting aneurysm was localized in the proximal part of the PICA. Procedural success was 100% (8/8), and there were no ischemic complications. One patient with subarachnoid hemorrhage died because of rebleeding (modified Rankin Scale (mRS), 6). Other than this patient all of the patients’ mRS scores were zero at discharge and at the clinical follow-up period (mean, 2.5 years). All of the aneurysms were completely occluded according to the latest angiographic controls (mean follow-up period of 19.5 months). Conclusions Treatment of PICA aneurysms with flow-diverter stents showed positive results with a high rate of technical success and low complication and mortality rates. The use of flow-diverter stents in the treatment of PICA aneurysms should be considered a safe and effective endovascular treatment option.

Endovascular Surgery for Proximal Posterior Inferior Cerebellar Artery Aneurysms: An Analysis of Glasgow Outcome Score by Hunt-Hess Grades

Neurosurgery ◽  
2006 ◽  
Vol 58 (4) ◽  
pp. 619-625 ◽  
Author(s):  
Robert A. Mericle ◽  
Adam S. Reig ◽  
Matthew V. Burry ◽  
Eric Eskioglu ◽  
Christopher S. Firment ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Endovascular Surgery ◽  
Glasgow Outcome Score ◽  
Clinical Grade ◽  
Outcome Score ◽  
Fisher Grade ◽  
Cerebellar Artery ◽  
Pica Aneurysms ◽  
Angiographic Result

Abstract OBJECTIVE: Proximal posterior inferior cerebellar artery (PICA) aneurysms represent a subset of posterior circulation aneurysms that can be routinely treated with either clipping or coiling. The literature contains limited numbers of patients with proximal PICA aneurysms treated with endovascular surgery. We report our experience with endovascular surgery of proximal PICA aneurysms with emphasis on patients with poor Hunt-Hess grades. METHODS: We reviewed 31 consecutive patients with proximal PICA aneurysms who were treated with endovascular surgery. The following data were analyzed: age, sex, size of aneurysm, Hunt-Hess grade at presentation, Fisher grade at presentation, angiographic result after embolization, complications, number of days hospitalized, duration of follow-up, angiographic follow-up results, and Glasgow Outcome Score at follow-up. RESULTS: Excellent angiographic occlusion was achieved in 30 of 31 (97%) patients. Clinical follow-up with Glasgow Outcome Score was performed on every patient an average of 10 months later. Twenty-one of 31 (68%) patients had good outcomes (Glasgow Outcome Score I or II) at follow-up. Of the patients who presented with a favorable clinical grade (Hunt-Hess 0–III), 13 of 15 (87%) had good outcomes at follow-up. Of the patients who presented with a poor clinical grade (Hunt-Hess Grade IV or higher), 8 of 16 (50%) had good outcomes at follow-up. CONCLUSION: This series demonstrates the safety and efficacy of endovascular surgery for proximal PICA aneurysms. Many patients with poor Hunt-Hess grades from ruptured PICA aneurysms ultimately had a good outcome. This could be secondary to early, aggressive treatment of hydrocephalus and the minimally invasive nature of the endovascular approach.

Endovascular sacrifice of the proximal posterior inferior cerebellar artery for treatment of ruptured intracranial aneurysms

2020 ◽  
Vol 12 (8) ◽  
pp. 777-782
Author(s):  
James G Malcolm ◽  
Jonathan A Grossberg ◽  
Nealen G Laxpati ◽  
Ali Alawieh ◽  
Frank C Tong ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
High Morbidity ◽  
Brainstem Compression ◽  
Cerebellar Artery ◽  
Diseased Segment ◽  
Suboccipital Decompression ◽  
Pica Aneurysms ◽  
Ruptured Intracranial Aneurysms ◽  
Dissecting Aneurysms

