Vertebral Artery Aneurysm Research Articles

Possibility of Worsening Flow Diversion Effect Due to Morphological Changes of a Stented Artery With Multiple Overlapping Stents for Partially Thrombosed Vertebral Artery Aneurysms.

Background: Morphological changes of a stented artery can cause a flow diversion effect to reduce intra-aneurysmal flow; however, there is a potential for the negative effect of increased intra-aneurysmal flow. We present cases with multiple overlapping stents for a partially thrombosed vertebral artery aneurysm and characterize the hemodynamic properties of a recurrent case by focusing on the morphological changes of the stented artery.Methods: Between October 2017 and April 2019, four consecutive cases of symptomatic unruptured large and giant partially thrombosed vertebral artery aneurysms were treated with multiple overlapping low-profile visualized intraluminal support stents and no coils. Both angiographic and clinical outcomes were assessed. Computational fluid dynamics analysis was performed to clarify hemodynamic features. The degree of pressure elevation was calculated as the pressure difference (Pd). Wall shear stress (WSS) was also calculated.Results: In three of the four cases, successful flow reduction was achieved with no morphological change of the stented arteries. The patients' symptoms were gradually improved. The remaining case required additional stents after the initial treatment. In the recurrent case, Pd was noticeably elevated at the aneurysm neck after treatment, and WSS was generally increased in the area due to altered blood flow into the aneurysm dome caused by morphological changes of the stented artery.Conclusion: Overlapping stents can be used for the treatment of large and giant thrombosed vertebral artery aneurysms with flow diversion effect; however, morphological changes of the stented artery requires careful attention as it may lead to an increase in the intra-aneurysmal flow, causing negative outcomes.

Dissecting spontaneous vertebral artery aneurysms (V4). Endovascular Reconstructive techniques with fd stents. Case series

Background: Spontaneous vertebral artery dissection (SVAD) is rare and occurs in young patients with subarachnoid hemorrhage (HSA) or stroke (3 to 5%). Only 11% occur in the V4 segment of VA. Its treatment changed in parallel with the progress of endovascular technology. Material and Methods: Six consecutive cases of dissecting vertebral artery aneurysms V4 are reported. All males with mean age 35 years. Clinical presentation with headache and neckache in all cases, ischemic stroke and SAH one case each. All patients underwent reconstructive endovascular treatment with FD stent, with or without microcoils. Results: All patients were under dual antiplatelet therapy before EVT (Aspirin 200mg and clopidogrel 75mg or ticagrelor 180mg/day). Reconstructive technique was performed with FD stent in two cases, associated of microcoils and “jailing technique” in two cases or multiple telescoping stents in three cases. Occlusion of the aneurysm and arterial permeability were found in long term follow up in 5 cases. In a case of fusiform aneurysm, there was late thrombosis of the telescoped stents and arterial occlusion without clinical repercussion. Conclusion: Due to the high rate of surgical morbidity, endovascular treatment became the first line for this kind of aneurysm. The reconstruction using a flow bypass and device reconstructive technique is an attractive alternative, showing long-term favorable clinical and angiographic outcomes with the ability to maintain patency of the parental and lateral branch arteries.

Endovascular treatment for ruptured vertebral dissecting aneurysms involving PICA: Reconstruction or deconstruction? Experience from 16 patients.

Ruptured vertebral dissecting aneurysms (VDAs) with posterior inferior cerebellar artery (PICA) involved require an optimal method to isolate the dissection and prevent the symptomatic infraction. This study aims to present our experience with both parent artery occlusion (PAO) and stent-assisted coiling (SAC), and provide a favorable strategy to the management of ruptured VDAs with PICA involved. We retrospectively reviewed patients with subarachnoid hemorrhage in our database from March 2013 to December 2018, suffering from dissecting aneurysms of the intradural vertebral arteries and endovascularly treated. A total of 16 cases with PICA involved were included. Basic information, aneurysm characteristics, procedure related complications and outcomes of patients were analyzed. 10 (62.5%) aneurysms were managed with PAO containing 3 proximal occlusion and 8 targeted-trapping preserved the PICA. 5 (31.3%) aneurysms were treated with SAC and one 6.3%) treated with vertebral artery to PICA stenting and trapping. Two (12.5%) patients died in the acute phase. Good clinical outcomes (modified Rankin Scale 0 to 3) were observed in 13(81.5%) cases in 30 days follow-up. PICA territory infraction was happened in one patient without any dysfunction. Favorable occlusion was observed in 9 of 12 (75%) which were free of further treatment. For patients with good contralateral circulation, PAO could be a first line management for ruptured VDAs with PICA involved. Targeted-trapping with either reserved PICA or proximal occlusion with moderate coiling in aneurysm are promising modalities to prevent severe PICA infraction.

