Vertebrobasilar Artery Aneurysms Research Articles

High-flow bypass for giant dolichoectatic vertebrobasilar aneurysms: illustrative cases

BACKGROUND Giant fusiform dolichoectatic vertebrobasilar artery aneurysms are challenging lesions with a poor natural history. When there is progressive brainstem compression from these lesions, endovascular treatment can be insufficient, and bypass surgery remains a possible salvage option. High-flow bypass surgery with proximal occlusion can potentially arrest aneurysm growth, promote aneurysm thrombosis, and reduce rupture risk. The authors describe their experience in two patients with giant fusiform dolichoectatic vertebrobasilar artery aneurysms treated with high-flow bypass. OBSERVATIONS Both patients presented with enlarging giant dolichoectatic vertebrobasilar aneurysms causing symptomatic brainstem compression. The authors performed staged treatment involving high-flow bypass from the external carotid artery to the posterior cerebral artery using a saphenous vein graft, Hunterian proximal vertebrobasilar occlusion, and finally posterior fossa decompression with or without direct aneurysm thrombectomy and debulking. Postoperative angiography revealed successful flow reversal, aneurysm exclusion, and no brainstem stroke. Clinically, one patient had improvement in their modified Rankin Scale (mRS) score from 3 preoperatively to 1 at 12-month follow-up. The second patient had a deterioration in their mRS score from 4 to 5 at 12-month follow-up. LESSONS High-flow bypass strategies remain high risk but can be a viable last resort in patients with neurological deficits and enlarging giant fusiform dolichoectatic vertebrobasilar artery aneurysms.

External carotid artery-radial artery graft-posterior cerebral artery bypass for complex vertebrobasilar aneurysms: efficacy and analysis of outcome in a single center.

The purpose of this research was to demonstrate the effectiveness and clinical outcome of an external carotid artery-radial artery graft-posterior cerebral artery (ECA-RAG-PCA) bypass in the treatment of complex vertebrobasilar artery aneurysms (VBANs) in a single-center retrospective study. An ECA-RAG-PCA bypass may be a last and very important option in the treatment of complex VBANs when conventional surgical clipping or endovascular interventions fail to achieve the desired outcome. This study retrospectively analyzed the clinical presentation, case characteristics, aneurysm location, size and morphology, choice of surgical strategy, complications, clinical follow-up, and prognosis of the patients enrolled. The data involved were analyzed by the appropriate statistical methods. A total of 24 patients with complex VBANs who met the criteria were included in this study. Eighteen (75.0%) were male and the mean age was 54.1 ± 8.83years. The aneurysms were located in the vertebral artery, the basilar artery, and in the vertebrobasilar artery with simultaneous involvement. All patients underwent ECA-RAG-PCA bypass surgery via an extended middle cranial fossa approach, with 8 (33.3%) undergoing ECA-RAG-PCA bypass only, 3 (12.5%) undergoing ECA-RAG-PCA bypass combined with aneurysm partial trapping, and 12 (50.0%) undergoing ECA-RAG-PCA bypass combined with proximal occlusion of the parent artery. The average clinical follow-up was 22.0 ± 13.35months. The patency rate of the high-flow bypass was 100%. At the final follow-up, 15 (62.5%) patients had complete occlusion of the aneurysm, 7 (29.2%) patients had subtotal occlusion of the aneurysm, and 2 (8.3%) patients had stable aneurysms. The rate of complete and subtotal occlusion of the aneurysm at the final follow-up was 91.7%. The clinical prognosis was good in 21 (87.5%) patients and no procedure-related deaths occurred. Analysis of the good and poor prognosis groups revealed a statistically significant difference in aneurysm size (P = 0.034, t-test). Combining the results of this study and the clinical experience of our center, we propose a surgical algorithm and strategy for the treatment of complex VBANs.The technical approach of ECA-RAG-PCA bypass for complex VBANs remains important, even in an era of rapid advances in endovascular intervention. When conventional surgical clipping or endovascular intervention has failed, an ECA-RAG-PCA bypass plays a role that cannot be abandoned and is a very important treatment option of last resort.

