Dissecting aneurysms of the posterior cerebral artery – A retrospective review of imaging,angiographic characteristics,endovascular management and outcome

PurposeTo review management, clinical and imaging outcomes of dissecting posterior cerebral artery (PCA) aneurysms with emphasis on endovascular management in the form of parent vessel occlusion (PVO) at a tertiary care center.MethodsThirty-six dissecting PCA aneurysms (19 ruptured) encountered at our center between January 2013 and November 2019 were reviewed for aneurysm location/size/presence of fetal PCA/management. Postprocedural imaging of patients who underwent endovascular intervention was reviewed for PCA territory infarcts and clinical records assessed for presence of neuro-deficits and outcome. None of the patients underwent a balloon test occlusion (BTO) prior to PVO.ResultsThe location of the aneurysms was as follows-P1 = 8/P1-P2 = 11/P2 = 5/P2-P3 = 10/P3 = 2. The mean size was 11.7x6.8 mm. Endovascular intervention was carried out in 20 patients in the form of PVO with coiling in 16 patients, coiling alone in 3 patients, and reconstruction of the left PCA with flow diverter deployment in one patient. Postprocedural PCA territory infarct was seen in 5 cases of PVO out of which 4 had a good functional recovery. Overall, 15/16 patients (93.7%) who underwent PVO had mRS ≤ 2 on follow-up. The single case with flow diverter also developed an infarct and had adverse outcome on follow up.ConclusionAmong the various management strategies for dissecting PCA aneurysms, PVO is feasible and relatively safe even in absence of BTO in scenarios like critically ill patients with ruptured aneurysms, difficult access and financial constraints. Thromboembolic complications and antiplatelet therapy is a concern in reconstructive strategies.     

Coiling of a recurrent broad-necked posterior communicating aneurysm incorporating a fetal cerebral artery: A technical case report

We describe a case of a right broad-necked posterior communicating artery (PcomA) aneurysm with a fetal posterior cerebral artery (PCA) incorporated in the aneurysm neck. We performed waffle cone stent-assisted coiling and achieved almost complete occlusion of the aneurysm. At 18-month follow-up angiography, the aneurysm was recanalized and further coiling was needed. The same waffle cone method of coiling might be expected to produce the same unsatisfactory results on follow-up, so we decided to use retrograde stent navigation and placement through the anterior communicating artery (AcomA) from the contralateral internal carotid artery (ICA) to the ipsilateral ICA and fetal PCA. The stent delivery microcatheter from the contralateral ICA could not be introduced in the AcomA. So 2 mg nimodipine was infused through the stent delivery microcatheter to the AcomA and the stent delivery microcatheter was passed through the AcomA easily and could be navigated to the ipsilateral A1, ICA, and to the fetal PCA. With this additional stent, the aneurysm was completely separated from the fetal PCA and ICA. Further coiling could be performed safely through the microcatheter in the ipsilateral ICA. The patient had stable aneurysm occlusion at the six-month follow up.     

血管内介入治疗椎动脉夹层动脉瘤的疗效分析

目的：评价血管内介入治疗椎动脉夹层动脉瘤的技术方法及临床疗效。方法：应用血管内介入治疗技术对29例椎动脉夹层动脉瘤的患者进行治疗,回顾性分析临床资料、血管内治疗方法以及临床疗效。结果：29例患者中有19例直接闭塞动脉瘤和载瘤动脉,5例行支架置入,5例行支架辅助弹簧圈栓塞。术后21例患者接受随访,随访时间为3～24个月,平均8个月。其中14例闭塞动脉瘤和载瘤动脉患者复查示动脉瘤未显影,3例支架辅助弹簧圈栓塞患者中1例复发,2例单支架置入患者复查示1例动脉瘤完全消失而另1例仍有动脉瘤残留,2例双支架置入患者复查示1例动脉瘤完全消失,另1例动脉瘤缩小。结论：将载瘤动脉连同动脉瘤完全闭塞是血管内治疗以破裂出血起病的椎动脉夹层动脉瘤最有效的方法。如果动脉瘤位于优势椎动脉,或动脉瘤体累及小脑后下动脉,使用支架置入技术是可供的选择。     

Endovascular repair of posterior communicating artery aneurysms,associated with oculomotor nerve palsy: A review of nerve recovery

Purpose

Oculomotor nerve palsy (ONP) is often the presenting symptom in patients with posterior communicating artery (PCOMM) aneurysms with variable recovery of oculomotor nerve function following treatment. In this study we report the ophthalmologic outcome of 20 patients treated by endovascular coiling for PCOMM aneurysm-induced ONP.