BackgroundRuptured aneurysms of the intracranial vertebral artery (VA) or posterior inferior cerebellar artery (PICA) are challenging to treat as they are often dissecting aneurysms necessitating direct sacrifice of the diseased segment, which is thought to carry high morbidity due to brainstem and cerebellar stroke. However, relatively few studies evaluating outcomes following VA or proximal PICA sacrifice exist. We sought to determine the efficacy and outcomes of endovascular VA/PICA sacrifice.MethodsA retrospective series of ruptured VA/PICA aneurysms treated by endovascular sacrifice of the VA (including the PICA origin) or proximal PICA is reviewed. Collected data included demographic, radiologic, clinical, and disability information.ResultsTwenty-one patients were identified. Median age was 57 years (IQR 11); 15 were female. The Hunt and Hess grade was mostly 3 and 4 (18/21). Seven cases (33%) involved VA-V4 at the PICA take-off, and 14 cases (67%) involved the PICA exclusively. For VA pathology, V4 was sacrificed in all cases, while for PICA pathology, sacrificed segments included anterior medullary (4/14), lateral medullary (7/14), and tonsillomedullary (3/14) segments. Four patients went to hospice (19%). Twelve patients (57%) had evidence of stroke on follow-up imaging: cerebellar (8), medullary (1), and both (3). One patient required suboccipital decompression for brainstem compression. No aneurysm re-rupture occurred. Median discharge modified Rankin Scale score was 2.0 (IQR 2), which decreased to 1.0 (IQR 1) at median follow-up of 6.5 months (IQR 23).ConclusionsEndovascular sacrifice of V4 or PICA aneurysms may carry less morbidity than previously thought, and is a viable alternative for poor surgical candidates or those with good collateral perfusion.

Endovascular treatment of posterior inferior cerebellar artery aneurysms: a 7-year single-center experience

2016 ◽  
Vol 9 (1) ◽  
pp. 45-51 ◽  
Author(s):  
Feng Xu ◽  
Yong Hong ◽  
Yongtao Zheng ◽  
Qiang Xu ◽  
Bing Leng
Keyword(s):  
Endovascular Treatment ◽  
Posterior Inferior Cerebellar Artery ◽  
Endovascular Embolization ◽  
Parent Artery ◽  
Selective Embolization ◽  
Single Center Experience ◽  
Cerebellar Artery ◽  
Long Term Follow Up ◽  
Pica Aneurysms

AimTo report our experience with endovascular treatment of posterior inferior cerebellar artery (PICA) aneurysms.MethodsBetween January 2007 and December 2014, 40 patients with 42 PICA aneurysms were treated with endovascular embolization at our institution. Twenty-eight patients had 29 saccular aneurysms and 12 patients had 13 fusiform/dissecting aneurysms. The endovascular modalities were: (1) selective occlusion of the aneurysm with or without stent assistance (n=19); (2) occlusion of the aneurysm and the parent artery (n=22); and (3) occlusion of the aneurysm including the vertebral artery and PICA origin (n=1). Specifically, selective embolization was performed in 93.3% of aneurysms (14/15) proximal to the telovelotonsillary segment.ResultsImmediate angiographic results included 31 complete occlusions (74%), 3 nearly complete occlusions (7%), and 8 incomplete occlusions (19%). Mean follow-up of 20 months in 31 aneurysms showed 27 stable results, 3 further thromoboses, and 1 recurrence. Final results included 27 complete occlusions (87.1%) and 4 incomplete occlusions (12.9%). There were 5 overall procedural-related complications (12.5%), including 1 infarction (2.5%) and 4 intraprocedural ruptures (10.0%). Procedure-related morbidity and morbidity was 5.0% (2/40) and 2.5% (1/40), respectively. Clinical outcome was excellent (Glasgow Outcome Scale 5 in 31 of 33 patients at long-term follow-up).ConclusionsPICA aneurysms may be effectively treated by different endovascular approaches with favorable clinical and radiologic outcomes. Further studies are required to compare the safety and efficacy of endovascular treatment with open surgery.

