Flow Diversion for Reconstruction of Intradural Vertebral Artery Dissecting Aneurysms Causing Subarachnoid Hemorrhage—A Retrospective Study From Four Neurovascular Centers

Abstract

Objective: Dissecting aneurysms (DAs) of the vertebrobasilar territory manifesting with subarachnoid hemorrhage (SAH) are associated with significant morbi-mortality, especially in the case of re-hemorrhage. Sufficient reconstruction of the affected vessel is paramount, in particular, if a dominant vertebral artery (VA) is impacted. Reconstructive options include stent-assisted coiling and flow diversion (FD). The latter is technically less challenging and does not require catheterization of the fragile aneurysm. Our study aims to report a multicentric experience with FD for reconstruction of DA in acute SAH.Materials and Methods: This retrospective study investigated 31 patients (age: 30–78 years, mean 55.5 years) who had suffered from SAH due to a DA of the dominant VA. The patients were treated between 2010 and 2020 in one of the following German neurovascular centers: University Hospital Leipzig, Katharinenhospital Stuttgart, BG Hospital Bergmannstrost Halle/Saale, and Heinrich-Braun-Klinikum Zwickau. Clinical history, imaging, implanted devices, and outcomes were reviewed for the study.Results: Reconstruction with flow-diverting stents was performed in all cases. The p64 was implanted in 14 patients; one of them required an additional balloon-expandable stent to reconstruct severe stenosis in the target segment. One case demanded additional liquid embolization after procedural rupture, and in one case, p64 was combined with a PED. Further 13 patients were treated exclusively with the PED. The p48MW-HPC was used in two patients, one in combination with two additional Silk Vista Baby (SVB). Moreover, one patient was treated with a single SVB, one with a SILK+. Six patients died [Glasgow Outcome Scale (GOS) 1]. Causes of death were periprocedural re-hemorrhage, thrombotic occlusion of the main pulmonary artery, and delayed parenchymal hemorrhage. The remaining three patients died in the acute–subacute phase related to the severity of the initial hemorrhage and associated comorbidities. One patient became apallic (GOS 2), whereas two patients had severe disability (GOS 3) and four had moderate disability (GOS 4). Eighteen patients showed a complete recovery (GOS 5).Conclusion: Reconstruction of VA-DA in acute SAH with flow-diverting stents is a promising approach. However, the severity of the condition is reflected by high overall morbi-mortality, even despite technically successful endovascular treatment.

Flow Diverter in Unruptured Intracranial Vertebral Artery Dissecting Aneurysm

“…The infarction occurred 2 months after the medication change. According to the flow diverter results in a ruptured VADA reported by Maybaum et al ( 1 ), hemorrhagic complications and ischemic complications occurred in 9.6%, respectively.…”

“…Even though vertebral artery dissection (VAD) is known as a rare disease, it is associated with potentially critical cerebrovascular lesions with a significant variety of unspecific symptoms (1).…”

“…Even though vertebral artery dissection (VAD) is known as a rare disease, it is associated with potentially critical cerebrovascular lesions with a significant variety of unspecific symptoms ( 1 ). VAD is a dynamic process that is variably manifested at angiography as stenosis, occlusion, and aneurysmal dilation, and clinical presentation of VAD is also diverse (e.g., asymptomatic, headache, neck pain, neurologic mass effect, posterior circulation stroke, or subarachnoid hemorrhage).…”

Indirect Flow Diversion for Off-Centered Bifurcation Aneurysms and Distant Small-Vessel Aneurysms, a Retrospective Proof of Concept Study From Five Neurovascular Centers

“…Nevertheless, as a consequence of the broad successful application of flow diversion, humanitarian off-label use has increased tremendously. For example, ruptured dissecting vertebrobasilar aneurysms and aneurysms arising from peripheral cerebral arteries have become recommendable targets for direct flow diversion ( 9 , 10 ).…”

“…The common therapeutic tenets are (a) inducing thrombosis within the aneurysm and (b) creating complete remodeling of the parent artery via providing a solid scaffold for the development of a neointima at the aneurysm-parent artery interface (4)(5)(6). Each class of hemodynamic implant has a specific aptitude for certain types of aneurysms-endosaccular flow disruptors have proved to be especially valuable for the treatment of wide-necked bifurcation aneurysms at and distal to the Circle of Willis (3,7), whereas flow-diverting stents are considered the treatment of choice for wide-necked sidewall aneurysms (8) and non-saccular aneurysms (9)(10)(11). Flow-diverting stents have also been used for off-label indications, such as the treatment of bifurcation aneurysms (12)(13)(14), but unsatisfactory aneurysm occlusion in a number of cases, together with ischemic and hemorrhagic complications, remains a concern according to some investigators (15,16).…”