Methods

We performed 230 PCOMM aneurysm endovascular coilings between the years 2006 and 2011, of which 20 cases presented with ONP. We recorded the degree of nerve recovery – complete, partial or none – while also documenting other predictive factors, such as degree of pre-intervention nerve deficit, presence of subarachnoid haemorrhage (SAH), size and location of the PCOMM aneurysm and length of follow-up.

Results

Of the 20 patients, 9 (45%) presented with complete ONP and 11 (55%) with partial ONP. After an average follow-up period of 16 months, all patients achieved oculomotor nerve recovery; 9 (45%) patients had complete recovery and 11 (55%) patients had partial recovery. Of the 9 patients who presented with complete ONP, 5 (56%) patients made a complete recovery and 4 (44%) made a partial recovery. Of the 11 patients who initially presented with partial ONP, 4 (36%) made a complete recovery and 7 (64%) made a partial recovery. 7 (35%) patients also had a SAH, of whom 3 (43%) made a complete recovery with 4 (57%) making a partial recovery.

Conclusions

ONP can occur with PCOMM aneurysm with or without SAH. Endovascular coiling is an effective treatment for ONP due to PCOMM aneurysms.     

血管内治疗后部循环脑动脉瘤（附30例报告）

目的通过对30例后循环脑动脉瘤探讨、分析血管内治疗的优势和不足之处。方法采用Seldinger法经股动脉穿刺插管,选择适宜微导管与GDC铂金微弹簧圈行栓塞术。结果痊愈23例,恢复良好3例,恢复差2例,死亡2例（1例为术后再出血凶猛,失去了抢救时机,1例为脑干受压严重,神经细胞发生不可逆改变）。结论血管内栓塞治疗后循环脑动脉瘤不能完全取代开颅显微直视下的动脉瘤夹闭术,但可作为不能接受外科手术治疗的最佳选择,而且具有创伤小、手术风险明显减少、成功率高,疗效肯定等优势。     

破裂和未破裂椎动脉瘤的血管内治疗

目的分析破裂与未破裂椎动脉瘤的成功血管内治疗。方法以在新乡市中心医院接受治疗的63例患者（共有65个椎动脉瘤,包括急性夹层和慢性大型动脉瘤）为分析对象,运用改良Rankin量表对临床结果进行评分。其中对44例患者进行了血管造影随访,为期3～16个月（平均8个月）。结果依据Hunt和Hess分级标准,未破裂动脉瘤34例,1级动脉瘤28例,2级动脉瘤1例。其中小脑后下动脉（PICA）远端动脉瘤25例,PICA近端动脉瘤22例,椎动脉-小脑后下动脉（VA-PICA）动脉瘤18例。63例患者中女12例,男51例。平均年龄为41.7岁（6～77岁）。63例患者中44例进行了血管造影随访。其中39例可以依据早期治疗后的血管造影片来确诊完全或基本完全的血栓形成。3例患者观察到了病灶轻微减小,而2例患者存在显著的残留病灶。临床随访表明90.5%的患者为mRS为0～2,4.8%的患者为mRS〉2,以及4.8%的患者死亡（mRS为6）。1例患者死于再次出血,2例患者死于或进展性占位效应/脑干局部缺血。结论使用血管内技术可以很好地治疗破裂与未破裂的椎动脉动脉瘤,90.5%的患者长期治疗效果良好。     

显微手术治疗后交通动脉镜像动脉瘤的临床分析

目的探讨后交通动脉镜像动脉瘤的显微手术治疗效果。方法回顾性分析10例后交通动脉镜像动脉瘤患者的临床资料,Hunt-Hess分级:I级1例,Ⅱ级3例,Ⅲ级5例,Ⅳ级1例。首次出血9例,未出血1例。采用一期与二期,先处理破裂动脉瘤,后处理未破裂动脉瘤的原则,显微手术夹闭后交通动脉镜像动脉瘤。结果所有动脉瘤均完全夹闭,术后经格拉斯哥(GOS)预后评分恢复良好8例,轻残1例,重残1例。术后随访1年,并发脑积水4例,行脑室-腹腔分流术后,患者恢复良好。结论显微手术夹闭后交通动脉镜像动脉瘤疗效确切,效果显著。     