Prevalence and manifestations of diagnosed fibromuscular dysplasia by sex and race: Analysis of >4500 FMD cases in the United States

ObjectiveFibromuscular Dysplasia (FMD) is a rare non-atherosclerotic non-inflammatory vascular disease associated with arterial aneurysms and dissections. The epidemiology of FMD is not well understood. We sought to characterize the epidemiology of FMD utilizing a large aggregated electronic medical record database. MethodsWe used a commercial database (Explorys, IBM Watson), which aggregates data from electronic health records from 26 major integrated healthcare systems in the United States. Fibromuscular dysplasia cases were identified using a unique systemized nomenclature of medical terminology (SNOMED CT) term. We calculated the overall and age-, race-, and sex-based prevalence of FMD, and evaluated sex and race-specific differences in manifestations. ResultsA total of 40,566,670 individuals were active in the database from January 2015 to January 2020. Of these, 4860 had a diagnosis of FMD with an overall prevalence of 12.0 cases per 100,000 individuals. The majority of patients with FMD were female (n=4130, 85.0%), Caucasian (n=3960, 80.5%) and adults aged 18 to 65 years (n=2610, 53.7%). FMD was more common in women (prevalence 18.4 per 100,000) than men (4.0 per 100,000) and among Caucasians (15.8 per 100,000) than African Americans (11.2 per 100,000). Men and African Americans with FMD were more likely to have traditional atherosclerotic risk factors (hypertension, diabetes mellitus type 2, smoking, obesity, hyperlipidemia, chronic kidney disease), and vascular manifestations (stroke, renal infarction, claudication), compared with women and Caucasians. Men with FMD were more likely to have dissection of aorta and renal artery as well as aneurysm of vertebral artery, coronary artery, aorta and iliac artery. African-Americans were more likely to have ruptured aortic aneurysms than Caucasians. ConclusionsThe overall prevalence of FMD in this large aggregated electronic medical record study is estimated at 12.0 per 100,000 persons. FMD is more common in women and Caucasians, with variable characteristics and manifestations.

Institutional Experience of Microsurgical Management in Posterior Circulation Aneurysm.

Introduction:Posterior circulation aneurysm constitutes 15%–20% of all intracerebral aneurysms. With the advancement of endovascular techniques, the microsurgery for posterior circulation aneurysms has been pushed back a little. Even the International Subarachnoid Aneurysmal Trial gave support to the concepts of endovascular procedures, but microsurgical modality should not be discouraged. We present our institutional experience of microsurgical techniques on posterior circulation aneurysms.Materials and Methods:We performed a retrospective analysis of 37 patients of posterior circulation aneurysm from 2015 to 2019, referred to Bantane Hospital, Japan. We included all posterior circulation aneurysms such as basilar tip, basilar trunk, and vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms, admitted and treated with clipping or bypass and trapping. We assessed the outcome as measured by modified Rankin Score (mRS), complications, and mortality.Results:Out of 37 patients, 10 cases were a basilar tip, one case was the basilar trunk, and 26 cases were VA-PICA aneurysm. Intraoperatively, neuromonitoring, indocyanine green dye, dual-image videoangiography (DIVA), and neuro endoscope were used. Two patients of basilar tip aneurysm developed third cranial nerve paresis and six patients of VA-PICA aneurysm developed lower cranial nerve paresis which resolved spontaneously. All the patients were discharged with mRS of 0 or 1. No mortality was recorded in our study.Conclusion:Microsurgical clipping of posterior circulation aneurysm is safe in unruptured aneurysm with a very low risk of mortality and morbidity under experienced hands. All postoperative complications in our study were transient and resolved with time with no residual deficits. Preoperative simulation, intraoperative neuromonitoring, DIVA, and neuro endoscope help achieve complete obliteration of aneurysmal sac and avoid complications.

