Endovascular Treatment of Posterior Cerebral Artery Trunk Aneurysm: The Status Quo and Dilemma

The posterior cerebral artery (PCA) is an important artery that can be divided into four segments (P1-4): segments P1-2 are proximal segments, and segments P3-4 are distal segments. Various aneurysms can occur along the PCA trunk. True saccular aneurysms are rare, and most PCA trunk aneurysms are dissecting. Sometimes, the PCA trunk can give rise to flow-related aneurysms in association with high-flow arteriovenous shunt diseases or moyamoya disease and internal carotid artery occlusion. Some PCA trunk aneurysms require treatment, especially ruptured or large/giant aneurysms. Recently, endovascular treatment (EVT) has become the mainstream treatment for PCA trunk aneurysms, and it mainly involves reconstructive or deconstructive techniques. Traditional EVT includes selective coiling with/without stent or balloon assistance and parent artery occlusion (PAO). For proximal aneurysms, the PCA should be preserved. For distal aneurysms, PAO can be performed. However, during EVT, preservation of the PCA must naturally be the prime objective. Recently, flow-diverting stents have been used and are a revolutionary treatment for unruptured dissecting aneurysms of the PCA trunk. Despite the associated complications, EVT remains an effective method for treating PCA trunk aneurysms and can result in a good prognosis.

Endovascular Management of Internal Carotid Artery Pseudoaneurysm Secondary to Pediatric Deep Neck Space Infection: A Case Report and Review of Literature

Pseudoaneurysms of extracranial internal carotid artery (ICA) are rare in children. Main causes include trauma, iatrogenic causes, and neck space infection. Prompt diagnosis and management is vital, in view of life-threatening complications like fatal airway hemorrhage and stroke. Endovascular management has currently become the preferred treatment strategy due to its minimally invasive nature and lower complication rates. We report a rare case of mycotic pseudoaneurysm of extracranial ICA in a 4-year-old child as a complication of neck space infection, which was successfully managed with endovascular parent artery occlusion.

Endovascular treatment of anterior inferior cerebellar artery trunk aneurysms

Background The anterior inferior cerebellar artery (AICA) is a very slender and anatomically variable artery that gives off many important perforating arteries that feed the brainstem and nerve-related arteries that feed the inner ear and labyrinth. AICA trunk aneurysms are rare entities that are also difficult to manage. At present, endovascular treatment (EVT) is the preferred choice; however, the understanding of EVT for AICA trunk aneurysms is limited. Methods In this article, we present a literature review on EVT for AICA trunk aneurysms. To promote understanding, we would also provide some illustrative educational cases of our institute. Results Aneurysms along the AICA trunk can occur alone (isolated AICA aneurysm) or secondary to cerebrovascular shunts (flow-related AICA aneurysm). According to their anatomical location, they can also be divided into proximal and distal types. At present, EVT is the mainstream treatment, mainly including selective coiling with parent artery preservation and parent artery occlusion. Both coils and liquid embolization materials can be used. Conclusions For AICA trunk aneurysms, EVT is a reasonable choice and should be based on the specific anatomical location, pathology, and collateral circulation. However, there is still controversy as to the specific type of treatment that should be chosen.

Abstract 1122‐000071: Large and Giant Intracranial Aneurysms, Clinico‐Radiological Outcome and Predictors with Flow Diverter Stent

Introduction : Endovascular treatment for large and giant aneurysms has included either a reconstructive approach or a deconstructive approach by parent artery occlusion. 1,2 Stent‐assisted coiling and balloon‐assisted coiling were alternative techniques developed to deal with such complex aneurysms, but studies have shown less expected efficacy. This study aims to assess the safety and efficacy of the flow diverter stents for treating large and giant intracranial aneurysms and to examine possible predictors for radiological and clinical outcomes such as location and presence of branching artery, bifurcation, and adjuvant coiling. Methods : This study had been conducted on 65 consecutive patients with 65 large and giant aneurysms (size ≥ 10 mm) treated with flow diverters; Periprocedural complications were reported in all patients and clinical outcomes. Follow‐up angiography was done for 60 patients (92.3%) at 12 months. Results : The study included 65 patients who harbored 65 aneurysms. The median age was 55.5 years (IQR: 44.25 ‐ 62.75 years), the female represented 70.8 % of all patients. The clinical presentation had been reported (Headache, cranial nerve palsy, motor deficit, seizures, and visual field defect in 40 patients (61.5%), nine patients (13.8%), seven patients (10.8%), five patients (7.7%), and four patients (6.2%) respectively. The vascular risk factors had been reviewed (HTN, DM, smoking, and Hyperlipidemia in 25 patients (9.2%), Six patients (9.2%), sixteen (24.6%), and 10 patients (15.4%) respectively). The median size of aneurysms was 16.4 mm (IQR: 12.50 ‐ 23.85 mm) and the median neck width was 7.15 mm (IQR: 5.85‐10.24 mm). Fourteen aneurysms (21.4 %) had previous treatment, eleven aneurysms (16.9%) were treated by coils only, one case (1.5%) by assisted procedure, one case (1.5%) by previous FDS, and parent artery occlusion in one case (1.5%). Complete occlusion in 50 from 60 aneurysms (83.4%), neck remnant in 8 aneurysms (13.3%), and sac remnant in two aneurysms (3.3%). Periprocedural problems were encountered in 14 patients (21.5%) with morbidity in six patients (9.2%) and mortality in one patient (1.5%). Univariate and multivariate logistic regression analysis was used to discover possible predictors of combined mortality and morbidity and occlusion in Table (1). Conclusions : From this study, it could be concluded that Endovascular treatment of the large and giant aneurysms with flow diverters represents a safe method for treating this kind of complex intracranial aneurysms. Complex aneurysms with branching artery and bifurcation were associated with aneurysm persistence and complications respectively while the location of the aneurysm was the only predictor for clinical outcome.