Stent-assisted coil embolization for an unruptured vertebral artery–posterior inferior cerebellar artery aneurysm with retrograde access via type 1 persistent primitive proatlantal artery: A case report

Vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysms are rare lesions that are difficult to treat with both endovascular and surgical techniques. Tight angulation of the PICA from VA may make access to the PICA difficult from ipsilateral VA if adjunctive techniques are needed. Recently, the safety and efficacy of retrograde access have been reported. We report a case of endovascular treatment for a VA-PICA aneurysm with a stent-assisted technique using retrograde access via contralateral persistent primitive proatlantal artery (PPA).The patient was a 76-year-old woman with an unruptured VA-PICA aneurysm on the dominant VA side. Coil embolization with a stent-assisted technique using retrograde access seemed appropriate. However, the origin of the left VA was not confirmed. Left common carotid artery angiography demonstrated that the PPA (type 1) branching from external carotid artery joined the VA V4 segment.Retrograde access via the PPA for stenting was performed. A microcatheter for stenting was retrogradely advanced to the right PICA at ease. After deploying the stent, coil insertion was completed from the right VA, and the final angiogram showed adequate occlusion of the aneurysm with preservation of the PICA.Thus, PPA may be an approach route in the treatment of VA-PICA aneurysms with unconfirmed contralateral VA orifice and apparent PPA on angiography, when retrograde access is needed.     

前交通动脉瘤的介入栓塞治疗

目的总结前交通动脉瘤栓塞治疗的经验。方法 2008年1月-2011年8月,23例前交通动脉瘤患者均在全身麻醉下行动脉瘤内栓塞治疗。其中4例在导丝或导管保护动脉瘤颈情况下行栓塞治疗;1例术中导丝刺破动脉瘤,继续快速填塞至动脉瘤完全栓塞;1例栓塞后弹簧圈突入载瘤动脉,行A1-A2段支架后置入。结果 23例患者手术技术成功率100%。术后即刻造影,动脉瘤完全栓塞11例,>90%栓塞8例,<90%栓塞4例。支架后置入患者术后出现脑梗死,经治疗1个月后康复出院。所有患者临床随访6～24个月,未见再出血。16例患者行全脑血管数字减影血管成像复查,动脉瘤未见复发,其中3例>90%栓塞、2例<90%栓塞患者动脉瘤完全闭塞。结论弹簧圈栓塞治疗前交通动脉瘤是一种安全、有效的治疗方式。但其技术难度相对较大,需要细致操作。     

Endovascular treatment of intracranial artery aneurysms in the posterior cerebral circulation

The purpose of the study was to determine the safety and effectiveness of electrolytically detachable platinum coils in the endovascular treatment of ruptured and unruptured aneurysms in the posterior cerebral circulation. The aneurysms were occluded with electrolytically detachable platinum coils. Six patients with posterior cerebral circulation aneurysms were treated. Four patients suffered a subarachnoid hemorrhage, in two patients the aneurysms were detected incidentally, in one due to mass effect. In all six patients, the diameters of the aneurysms were less than 12 mm and were therefore classified as small aneurysms. Complete occlusion (100%) was achieved in 4 patients, the rate of occlusion in the other two patients was estimated at 75% in one case and at 90% in the other. The clinical outcome in five patients was excellent, without any additional neurological deficit. One patient died five weeks after the procedure due to respiratory complications. At the time of endovascular treatment, she had been graded clinically as grade 5 according to Hunt and Hesse. None of the patients experienced any recurrence of hemorrhage during the follow up period of 12 months. Endovascular occlusion of posterior cerebral artery aneurysms with detachable coil system is an effective alternative therapy to established surgical treatment and could become the treatment of choice. The method is minimally invasive and there is no need for skull trepanation.     

Anatomical features of the vertebral artery for transbrachial direct cannulation of a guiding catheter to perform coil embolization of cerebral aneurysms in the posterior cerebral circulation

Background

Transbrachial approach is an alternative technique for coil embolization of posterior circulation aneurysms. The purpose of our study was to investigate the anatomical features of the vertebral artery (VA) for transbrachial direct VA cannulation of a guiding catheter (GC) to perform coil embolization of posterior circulation aneurysms.