Endovascular treatment of bilateral intracranial vertebral artery aneurysms: an algorithm based on a 10-year neurointerventional experience

BackgroundThe management of bilateral intracranial vertebral artery dissecting aneurysms (IVADAs) is controversial, and requires the development of endovascular treatment modalities and principles. We aim to investigate the endovascular treatment strategy...

Far lateral approach without occipital condylar resection for intradural ventral/ventrolateral foramen magnum tumors and aneurysms of V4 segment of vertebral artery: Review of surgical results

BackgroundControversies exist regarding the need and extent of condylar resection for safe surgical management of intradural ventral/ventrolateral foramen magnum (VFM) tumors and aneurysms of V4 segment of vertebral artery (VA) by far lateral approach. This retrospective study was conducted to evaluate the results of basic far lateral approach(retrocondylar approach) without upfront occipital condylar resection. Methods and ResultsTwenty one patients underwent surgery via far lateral approach for intradural VFM tumors and aneurysms of V4 segment of VA at Sri Sathya Sai Institute of Higher Medical Sciences during 9 years(2008–2016) study period. Eight patients had VA aneurysms and 13 patients had intradural VFM tumors. After basic far lateral approach(retrocondylar approach), dura was opened and checked if the exposure was adequate for safe surgery. Retrocondylar approach provided adequate exposure for all these lesions and resection of occipital condyle/jugular tubercle was not required in any of these cases. Skeletonization or transposition of VA was not done in any of these cases. Gross total resection of the tumor could be done in 9 patients(9/13–69.2 %) and near total excision (>95 %) in 4 patients (4/13–30.8 %). Seven of the 8 VA aneurysms were successfully clipped. Outcome at a final follow up of 3 months or more was good(mRS<2) in 19 patients(19/21–90.5 %) and poor in 2 patients. Complications included lower cranial nerve deficits [transient-2/21(9.5 %), persisting-2/21(9.5 %)], motor deficits(2/21−9.5%), seventh nerve paresis(1/21−4.8%), sixth nerve paresis(2/21−9.5%) and pseudomeningocele(1/21−4.8%). ConclusionBasic far lateral (retrocondylar) approach provides excellent exposure for majority of VFM tumors and aneurysms of V4 segment of VA. Condylar resection(transcondylar approach), drilling of jugular tubercle (transtubercular approach), skeletonization/transposition of VA might not be required for safe surgical management of majority of these lesions.

Reconstructive vs Deconstructive Endovascular Approach to Intradural Vertebral Artery Aneurysms: A Multicenter Cohort Study.

Parent vessel sacrifice (PVS) has been a traditional way of treating complex aneurysms of the intradural vertebral artery (VA). Flow diversion (FD) has emerged as an alternative reconstructive option. To compare the long-term clinical and radiographic outcomes of intradural VA aneurysms following PVS or FD. We retrospectively reviewed and evaluated 43 consecutive patients between 2009 and 2018 with ruptured and unruptured intradural VA aneurysms treated by PVS or FD. Medical records including clinical and radiological details were reviewed. A total of 43 intradural VA aneurysms were treated during this period. In the 14 PVS patients, the mean follow-up was 19.5 mo, and 71.4% of cases achieved modified Rankin scale (mRS) ≤2 at the last follow-up. A total of 86.5% of cases achieved complete occlusion. There was a 14.3% (2 cases) mortality rate, 14.3% (2 cases) postoperative ischemic complication rate, and 0% postoperative hemorrhaging rate. Retreatment was required in 1 case (7.1%). In the 29 FD patients, the mean follow-up was 21.8 mo, and 89.7% of cases achieved mRS ≤2 at the final follow-up. There was a 3.2% (1 case) mortality rate, 19.4% (6 cases) of postoperative ischemic complications, and 6.5% (2 cases) of postoperative hemorrhagic complications. Complete occlusion was seen in 86.5% patients. No cases required retreatment. Mortality and complication rates were not significantly different between PVS and PED (Pipeline Embolization Device) groups. PVS was associated with comparable intraprocedural complications for VA aneurysms as compared to FD in the largest multicenter study to date. Both procedures have good long-term clinical and radiological outcomes.

