Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion

Fusiform aneurysms are uncommon compared with their saccular counterparts, yet they remain very challenging to treat and are associated with high rates of rebleeding and morbidity. Lack of a true aneurysm neck renders simple clip reconstruction or coil embolization usually impossible, and more advanced techniques are required, including bypass, stent-assisted coiling, and, more recently, flow diversion. In this article, the authors review posterior circulation fusiform aneurysms, including pathogenesis, natural history, and endovascular treatment, including the role of flow diversion. In addition, the authors propose an algorithm for treatment based on their practice.

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Treatment of posterior circulation non-saccular aneurysms with flow diversion versus stent-assisted coiling: a systematic review and meta-analysis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016294 ◽

2020 ◽

pp. neurintsurg-2020-016294 ◽

Cited By ~ 2

Author(s):

Ricardo A Domingo ◽

Shashwat Tripathi ◽

Carlos Perez-Vega ◽

Tito Vivas-Buitrago ◽

Victor M Lu ◽

...

Keyword(s):

Clinical Outcomes ◽

Meta Analysis ◽

Similar Efficacy ◽

Posterior Circulation ◽

Flow Diversion ◽

True Aneurysm ◽

Aneurysm Neck ◽

Significant Difference ◽

Occlusion Rate ◽

Saccular Aneurysms

Treatment of non-saccular aneurysms of the posterior circulation poses a great challenge with unpredictable outcomes due to the absence of a true aneurysm neck and the presence of perforating vessels. In this article, we aim to compare endovascular treatment of unruptured posterior circulation non-saccular aneurysms with stent-assisted coiling (SAC) and flow diversion (FD) in terms of occlusion rate and clinical outcomes. A systematic search of electronic databases from inception to August 2019 identified 484 articles for screening. After proper inclusion/exclusion criteria, 15 articles were included and data were extracted and analyzed using meta-analysis of proportions. The pooled cohort consisted of 430 aneurysms: 128 (29.7%) treated with SAC in 5 studies and 302 (70.3%) treated with FD in 11 studies. Complete/near-complete occlusion was achieved in 83% after FD (95% CI 0.75 to 0.90; I2=45%) and 84% after SAC (95% CI 0.72 to 0.91; I2=22%), with no significant difference between techniques (p=0.95). Periprocedural complications were observed in 18% after FD (95% CI 0.14 to 0.23; I2=0%) and 6% after SAC (95% CI 0.02 to 0.13; I2=0%); the subgroup analysis was statistically significant (p=0.008). Furthermore, no statistically significant difference was observed in favorable clinical outcomes between groups. These results suggest similar efficacy in occlusion rate and favorable clinical outcome for posterior circulation non-saccular aneurysms treated with SAC and FD. Stroke was the most common complication regardless of treatment modality, and a lower periprocedural complication rate was noted with SAC. Further studies are needed with the primary focus of reducing the risk of stroke with either modality.

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125 Staged Endovascular Treatment of Ruptured Intracranial Aneurysms: Acute Coiling Followed By Delayed Flow Diversion

Neurosurgery ◽

10.1093/neuros/nyx417.125 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 228-228

Author(s):

Erick Michael Westbroek ◽

Matthew Bender ◽

Narlin B Beaty ◽

Bowen Jiang ◽

Risheng Xu AB ◽

...

Keyword(s):

Endovascular Treatment ◽

Complication Rate ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Major Complication ◽

