Cardiovasc Intervent Radiol DOI 10.1007/s00270-014-0981-3
CLINICAL INVESTIGATION
Treatment of Ruptured Vertebral Artery Dissecting Aneurysms Distal to the Posterior Inferior Cerebellar Artery: Stenting or Trapping? Yi-Bin Fang • Kai-Jun Zhao • Yi-Na Wu • Yu Zhou Qiang Li • Peng-Fei Yang • Qing-Hai Huang • Wen-Yuan Zhao • Yi Xu • Jian-Min Liu
•
Received: 21 March 2014 / Accepted: 27 July 2014 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2014
Abstract Purpose The treatment of ruptured vertebral artery dissecting aneurysms (VADAs) continues to be controversial. Our goal was to evaluate the safety, efficacy, and long-term outcomes of internal trapping and stent-assisted coiling (SAC) for ruptured VADAs distal to the posterior inferior cerebellar artery (supra-PICA VADAs), which is the most common subset. Methods A retrospective review was conducted of 39 consecutive ruptured supra-PICA VADAs treated with internal trapping (n = 20) or with SAC (n = 19) at our institution. The clinical and angiographic data were retrospectively compared. Results The immediate total occlusion rate of the VADAs was 80 % in the trapping group, which improved to 88.9 % at the follow-ups (45 months on average). Unwanted occlusions of the posterior inferior cerebellar artery (PICA) were detected in three trapped cases. Incomplete obliteration of the VADA or unwanted occlusions of the PICA were detected primarily in the VADAs closest to the PICA. Yi-Bin Fang and Kai-Jun Zhao are co-first authors.
In the stenting group, the immediate total occlusion rate was 47.4 %, which improved to 100 % at the follow-ups (39 months on average). The immediate total occlusion rate of the VADAs was higher in the trapping group (p \ 0.05), but the later total occlusion was slightly higher in the stenting group (p [ 0.05). Conclusions Our preliminary results showed that internal trapping and stent-assisted coiling are both technically feasible for treating ruptured supra-PICA VADAs. Although not statistically significant, procedural related complications occurred more frequently in the trapping group. When the VADAs are close to the PICA, we suggest that the lesions should be treated using SAC. Keywords Vertebral artery dissecting aneurysm Internal trapping Stent-assisted coiling Abbreviations VA VADAs PICA
Vertebral artery Vertebral artery dissecting aneurysms Posterior inferior cerebellar artery
Y.-B. Fang K.-J. Zhao Y.-N. Wu Y. Zhou Q. Li P.-F. Yang Q.-H. Huang W.-Y. Zhao Y. Xu (&) J.-M. Liu (&) Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai 200433, China e-mail: [email protected]
Y.-N. Wu e-mail: [email protected]
J.-M. Liu e-mail: [email protected]
P.-F. Yang e-mail: [email protected]
Y.-B. Fang e-mail: [email protected]
Q.-H. Huang e-mail: [email protected]
K.-J. Zhao e-mail: [email protected]
W.-Y. Zhao e-mail: [email protected]
Y. Zhou e-mail: [email protected] Q. Li e-mail: [email protected]
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Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ?
supra-PICA VADAs SAH mRS
VADAs distal to the posterior inferior cerebellar artery Subarachnoid hemorrhage Modified Rankin Scale score
clinical follow-up. A total of 39 consecutive patients (M:F = 22:17; median age, 48.3 years; range, 29–67 years) with 39 VADAs (Hunt-Hess grades: I in 15, II in 17, III in 6, IV in 1; Tables 1 and 2) were identified and enrolled in this study. Nineteen cases treated with endovascular SAC also were enrolled in our prior publication [8].
