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.

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.

Endovascular parent vessel sacrifice in ruptured dissecting vertebral and posterior inferior cerebellar artery aneurysms: clinical outcomes and review of the literature

2015 ◽  
Vol 8 (8) ◽  
pp. 796-801 ◽  
Author(s):  
Thomas P Madaelil ◽  
Adam N Wallace ◽  
Arindam N Chatterjee ◽  
Gregory J Zipfel ◽  
Ralph G Dacey ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Treatment Method ◽  
Aneurysm Rupture ◽  
Dissecting Aneurysm ◽  
Parent Vessel ◽  
Cerebellar Artery ◽  
Pica Aneurysms ◽  
Dissecting Aneurysms

BackgroundRuptured intracranial dissecting aneurysms must be secured quickly to prevent re-hemorrhage. Endovascular sacrifice of the diseased segment is a well-established treatment method, however postoperative outcomes of symptomatic stroke and re-hemorrhage rates are not well reported, particularly for the perforator-rich distal vertebral artery or proximal posterior inferior cerebellar artery (PICA).MethodsWe retrospectively reviewed cases of ruptured distal vertebral artery or PICA dissecting aneurysms that underwent endovascular treatment. Diagnosis was based on the presence of subarachnoid hemorrhage on initial CT imaging and of a dissecting aneurysm on catheter angiography. Patients with vertebral artery aneurysms were selected for coil embolization of the diseased arterial segment based on the adequacy of flow to the basilar artery from the contralateral vertebral artery. Patients with PICA aneurysms were generally treated only if they were poor surgical candidates. Outcomes included symptomatic and asymptomatic procedure-related cerebral infarction, recurrent aneurysm rupture, angiographic aneurysm recurrence, and estimated modified Rankin Scale (mRS).ResultsDuring the study period, 12 patients with dissecting aneurysms involving the distal vertebral artery (n=10) or PICA (n=2) were treated with endovascular sacrifice. Two patients suffered an ischemic infarction, one of whom was symptomatic (8.3%). One patient (8.3%) died prior to hospital discharge. No aneurysm recurrence was identified on follow-up imaging. Ten patients (83%) made a good recovery (mRS ≤2). Median clinical and imaging follow-up periods were 41.7 months (range 0–126.4 months) and 14.3 months (range 0.03–88.6 months), respectively.ConclusionsIn patients with good collateral circulation, endovascular sacrifice may be the preferred treatment for acutely ruptured dissecting aneurysms involving the distal vertebral artery.

Dissecting aneurysms of the posterior inferior cerebellar artery: retrospective evaluation of management and extended follow-up review in 6 patients

2008 ◽  
Vol 109 (1) ◽  
pp. 23-27 ◽  
Author(s):  
Eric S. Nussbaum ◽  
Michael T. Madison ◽  
Mark E. Myers ◽  
James Goddard ◽  
Tariq Janjua
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Occipital Artery ◽  
Management Protocol ◽  
Cerebellar Artery ◽  
Acute Subarachnoid Hemorrhage ◽  
Pica Aneurysms ◽  
Proximal Occlusion ◽  
Individualized Management ◽  
Dissecting Aneurysms

Object The authors report the management protocol and successful outcomes in 6 patients with dissecting aneurysms of the posterior inferior cerebellar artery (PICA). Methods Medical records and neuroimaging studies of 6 patients who underwent surgical treatment of dissecting PICA aneurysms were reviewed. The mean follow-up duration was 1.8 years. No patient was lost to follow-up review. Results Four patients presented with acute subarachnoid hemorrhage and 2 with PICA ischemia. All patients underwent surgery, which entailed proximal occlusion with distal revascularization in 3 cases and circumferential wrap/clip reconstruction in 3 cases. The revascularization techniques used were occipital artery–PICA bypass and PICA–PICA anastomosis. Delayed follow-up angiography was performed in all cases. In patients treated with proximal occlusion, delayed angiography showed minimal retrograde opacification of the dissected segments. The 3 patients treated with wrap/clip reconstruction showed unexpectedly significant normalization of their lesions on angiographic studies. Outcome was good in all cases. Conclusions Dissecting PICA aneurysms are rare lesions with an apparent propensity for bleeding. Individualized management including distal revascularization with PICA sacrifice or circumferential wrap/clip reconstruction to reinforce the dissected segment produced good outcomes. Patients treated with aneurysm wrapping may show dramatic angiographic improvement of the dissected segment.