Predictors of cerebral aneurysm persistence and occlusion after flow diversion: a single-institution series of 445 cases with angiographic follow-up

2018 ◽  
Vol 130 (1) ◽  
pp. 259-267 ◽  
Author(s):  
Matthew T. Bender ◽  
Geoffrey P. Colby ◽  
Li-Mei Lin ◽  
Bowen Jiang ◽  
Erick M. Westbroek ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Flow Diversion ◽  
Single Institution ◽  
Anterior Circulation ◽  
Complete Occlusion ◽  
Aneurysm Size ◽  
Branch Vessel ◽  
Aneurysm Occlusion ◽  
Anterior Circulation Aneurysms

OBJECTIVEFlow diversion requires neointimal stent overgrowth to deliver aneurysm occlusion. The existing literature on aneurysm occlusion is limited by heterogeneous follow-up, variable antiplatelet regimens, noninvasive imaging modalities, and nonstandard occlusion assessment. Using a large, single-center cohort with low attrition and standardized antiplatelet tapering, the authors evaluated outcomes after flow diversion of anterior circulation aneurysms to identify predictors of occlusion and aneurysm persistence.METHODSData from a prospective, IRB-approved database was analyzed for all patients with anterior circulation aneurysms treated by flow diversion with the Pipeline embolization device (PED) at the authors’ institution. Follow-up consisted of catheter cerebral angiography at 6 and 12 months postembolization. Clopidogrel was discontinued at 6 months and aspirin was reduced to 81 mg daily at 12 months. Occlusion was graded as complete, trace filling, entry remnant, or aneurysm filling. Multivariate logistic regression was performed to identify predictors of aneurysm persistence.RESULTSFollow-up catheter angiography studies were available for 445 (91%) of 491 PED procedures performed for anterior circulation aneurysms between August 2011 and August 2016. Three hundred eighty-seven patients accounted for these 445 lesions with follow-up angiography. The population was 84% female; mean age was 56 years and mean aneurysm size was 6.6 mm. Aneurysms arose from the internal carotid artery (83%), anterior cerebral artery (13%), and middle cerebral artery (4%). Morphology was saccular in 90% of the lesions, and 18% of the aneurysms has been previously treated. Overall, complete occlusion was achieved in 82% of cases at a mean follow-up of 14 months. Complete occlusion was achieved in 72%, 78%, and 87% at 6, 12, and 24 months, respectively. At 12 months, adjunctive coiling predicted occlusion (OR 0.260, p = 0.036), while male sex (OR 2.923, p = 0.032), aneurysm size (OR 3.584, p = 0.011), and incorporation of a branch vessel (OR 2.206, p = 0.035) predicted persistence. Notable variables that did not predict aneurysm occlusion were prior treatments, vessel of origin, fusiform morphology, and number of devices used.CONCLUSIONSThis is the largest single-institution study showing high rates of anterior circulation aneurysm occlusion after Pipeline embolization. Predictors of persistence after flow diversion included increasing aneurysm size and incorporated branch vessel, whereas adjunctive coiling predicted occlusion.

scholarly journals Ten years of experience in endovascular treatment of ruptured aneurysms of the posterior inferior cerebellar artery

2016 ◽  
Vol 22 (2) ◽  
pp. 129-137 ◽  
Author(s):  
Robert Juszkat ◽  
Paweł Kram ◽  
Katarzyna Stanisławska ◽  
Roman Jankowski ◽  
Bogumiła Stachowska-Tomczak ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Clinical Presentation ◽  
Posterior Inferior Cerebellar Artery ◽  
Years Of Experience ◽  
Endovascular Stents ◽  
Ruptured Aneurysms ◽  
Ruptured Intracranial Aneurysm ◽  
Cerebellar Artery ◽  
Pica Aneurysms

Background The aim of this study is to present our 10 years of experience in endovascular treatment of ruptured posterior inferior cerebellar artery (PICA) saccular aneurysms and to compare clinical presentation and outcome after endovascular treatment between patients with PICA aneurysms and patients with aneurysms in different locations. Methods and findings Out of 932 patients with a ruptured intracranial aneurysm treated endovascularly in our institution, 38 aneurysms were located at the posterior inferior cerebellar artery. Clinical presentation, mean aneurysm diameter and outcome of the therapy in this group were compared with the same for ruptured aneurysms in other locations. Patients discharged with favourable outcomes were checked angiographically in the follow-up period. Thirty-four patients with ruptured PICA aneurysms were treated by selective endovascular coiling. Two patients with wide-necked aneurysms had endovascular stents implanted. In two cases, the parent vessel was occluded due to failure to catheterise the target aneurysm. The evaluated variables did not differ significantly between two groups, but significantly more ruptured aneurysms in the PICA group were under 6 mm in diameter. 29.4% of controlled aneurysms needed additional reembolisation in the follow-up period. Conclusions Clinical presentation, extension of subarachnoid haemorrhage and outcome after endovascular treatment did not differ significantly between patients with ruptured aneurysms located on the PICA and patients with aneurysms located elsewhere intracranially. Endovascular treatment is an effective method of therapy in patients with ruptured PICA aneurysms. In our experience, even when sacrificing of the PICA is required, the results of treatment are favourable.