Flow Diversion ◽

Neurological Deficits ◽

Major Complication Rate ◽

Ruptured Intracranial Aneurysms

Abstract INTRODUCTION ISAT demonstrated that coiling is effective for aneurysm treatment in subarachnoid hemorrhage (SAH); however, complete occlusion of wide-necked aneurysms frequently requires adjuvants relatively contraindicated in SAH. As such, a limited “dome occlusive” strategy is often pursued in the setting of SAH. We report a single institution series of coiling of acutely ruptured aneurysms followed by delayed flow diversion for definitive, curative occlusion. METHODS A prospectively collected IRB-approved database was screened for patients with aneurysmal SAH who were initially treated by coil embolization followed by planned flow diversion at a single academic medical institution. Peri-procedural outcomes, complications, and angiographic follow-up were analyzed. RESULTS >50 patients underwent both acute coiling followed by delayed, planned flow diversion. Average aneurysm size on initial presentation was 9.5 mm. Common aneurysm locations included Pcomm (36%), Acomm (30%), MCA (10%), ACA (10%), and vertebral (5%). Dome occlusion was achieved in all cases following initial coiling. Second-stage implantation of a flow diverting stent was achieved in 49/50 cases (98%). Follow-up angiography was available for 33/50 patients (66%), with mean follow-up of 11 months. 27 patients (82%) had complete angiographic occlusion at last follow up. All patients with residual filling at follow-up still had dome occlusion. There were no mortalities (0%). Major complication rate for stage I coiling was 2% (1 patient with intra-procedural aneurysm re-rupture causing increase in a previous ICH). Major complication rate for stage 2 flow diversion was 2% (1 patient with ischemic stroke following noncompliance with dual antiplatelet regimen). Minor complications occurred in 2 additional patients (4%) with transient neurological deficits. CONCLUSION Staged endovascular treatment of ruptured intracranial aneurysms with acute dome-occlusive coil embolization followed by delayed flow diversion is a safe and effective treatment strategy.

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Panacea or problem: flow diverters in the treatment of symptomatic large or giant fusiform vertebrobasilar aneurysms

Journal of Neurosurgery ◽

10.3171/2012.2.jns111942 ◽

2012 ◽

Vol 116 (6) ◽

pp. 1258-1266 ◽

Cited By ~ 179

Author(s):

Adnan H. Siddiqui ◽

Adib A. Abla ◽

Peter Kan ◽

Travis M. Dumont ◽

Shady Jahshan ◽

...

Keyword(s):

Natural History ◽

Intracranial Aneurysms ◽

Neurological Status ◽

Posterior Circulation ◽

The Other ◽

Flow Diversion ◽

Morbidity And Mortality ◽

Anterior Circulation ◽

Subsequent Withdrawal ◽

Vertebrobasilar Aneurysms

Object The use of flow-diverting stents has gained momentum as a curative approach in the treatment of complex proximal anterior circulation intracranial aneurysms. There have been some reported attempts of treating formidable lesions in the posterior circulation. Posterior circulation giant fusiform aneurysms have a particularly aggressive natural history. To date, no one approach has been shown to be comprehensively effective or low risk. The authors report the initial results, including the significant morbidity and mortality encountered, with flow diversion in the treatment of large or giant fusiform vertebrobasilar aneurysms at Millard Fillmore Gates Circle Hospital. Methods The authors retrospectively reviewed their prospectively collected endovascular database to identify patients with intracranial aneurysms who underwent treatment with flow-diverting devices and determined that 7 patients had presented with symptomatic large or giant fusiform vertebrobasilar aneurysms. The outcomes of these patients, based on the modified Rankin Scale (mRS), were tabulated, as were the complications experienced. Results Among the 7 patients, Pipeline devices were placed in 6 patients and Silk devices in 1 patient. At the last follow-up evaluation, 4 patients had died (mRS score of 6), all of whom were treated with the Pipeline device. The other 3 patients had mRS scores of 5 (severe disability), 1, and 0. The deaths included posttreatment aneurysm ruptures in 2 patients and lack of improvement in neurological status related to presenting brainstem infarcts and subsequent withdrawal of care in the other 2 patients. Conclusions Whether flow diversion will be an effective strategy for treatment of large or giant fusiform vertebrobasilar aneurysms remains to be seen. The authors' initial experience suggests substantial morbidity and mortality associated with the treatment and with the natural history. As outcomes data slowly become available for patients receiving these devices for fusiform posterior circulation aneurysms, practitioners should use these devices judiciously.

