Application of parallel stent placement in the treatment of unruptured vertebrobasilar fusiform aneurysms

OBJECTIVE Large vertebrobasilar fusiform aneurysms (VFAs) represent a small subset of intracranial aneurysms and are often among the most difficult to treat. Current surgical and endovascular techniques fail to achieve a complete or acceptable result because of complications, including late-onset basilar artery thrombosis and perforator infarction. The parallel-stent placement technique was established in the authors' department, and this study reports the application of this technique in the treatment of unruptured VFAs. METHODS Eight patients with 8 unruptured VFAs who underwent parallel stent placement between April 2011 and August 2012 were included. The diameters of the VFAs ranged from 7.9 to 14.0 mm, and the lengths from 27.5 to 54.4 mm. Of the 8 patients with unruptured VFAs, 3 received double or triple parallel stents and 5 patients received a series-connected stent with another 1 or 2 stents deployed parallel to them. Outcomes for these patients were tabulated, based on the modified Rankin Scale (mRS) score and angiographic results. RESULTS All of the 25 stents were successfully placed without any treatment-related complications. During follow-up, 5 patients had decreased mRS scores, 2 were unchanged, and 1 was increased for subarachnoid hemorrhage. Immediate and follow-up clinical outcome was completely or partially recovered in most patients. Follow-up angiograms revealed 2 aneurysms were reduced in size and 6 were unchanged after stent placement. No in-stent stenosis, occlusion of the posterior inferior cerebellar artery, or perforators jailed by the stent occurred in any of the aneurysms. CONCLUSIONS These results provide encouraging support for the parallel-stent placement technique, which can be envisaged as an alternative strategy against unruptured VFAs. However, testing in more patients is needed.

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Stent Placement to Treat Ruptured Vertebral Dissecting Aneurysms

Interventional Neuroradiology ◽

10.1177/159101991301900412 ◽

2013 ◽

Vol 19 (4) ◽

pp. 479-482 ◽

Cited By ~ 12

Author(s):

Yong-An Chen ◽

Rong-Bo Qu ◽

Yu-Song Bian ◽

Wei Zhu ◽

Kun-Peng Zhang ◽

...

Keyword(s):

Endovascular Treatment ◽

Stent Placement ◽

Posterior Inferior Cerebellar Artery ◽

Aneurysm Rupture ◽

Dissecting Aneurysm ◽

Related Complication ◽

Cerebellar Artery ◽

Good Patency ◽

Dissecting Aneurysms

Conventional endovascular treatment may have limitations for vertebral dissecting aneurysm involving the origin of the posterior inferior cerebellar artery (PICA). We report our experiences of treating vertebral dissecting aneurysm with PICA origin involvement by placing a stent from the distal vertebral artery (VA) to the PICA to save the patency of the PICA. Stenting from the distal VA to the PICA was attempted to treat ruptured VA dissecting aneurysm involving the PICA origin with sufficient contralateral VA in eight patients. The procedure was successfully performed in seven patients with one failure because of PICA origin stenosis, which was treated with two overlapping stents. In the seven patients, PICAs had good patency on postoperative angiography and transient lateral brainstem ischemia represents a procedure-related complication. Follow-up angiographies were performed in seven patients and showed recanalization of the distal VA in three patients without evidence of aneurysmal filling. There was no evidence of aneurysm rupture during the follow-up period, and eight patients had favorable outcomes (mRS, 0–1). Placing a stent from the distal VA to the PICA with VA occlusion may present an alternative to conventional endovascular treatment for vertebral dissecting aneurysm with PICA origin involvement with sufficient contralateral VA.

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Hemifacial Spasm: Endoscopic Vascular Decompression

Otolaryngology ◽

10.1016/s0194-5998(97)70118-9 ◽

1997 ◽

Vol 117 (4) ◽

pp. 308-314 ◽

Cited By ~ 32

Author(s):

J. Magnan ◽

F. Caces ◽

P. Locatelli ◽

A. Chays

Keyword(s):

Hemifacial Spasm ◽

Marked Improvement ◽

Cerebellopontine Angle ◽

Posterior Inferior Cerebellar Artery ◽

Endoscopic Examination ◽

Anterior Inferior Cerebellar Artery ◽

Cerebellar Artery ◽

The Mean ◽

Vascular Decompression

Sixty patients with primitive hemifacial spasm were treated by means of a minimally invasive retrosigmoid approach in which endoscopic and microsurgical procedures were combined. Intraoperative endoscopic examination of the cerebellopontine angle showed that for 56 of the patients vessel-nerve conflict was the cause of hemifacial spasm. The most common offending vessel was the posterior inferior cerebellar artery (39 patients), next was the vertebral artery (23 patients), and last was the anterior inferior cerebellar artery (16 patients). Nineteen of the patients had multiple offending vascular loops. In one patient, another cause of hemifacial spasm was an epidermoid tumor of the cerebellopontine angle. For three patients, it was not possible to determine the exact cause of the facial disorder. Follow-up information was reviewed for 54 of 60 patients; the mean follow-up period was 14 months. Fifty of the patients were in the vessel-nerve conflict group. Forty of the 50 were free of symptoms, and four had marked improvement. The overall success rate was 88%, and there was minimal morbidity (no facial palsy, two cases of severe hearing loss).