Flow Diversion vs. Stent-Assisted Coiling in the Treatment of Intradural Large Vertebrobasilar Artery Aneurysms.

ObjectiveTo compare the safety, angiographic, and long-term clinical outcomes of intradural large vertebrobasilar artery (VBA) aneurysms following flow diversion (FD) or conventional stent-assisted coiling (SAC).MethodsWe performed a retrospective study of 66 consecutive patients with intradural large VBA aneurysms between 2014 and 2021 who underwent FD or SAC. Patients' characteristics, postprocedural complications, and clinical and angiographic outcome details were reviewed.ResultsA total of 66 intradural large VBA aneurysms were included, including 42 (63.6%), which were treated with SAC (SAC group) and 24 (36.4%), which were treated with FD (FD group). Clinical follow-up was obtained at the median of 24.0 [interquartile range (IQR) 12.0–45.0] months, with 34 (81.0%) patients achieved the modified Rankin Scale (mRS) ≤ 2 in the SAC group and 21 (87.5%) patients in the FD group. Thirteen (19.7%) patients experienced neurological complications, of which 9 (13.6%) patients first occurred during the periprocedural phase and 4 (6.1%) patients first occurred during follow-up. The overall complication rate and periprocedural complication rate were both higher in the SAC group, but did not reach statistical significance (23.8 vs. 12.5%, P = 0.430; 16.7 vs. 8.3%, P = 0.564). The mortality rates were similar between the groups (11.9 vs. 12.5%). Angiographic follow-up was available for 46 patients at the median of 7 (IQR 6–14) months, with a numerically higher complete occlusion rate in the SAC group (82.1 vs. 55.6%, P = 0.051) and similar adequate aneurysm occlusion rates between the groups (85.7 vs. 83.3%, P = 1.000). In the multivariate analysis, ischemic onset (P = 0.019), unilateral vertebral artery sacrifice (P = 0.008), and older age (≥60 years) (P = 0.031) were significantly associated with complications.ConclusionThere was a trend toward lower complication rate and lower complete occlusion rate for intradural large VBA aneurysms following FD as compared to SAC. FD and SAC have comparable mortality rates and favorable outcomes. Ischemic onset, unilateral vertebral artery sacrifice, and older age could increase the risk of complications.

Development and Validation of Scoring Indication of Surgical Clipping and Endovascular Coiling for Aneurysmal Subarachnoid Hemorrhage from the Post Hoc Analysis of Japan Stroke Data Bank.

There are no scoring methods for optimal treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH). We developed a scoring model to predict clinical outcomes according to aSAH risk factors using data from the Japan Stroke Data Bank (JSDB). Of 5344 patients initially registered in the JSDB, 3547 met the inclusion criteria. Patients had been diagnosed with aSAH and treated with surgical clipping or endovascular coiling between 1998 and 2013. We performed multivariate logistic regression for poor outcomes at discharge, indicated by a modified Rankin Scale (mRS) score >2, and in-hospital mortality for both treatment methods. Based on each risk factor, we developed a scoring model assessing its validity using another dataset of our institution. In the surgical clipping group, scoring criteria for aSAH were age >72 years, history of more than once stroke, World Federation of Neurological Societies (WFNS) grades II–V, aneurysmal size >15 mm, and vertebrobasilar artery (VBA) aneurysm location. In the endovascular coiling group, scoring criteria were age >80 years, history of stroke, WFNS grades III–V, computed tomography (CT) Fisher group 4, and aneurysmal location in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). The rates of poor outcome of mRS score >2 in an isolated dataset using these scoring criteria were significantly correlated with our model’s scores, so this scoring model was validated. This scoring model can help in the more objective treatment selection in patients with aSAH.

