Intracranial Vertebral Artery Aneurysms Research Articles

Embolization of an Intracranial Vertebral Artery Aneurysm via the Deep Cervical Artery.

Treatment of vertebral artery aneurysms can be challenging due to the unusual vascular anatomy or unfeasibility of traditional endovascular techniques. We describe a novel approach for endovascular treatment of a ruptured intracranial vertebral artery aneurysm with bilateral vertebral artery occlusions and hypoplasia of the posterior communicating arteries. Successful coil embolization was performed using a collateral pathway for microcatheterization via anastomosis between the deep cervical artery and the vertebral artery. This case report highlights a novel alternative endovascular treatment approach for vertebrobasilar aneurysms in case of a poor vascular status with occlusion or lack of traditional endovascular access routes.

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...

High-resolution cone beam CT for evaluation of vascular channel in intracranial partial thrombosed aneurysm.

ABSTRACTThe authors present a 60-year-old man with a partially thrombosed, intracranial vertebral artery aneurysm. A vascular channel in intra-aneurysmal thrombus was effectively identified with high-resolution cone beam CT (DynaCT Micro: Siemens Medical Solutions, Erlangen, Germany). Pre-procedural vertebral angiogram implied a perforating artery arising from near neck of the aneurysm and DynaCT Micro performed before approaching to the lesion demonstrated a vascular channel running in intra-aneurysmal thrombus which could not be distinguished from perforators with other imaging modalities. It was confirmed that perforators around the aneurysm were not identified and safely treated the aneurysm with stent-assisted coil embolization. High-resolution cone beam CT is enable to sharply visualize vessel lumens, thrombus, and intra-thrombus structures, and is useful to identify a vascular channel in intracranial partially thrombosed aneurysm.

E-131 endovascular reconstruction of intradural vertebral artery fusiform dissecting aneurysms with the pipeline embolization device

Introduction/purpose Dissecting aneurysms of the vertebral artery (VA) are difficult to treat using current surgical and endovascular techniques. Currently, there is no consensus on management strategies of dissecting VA aneurysms. The characteristics of flow diverter stents appear to have ideal requirements for the treatment of dissecting VA aneurysms. In this study, we retrospectively analyzed the efficacy and safety of flow diverters in the treatment of such lesions. Materials and methods We identified six patients with six VA dissecting aneurysms either arising from the V4 or V3–V4 junction that were treated with the pipeline embolization device (PED) at our institution from July 2012 to February 2015. Among other parameters, technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated. Results Six patients, 3 females and 3 males, with a mean age of 52.8 years (age range 39–63 years) were identified. Vascular risk factors included hypertension (4/6), dyslipidemia (2/6), fibromuscular dysplasia (1/6) and smoking (1/6). The aneurysms were incidental findings in 3 cases, whereas the other 3 patients presented with neurological symptoms such as visual changes, ataxia, facial numbness or vertigo. Diagnostic angiography confirmed the presence of fusiform dissecting aneurysms centered at the V4 segment in 5 cases and at the vertebral V3–V4 junction in one case. PED placement was achieved in all cases and immediate angiography follow-up demonstrated intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of dysarthria was noted in one patient. Major procedure-related complications were not observed. 6-month follow-up (n = 5) demonstrated complete/near complete aneurysm obliteration in 4 and partial obliteration in 1 patient. At 1-year follow-up (n = 4) stable complete aneurysm occlusion was seen in 2 patients. One patient demonstrated progression from near complete to complete occlusion and the previously noted partial occlusion remained stable. No aneurysmal bleeding, in-stent stenosis or thromboembolic complication was observed. NIHSS and mRS scores remained unchanged from admission to discharge. Conclusion Our preliminary experience with endoluminal reconstruction of intradural dissecting VA aneurysms with the PED confirms this treatment approach to be feasible and safe with good short-term angiographic and clinical outcomes. Long-term and larger cohort studies will need to provide further information on durable aneurysm obliteration in response to hemodynamic intravascular flow changes and the occurrence of delayed hemorrhage and in-stent thrombosis. The promising results obtained so far, however, appear to support the use of flow diverter in the treatment of dissecting intracranial VA aneurysms; especially in circumstances where maintaining parent artery and side branch patency is required. Disclosures A. Kuhn: None. F. Massari: None. J. Lozano: None. S. Hou: None. M. Howk: None. M. Perras: None. C. Brooks: None. P. Kan: None. M. Gounis: 1; C; NIH, Philips Healthcare, Covidien/eV3 Neurovascular, Codman Neurovascular, Stryker Neurovascular, Wyss Institute, Tay Sachs Foundation. 2; C; fee-per-hour consultation, Stryker Neurovascular. A. Wakhloo: 1; C; Philips Medical. 2; C; Stryker Neurovascular. 3; C; Harvard Postgraduate Course and Miami Baptist Vascular Institute. A. Puri: None.