Introduction
Internal Trapping
The rupture of intradural vertebral artery dissecting aneurysms (VADA) is an important cause of subarachnoid hemorrhages (SAH), which result in a high risk of subsequent rebleeding and a poor prognosis. Although a high risk of postprocedural ischemic complications have been reported [1], the internal trapping has been effective in controlling rebleeding and has been considered the first choice of treatment for ruptured VADAs [2–4]. With the development of self-expandable stents for the reconstructive treatment of intracranial aneurysms, endovascular reconstruction has shown favorable safety and efficacy in treating VADAs [5–7]. In this context, whether it is reasonable to consider parent artery occlusion the preferred treatment is an important question to answer. In this study, we compared the safety and efficacy of internal trapping and stent-assisted coiling in the treatment of ruptured vertebral artery dissecting aneurysms distal to the posterior inferior cerebellar artery (supra-PICA VADAs), for which internal trapping has been thought to be the most suitable method.
Platinum coils were used to trap the vessel from the distal VA through the aneurysmal dilation to the proximal VA. When necessary, a microwire or stent was introduced from the proximal VA into the PICA, which followed the VA coil trapping outside the stent. Total occlusion was defined as no contrast medium filling in the aneurysmal dilation on a bilateral VA angiogram. Stent-Assisted Coiling In the early period, the balloon-expandable stent (BX) was employed. Recently, self-expanding neurovascular stents (e.g., Neuroform III, Leo, Enterprise, and Solitaire) have been preferred for reconstructing the entire dissected segment based on the operator’s experience, anatomical characteristics of the affected and contralateral segments, and the hemodynamic modification status after the deployment of the first stent. The perioperative antiplatelet and anticoagulation strategies for the endovascular stenting were the same as those used in our published data [8]. Follow-up
Materials and Methods The institutional review board approved this retrospective study, and the requirement for informed consent was waived. Patient Population A retrospective review of intradural VADAs that had been managed using endovascular modalities from October 2000 to March 2011 was performed at our institution. All of the cases met the following inclusion criteria: (1) a history of SAH relevant to intracranial VADAs, as confirmed by angiography; (2) the VADAs were located distal to the PICA and proximal to the basilar artery (BA); and (3) the initial treatment was either internal trapping or stentassisted coiling. The exclusion criteria included the following: (1) a traumatic and iatrogenic history; (2) unruptured lesions; (3) bilateral VADAs; and (4) patients without
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A follow-up angiography was performed 6 months after the embolization. Contrast enhanced magnetic resonance angiography (MRA) and MRI were performed at 3 months and 1 year after treatment and annually thereafter. The clinical outcomes at discharge and at the follow-ups were assessed using the modified Rankin Scale (mRS) score through either a neurological examination or a telephone interview, and the results were based on the most recent clinical follow-up at the time of the study. Statistical Analysis The baseline demographics, procedural complications, and clinical and angiographic results were retrospectively compared between the trapping group and the stenting group. All of the statistical analyses were performed using SPSS for the MAC (SPSS 20.0); p \ 0.05 was considered statistically significant.
Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ? Table 1 Angiographic and clinical results in 20 ruptured supra-VADAs treated with internal trapping No.
