The Experience With Flow Diverters in the Treatment of Posterior Inferior Cerebellar Artery Aneurysms

Abstract

BACKGROUND The use of the pipeline embolization device (PED; Medtronic, Dublin, Ireland) in the posterior circulation has been limited and infrequently reported compared to other off-label utilizations. Posterior inferior cerebellar artery aneurysms (PICAA) constitute 1 of the least reported posterior circulation aneurysms treated with PED. No clinical studies have addressed the treatment of these aneurysms with flow diversion exclusively. OBJECTIVE To appraise the feasibility and the safety of PED in the treatment of PICAAs. METHODS Data on 12 consecutive patients, treated between 2011-2017 with PED for their PICAA, was retrospectively reviewed. To control confounding, we used multivariable logistic regression and propensity score conditioning. RESULTS Of 534 patients, 12 (9/12, 75% males) were identified and constituted our study population. The average aneurysm size was 8.47 mm (SD = 2.6, 3.7-14). Patients were followed-up for an average of 10.3 months (SD = 11 mo). Two of 12 (16.7%) had a prior history of subarachnoid hemorrhage. Eight of 12 (67%) of the aneurysms were saccular, 3/12 (25%) were dolichoectatic, and 1/12 (8%) was a small blister aneurysm. Eleven of 12 (92%) aneurysms were treated with 1 PED; 2/12 (16.7%) patients received combined pipeline assisted coiling. All patients had a complete occlusion, regression, and resolution of their aneurysm(s). PED deployment was neither complicated with any hemorrhagic or clinically significant thromboembolic events nor with device migration in any of our patients. Three of 12 (25%) patients had a benign intrastent stenosis. No mortality, among our 12 patients, was noted throughout the follow-up period. CONCLUSION PED, deployed by specialized experts, should be safe in treating PICAA. It can be contemplated as a novel alternative treatment of aneurysms located at the PICA-VA bifurcation or within the PICA.

Flow diverters for the posterior inferior cerebellar artery aneurysms: A systematic review and a single-arm meta-analysis

“…We identified 591 studies through the database search, of which 582 were excluded following title or abstract screening. Then, of the remaining nine studies, we included six 16–21 in the meta-analysis after reading the full text. The six studies involved 46 FD-treated PICA aneurysms.…”

Microsurgical Clipping of a Posterior Inferior Cerebellar Artery Aneurysm Following Failed Pipeline Stent

“…The patient in this case initially underwent a pipeline embolization to manage her PICA aneurysm, a strategy which has shown promising results in the past few years [3][4]. Many times, management of PICA aneurysms using pipeline embolization devices (PED) involves placing the device in the vertebral artery.…”

“…To access the aneurysm, the occipital condyle often had to be removed, causing many patients to experience craniocervical instability. In recent years, pipeline embolization has been shown to be a minimally invasive method of occluding the aneurysm [3][4]. The use of the pipeline stent has been shown to have reduced morbidity compared to microsurgical clipping [5].…”

Posterior Inferior Cerebellar Artery Aneurysm: Microsurgical Clipping of a Ruptured Posterior Inferior Cerebellar Artery (PICA) Aneurysm Not Well Suited to Endovascular Treatment, Far-Lateral Transcondylar Approach to the Anterior Medullary Segment of the PICA, Complete Exclusion of the Aneurysm with Preservation of the Parent Artery

“…Novel devices such as flow diverting stents (FDS) have recently been added to the interventional armamentarium, and initial reports showed complete aneurysm occlusion with preservation not only of the parent vessel but also of perforators (Alokaili and Ahmed 2014;Bhogal et al 2018). More recently, a case series of 12 patients with PICA aneurysms treated with FDS was published, with good clinical and radiological results (Atallah et al 2019). However, this study was performed in a highly specialized center with an average follow-up of 10.3 months.…”