Intracranial Vertebral Artery Aneurysms: Clinical Features and Outcome of 190 Patients

Vertebral artery (VA) aneurysms comprise approximately one-third of posterior circulation aneurysms. They are morphologically variable, and located critically close to the cranial nerves and the brainstem. We aim to represent the characteristics of these aneurysms and their treatment, and to analyze the outcome. We reviewed retrospectively 9709 patients with intracranial aneurysms. Of these, we included 190 with aneurysms at the VA or VA-posterior inferior cerebellar artery junction. These patients were treated in the Department of Neurosurgery, Helsinki, Finland, between 1934 and 2011. The 190 patients had 193 VA aneurysms, among which 131 (68%) were ruptured. The VA aneurysm caused a mass effect in 7 and ischemia in 2 patients. Compared to 4387 patients with a ruptured aneurysm in other locations, those with a VA aneurysm were older, their aneurysms were more often fusiform, and more often caused intraventricular hemorrhages. Among surgically treated aneurysms, clipping was the treatment in 91 (88%) saccular and 11 (50%) fusiform aneurysms. Treatment was endovascular in 13 (9%), and multimodal in 6 (4%) aneurysms. Within a year after aneurysm diagnosis, 53 (28%) patients died. Among the survivors, 104 (93%) returned to an independent or to their previous state of life; only 2 (2%) were unable to return home. Microsurgery is a feasible treatment for VA aneurysms, although cranial nerve deficits are more common than in endovascular surgery. Despite the challenge of an often severe hemorrhage, of challenging morphology, and risk for laryngeal palsy, most patients surviving the initial stage return to normalcy.

Endovascular treatment of fusiform intracranial vertebral artery aneurysms using reconstructive techniques

ObjectiveTo report our single center experience in the treatment of fusiform aneurysms involving the intracranial vertebral arteries using reconstructive endovascular techniques.Patients and methodsThe neurointerventional database of our institution was retrospectively...

Reconstruction of intracranial vertebral artery with radial artery and occipital artery grafts for fusiform intracranial vertebral aneurysm not amenable to endovascular treatment: technical note

Symptomatic fusiform intracranial vertebral artery aneurysms pose a formidable treatment challenge when not amenable to endovascular treatment. In this paper, we illustrate the microsurgical management of such an aneurysm. To prevent neurological deterioration, anatomical reconstruction preserving all vessels including posterior inferior cerebellar artery and perforators is essential. In this case illustration, the occipital artery was used as a donor to a perforator originating from the aneurysmal segment. This bypass was performed in an end-to-side fashion. Subsequently, the aneurysmal component of the vertebral artery was resected and an end-to-side (V4 to V3) bypass was performed using a radial artery graft. The patient achieved complete resection of the aneurysm preserving normal anatomy of the posterior circulation without any ischemic complications. Complex cerebral artery bypass techniques are essential in the armamentarium of cerebrovascular for the treatment of complex lesions not amenable to endovascular therapy.

E-063 Endovascular treatment of fusiform intracranial vertebral artery aneurysms using reconstructive techniques: single center experience

ObjectiveFusiform intracranial aneurysms are challenging lesions that occur secondary to atherosclerosis or dissection. Although unclear, the prognosis of patients with fusiform aneurysms seems to be poor. We report our single...