Endovascular Management of Cerebral Aneurysms of the Posterior Cerebral Artery

Purpose: To investigate the safety and efficacy of endovascular embolization of cerebral aneurysms at the P1–P3 segments of the posterior cerebral artery (PCA).Materials and Methods: Seventy-seven patients with 77 PCA aneurysms who were treated with endovascular embolization were enrolled, including 35 (45.5%) patients with ruptured aneurysms and 42 (54.5%) with unruptured ones. The pretreatment clinical data and aneurysm occlusion status after treatment and at follow-up were analyzed.Results: All patients were successfully treated endovascularly, including coiling alone in 10 (13.0%) patients, stent-assisted coiling in 18 (23.4%), parent artery occlusion in 25 (32.5%), and pipeline embolization device (PED) in 24 (31.2%). Complete occlusion was achieved in 48 (62.3%) aneurysms, residual neck in 4 (5.2%), and residual aneurysm in the other 25 (32.5%) at the end of embolization. Periprocedural complications occurred in eight patients, including acute thrombosis in seven (9.1%) and intraprocedural subarachnoid hemorrhage in one (1.3%), with the total complication rate of 10.4%. Follow-up was performed in 60 patients (77.9%) for 42 ± 11 months; the mRS score was 0–2 in 55 (91.7%) patients, three in four patients (6.7%), and six in one patient (1.7%). Fifty-three (88.3%) patients (53 aneurysms) had stable or complete occlusion, and seven (11.7%) patients had aneurysm recurrence or residual aneurysm. Among 19 patients treated with PED at follow-up, 15 aneurysms (78.9%) proceeded to complete occlusion while four (21.1%) aneurysms showed residual aneurysm.Conclusion: Endovascular embolization remains a good choice of treatment with high safety and efficacy for posterior cerebral artery aneurysms.

Cascade of Complications Following Carotid Body Tumor Excision

Carotid body tumor excision can lead to various complications including vascular injury and pseudoaneurysm formation. Here we describe a case of carotid body tumor excision followed by series of complications including pseudoaneurysm formation, failure of primary surgical repair, carotid stump syndrome following parent artery occlusion, and persistent hypotension.

Radical treatment of ruptured dissecting aneurysm on the P1 segment with monotherapy using multiple LVIS stents

The standard endovascular treatment for ruptured dissecting aneurysm is a parent artery occlusion. However, this treatment is unsuitable when the artery of the lesion gives off perforating vessels that supply blood to critical regions or when the collateral flow cannot be expected due to the sacrifice of the parent artery. Here, we present an infrequent case of ruptured dissecting aneurysm on P1 segment of the posterior cerebral artery. The aneurysm had little sac for coiling and the artery of the lesion had some perforator branches; thus, we selected the monotherapy with three overlapping low-profile visualised intraluminal support stents as radical treatment, which resulted in prompt obliteration of the aneurysm. The patient was fully recovered at 3 months after the procedure. Previous studies have reported the effectiveness of multiple stents alone for dissecting aneurysms, whereas this case showed that overlapping stents may also be effective on the P1 segment.