scholarly journals Microneurosurgical Management of Posterior Inferior Cerebellar Artery Aneurysms: Results of a Consecutive Series

2021 ◽  
pp. 33-38
Author(s):  
Mattia Del Maestro ◽  
Sabino Luzzi ◽  
Renato Galzio
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Lateral Approach ◽  
Senior Author ◽  
Preoperative Imaging ◽  
Imaging Evaluation ◽  
Complex Anatomy ◽  
Cerebellar Artery ◽  
Pica Aneurysms

AbstractAneurysms of the posterior inferior cerebellar artery (PICA) are uncommon. The complex anatomy of PICA and its intimate relationships with medulla, lower cranial nerves, and jugular tubercle makes the surgical treatment of these aneurysms fascinating. The reported is study aimed at a critical review of the overall results of a personal series of PICA aneurysms, treated by the senior author, R. Galzio. Demographics, charts, videos, outcome, and follow-up of a cohort of PICA aneurysms managed in the last 10 years were retrospectively analyzed, focusing only upon those treated with microneurosurgery. Twenty-five patients, harboring a single aneurysm, were operated on. Fifteen aneurysms were ruptured. Nineteen were proximal, all of these being been treated through a far-lateral approach. Trans-condylar or trans-tubercular variants were rarely necessary and however reserved to peculiar cases. Twenty-three aneurysms underwent direct treatment consisting of clip ligation. At 6-month follow-up, 60% of patients had a modified Rankin Score (mRS) of 0–2. Given the high anatomical variability of both PICA and patients’ bony anatomy, a case-by-case meticulous preoperative imaging evaluation is mandatory for the choice of the most suitable and tailored surgical corridor which, in turn, is pivotal to achieve the best outcome.

scholarly journals Vertebral artery aneurysms and the risk of cord infarction following spinal artery coverage during flow diversion

2020 ◽  
pp. 1-10
Author(s):  
Adam A. Dmytriw ◽  
Anish Kapadia ◽  
Alejandro Enriquez-Marulanda ◽  
Carmen Parra-Fariñas ◽  
Anna Luisa Kühn ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Flow Diverter ◽  
Thromboembolic Complication ◽  
Flow Diversion ◽  
Cerebellar Artery ◽  
Aneurysm Occlusion ◽  
Aneurysm Diameter ◽  
Flow Diverters

OBJECTIVECoverage of the anterior spinal artery (ASA) ostia is a source of considerable consternation regarding flow diversion (FD) in vertebral artery (VA) aneurysms due to cord supply. The authors sought to assess the association between coverage of the ASA, posterior spinal artery (PSA), or lateral spinal artery (LSA) ostia when placing flow diverters in distal VAs and clinical outcomes, with emphasis on cord infarction.METHODSA multicenter retrospective study of 7 institutions in which VA aneurysms were treated with FD between 2011 and 2019 was performed. The authors evaluated the risk of ASA and PSA/LSA occlusion, associated thromboembolic complication, complications overall, aneurysm occlusion status, and functional outcome.RESULTSSixty patients with 63 VA and posterior inferior cerebellar artery aneurysms treated with FD were identified. The median aneurysm diameter was 7 mm and fusiform type was the commonest morphology (42.9%). During a procedure, 1 (61.7%) or 2 (33.3%) flow diverters were placed. Complete occlusion was achieved in 71.9%. Symptomatic thromboembolic complications occurred in 7.4% of cases and intracranial hemorrhage in 10.0% of cases. The ASA and PSA/LSA were identified in 51 (80.9%) and 35 (55.6%) complications and covered by the flow diverter in 29 (56.9%) and 13 (37.1%) of the procedures, respectively. Patency after flow diverter coverage on last follow-up was 89.2% for ASA and 100% for PSA/LSA, not significantly different between covered and noncovered groups (p = 0.5 and p > 0.99, respectively). No complications arose from coverage.CONCLUSIONSFD aneurysm treatment in the posterior circulation with coverage of ASA or PSA/LSA was not associated with higher rates of occlusion of these branches or any instances of cord infarction.