Methods

Included in retrospective analysis were patients who underwent transbrachial coil embolization of cerebral aneurysms in the posterior cerebral circulation by direct VA cannulation of a GC from 2007 to 2013. Investigated were patient characteristics, preoperative sizes of aneurysms, aneurysms location, the angle formed by the target VA and the subclavian artery (AVS), and the VA diameter at the level of the fourth cervical vertebral body (VAD) in the side of the transbrachial access route.

Results

Thirty-one patients with 32 aneurysms met our criteria. The locations of aneurysms were the VA (n = 16), basilar artery (BA) tip (n = 10), BA trunk (n = 3), BA superior cerebellar artery (n = 1), BA anterior inferior cerebellar artery (n = 1), and VA posterior inferior cerebellar artery (n = 1). The right brachial artery was punctured in 27 cases with 28 aneurysms as transbrachial direct cannulation of a GC, and left was in 4 cases with 4 aneurysms. The average AVS, ranging from 45° to 95°, was 77°, and the average VAD, ranging from 3.18 to 4.45 mm, was 3.97 mm.

Conclusion

For transbrachial direct cannulation of a GC, it seems required that the AVS is about 45° or more and the VAD is about 3.18 mm or more.     

Direct vertebral artery access for the endovascular treatment of basilar artery aneurysms

The femoral approach has been considered the preferred technique for the endovascular treatment of intracranial aneurysms. Occasionally, aneurysms are not amenable to the standard femoral approach. We describe four cases of basilar artery aneurysm that were treated by the direct vertebral artery access of V1 at the cervical region. The direct vertebral artery access technique can provide an alternative route in selected cases for the treatment of basilar artery aneurysms.     

Willis覆膜支架治疗颅内段颈内动脉复杂性病变的临床应用

目的评价Willis覆膜支架治疗颅内段颈内动脉复杂性病变的安全性和有效性。方法回顾性分析2015年7月~2017年1月14例颅内段颈内动脉复杂性病变患者接受Willis覆膜支架治疗的病例资料。术后随访3~18个月复查DSA和临床观察结果 ,收集最初及最终造影结果、病死率、致残率及临床结果等数据。结果 14例患者共成功置入Willis覆膜支架15枚,其中血泡样动脉瘤8例,假性动脉瘤3例,多发动脉瘤1例,大动脉瘤2例,技术成功率100%。Willis覆膜支架释放部位C7段3枚,C6段8枚,C5段2枚,C4段2枚;支架植入后即时造影显示病变完全消失10例,内漏4例,经球囊扩张后2例内漏消失,1例仍存在微小内漏,1例再植入1枚支架后病变完全不显影。支架覆盖眼动脉2例,脉络膜前动脉1例,患者无明显神经系统症状。术后3~12个月随访复查DSA显示载瘤动脉通畅13例,轻度狭窄1例;病变完全不显影13例,1例复发。临床随3~18个月,m RS评分0分12例,1分2例,存活患者无新发神经功能缺失。结论 Willis覆膜支架治疗颅内段颈内动脉复杂性血管病变具有良好的安全性和短中期临床结果。     

Transcirculation Silk Vista Baby-assisted coiling in half-T configuration for the treatment of posterior communicating artery aneurysms associated with a fetal posterior circulation: An alternative flow diversion strategy

Flow diverter devices have become a routine first-line option for treatment of an increasing population of intracranial aneurysms at many neurovascular centers. Despite the promising results of flow diverter stents on anterior circulation, incomplete occlusion on the presence of fetal posterior circulation has been described on several reports. Here we describe a novel technical alternative to conventional flow diversion approach for this specific subgroup of aneurysms using the low-profile flow diverter, Silk Vista Baby. The device was selectively placed into the fetal type posterior cerebral artery in half-T configuration for the treatment of a posterior communicating aneurysm using a transcirculation approach through the anterior communicating artery. This represents a useful and effective technique and should be considered when encountering the above-described situation.     

颈内动脉颅内段慢性闭塞血管内开通术的临床分析

目的 探讨血管内再通术治疗症状性颈内动脉颅内段慢性闭塞的安全性和有效性.方法 对颈内动脉颅内段慢性闭塞患者行血管内再通术治疗的患者9例,闭塞部位在颈内动脉C6-C7段,其中8例再通患者中全部使用了扩张球囊,其中2例使用球扩支架,6例使用自膨支架,收集全部患者的临床资料、影像学及随访资料进行回顾分析.结果 从首次发病到介...     