Endovascular Treatment of Bilateral Intracranial Vertebral Artery Dissecting Aneurysms Presenting With Subarachnoid Hemorrhage

2011 ◽  
Vol 70 (suppl_1) ◽  
pp. ons75-ons81 ◽  
Author(s):  
Yong Sam Shin ◽  
Byung Moon Kim ◽  
Se-Hyuk Kim ◽  
Sang Hyun Suh ◽  
Chang Woo Ryu ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Endovascular Treatment ◽  
Vertebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Stent Insertion ◽  
Treatment Methods ◽  
Cerebellar Artery ◽  
Endovascular Methods ◽  
Dissecting Aneurysms

Abstract BACKGROUND: Optimal management of bilateral vertebral artery dissecting aneurysms (bi-VDAs) causing subarachnoid hemorrhage (SAH) remains unclear. OBJECTIVE: To investigate the treatment methods and outcomes of bi-VDA causing SAH. METHODS: Seven patients were treated endovascularly for bi-VDA causing SAH. Treatment methods and outcomes were evaluated retrospectively. RESULTS: Two patients were treated with 2 overlapping stents for both ruptured and unruptured VDAs, 2 with 2 overlapping stents and coiling for ruptured VDA and with conservative treatment for unruptured VDA, 1 with internal trapping (IT) for ruptured VDA and stent-assisted coiling for unruptured VDA, 1 with IT for ruptured VDA and 2 overlapping stents for unruptured VDA, and 1 with IT for ruptured VDA and a single stent for unruptured VDA. None had rebleeding during follow-up (range, 15-48 months). All patients had favorable outcomes (modified Rankin Scale score, 0-2). On follow-up angiography at 6 to 36 months, 9 treated and 2 untreated VDAs revealed stable or improved state, whereas 3 VDAs in 2 patients showed regrowth. Of the 3 recurring VDAs, 1 was initially treated with IT but recurred owing to retrograde flow to the ipsilateral posterior inferior cerebellar artery (PICA), the second was treated with single stent but enlarged, and the last was treated with 2 overlapping stents and coiling but recurred from the remnant sac harboring the PICA origin. All 3 recurred VDAs were retreated with coiling with or without stent insertion. CONCLUSION: Bilateral VDAs presenting with SAH were safely treated with endovascular methods. However, endovascular treatment may be limited for VDAs with PICA origin involvement.

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.

Intracranial Bypass of Posterior Inferior Cerebellar Artery Aneurysms: Indications, Technical Aspects, and Clinical Outcomes

2017 ◽  
Vol 13 (5) ◽  
pp. 586-595 ◽  
Author(s):  
David J. Bonda ◽  
Mohamad Labib ◽  
Jeffrey M. Katz ◽  
Rafael A. Ortiz ◽  
David Chalif ◽  
...  
Keyword(s):  
Cranial Nerve ◽  
Posterior Inferior Cerebellar Artery ◽  
Surgical Techniques ◽  
Occipital Artery ◽  
Traumatic Aneurysm ◽  
Surgical Clipping ◽  
Bypass Patency ◽  
Cerebellar Artery ◽  
Diseased Segment ◽  
Pica Aneurysms