Evaluation of the immediate and long-term results of endovascular treatment of ruptured vertebrobasilar artery aneurysms in an acute period of hemorrhage

The study objective is to evaluate the results of endovascular treatment of patients with subarachnoid hemorrhage due to rupture of the vertebrobasilar artery aneurysm.Materials and methods. From 2011 to 2017, 26 patients underwent endovascular occlusion of the ruptured vertebrobasilar artery aneurysm in an acute period of hemorrhage in Surgut Clinical Hospital for Traumatology.Results. Endovascular interventions were performed in 1–14 days after the episode of the primary subarachnoid hemorrhage. Among the patients 53.8 % were in good condition at admission (Hunt–Hess grade I–II), 46.2 % had moderate and severe neurologic disability (Hunt–Hess grade III–IV). A good and satisfactory degree of aneurysm occlusion was achieved in 18 (69.3 %). Favorable outcome (modified Rankin Scale (mRS) 0–2) was achieved in 21 (80.7 %); 1 (3.7 %) had severe disability (mRS 4), 2 (7.8 %) – vegetative state (mRS 5). Lethal outcome (mRS 6) occurred in 2 (7.8 %). Unfavorable outcomes were caused by a severe vasospasm.Conclusions. Endovascular occlusion of vertebrobasilar artery aneurysms in the acute period of hemorrhage is an effective and safe method of treatment in patients with Hunt–Hess grade I–IV.

Rupture of Intradural Giant Aneurysms: The Mode of Treatment, Anatomical, and Mechanical Factors.

Aneurysm rupture is often a fatal complication of giant intradural aneurysm (GIA) treatments. The purpose of this study was to review aneurysm rupture in GIA treatment. We performed a systematic review on aneurysm rupture related to GIA treatment. For each reported case, we collected the following information: aneurysm location, size and rupture status, the mode of treatment, timing of the hemorrhage, anatomical, and hemodynamic factors. We identified 56 aneurysm ruptures related to treatment in 38 published studies. Of the nine intraoperative ruptures, eight occurred during endovascular procedures and one in surgical treatment. Of the 47 delayed ruptures, 72.3% occurred within 2 weeks. The prognosis of intraoperative and delayed ruptures was poor, with 83.9% experiencing death. Of these aneurysms, 75% were initially unruptured. Of the delayed ruptured aneurysms, 21.3% had prior surgical treatment, 74.4% had prior endovascular treatment, and 4.3% had prior combined surgical and endovascular treatments. Vertebrobasilar artery (VBA) location was significantly associated with aneurysm rupture after treatment, occurring at 57.2%. Flow diverter (FD) treatment seemed to elevate the delayed rupture proportion of giant paraclinoid internal carotid artery (ICA) aneurysms from 22.0% to 42.9%. FD treatment did not lower the rupture risk of giant VBA aneurysms and the corresponding death rate. Intraoperative and delayed aneurysm ruptures were the most challenging in endovascular treatment of GIAs. Giant VBA aneurysm had the highest rupture risk after treatment. FD seemed to elevate the delayed rupture proportion of giant paraclinoid aneurysms.

A systematic review of pipeline embolization device for giant intracranial aneurysms.

The experience with respect to the treatment of giant intracranial aneurysms with flow-diversion devices is limited. The aim of the present systematic review was to evaluate the effect of the pipeline embolization device (PED) on giant intracranial aneurysms. Eligible related articles were identified by searching the PubMed, Web of Science, Springer, ScienceDirect, and OVID databases using "giant aneurysm" and "pipeline" as the search items. The date of the last search was November 20, 2015. This systematic review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In a total of 9 eligible studies with 200 patients and 215 aneurysms, 40 (18.6%) giant (aneurysm diameter >25mm) intracranial aneurysms treated with PED were analyzed. During a 6 to 34 month follow-up, complete occlusion was achieved in 23 (57.5%) cases. Seven patients (17.5%) developed intracranial hemorrhage, 5 developed ischemic attack (12.5%), and 13 (32.5%) developed a mass effect after PED treatment. The complication rate was 77.8% in PED for giant vertebrobasilar artery aneurysms. The cumulative mortality rate for giant paraclinoid carotid artery and middle cerebral artery aneurysms was 13.3% and increased up to 50% for giant vertebrobasilar artery aneurysms. The complete obliteration rate of PED for giant intracranial aneurysms was approximately 60%. Mass effect is the most mechanism of complications. Complication and mortality rates associated with PED for giant vertebrobasilar artery aneurysms are still extremely high.