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Bipolar radiofrequency ablation of aneurysm remnants after coil embolization can improve endovascular treatment of experimental bifurcation aneurysms

Journal of Neurosurgery ◽

10.3171/2016.3.jns152871 ◽

2017 ◽

Vol 126 (5) ◽

pp. 1537-1544 ◽

Cited By ~ 2

Author(s):

Xavier Boileau ◽

Han Zeng ◽

Robert Fahed ◽

Fabrice Bing ◽

Alina Makoyeva ◽

...

Keyword(s):

Radiofrequency Ablation ◽

Endovascular Treatment ◽

Coil Embolization ◽

Treated Group ◽

Experimental Models ◽

Ordinal Scale ◽

Control Group ◽

Median Score ◽

Aneurysm Neck ◽

Bipolar Radiofrequency

OBJECTIVEEndovascular treatment of aneurysms may result in incomplete initial occlusion and aneurysm recurrence at angiographic follow-up studies. This study aimed to assess the feasibility and efficacy of bipolar radiofrequency ablation (RFA) of aneurysm remnants after coil embolization.METHODSBipolar RFA was accomplished using the coil mass as 1 electrode, while the second electrode was a stent placed across the aneurysmal neck. After preliminary experiments and protocol approval from the Animal Care committee, wide-necked bifurcation aneurysms were constructed in 24 animals. Aneurysms were allocated to 1 of 3 groups: partial intraoperative coil embolization, followed by RFA (n = 12; treated group) or without RFA (n = 6; control group 1); or attempted complete endovascular coil embolization 2–4 weeks later (n = 6; control group 2). Angiographic results were compared at baseline, immediately after RFA, and at 12 weeks, using an ordinal scale. Pathological results and neointima formation at the neck were compared using a semiquantitative grading scale.RESULTSBipolar RFA was able to reliably target the aneurysm neck when the coil mass and stent were used as electrodes. RFA improved angiographic results immediately after partial coiling (p = 0.0024). Two RFA-related complications occurred, involving transient occlusion of 1 carotid artery and 1 hemorrhage from an adventitial arterial blister. At 12 weeks, angiographic results were improved with RFA (median score of 0), when compared with controls (median score of 2; p = 0.0013). Neointimal closure of the aneurysm neck was better with RFA compared with controls (p = 0.0003).CONCLUSIONSBipolar RFA can improve results of embolization in experimental models by selectively ablating residual lesions after coil embolization.

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Intracranial pediatric aneurysms: endovascular treatment and its outcome

Journal of Neurosurgery Pediatrics ◽

10.3171/2012.5.peds1210 ◽

2012 ◽

Vol 10 (3) ◽

pp. 230-240 ◽

Cited By ~ 52

Author(s):

Rashmi Saraf ◽

Manish Shrivastava ◽

Wuppalapati Siddhartha ◽

Uday Limaye

Keyword(s):