Abstract BACKGROUND: For some posterior inferior cerebellar artery (PICA) aneurysms, there is no constructive endovascular or direct surgical clipping option. Intracranial bypass is an alternative to a deconstructive technique. OBJECTIVE: To evaluate the clinical features, surgical techniques, and outcome of PICA aneurysms treated with bypass and obliteration of the diseased segment. METHODS: Retrospective review of PICA aneurysms treated via intracranial bypass was performed. Outcome measurements included postoperative stroke, cranial nerve deficits, gastrostomy/tracheostomy requirement, bypass patency, modified Rankin scale (mRS) at discharge, and mRS at 6 mo. RESULTS: Seven patients with PICA aneurysms treated with intracranial bypass were identified. Five had fusiform aneurysms (4 ruptured, 1 unruptured), 1 had a giant partially thrombosed saccular aneurysm (unruptured), and 1 had a dissecting traumatic aneurysm (ruptured). Two aneurysms were at the anteromedullary segment, 4 at the lateral medullary segment, and 1 at the tonsillomedullary segment. Three patients underwent PICA-to-PICA side to side anastomoses, 2 PICA-to-PICA reanastomosis, 1 vertebral artery-to-PICA bypass, and 1 occipital artery-PICA bypass. Six out of 7 aneurysms were obliterated surgically and 1 with additional endovascular occlusion after the bypass. All bypasses were patent intraoperatively; 2 were later demonstrated occluded without radiological signs or symptoms of stroke. No patients had new cranial nerve deficit postoperatively. With the exception of 1 death due to pulmonary emboli 3 mo postoperatively, all others remain at a mRS ≤ 2. CONCLUSION: Constructive bypass and aneurysm obliteration remains a viable alternative for treatment of PICA aneurysms not amenable to direct surgical clipping or to a vessel-preserving endovascular option.

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.

scholarly journals Endovascular Treatment of Ruptured Dissecting Posterior Inferior Cerebellar Artery Aneurysms

2012 ◽  
Vol 18 (4) ◽  
pp. 442-448 ◽  
Author(s):  
I. Ioannidis ◽  
N. Nasis ◽  
A. Andreou
Keyword(s):  
Endovascular Treatment ◽  
Medical Center ◽  
Posterior Inferior Cerebellar Artery ◽  
Vascular Anatomy ◽  
Parent Artery ◽  
Parent Vessel ◽  
Cerebellar Artery ◽  
Clinical Records ◽  
Dissecting Aneurysms

Dissecting aneurysms of the posterior inferior cerebellar artery (PICA) distal to its origin from vertebral artery (VA) are very rare. Although rare, they associated with a high risk of rebleeding and they present a therapeutic challenge. This study reviewed the clinical presentations, angiographic characteristics of dissecting aneurysms of the PICA and to assess the clinical and angiographic outcomes of patients who underwent endovascular treatment. Ten patients with ten dissecting aneurysms who underwent endovascular treatment were identified in the clinical records of a single medical center from January 2000 to December 2010. The mean follow-up duration was 2.8 years. All patients presented with subarachnoid hemorrhage (SAH). They all underwent endovascular treatment, which included occlusion of the dissected segment and the parent artery after detailed angiographic evaluation of the vascular anatomy, and test occlusion of the PICA. In all patients the endovascular treatment was successfully completed without procedure related complications. Long-term follow-up studies in seven out of ten patients showed complete occlusion of the aneurysm with no new neurologic deficits. The clinical outcome was good in eight cases, whereas two patients with poor clinical condition at admission died during their initial hospital stay. Endovascular occlusion of the parent vessel and the dissected segment is relatively safe treatment option for dissecting aneurysms of the PICA distal to its origin.

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms

2009 ◽  
Vol 110 (3) ◽  
pp. 418-426 ◽  
Author(s):  
Min He ◽  
Heng Zhang ◽  
Ding Lei ◽  
Bo-Yong Mao ◽  
Chao You ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Stent Graft ◽  
Posterior Inferior Cerebellar Artery ◽  
Covered Stent ◽  
Stent Grafts ◽  
Graft Placement ◽  
Cerebellar Artery ◽  
Covered Stent Graft ◽  
Dissecting Aneurysms

Object Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation. Methods Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically. Results Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement. Conclusions Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.

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.

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