Presigmoid Approach to Vertebrobasilar Artery Aneurysms: A Series of 31 Patients and Review of the Literature

The presigmoid approach can be used to treat vertebrobasilar artery aneurysms when circumstances require more operative exposure. High morbidity and mortality in these cases have been reported. In this study, we describe our modified presigmoid approach for vertebrobasilar artery aneurysms and our clinical results. This series includes patients with vertebrobasilar aneurysms clipped via the modified presigmoid approach at the Department of Neurosurgery at Helsinki University Hospital from 1998 to 2014. Data were collected from the operating record books, patients' medical records, and a radiologic database server. Thirty-three presigmoid procedures of 31 patients were performed to treat 34 aneurysms (14 ruptured, 20 unruptured). The aneurysms had a mean distance from the posterior clinoid process to the aneurysm neck of 12.2 mm (range, 0-26.6 mm). A favorable outcome was achieved in 21 patients (64%). A favorable outcome was achieved in 74% of unruptured and good-grade patients, whereas favorable outcome was achieved in only 36% of poor-grade patients. Complete or near-complete occlusion was achieved in 79%. Larger aneurysms, fusiform morphology, and anterior dome projection had lower occlusion rates. We have described our experiences of using the presigmoid approach to treat vertebrobasilar aneurysms. The clinical and radiographic results are acceptable given the complex location and configuration of the treated aneurysms. Unfavorable outcomes are related to the poor admission Hunt and Hess grade, aneurysm morphology, and aneurysm size.

Bypass Surgeries in the Treatment of Cerebral Aneurysms.

During surgery for cerebral aneurysm, revascularization techniques are occasionally needed to (1) treat an aneurysm (trapping or flow alteration); (2) preserve blood flow during temporary parent artery occlusion (insurance); and (3) repair accidentally injured vessels (troubleshooting). Herein we present our surgical case experiences. Revascularization modalities were employed in 33 (7.6 %) of 452 cases of surgically treated aneurysms. The aneurysm locations and associated required bypass procedures were: (1) 7 middle cerebral artery (MCA) aneurysms with 7 superficial temporal artery (STA)-MCA bypass procedures; (2) 10 internal carotid artery (ICA) aneurysms with 9 high-flow and 1 STA-MCA procedures; (3) 10 vertebro-basilar artery aneurysms with 2 high-flow, 6 occipital artery (OA)-posterior ICA, and 1 STA-superior cerebellar artery (SCA) procedures; (4) 1 posterior cerebral artery (PCA) aneurysm with OA-PCA bypass; and (5) 5 anterior cerebral artery aneurysms with 4 A3-A3 and 1 A3-STA-A3 procedure. Curative bypasses for aneurysmal treatment, temporary bypasses, and troubleshooting procedures were performed in 25, 3, and 5 cases, respectively. Among the 26 aneurysms treated via curative bypass, 16 aneurysms that were trapped or clipped using revascularization techniques had better outcomes (no aneurysmal rupture and 1 perforator infarction), whereas among the 10 aneurysms that could not be trapped or clipped and were thereby treated via flow alteration (e.g., bypass plus proximal artery clipping), 2 developed symptomatic infarction and 2 exhibited aneurysmal rupture after partial thrombosis. Patients whose bypass procedures were used for temporary parent artery occlusion (insurance) or troubleshooting had no complications. Complex aneurysm clipping or trapping using bypass techniques yielded good results. In particular, perforator vessel ischemia still requires resolution. Flow alteration techniques leading to aneurismal thrombosis carried the risks of ischemic and hemorrhagic complications when applied to intracranial aneurysms. Bypasses for temporary use or troubleshooting were quite effective.

The safety of Pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center.