Trapping and P2-P3 Posterior Inferior Cerebellar Artery Reanastomosis for Treatment of a Ruptured Fusiform Aneurysm: Application of Fourth-Generation Technique: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Tyler T Lazaro ◽  
Visish M Srinivasan ◽  
Patrick C Cotton ◽  
Jacob Cherian ◽  
Jeremiah N Johnson
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Lateral Approach ◽  
Fourth Generation ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Close Proximity ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Distal Artery

Abstract Aneurysms of the posterior inferior cerebellar artery (PICA) represent the second most common posterior circulation aneurysm and commonly have complex morphology. Various bypass options exist for PICA aneurysms,1-6 depending on their location relative to brainstem perforators and the vertebral artery, and the presence of nearby donor arteries. We present a case of a man in his late 40s who presented with 3 d of severe headache. He was found to have a fusiform right P2-segment PICA aneurysm. Preoperative angiogram demonstrated the aneurysm and a redundant P3 caudal loop that came in close proximity to the healthy P2 segment proximal to the aneurysm. The risks and benefits of the procedure were discussed with the patient, and they consented for a right far lateral approach craniotomy with partial condylectomy for trapping of the aneurysm with bypass. The aneurysm was trapped proximally and distally. The P3 was transected just distal to the aneurysm and brought toward the proximal P2 segment, facilitated by a lack of perforators on this redundant distal artery. An end-to-side anastomosis was performed. Postoperative angiogram demonstrated exclusion of the aneurysm and patent bypass. The patient recovered well and remained without any neurological deficit at 6-mo follow-up.  This case demonstrates the use of a “fourth-generation”5,7,8 bypass technique. These techniques represent the next innovation beyond third-generation intracranial-intracranial bypass. In this type 4B reanastomosis bypass, an unconventional orientation of the arteries was used. Whereas reanastomosis is typically performed end-to-end, the natural course of these arteries and the relatively less-mobile proximal P2 segment made end-to-side the preferred option in this case. Fourth-generation bypass techniques open up more configurations for reanastomosis, using the local anatomy to the surgeon's advantage.  The patient consented to the described procedure and consented to the publication of their image.

Remote distal outflow occlusion: a novel treatment option for complex dissecting aneurysms of the posterior inferior cerebellar artery

2009 ◽  
Vol 111 (1) ◽  
pp. 78-83 ◽  
Author(s):  
Eric S. Nussbaum ◽  
Michael T. Madison ◽  
James K. Goddard ◽  
Jeffrey P. Lassig ◽  
Tariq M. Janjua ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Novel Treatment ◽  
Cerebellar Artery ◽  
Aneurysmal Dilation ◽  
History Of ◽  
The Mean ◽  
Pica Aneurysms ◽  
Lost To Follow Up ◽  
Dissecting Aneurysms

The authors report a novel management option for patients with complex dissecting aneurysms of the posterior inferior cerebellar artery (PICA). The authors reviewed the medical records and neuroimaging studies of 3 patients who underwent a novel surgical treatment for complicated dissecting PICA aneurysms. The mean follow-up period was 1.1 years, and no patient was lost to follow-up. Two patients were in poor condition following an acute, severe subarachnoid hemorrhage, and 1 presented with headaches and a remote history of bleeding. All patients underwent surgical occlusion of the PICA beyond the tonsillar loop, distal to the aneurysmal segment. Intraoperative and delayed follow-up angiography demonstrated progressive diminution in size of the aneurysmal dilation but persistent filling of the proximal PICA segments supplying the brainstem. Outcome was good in all cases. This novel technique has been used successfully in 3 cases and, to the authors' knowledge, has not been reported previously.

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