Treatment of posterior circulation fusiform aneurysms.

Perforator arteries, the absence of an aneurysm discrete neck, and the often-extensive nature of posterior circulation fusiform aneurysms present treatment challenges. There have been advances in microsurgical and endovascular approaches, including flow diversion, and the authors sought to review these treatments in a long-term series at their neurovascular referral center. The authors performed a retrospective chart review from 1990 to 2018. Primary outcomes were modified Rankin Scale (mRS) scores and Glasgow Outcome Scale (GOS) scores at follow-up. The authors also examined neurological complication rates. Using regression techniques, they reviewed independent and dependent variables, including presenting features, aneurysm location and size, surgical approach, and pretreatment and posttreatment thrombosis. Eighty-four patients met the inclusion criteria. Their mean age was 53 years, and 49 (58%) were female. Forty-one (49%) patients presented with subarachnoid hemorrhage. Aneurysms were located on the vertebral artery (VA) or posterior inferior cerebellar artery (PICA) in 50 (60%) patients, basilar artery (BA) or vertebrobasilar junction (VBJ) in 22 (26%), and posterior cerebral artery (PCA) in 12 (14%). Thirty-one (37%) patients were treated with microsurgical and 53 (63%) with endovascular approaches. Six aneurysms were treated with endovascular flow diversion. The authors found moderate disability or better (mRS score ≤ 3) in 85% of the patients at a mean 14-month follow-up. The GOS score was ≥ 4 in 82% of the patients. The overall neurological complication rate was 12%. In the regression analysis, patients with VA or PICA aneurysms had better functional outcomes than the other groups (p < 0.001). Endovascular strategies were associated with better outcomes for BA-VBJ aneurysms (p < 0.01), but microsurgery was associated with better outcomes for VA-PICA and PCA aneurysms (p < 0.05). There were no other significant associations between patient, aneurysm characteristics, or treatment features and neurological complications (p > 0.05). Patients treated with flow diversion had more complications than those who underwent other endovascular and microsurgical strategies, but the difference was not significant in regression models. Posterior circulation fusiform aneurysms remain a challenging aneurysm subtype, but an interdisciplinary treatment approach can result in good outcomes. While flow diversion is a useful addition to the armamentarium, traditional endovascular and microsurgical techniques continue to offer effective options.

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

Trapping and Thrombectomy of Giant Thrombosed Vertebral Artery Aneurysm via Bilateral Subocciptal Approach – Technical Note

Background: Giant aneurysms arising from the vertebral artery (VA) are rare; they represent 4% to 6% of all intracranial giant aneurysm. The natural history of thrombosed aneurysms is extremely poor. Most such lesions progressively enlarge and result in irreversible progression of neurological deficits and fatal sequelae through resultant compression of the brainstem. We present the clinical experience of giant thrombosed vertebral artery aneurysm successfully treated via a bilateral suboccipital approach. A 62 –year-old woman presented with slight dysarthria and ataxia for one year. Neurological examination showed right lateral gaze nystagmus, bilateral absent corneal reflex, absent gag reflex, bilateral dysdiadochokinesia, poor right finger nose test, and slightly poor tandem gait. MRI showed a 27 mm giant thrombosed left VA aneurysm with brain stem compression. We performed trapping of the aneurysm and thrombectomy through a bilateral suboccipital approach. First, the distal portion was clipped from the left side. Next, the proximal portion was approached from the right side. Thrombectomy was performed and after shrinkage of the aneurysm, the clips were applied involving some part of the aneurysm just distal to PICA.&#x0D; Conclusion: The optimum treatment for aneurysm of this type is thought to be complete obliteration of the parent artery with trapping and thrombectomy to decompress the brainstem. Sometimes if PICA could not be preserved Occipital artery (OA)-PICA bypass should be considered.