Endovascular Treatment ◽

Pediatric Patients ◽

Clinical Presentation ◽

Morphological Characteristics ◽

Posterior Circulation ◽

Anterior Communicating Artery ◽

Endovascular Management ◽

Parent Vessel ◽

Anterior Circulation ◽

Common Location

Object The aim of this study was to analyze the location, clinical presentation, and morphological characteristics of pediatric aneurysms and the safety, feasibility, and durability of endovascular treatment. Methods The authors conducted a retrospective study of all cases involving patients 18 years old or younger who underwent endovascular treatment for pediatric aneurysms at their institution between July 1998 and July 2010. The clinical presentation, aneurysm location, endovascular management, and treatment outcome were studied. Results During the study period, 23 pediatric patients (mean age 13 years, range 2 months–18 years) were referred to the authors' department and underwent endovascular treatment for aneurysms. The aneurysms were saccular in 6 cases, dissecting in 4, infectious in 5, and giant partially thrombosed lesions in 8. Fourteen of the aneurysms were ruptured, and 9 were unruptured. Thirteen were in the anterior circulation and 10 in the posterior circulation. The most common location in the anterior circulation was the anterior communicating artery; in the posterior circulation, the most common location was the basilar artery. Saccular aneurysms were the most common type in the anterior circulation; and giant partially thrombosed and dissecting aneurysms were the most common types in the posterior circulation. Coil embolization was performed in 7 cases, parent vessel sacrifice in 10, flow reversal in 3, glue embolization in 2, and stent placement in 1. Immediate angiographic cure was seen in 21 (91%) of 23 patients. Complications occurred in 4 patients, 3 of whom eventually had a good outcome. No patient died. Overall, a favorable outcome was seen in 22 (96%) of 23 patients. Follow-up showed stable occlusion of aneurysms in 96% of the patients. Conclusions Pediatric aneurysms are rare. Their clinical presentation varies from intracranial hemorrhage to mass effect. They may also be found incidentally. Among pediatric patients with aneurysms, giant aneurysms are relatively common. Endovascular management is associated with low rates of complications and is a safe, durable, and effective treatment for pediatric aneurysms.

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White-collar sign as a predictor of outcome after endovascular treatment for cerebral aneurysms

Journal of Neurosurgery ◽

10.3171/2016.2.jns152976 ◽

2017 ◽

Vol 126 (3) ◽

pp. 831-837 ◽

Cited By ~ 1

Author(s):

Kenji Fukuda ◽

Toshio Higashi ◽

Masakazu Okawa ◽

Mitsutoshi Iwaasa ◽

Tsutomu Yoshioka ◽

...

Keyword(s):

Endovascular Treatment ◽

Coil Embolization ◽

Cerebral Aneurysms ◽

White Collar ◽

Negative Group ◽

Positive Group ◽

Complete Occlusion ◽

Neck Size ◽

Aneurysm Neck ◽

Endovascular Coil Embolization

OBJECTIVE The white-collar sign (WCS) is known as a thick neointimal tissue formation at the aneurysm neck after endovascular coil embolization of cerebral aneurysms, which may prevent aneurysm recanalization. The purpose of this study was to evaluate factors involved in the appearance of WCS and to identify radiological and clinical outcomes of treated aneurysms with WCS. METHODS The study included 140 patients with 149 aneurysms in which it was possible to confirm the aneurysm neck between the aneurysm sac and parent artery by using conventional angiography. The WCS was defined as a radiolucent band at the aneurysm neck on the angiogram at 6 months after initial embolization. The radiological outcome was evaluated using MR angiography. RESULTS In 23 of 149 aneurysms (15.4%), a WCS appeared. The WCS-positive group had a significantly smaller neck size (3.3 ± 0.8 mm vs 4.2 ± 1.1 mm, p < 0.001) and smaller aneurysm size (4.3 ± 0.9 mm vs 6.0 ± 2.1 mm, p < 0.001) than the WCS-negative group. Multivariate analysis revealed that WCS appearance was associated with small neck size (OR 0.376, 95% CI 0.179–0.787; p = 0.009). In 106 of 149 aneurysms, the rate of complete occlusion was significantly higher in the WCS-positive group (18/18, 100%) than in the WCS-negative group (n = 54/88, 61.4%; p = 0.001) in the mean follow-up period of 31.0 ± 9.7 months (range 5–52 months). Neither major recanalization nor rupture of the aneurysm occurred in the WCS-positive group. CONCLUSIONS Appearance of the WCS was associated with complete occlusion and good clinical outcome after endovascular coil embolization. The WCS would help to determine the prognosis of cerebral aneurysms after endovascular treatment.