OBJECT Pessimism exists regarding flow diversion for posterior circulation aneurysms because of reports of perforator territory infarcts and delayed ruptures. The authors report the results of patients who underwent Pipeline Embolization Device (PED) flow diversion using novel strategies for treatment of fusiform posterior circulation aneurysms, and compare these results with those from previously reported series. METHODS The authors conducted a retrospective review of data from consecutive patients with fusiform vertebrobasilar artery aneurysms treated with the PED. RESULTS This review resulted in the identification of 12 such patients (mean [± SD] age 55.1 ± 14.1 years). Eleven patients had symptoms; 1 had a dissecting aneurysm identified on imaging for neck pain. The average aneurysm size was 13.25 ± 4.5 mm. None of the aneurysms were ruptured or previously treated. The average clinical follow-up duration was 22.1 ± 10.7 months and radiological follow-up was 14.5 ± 11.1 months from the index PED treatment. One patient suffered a perforator stroke and had a modified Rankin Scale (mRS) score of 4 at last follow-up. Another patient had a retained stent pusher requiring retrieval via surgical cut-down but recovered to an mRS score of 0 at last follow-up. Eleven (91.7%) of 12 patients recovered to an mRS score of 0 or 1. Two patients had aneurysmal remnants at 7 and 10 months, respectively, after the index PED, which were retreated with PEDs. At last follow-up, all 12 aneurysms were occluded and PEDs were patent. The minimum follow-up duration was 12 months from the index PED treatment; no patient experienced delayed hemorrhage, stroke, or in-stent stenosis. CONCLUSIONS Flow diversion with selective adjunctive techniques is evolving to become a safer treatment option for posterior circulation aneurysms. This is the longest clinical follow-up duration reported for a single-center experience of flow-diversion treatment of these aneurysms.

Posterior Inferior Cerebellar Artery Patency after Flow-Diverting Stent Treatment.

The rate of PICA occlusion after flow-diverting stent placement for vertebral and vertebrobasilar artery aneurysms is not known. The purpose of this study is to determine the medium-term rate of PICA patency and risk factors for occlusion after such aneurysm treatment. Patients were identified who had vertebral or vertebrobasilar artery aneurysms and who were treated by placing a flow-diverting stent across the PICA ostium. Demographic and procedural factors associated with stent placement were recorded. Patency of the PICA was evaluated immediately after stent placement and on follow-up angiography. Thirteen patients with vertebral or vertebrobasilar artery aneurysms were treated in the study period, of whom 4 presented with subarachnoid hemorrhage. The average number of devices that spanned the PICA ostium was 1.77 (range, 1-3), with no immediate PICA occlusions. There were no postoperative strokes in the treated PICA territory, although there was 1 contralateral PICA-territory stroke of unclear etiology without clinical sequelae. In 11 patients with follow-up angiography at a mean of 10.6 months (range, 0.67-27.9 months), the PICA patency rate remained 100%. Flow-diverting stent placement across the PICA ostium in the treatment of vertebral and vertebrobasilar artery aneurysms may not result in immediate or midterm PICA occlusion.

Internal carotid artery-to-posterior cerebral artery bypass for revascularization of the brainstem

We describe a novel bypass technique used to revascularize the brainstem by anastomosing the internal carotid artery (ICA) to the posterior cerebral artery (PCA) using a radial artery graft, effectively creating a functional alternative to the posterior communicating artery. A 72-year-old male patient presented with rapidly progressive neurological symptoms attributable to brainstem compression; imaging showed a giant, fusiform, partially thrombosed, vertebrobasilar artery aneurysm. An Alcock’s test revealed no significant collateral circulation from the posterior communicating arteries. To revascularize the top of the basilar artery, we performed an ICA-to-PCA bypass using a radial artery interposition graft. Specifically, we used the radial artery graft to connect the supraclinoid ICA to the P2 segment of the PCA. The basilar artery was subsequently occluded during the same operation by placing a clip below the superior cerebellar arteries. Although the bypass remained patent, the patient suffered an acute thrombosis of the aneurysm, resulting in fatal pontine infarction.

Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results

Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may use the same techniques through an alternative corridor. The aim of this article is to report a series of patients who underwent an endoscopic endonasal approach (EEA) for microsurgical clipping of intracranial aneurysms. We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures are discussed. Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal internal carotid artery (n = 9) and vertebrobasilar system (n = 2). The internal carotid artery aneurysms projected medially, whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all patients. In all cases, aneurysms were completely occluded. Among complications, 3 patients had postoperative cerebrospinal fluid leakage and 2 other patients had meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms. EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery, working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.