Characteristics and endovascular treatment of intracranial vertebral artery aneurysms

The clinical and angiographic characteristics of vertebral artery (VA) aneurysm were evaluated to demonstrate the safety and efficacy of endovascular techniques of VA aneurysms. Case records of 38 consecutive patients with 40 VA aneurysms admitted during a 2-year period were reviewed. The data analyzed included age, sex, size of aneurysm, ruptured or unruptured, endovascular techniques, angiographic results after embolization, duration of follow-up, angiographic follow-up results and Glasgow Outcome Score at follow-up. Of the 38 patients, 33 patients had 35 dissecting aneurysms and five patients had five saccular aneurysms. Seventeen (42.5%) aneurysms were ruptured. Of the 34 patients treated with endovascular techniques, immediate post-procedural angiograms showed complete and subtotal occlusion (>90%) of 27 (67.5%) aneurysms and incomplete and no occlusion of 13 (32.5%) aneurysms, including four conservatively treated aneurysms. A clinical improvement or stable outcome was achieved in all the patients (100%) during a mean 12.1-month follow-up. There was no complication related to endovascular treatment and no rebleeding during the follow-up period. Angiographic follow-up (mean of 7.2 months, range 1-18 months) was available in all the patients. Complete and subtotal occlusion was observed in 31 (81.6%) patients, including one spontaneous thrombosis of a conservatively treated VA dissecting aneurysm. Recanalization in two patients (5.9%) at 6 and 9 months did not require retreatment. This series demonstrates the safety and efficacy of multimodality of endovascular techniques for VA aneurysms.

DEFINITIVE RECONSTRUCTION OF CIRCUMFERENTIAL, FUSIFORM INTRACRANIAL ANEURYSMS WITH THE PIPELINE EMBOLIZATION DEVICE

The Pipeline embolization device (PED; Chestnut Medical, Menlo Park, CA) is a new endovascular construct designed to exclude aneurysms from the parent cerebrovasculature. We report the results of the first two human implantations of this device in North America. Two patients presenting with large, symptomatic, circumferential, fusiform intracranial vertebral artery aneurysms were treated with the PED. In both cases, more traditional open microneurosurgical and neuroendovascular treatment strategies had either failed or were associated with unacceptably high risk. Three PEDs were placed across the aneurysms in each of the patients to achieve reconstruction of a new parent vessel through the center of a circumferential aneurysm. In the first patient, who had previously been treated with stent-supported coil embolization, the PED construct alone was sufficient to achieve parent vessel reconstruction and exclusion of the recurrent aneurysm. In the second patient, a microcatheter was jailed within the saccular portion of the aneurysm and the parent vessel was reconstructed with three telescoped PEDs. Although the PED construct dramatically reduced flow into the aneurysm, the lesion remained patent. Coiling of the saccular portion of the aneurysm was subsequently performed via the jailed microcatheter. Follow-up angiography performed 72 hours after the procedure demonstrated occlusion of the aneurysm with cylindrical reconstruction of the affected vascular segment. Neither patient has experienced any complication in the periprocedural period (30 d) or during subsequent long-term (>1 year) follow-up. The PED represents an important advance in the endovascular therapy of cerebral aneurysms, targeting primary parent vessel reconstruction rather than endosaccular occlusion as a means by which to achieve exclusion of the aneurysm and definitive anatomic reconstruction of the parent artery.

Treatment of extracranial and intracranial aneurysms and arteriovenous fistulae using stent grafts.