Deconstructive versus reconstructive endovascular approaches for intracranial dissecting aneurysms

Background The annual incidence of the intracranial dissecting aneurysms is about 1 to 1.5 per 100,000. This is a well-known cause of stroke and subarachnoid hemorrhage in young and middle-aged patients (Santos-Franco et al. in Neurosurg Rev, 2008. https://doi.org/10.1007/s10143-008-0124-x). Various surgical and endovascular treatment methods have been proposed for intracranial dissecting aneurysms. All treatment methods aim to reduce the blood flow in the dissected region. Deconstructive techniques sacrifice the parent artery, whereas reconstructive techniques aim to maintain a parent artery (Stéphanie et al. in Lancet Neurol 14(6):640–654, 2015. https://doi.org/10.1016/S1474-4422(15)00009-5). Due to its dissecting nature, wall friability can make surgical clipping difficult and even risky. On the other hand, recanalization after coiling alone is almost certain. Therefore, deconstructive modalities of treatment like trapping or parent vessel occlusion, performed either surgically or endovascularly, have predominated for managing those lesions, usually with good results. Nevertheless, in absence of efficient collateral pathways, the deconstructive technique carries an ischemic risk. In situations in which parent artery preservation is mandatory, the use of stent-assisted techniques may be the most appropriate choice (de Barros Faria et al. in Am J Neuroradiol 32(11):2192–2195, 2011. https://doi.org/10.3174/ajnr.A2671). However, the usage of stent with recently ruptured aneurysms is always perplexing due to the necessity of dual antiplatelet administration. Hence the management of dissecting aneurysms remain challenging. Results Between January 2017 and July 2019, 19 patients presenting with intracranial dissecting aneurysms were referred to our department for endovascular treatment. Among the nineteen patients, 11 cases were treated by parent artery occlusion representing 57.9% of the cases, and 7 cases (36.8%) were treated by artery preserving technique, and only one case (5.3%) was treated by combination of parent artery occlusion and artery preserving technique. One week after the intervention 26.3% of patients had no disability (mRS = 0), 47.4% had no significant disability (mRS = 1), 15.8% had slight disability (mRS = 2) and 10.5% had moderate to severe disability (mRS = 3–4). After three months we found an overall improvement of the clinical outcome, as 57.9% of patients had no disability (mRS = 0), 26.3% had no significant disability (mRS = 1) and 15.8% had mild disability (mRS = 2). Finally, after six months reassessment with angiography showed that 89.5% of patients had stable aneurysmal occlusion, and 10.5% had recurrence of aneurysm. Conclusions Both endovascular approaches, whether parent artery occlusion or artery preserving technique showed favorable outcome which indicates the safety and efficacy of both approaches if selected properly according to the morphology of the aneurysm.

True Mycotic Aneurysms: A Report of Three Patients with Internal Carotid Artery Aneurysm and Mucormycosis, and Literature Review

Background Aneurysm formation of internal carotid arteries (ICA) in patients with mucormycosis is a scarce phenomenon. However, the prevalence of rhino-cerebral mucormycosis has been reported to increase after the coronavirus disease 2019 (COVID-19) pandemic. Methods Three patients with stroke and subarachnoid hemorrhage due to ICA aneurysm after the involvement of adjacent paranasal sinuses with mucormycosis were presented. All patients were recruited from Namazi and Khalili hospitals affiliated with Shiraz University of Medical Sciences in Iran from April 2021 to May 2021. Results They had a history of diabetes and corticosteroid use. Also, one of them was treated with imatinib. Two out of three patients were infected with SARS-CoV-2 infection before developing mucormycosis. Two patients had diagnostic angiography before endovascular intervention. One patient did not undergo any therapeutic intervention due to total artery occlusion, whereas the other patient experienced a successful parent artery occlusion by coiling, and only this patient survived. Although all patients received antifungal treatment and surgical debridement, two of them died. Conclusions In the patients with rhino-cerebral mucormycosis evolving of aneurysm should be promptly and meticulously investigated by magnetic resonance angiography (MRA) and computed tomography angiography (CTA). As this type of aneurysms was very fast-growing, as soon as the involvement of sphenoid sinus was detected, the possibility of ICA aneurysm formation should always be kept in mind. If the patient developed an aneurysm, prompt intensive antifungal therapy and therapeutic endovascular interventions such as stenting, coiling, or sacrificing should be considered as soon as possible to optimize outcomes.

Refractory in-stent stenosis after flow diverter stenting associated with delayed cobalt allergic reaction

In-stent stenosis (ISS) triggered by a metal-induced allergic reaction of Pipeline embolization device (PED) placement is extremely rare. The present report describes a patient who presented with delayed parent artery occlusion and refractory ISS after PED placement due to cobalt allergy. A patient in her 70s underwent PED placement for a right internal carotid artery (ICA) large aneurysm; 4 months later, the patient presented with left-sided hemiparesis, and MRI revealed right ICA occlusion even though antiplatelet therapy was optimal. She underwent mechanical thrombectomy, and successful recanalization was achieved. However, follow-up angiography 6 months after the thrombectomy revealed severe ISS, and the patch testing showed a positive reaction for cobalt. As a result of long-term administration of oral steroids and antihistamine, progression of ISS was suppressed. It was supposed that a delayed hypersensitivity reaction to cobalt might induce refractory ISS after PED placement.