Natural Course of Dissecting Vertebrobasilar Artery Aneurysms without Stroke

The natural history and therapeutic management of dissecting vertebrobasilar aneurysms without ischemic or hemorrhagic stroke (nonstroke dissecting vertebrobasilar aneurysms) are not well-established. We conservatively followed patients with nonstroke dissecting vertebrobasilar aneurysms and evaluated the factors related to clinical and morphologic deterioration. One hundred thirteen patients were enrolled and divided by clinical presentation at diagnosis: asymptomatic (group 1, n = 52), pain only (group 2, n = 56), and mass effect (group 3, n = 5). Patients were conservatively managed without intervention and antithrombotic therapy. Clinical outcomes and morphologic changes were analyzed. A total of 113 patients who were diagnosed with nonstroke dissecting vertebrobasilar aneurysm had a mean follow-up of 2.9 years (range, 27 days to 8 years). Throughout that period, 1 patient in group 1 (1.9%) and 1 patient in group 2 (1.8%) showed clinical deterioration due to mass effect, and 1 patient in group 3 (20%) developed ischemic stroke followed by subarachnoid hemorrhage. Most patients (97.3%) were clinically unchanged. Three patients who had clinical deterioration showed aneurysm enlargement (P < .001). Aneurysms remained morphologically unchanged in 91 patients (80.5%). Aneurysm enlargement was seen in 5 patients (4.4%); risk of enlargement was significantly associated with either maximum diameter (hazard ratio = 1.30; 95% CI, 1.11-11.52; P = .001) or aneurysm ≥10 mm (hazard ratio = 18.0; 95% CI, 1.95-167; P = .011). The natural course of these lesions suggests that acute intervention is not always required and close follow-up without antithrombotic therapy is reasonable. Patients with symptoms due to mass effect or aneurysms of >10 mm may require treatment.

Various techniques of stent-assisted coil embolization of wide-necked or fusiform artherosclerotic and dissecting unruptured vertebrobasilar artery aneurysms for reducing recanalization: mid-term results

Coil embolization of wide-necked or fusiform vertebrobasilar aneurysms is challenging and tends to involve frequent recanalization. The aim of our study was to evaluate complications and mid-term outcomes of complex vertebrobasilar artery aneurysms after stent-assisted coiling with various techniques. We retrospectively evaluated 28 cases of unruptured vertebrobasilar aneurysm treated by stent-assisted coiling. Forty-four of the 45 stents placed in 28 patients were deployed at the desired location (97.8 %). Single stent-assisted coiling was performed in 14 aneurysms, a stent-within-a-stent (SWS) technique was used in 12 aneurysms, and Y-stent-assisted coiling was employed in four basilar tip aneurysms. Two basilar tip aneurysms treated by single stent-assisted coiling recurred and were retreated by SWS and Y-stent-assisted coiling. Complete embolization was achieved in 19 aneurysms (67.8 %), and remnant neck persisted in eight aneurysms (28.6 %) and remnant aneurysm was noted in one aneurysm (3.6 %). Permanent neurologic deficit (Modified Rankin Scale 1 and 4) was noted in two patients (7.1 %). Angiographic follow-up (mean follow-up period: 20.8 months) was performed in 20 patients. Major recanalization occurred in two basilar tip aneurysms (10 %) and minor compaction was noted in one superior cerebellar artery aneurysm. The remaining 17 aneurysms were stable or improved (85 %). Complex vertebrobasilar aneurysm embolization with stent-assisted techniques was effective and feasible as a method for reducing recanalization during midterm angiographic follow-up. Large and wide-necked basilar tip aneurysms showed frequent major recanalization, and compact packing with single or Y-stent-assisted coiling is needed to prevent recanalization even if coiling will be done without stenting.