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

Operative Neurosurgery ◽

10.1227/neu.0b013e31822ed1f0 ◽

2011 ◽

Vol 70 (suppl_1) ◽

pp. ons75-ons81 ◽

Cited By ~ 1

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.

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

Neurosurgery ◽

10.1227/01.neu.0000204127.81249.28 ◽

2006 ◽

Vol 58 (4) ◽

pp. 619-625 ◽

Cited By ~ 51

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.

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The use of flow diverters to treat aneurysms of the posterior inferior cerebellar artery: Report of three cases

Interventional Neuroradiology ◽

10.1177/1591019918774877 ◽

2018 ◽

Vol 24 (5) ◽

pp. 489-498 ◽

Cited By ~ 16

Author(s):

Pervinder Bhogal ◽

Jorge Chudyk ◽

Carlos Bleise ◽

Ivan Lylyk ◽

Hans Henkes ◽

...

Keyword(s):

Treatment Option ◽

Intraoperative Complications ◽

Posterior Inferior Cerebellar Artery ◽

Endovascular Coiling ◽

Medical Illness ◽

Unruptured Aneurysms ◽

Alternative Treatment Option ◽

Cerebellar Artery ◽

Flow Diverters

Objective The objective of this study was to report our experience on the use of flow diverting stents placed within the posterior inferior cerebellar artery (PICA) as a treatment option for aneurysms of the PICA. Methods Three patients with aneurysms of the PICA, both ruptured and unruptured, underwent treatment of their aneurysms with placement of a single flow diverter in the PICA across the neck of the aneurysm. Adjunctive techniques such as coiling were not used. We present the angiographic and clinical follow-up data. Results The procedure was a technical success in all cases and there were no intraoperative complications. Follow-up data were available for two patients and this showed complete occlusion of the aneurysm with the PICA remaining patent. There was no evidence, either clinical or radiological, of medullary or pontine infarction. One patient died during the follow-up period from an unrelated medical illness (community acquired pneumonia). Conclusion Flow diverters can be successfully placed within the PICA to treat both ruptured and unruptured aneurysms, and they represent an alternative treatment option to endovascular coiling or microscopic neurosurgery.

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LVIS Blue as a low porosity stent and coil adjuvant

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013608 ◽

2018 ◽

Vol 10 (7) ◽

pp. 682-686 ◽

Cited By ~ 7

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.

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Direct puncture of the V3 segment of the vertebral artery in acute basilar artery stroke: an alternative approach in desperate circumstances

BMJ Case Reports ◽

10.1136/bcr-2019-231335 ◽

2019 ◽

Vol 12 (8) ◽

pp. e231335 ◽

Cited By ~ 1

Author(s):

Sean Thomas O’Reilly ◽

Ian Rennie ◽

Jim McIlmoyle ◽

Graham Smyth

Keyword(s):

Vertebral Artery ◽

Basilar Artery ◽

Posterior Inferior Cerebellar Artery ◽

Left Vertebral Artery ◽

Basilar Artery Thrombosis ◽

Direct Puncture ◽

Alternative Approach ◽

Cerebellar Artery ◽

First Pass ◽

The Right

A patient in his mid-40s presented with acute basilar artery thrombosis 7 hours postsymptom onset. Initial attempts to perform mechanical thrombectomy (MT) via the femoral and radial arterial approaches were unsuccessful as the left vertebral artery (VA) was occluded at its origin and the right VA terminated in the posterior inferior cerebellar artery territory, without contribution to the basilar system. MT was thus performed following ultrasound-guided direct arterial puncture of the left VA in its V3 segment, with antegrade advancement of a 4 French radial access sheath. First pass thrombolyisis in cerebral infarction (TICI) 3 recanalisation achieved with a 6 mm Solitaire stent retriever and concurrent aspiration on the 4 French sheath. Vertebral closure achieved with manual compression.

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Revascularization and Aneurysm Surgery

Neurosurgery ◽

10.1227/neu.0000000000000312 ◽

2014 ◽

Vol 74 (5) ◽

pp. 482-498 ◽

Cited By ~ 66

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016261 ◽

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.

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Woven Endobridge device for treatment of dissection-related PICA aneurysm

Interventional Neuroradiology ◽

10.1177/1591019920968349 ◽

2020 ◽

pp. 159101992096834

Author(s):

Nicolas K Khattar ◽

Andrew C White ◽

Aurora S Cruz ◽

Shawn W Adams ◽

Kimberly S Meyer ◽

...

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Sudden Onset ◽

Dissecting Aneurysm ◽

Excellent Outcome ◽

Cerebellar Artery ◽

Woven Endobridge ◽

Web Device ◽

Work Up ◽

Distal Vessel

Ruptured vertebrobasilar dissecting aneurysms require urgent, often challenging treatment as they have with a high re-hemorrhage rate within the first 24 hours. The patient is a 57-year-old woman who presented with severe-sudden onset headache. Further work up showed a ruptured dissecting aneurysm of the caudal loop of the posterior inferior cerebellar artery (PICA) with associated narrowing distally, in the ascending limb. The aneurysm was immediately occluded with a Woven Endobridge (WEB) device (MicroVention, Tustin, CA, USA) while flow diversion treatment of the diseased ascending limb was postponed. Follow-up angiography three months later showed complete occlusion of the aneurysm, as well as healing of the diseased distal vessel, obviating the need for further intervention. WEB embolization of a ruptured dissecting posterior circulation aneurysm provided an excellent outcome for this patient.

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