Intravenous cangrelor and oral ticagrelor as an alternative to clopidogrel in acute intervention

BackgroundDual antiplatelet therapy (DAP) is necessary to prevent thromboembolic events during carotid stenting, stent-assisted coil embolization, and implant of flow diverters (FD). However, DAP in the acute phase may be...

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

Coverage 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. A 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. Sixty 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. FD 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.

A comparison of endovascular strategies in the treatment of ruptured vertebral artery aneurysms

BackgroundContemporary management of ruptured vertebral artery dissecting aneurysms (VADA) has evolved beyond proximal parent artery occlusion (PPAO) to include endovascular trapping (ET) of the diseased segment and vessel preserving stent treatments. The aim of this retrospective cohort study was to assess the outcomes of patients with ruptured VADAs who underwent endovascular management with trapping of the diseased segment as the first-line treatment approach. MethodsWe evaluated an institutional database of patients with ruptured VADAs who were treated at Auckland City Hospital from 1998 to 2017. Baseline and outcomes data were analyzed. High-grade SAH was defined as a World Federation of Neurological Surgeons or a Hunt and Hess grade of IV-V. Favorable outcome was defined as a modified Rankin Scale of 0–2. ResultsThe study cohort was comprised of 45 ruptured VADA patients with a mean age of 50 years. The mean follow-up duration was 12.9 months. ET of the diseased segment was performed in 32 cases (71.1%), PPAO of the VA was performed in 12 cases (26.7%) and reconstruction using a flow diverting stent was performed in 1 case (2.2%). The overall procedural complication rate was 13%, including procedural neurological morbidity in 4.4%. At last follow-up, no further aneurysm filling was seen in any case, and 77.8% had a favorable outcome. ConclusionET affords a favorable risk to benefit profile for patients with ruptured VADAs. ET remains a reasonable option for ruptured VADAs in patients with sufficient collateral supply to the vertebrobasilar system.

Blind-Alley Formation and Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for the Treatment of Unclippable Vertebral Artery Aneurysms with Posterior Inferior Cerebellar Artery Involvement

Unclippable vertebral artery aneurysms (UVAs) are difficult to treat with direct clipping, especially in cases involving the origin of the posterior inferior cerebellar artery (PICA). Bypass with trapping is the common procedure used for these conditions. The authors used the blind-alley formation technique, which is a simpler method than trapping and can avoid some complications. To report 7 cases of UVA with PICA involvement treated with blind-alley formation and occipital artery (OA)-PICA bypass as well as their surgical outcomes and complications and to describe the operative techniques. Seven patients with UVA and PICA involvement underwent OA-PICA bypass and blind-alley formation (occlusions of the PICA origin and vertebral artery proximal to the aneurysm). Vertebral artery dissecting aneurysms and fusiform atherosclerotic vertebral artery aneurysms were detected in 6 patients and 1 patient, respectively. All patients presented with subarachnoid hemorrhage, and 71.4% of them were classified into the poor-grade group. Good bypass patency and complete aneurysm obliteration were achieved in all cases. Six aneurysms (85.7%) were completely obliterated according to computed tomography angiography performed immediately postoperatively. Another aneurysm was 50% and 100% thrombosed immediately and at 7 days after the operation, respectively. Surgical complications were found in 1 patient (14.3%) who had postoperative diparesis with dysphagia. Three patients (42.9%) achieved a Glasgow Outcome Score of 4 or 5 one month after the operation. Blind-alley formation and OA-PICA bypass are simple, safe, and effective for the treatment of patients with UVA with PICA involvement.

Stent-assisted Coil Embolization of Fusiform Vertebral Artery Aneurysms with Preservation of the Parent Artery

Stent-assisted Coil Embolization of Fusiform Vertebral Artery Aneurysms with Preservation of the Parent Artery

The Pitfalls of the Transcondylar Fossa Approach for the Management of Vertebral Artery Aneurysm

The Pitfalls of the Transcondylar Fossa Approach for the Management of Vertebral Artery Aneurysm

Vertebral artery and posterior inferior cerebellar artery aneurysms: Results of microsurgical treatment of eighty patients.