Abstract 3708: Safety and Efficacy of Antiplatelet Monotherapy (clopidogrel) in Stent Assisted Elective Coil Embolization of Cerebral Aneurysms

BACKGROUND AND PURPOSE: Thromboembolic events are the most common complication seen in elective coil embolization of cerebral aneurysms. Previous studies have shown that administration of oral clopidogrel and/or aspirin may lower the thromboembolic complication rate but little data exists regarding clinical outcome with the use of antiplatelet monotherapy in stent assisted elective aneurysm coil embolization. Objectives: To assess the safety and efficacy of antiplatelet monotherapy (clopidogrel) in elective stent assisted coil embolization of cerebral aneurysms MATERIALS AND METHODS: Retrospective chart review was performed in 94 consecutive patients who underwent endovascular treatments for elective coil embolization of cerebral aneurysms between 2008-2010. Thirty patients were included in this study who met the inclusion criteria of stent assisted coil embolization. All these patients received 75mg clopidogrel for one week prior to the procedure. Clopidogrel was continued post procedure for six to eight weeks. Primary outcome measure was peri-procedure and post-procedure symptomatic thromboembolic complications. RESULTS The study included 23 females and 7 males with mean age 52.6 years.Twenty (66.7%) patients had anterior circulation aneurysms and 10 (33.3%) patients had posterior circulation aneurysms. Twenty (66.7%) patients were treated with Neuroform, 9 (30%) patients with Enterprise stent and 1 (3.3%) patient was treated with both Neuroform and Enterprise stent assisted coil embolization. One (3.3%) patient had an iatrogenic flow limiting vertebral artery dissection during embolization of vertebrobasilar artery aneurysm with no clinical deficit. The patient’s vertebral artery dissection was treated with 2 Wingspan stents and 1 Medtronic driver stents. Symptomatic thromboembolic complication was seen in 1 patient (3.3%) at discharge. The patient had a giant basilar tip aneurysm which was treated with stent assisted coil embolization. Postprocedure the patient had a right facial palsy with gaze deviation. The MRI was consistent with acute posterior circulation stroke. The patient was discharged home with a modified Rankin Scale &lt;2. Follow up at six to eight weeks post procedure clinical data was available for 21 patients (73.3%). No delayed thromboembolic complication was observed in these patients at follow up visit. CONCLUSION: Oral clopidogrel is safe and efficacious as an antiplatelet monotherapy during elective stent assisted coil embolization. Further multicenter prospective trials are warranted to evaluate safety and efficacy of clopidogrel as a monotherapy for elective stent assisted coil embolization.

Investigation of the endovascularly treated and untreated unruptured vertebrobasilar artery aneurysms

Background and purposeThe present study aimed to investigate the endovascular indication with close monitoring of both endovascularly treated and untreated unruptured vertebrobasilar aneurysms. Materials and methodsIn the past 2 years, 36 patients [7 women and 29 men with a mean age of 48.5 years (range, 13–75 years)] who had 40 unruptured vertebrobasilar artery aneurysms were reviewed. The decision of the endovascular treatment was not randomized. In both endovascularly untreated and treated patients, overall mortality and morbidity corresponding to Glasgow outcome scale (GOS) score III or worse was counted as unruptured aneurysm related event. The ratio of event free was compared between endovascularly treated and untreated patients using Log-rank test. In a univariate analysis, poor outcome was predicted by endovascularly untreated. ResultsThirty-six patients were followed with a mean period of 10.7 months (range, 0.7 months–21 months). In untreated cases, new neurological deficits caused by the aneurysm were noted in 2 cases. The annual deterioration rate of the untreated cases was 9.1%. In endovascularly treated cases, there was no mortality and morbidity. There was no SAH in all cases during follow-up period. When ratio of event free was compared, significant advantage of endovascular treatment was noted (X2=4.429, P=0.035). ConclusionsThe present results indicated that endovascular treatment has a benefit for the unruptured vertebrobasilar artery aneurysms.