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Targeted endovascular treatment of haemorrhagic posterior fossa proliferative angiopathy

Interventional Neuroradiology ◽

10.1177/1591019918761640 ◽

2018 ◽

Vol 24 (4) ◽

pp. 440-443 ◽

Cited By ~ 3

Author(s):

Suresh Giragani ◽

Santhosh Kumar Pavunesan ◽

Anandh Balasubramaniam

Keyword(s):

Endovascular Treatment ◽

Posterior Fossa ◽

Clinical Features ◽

Arteriovenous Malformations ◽

Treatment Options ◽

Focal Lesion ◽

Imaging Findings ◽

Endovascular Management ◽

Vascular Abnormality

Cerebral proliferative angiopathy (CPA) is a rare vascular abnormality and separate from “classical” brain arteriovenous malformations. Haemorrhage due to proliferative angiopathy is rarely reported. We describe the clinical features, imaging findings and targeted endovascular management for a 12-year-old boy having proliferative angiopathy of the posterior fossa presenting with haemorrhage. Targeted endovascular embolisation in CPA is not previously described in the literature. The optimal treatment options for haemorrhagic CPA are debatable, and we wish to highlight the role of targeted treatment for culprit focal lesion demonstrable on imaging.

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Predictors of recanalization after endovascular treatment of posterior circulation aneurysms

Polish Journal of Surgery ◽

10.5604/01.3001.0010.6734 ◽

2017 ◽

Vol 89 (6) ◽

pp. 7-11

Author(s):

Karol Wiśniewski ◽

Bartłomiej Tomasik ◽

Ernest J. Bobeff ◽

Ludomir Stefańczyk ◽

Dariusz J. Jaskólski

Keyword(s):

Endovascular Treatment ◽

Coil Embolization ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Treatment Strategies ◽

Posterior Circulation ◽

High Rate ◽

Complication Rates ◽

Morphometric Features ◽

Posterior Circulation Aneurysms ◽

Aneurysmal Neck

Introduction. Posterior circulation aneurysms account for approximately 30% of all intracranial aneurysms, and their rupture often causes aneurysmal subarachnoid hemorrhage (aSAH). Because surgical treatment of posterior circulation aneurysms is difficult, endovascular treatment is commonly indicated. However, simple coil embolization is associated with a high rate of recanalization. Our goal was to investigate morphometric aneurysmal features assessed on pre-embolization computed tomography angiography (CTA) as predictors of recanalization in patients with posterior circulation aneurysms. Material and Methods. We retrospectively analyzed data of 24 patients who underwent coil embolization due to rupture of saccular posterior circulation aneurysms. The morphometric features of aneurysms were measured based on pre-embolization 3D-CTA-aneurysm models, and aneurysmal size and volume were measured on digital subtraction angiography (DSA) images. The effectiveness of initial endovascular treatment was determined visually with the modified Raymond Roy classification directly after embolization and on follow-up DSAs. Recanalization was diagnosed when, compared to the primary embolization aneurysm appearance, compaction and filling of the aneurysm occurred. Statistical analysis was performed with Statistica 13.1 software. Results. Higher maximal aneurysm height perpendicular to the aneurysmal neck was associated with a greater aneurysm recanalization risk (12.12±5.13mm vs. 7.41±3.97mm, p=0.039), and this relationship remained significant after adjustment for patient’s age, sex and aneurysm localization (OR=1.26, 95%CI: 1.01-1.60, p=0.047). Maximal aneurysm height perpendicular to the aneurysmal neck distinguished well between recanalized and non-recanalized aneurysms (AUC=0.755, 95%CI: 0.521- 0.989, p=0.033). Conclusions. Predictors of aneurysm recanalization can help choose best endovascular treatment strategies, which could reduce complication rates.