血管内支架技术治疗颅内椎动脉动脉瘤

目的探讨血管内支架技术在颅内椎动脉动脉瘤的应用价值.方法回顾性分析18例采用支架治疗的颅内椎动脉动脉瘤,其中椎动脉梭形动脉瘤10例,全部一期支架结合弹簧圈技术治疗;椎动脉夹层动脉瘤8例,单纯支架技术4例,支架技术二期联合弹簧圈技术治疗4例.结果 16例造影随访3～24个月全部治愈,无复发及狭窄.2例术后出现一过性脑缺血的表现.结论在治疗椎动脉梭形及夹层动脉瘤时应区别对待,血管内支架辅助GDC技术可保持载瘤动脉通畅,是一种安全、有效的选择.     

单一支架置入技术治疗颈内动脉微小动脉瘤的初步探讨

目的探讨单一支架置入技术栓塞治疗微小颅内动脉颈内动脉段（ICA）动脉瘤的预后。方法收集2003年8月至2012年1月收治的微小ICA动脉瘤（直径小于3mm）患者14例的临床资料,其中男4例,女10例;年龄35-72岁。采用单一支架置入技术栓塞治疗5例,采用支架辅助弹簧圈栓塞技术治疗9例。结果 13例血管内栓塞治疗微小ICA动脉瘤手术完全成功,1例（7.1%）患者出现术中动脉瘤破裂出血。仅支架置入组9个月后动脉瘤完全闭塞率80.0%,完全无症状率60.0%;支架辅助弹簧圈组12个月后完全闭塞率88.9%,完全无症状率55.5%。统计结果显示,仅支架置入组患者的改良Rankin量表（mRS）评分较支架辅助弹簧圈组高（t=4.21,P=0.039）,但是其动脉瘤完全闭塞率较低（χ2=5.09,P=0.011）。结论采用单一支架置入栓塞微小动脉瘤的患者完全闭塞率较低,但是患者的并发症少、预后生存质量较高。     

Mechanical thrombectomy for acute occlusion of the posterior inferior cerebellar artery: A case report

BACKGROUNDMechanical thrombectomy (MT) has been demonstrated to be useful for the treatment of ischemic stroke in patients with large vessel occlusions. However, recanalization by MT is not recommended for distal vessels such as second-order branches of the middle cerebral artery and posterior inferior cerebellar artery (PICA). Because of the small size and tortuosity of these arteries, the risks of using the available endovascular devices outweigh the benefits of treatment. However, MT appears to be effective in patients with primary distal vessel occlusion in eloquent areas, those with a high National Institutes of Health Stroke Scale score, and those ineligible for recombinant tissue plasminogen activator therapy. Here, we report the use of MT for treating acute occlusion of the PICA using a direct-aspiration first-pass technique (ADAPT).CASE SUMMARYIn this case, the patient received acute occlusion of the PICA with ADAPT when right internal carotid artery stenting was performed.CONCLUSIONWith the introduction of advanced endovascular devices, MT may now be a feasible treatment for acute occlusion of the PICA.     

Review article: Non-penetrating neck artery dissection in young adults: Not to be missed!

Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front-line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi-disciplinary team management of this condition. In general, guideline-based recommendation for the management of neck artery dissection involving an intimal flap is by anti-platelet therapy while treatment of neck artery dissection that results in a pseudo-aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.     

颈内动脉狭窄或闭塞后交通动脉的DSA和MRA评价

目的 应用DSA、MRA研究颈内动脉狭窄或闭塞患者后交通动脉的变化。方法 分析74例颈内动脉狭窄或闭塞患者以及120例脑血管正常表现者的DSA和MRA结果。结果 疾病组中颈内动脉狭窄或闭塞同侧后交通动脉DSA出现率和对照组间无明显差异(P>0.05);在MRA上明显高于对照组(P<0.01);同侧后交通动脉的DSA和MRA测量值均较对照组增大(P<0.01)。对照组中,后交通动脉DSA出现率高于MRA(P<0.01),DSA和MRA其测量值无统计学差异(P>0.05);疾病组中,后交通动脉DSA出现率高于MRA(P<0.05),单侧和双侧病变其出现率和增粗率无明显差异。结论 后交通动脉在颈内动脉阻塞中有重要代偿作用,DSA上增粗及MRA上出现和增粗均有一定代偿意义。DSA对后交通动脉的评价有很高价值,MRA无创、整体性好,能从功能上评价其作用。