Background:The choice of surgical approaches and options for the microsurgical vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms repair remains controversial.Methods:A retrospective analysis of the clinical, surgical, and angiographic data of 80 patients with VA and PICA aneurysms treated from 2012 to 2018 was performed.Results:The aneurysms were saccular in 50 cases (62.5%) and fusiform in 30 cases (37.5%). The median suboccipital craniotomy was the most common approach (73.8%). Retrosigmoid craniotomy was performed in 25% of patients. There were the following types of microsurgical operations: neck clipping (61.25%), clipping with the artery lumen formation (13.75%), trapping (10%), proximal clipping (5%), and deconstruction with anastomosis (10%). Fifty-seven (71.3%) patients were discharged without worsening of the clinical signs after surgery. The most common postoperative neurological disorder was palsy of IX and X cranial nerve revealed in 14 (17.5%) patients. No fatal outcomes or patients in vegetative state were identified. The complete occlusion of PICA and VA aneurysms according angiography was in 77 (96.3%) cases.Conclusion:Microsurgical treatment is an effective method for VA and PICA aneurysms. The majority of VA and PICA aneurysms do not require complex basal approaches. A thorough preoperative planning, reconstructive clipping techniques, and anastomoses creation, as well as patient selection based on the established algorithms and consultations with endovascular surgeons, may reduce the number of complications and increase the rate of complete microsurgical occlusion in VA and PICA aneurysms.

Endovascular treatment of vertebral artery dissecting aneurysm: A single-center experience.

The aim of the present study was to explore the optimal treatment strategy for patients with vertebral artery dissecting aneurysms via the endovascular approach. A total of 47 patients (50 aneurysms, including 28 ruptured and 22 unruptured) underwent endovascular treatment between January 2012 and March 2018. Of these aneurysms, 18 were treated by parent artery occlusion, 11 by stent implantation and 21 by stent-assisted coiling. The complete occlusion rate was 100% (18/18) in aneurysms treated by parent artery occlusion and 46.9% (15/32) for stent implantation with or without coiling. External drainage was performed in 8 patients with ruptured aneurysms. Post-operative bleeding occurred in 2 patients treated by stent-assisted coiling. Ventriculo-peritoneal shunt was performed in 4 patients due to delayed hydrocephalus. Post-operative frontal hematoma occurred in one patient treated by stent-assisted coiling. The mortality was 6.4% (3/47) prior to discharge. The recurrence rate was 8.3% (1/12) in aneurysms treated by parent artery occlusion and 13.6% (3/22) in those treated by stent implantation with or without coiling. A total of 39 patients were followed up for 14.56±14.91 months. The good outcome rates were 100% (28/28) in patients with unruptured aneurysms and a Hunt-Hess grade of 1–3, and 72.7% (8/11) in patients with a Hunt-Hess grade of 4 or 5. In conclusion, the present study indicated that endovascular treatment is a safe and efficient method for patients with vertebral artery aneurysm. The treatment strategy should be based on the patient's condition and aneurysmal characteristics. Parent artery occlusion may be suitable for selected patients with ruptured vertebral artery aneurysms.

Radial Artery Access for Treatment of Posterior Circulation Aneurysms Using the Pipeline Embolization Device: Case Series.

The treatment of selected wide-neck and fusiform posterior circulation aneurysms is challenging for clipping as well as for endovascular route. To describe an endovascular approach for vertebral artery aneurysm treatment using transradial access (TRA) instead of the conventional transfemoral access. We collected cases from two institutions in which TRA was used for posterior circulation Pipeline Embolization Device (Medtronic, Dublin, Ireland) deployment. A total of four patients were treated. TRA was useful in the setting of extreme vessel tortuosity. We utilized 5F Terumo Glidesheath (Terumo Medical, Somerset, New Jersey), intermediate catheter, and a 027 microcatheter for Pipeline deployment. TRA was not associated with any access or deployment difficulties. Early experience suggests that TRA for Pipeline Embolization Device placement for posterior circulation aneurysm is a safe and efficient alternative to standard transfemoral access. While this approach was initially applied to patients with vascular anatomy that may not allow for safe femoral access or navigation, experience so far argues for considering a radial approach towards some posterior circulation aneurysm treatment.