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Endovascular Management of Intracranial Aneurysms: Current Experience and Future Advances

Neurosurgery ◽

10.1227/01.neu.0000237512.10529.58 ◽

2006 ◽

Vol 59 (suppl_5) ◽

pp. S3-93-S3-102 ◽

Cited By ~ 50

Author(s):

Christopher J. Koebbe ◽

Erol Veznedaroglu ◽

Pascal Jabbour ◽

Robert H. Rosenwasser

Keyword(s):

Endovascular Treatment ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Early Recognition ◽

Treatment Method ◽

Endovascular Embolization ◽

Interventional Treatment ◽

Endovascular Management ◽

The Past

Abstract OBJECTIVE: The past 15 years have seen a revolution in the treatment of intracranial aneurysms. Endovascular technology has evolved rapidly since the Food and Drug Administration approval of Guglielmi detachable coils in 1995, which now allows successful treatment of most aneurysms. The authors provide a review of their 11-year experience at Jefferson Hospital for Neuroscience with endovascular embolization of intracranial aneurysms and discuss clinical trial outcomes and future directions of this treatment method. METHODS: The authors reviewed the clinical and angiographic outcomes for 1307 patients undergoing endovascular treatment of intracranial aneurysms. Their analysis focuses on posterior circulation and middle cerebral artery aneurysms, as well as cases of stent-assisted coil embolization. They review their procedural protocol and patient selection criteria for endovascular management. RESULTS: Several large clinical trials have demonstrated the safety and efficacy of endovascular treatment of intracranial aneurysms. The International Subarachnoid Aneurysm Trial provides Level I evidence demonstrating a significant reduction in disability or death with endovascular treatment compared with surgical clipping. The most common procedural complications include intraprocedural rupture and thromboembolic events; avoidance strategies are also discussed. Vasospasm after subarachnoid hemorrhage causes neurological morbidity and mortality and can be successfully managed by early recognition and interventional treatment with angioplasty, pharmacologic agents, or both. CONCLUSION: Long-term studies evaluating experience with aneurysm coil embolization during the past decade indicate that this is a safe and durable treatment method. The introduction of stent-assist techniques has improved the management of wide-neck aneurysms. Future technology developments will likely improve the durability of endovascular treatment further by delivering bioactive agents that promote aneurysm thrombosis beyond the coil mass alone. It is clear that endovascular therapy of both ruptured and unruptured aneurysms is becoming a mainstay of practice in this patient population. Although not replacing open surgery, the continued improvements have allowed aneurysms that previously were amenable only to open clip ligation to be treated safely with durable long-term outcomes.

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Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend?

Frontiers in Neurology ◽

10.3389/fneur.2021.761006 ◽

2021 ◽

Vol 12 ◽

Author(s):

Kun Zhang ◽

Chao Li ◽

Kun Hou ◽

Jinlu Yu

Keyword(s):

Blood Flow ◽

Arteriovenous Malformation ◽

Endovascular Treatment ◽

Vertebral Artery ◽

Arteriovenous Fistula ◽

Vascular Diseases ◽

Posterior Circulation ◽

Anterior Spinal Artery ◽

Collateral Channel

The cervical anterior spinal artery (ASA) is a very important artery arising from the intracranial vertebral artery (VA). It can play different roles in endovascular treatment (EVT) of spinal vascular diseases. The current understanding of these roles is incomplete; therefore, we performed this review. We found that cervical ASA can be involved in many spinal vascular diseases, such as arteriovenous fistula (AVF), arteriovenous malformation (AVM), and aneurysm, and can serve as a collateral channel in proximal VA occlusion. In AVF and AVM, when the cervical ASA is involved, it often plays the role of an accomplice or victim because it acts as the feeder or as a bystander that does not provide blood flow to the AVF and AVM. In cervical ASA aneurysm, the ASA is a victim. During EVT of VA aneurysms or stenoses, the cervical ASA ostia can be covered or occluded, resulting in ASA ischemia. In this situation, the ASA is a victim. In VA occlusion or the subclavian steal phenomenon, the cervical ASA can serve as a collateral channel to provide blood flow to the posterior circulation. In this case, the ASA plays the role of a friend. According to the role of the cervical ASA in spinal vascular diseases, EVT should be determined “case by case.” Most importantly, when EVT is performed to treat these diseases, the cervical ASA axis must be preserved. Therefore, understanding the role of the cervical ASA in spinal vascular diseases is crucial.

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