Treatment of 11 patients with aneurysms or arteriovenous fistulae of the craniocervical arteries with stent grafts. Peripheral stent grafts were deployed in two extracranial internal carotid arteries. Coronary stent grafts were used to treat two giant aneurysms, five direct carotid-cavernous fistulae, one vertebrojugular fistula, and two dissecting aneurysms of the vertebral artery (V2 and V4). Stent grafts were used successfully in two extracranial internal carotid and two extracranial vertebral arteries, one dissecting aneurysm of the intracranial vertebral artery, one giant aneurysm and one pseudoaneurysm of the cavernous internal carotid artery, and five direct carotid-cavernous sinus fistulae. Angiographic follow-up examinations (available in nine patients; obtained at 3 mo to 5 yr; average, 24 mo) revealed normal vessel caliber, and the stent grafts in all 9 of 11 initial patients were patent. There was a recurrent saccular aneurysm adjacent to the stent graft in the patient with the intracranial vertebral artery aneurysm. The following five complications were encountered: transient hemiparesis (n = 2), increased hemiparesis, postprocedural management-related fatality, and ICA dissection. In six patients, stent graft deployment was accomplished without any technical or clinical complication. There were no permanent neurological deficits consequent to stent graft placement. Stent grafts are a useful tool for the endovascular treatment of head and neck aneurysms and direct arteriovenous fistulae in selected patients. The major disadvantage of the currently available stent grafts is their lack of mechanical flexibility. Maneuvering stent grafts in the intracranial arteries carries the risk of iatrogenic vessel dissection and may require supportive measures and protection of the target site by conventional stents.

Operative or endovascular treatment of ruptured intracranial vertebral artery aneurysms?

Our purpose was to evaluate the surgical and endovascular treatment outcomes of ruptured intracranial vertebral artery aneurysms (RIVAA). The outcomes of 44 patients with RIVAA treated between 1983 and 1998 surgically (26), endovascularly (20) or both (2) were evaluated. The aneurysms were clipped in 24 patients, and clipped and wrapped in two. We treated 20 by the endovascular approach, 12 with Guglielmi detachable coils (GDC), and eight by parent-vessel occlusion using detachable balloons. Three patients had endovascular treatment after a failed or inadequate surgical attempt. Posttreatment follow-up was 17-183 months (mean 101 months) for surgically treated patients. For the GDC-treated group angiographic follow-up was carried at 8-49 months (mean 19 months). The condition of seven (27 %) of the surgically treated patients worsened due to procedure-related complications, compared with 10% in the endovascular treatment group. Of the patients initially presenting with Hunt and Hess grade IV or V, three of five (60%) died who were treated surgically and two of eight (25%) who were treated endovascularly. A good outcome was achieved in 17 surgically treated patients (85% of the survivors) and in 16 of the endovascular group (89% of the survivors). This present "same-site" report on treatment of a specific abnormality, RIVAA, treated surgically or by an endovascular approach indicates that especially in poorer Hunt and Hess grade patients, the latter may offer a clinical outcome as good as that of surgery, although long-term efficacy of GDC treatment is still to be determined.

Vertebrobasilar junction fenestration associated with dissecting aneurysm of intracranial vertebral artery.

Vertebrobasilar junction fenestration is considered to be a subtype of fenestration of the proximal basilar artery, which has been described only in autopsy cases. The fenestration associated with a dissecting vertebral aneurysm is extremely rare. A 47-year-old man presented with subarachnoid hemorrhage. The four-vessel angiogram showed a fusiform dilatation with an intimal flap of the left vertebral artery distal to the origin of the posterior inferior cerebellar artery and a fenestration at the vertebrobasilar junction, in which a small limb of the fenestration arising from the distal portion of the left vertebral artery bridged the proximal basilar trunk, while another limb had a large diameter showing the same diameter as the basilar artery. The dissecting aneurysm was treated with body clipping by directly clipping the ruptured portion of the aneurysm via a suboccipital approach in an early operation 48 hours after the ictus. The patient had a good recovery and returned to his work. He is well at a 5-year follow-up. The relevant angiographic features of the vertebrobasilar junction fenestration and the surgical treatment of such associated aneurysms are discussed.

Posterior inferior to posterior inferior cerebellar artery anastomosis combined with trapping for vertebral artery aneurysm

A case is presented in which a giant intracranial vertebral artery aneurysm gave rise to an associated ipsilateral posterior inferior cerebellar artery (PICA) from its waist. Proximal vertebral artery ligation at C-1 was achieved. The aneurysm filled from the opposite vertebrobasilar junction. Direct intracranial trapping of the right vertebral aneurysm was followed by successful anastomosis of the proximally sectioned right PICA to the adjacent left PICA in an end-to-end fashion.