Successful endovascular treatment of a growing megadolichoectasic vertebrobasilar artery aneurysm by flow diversion using the “diverter-in-stent” technique

Giant dolichoectatic and fusiform aneurysms of the vertebrobasilar artery are among the most difficult and dangerous aneurysms to treat. Conservative management may be reasonable in asymptomatic elderly patients. Nevertheless, due to the frequent presence of mass effect on the brainstem and the risks of thromboembolic events and rupture, these aneurysms often demand treatment rather than observation. With the advancement of endovascular techniques some of these lesions have become treatable without the high morbidity and mortality rates associated with open surgical treatment. When dealing with giant, progressively enlarging symptomatic aneurysms, more limited therapeutic alternatives are available. The authors present a case of a growing megadolichoectatic vertebrobasilar artery aneurysm causing major disability due to increasing mass effect in a 51-year-old man. The aneurysm was treated with flow diversion by placing multiple telescoped stents and diverters (“diverter-in-stent” technique), achieving thrombosis of the aneurysm and reduction of the mass effect on the brainstem, with neurological improvement. The successful clinical and angiographic results observed in our case of giant dolichoectasic vertebrobasilar aneurysm contribute to the literature on giant aneurysms treated by means of flow diversion.

Fatal Subarachnoid Hemorrhage Due to Ruptured Vertebrobasilar Aneurysm Associated With Giant Cell Arteritis in a Child

A 3 ½-year-old previously healthy female experienced an episode of sudden unresponsiveness witnessed by her mother. Upon arrival to the local hospital, imaging studies of the still unresponsive child revealed severe bilateral "flash" pulmonary edema and diffuse anoxic brain injury. Aggressive resuscitative efforts were unsuccessful, and she was pronounced dead. External examination at autopsy was essentially unremarkable. Internal examination of the head revealed diffuse basilar subarachnoid blood originating from a collapsed, 2 cm irregular aneurysm arising from the junction of the vertebral and basilar arteries. Additionally, multiple calcified subpleural, parenchymal, and hilar nodal pulmonary granulomas were identified. The remaining internal examination, including that of the aorta and its major branches, was unremarkable. Histologic examination of the aneurysm revealed alternating mural attenuation and thickening, the latter resulting from prominent intimal proliferation with active fibroplasia. Most notably, numerous isolated and clustered multinucleated giant cells were seen, most prominently in areas of more intense inflammation. Specific immunolabeling and silver staining of the pulmonary granulomas revealed evidence of histoplasmosis, but both were negative for fungal elements in the aneurysm, as was ultrastructural examination. The cause of death is fatal subarachnoid hemorrhage due to rupture of a vertebrobasilar artery aneurysm caused by isolated intracranial giant cell arteritis.

Vertebrobasilar Artery Aneurysms: An Uncommon Cause of Vertigo

Objective: Review our experience with vertebrobasilar artery aneurysms and discuss factors which may enable clinicians to distinguish between these potentially life-threatening posterior circulation aneurysms and other conditions with similar presentations. Method: Case series with chart review. The charts of patients who underwent surgical management of posterior circulation aneurysms at a tertiary care center between December 1995 and February 2008 were reviewed. Results: A total of 57 patients (40 females, 17 males) with an average age of 52.8 years (range, 27-79 years) were included. A total of 44 patients were white, 5 were African American, and 8 were unspecified. Aneurysms of the posterior communicating artery and posterior inferior cerebellar artery were most common, occurring in 28 (49%) and 26 (46%) of patients, respectively. The most common initial symptoms were headache in 31 patients (54%) and acute mental status changes in 18 patients (32%). Eight patients (14%) presented acutely with dizziness or vertigo. 26 patients (46%) underwent suboccipital craniotomy with aneurysm clipping. Fifteen (26%) underwent frontotemporal craniotomy, and 5 (9%) underwent a combined neurosurgical-neurotologic approach. There were 8 deaths. Conclusion: Vertebrobasilar aneurysms are uncommon and typically present emergently after rupture. A small number of patients with such aneurysms may present with neurotologic symptoms, such as vertigo and disequilibrium. Given the potentially grave consequences of a ruptured aneurysm, it is essential that otolaryngologists remain cognizant of the presentation of posterior circulation aneurysms.