1
Age (yr)/ sex
H&H grade
Side
58/M
1
L
VADA to PICAa
Dominant vessel
Immediate results
Angiographic FU
mRS score
VADA
PICA
Method (mo)
VADA
PICA
AD
FU (mo)
DIS
Co
TO
Patent
DSA (24)
TO
Patent
1
0 (143)
MRAb (109) 2
46/F
1
R
CLS
Co
PO
Patent
MRA (62)
TO
Patent
2
0 (136)
3
60/F
1
L
CLS
LVA
TO
Patent
DSA (26)
TO
Patent
1
1 (115)
MRA (68) 4
57/F
2
R
DIS
Co
TO
Patent
NA
NA
NA
3
2 (103)
5 6
43/F 50/M
2 2
R R
DIS CLS
Co Co
TO TO
Patent Patent
MRA (58) NA
TO NA
Patent NA
1 2
1 (98) 1 (92)
7
46/M
2
R
DIS
Co
TO
Patent
MRA (36)
TO
Patent
2
2 (86)
8
29/M
3
L
CLS
LVA
TO
Occluded
DSA (9)
TO
Occluded
3
2 (85)
TO
Occluded
1
1 (83)
MRA (71) 9
49/M
1
R
DIS
Co
TO
Patent
DSA (7) MRA (53)
10
41/M
3
L
CLS
Co
PO
Patent
DSA (2)
Progression
Patent
4
6 (3)
11
50/F
2
L
CLS
Co
TO
Patent
DSA (6)
TO
Patent
4
3 (79) 0 (75)
MRA (43) 12c
49/M
1
R
DIS
Co
TO
Patent
MRA (42)
TO
Patent
1
13
39/M
2
R
CLS
Co
PO
Patent
MRA (36)
TO
Patent
2
1 (65)
14
40/M
2
R
DIS
LVA
TO
Patent
DSA (18)
TO
Patent
1
0 (62)
15
47/M
2
L
DIS
Co
TO
Patent
DSA (37)
TO
Patent
1
0 (62)
16c 17c
51/F 55/M
2 1
R R
CLS DIS
LVA Co
PO TO
Patent Patent
DSA (28) DSA (12)
Progression TO
Patent Patent
2 1
1 (56) 1 (55)
MRA (49)
MRA (37) 18
53/M
2
R
DIS
Co
TO
Patent
MRA (22)
TO
Patent
1
0 (38)
19
34/M
2
R
CLS
Co
TO
Patent
DSA (26)
TO
Occluded
1
0 (37)
20c
57/F
1
R
CLS
Co
TO
Patentd
DSA (11)
TO
Patent
1
3 (25)
MRA (24) L left; R right; Co comparable; TO total occlusion; PO partial occlusion; mRS modified Rankin Scale; AD at discharge; FU follow-up; NA not applicable a
Distance between the VADA and the PICA. ‘‘DIS’’ indicates that the VAD was derived at a distance from the PICA, and ‘‘CLS’’ indicates that the VAD was derived close to the PICA
b
‘‘MRA’’ indicates contrast enhanced magnetic resonance angiography
c
Accompanying ICA aneurysm was treated during a second session
d
VADA was treated with internal trapping under the protection of a microwire, which was deployed from the VA into the PICA
Results All of the results are detailed in Tables 1 and 2. Twenty lesions were treated using endovascular coil trapping, in which the PICA was protected by the deployment of a stent in 1 case and by a microwire in another case. Nineteen VADAs were successfully treated by stent-assisted coiling (Fig. 1). Complications In the stenting group, one patient (case 31, Table 3) who was successfully treated using triple stents and coils
suffered a severe vasospasm and died from a right hemispheric brain infarction (5.3 %, 1/19). The other 18 patients experienced an uneventful postoperative procedure. Three treatment-related complications occurred in the trapping group (15 %, 3/20), all of which were ischemic complications (Table 3). In case 8, coil trapping was performed successfully for a dissecting aneurysm located at the dominant VA. However, an immediate PICA occlusion was detected on the post-operative angiogram that resulted in an acute infarction at PICA territory (mRS, 3). In case 11, a newly derived brain stem infarction was detected after the total occlusion of the VA despite the patent PICA,
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Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ? Table 2 Angiographic and clinical results in 19 ruptured supra-VADAs treated with stent-assisted coiling No.
21
Age (yr)/ sex
H&H grade
Side
50/M
1
R
VADA to PICAa
Dominant vessel
Stents
DIS
Co
BX*1
Immediate results
Angiographic FU
mRS score
VADA
PICA
Method (mo)
VADA
PICA
AD
FU (mo)
PO
Patent
DSA (20)
TO
Patent
1
0 (156)
TO
Patent
1
0 (131)
MRAb (62) 22
58/M
3
L
DIS
Co
BX*1
TO
Patent
DSA (48)
23
44/F
1
R
CLS
Co
BX*1
TO
Patent
DSA (66)
TO
Patent
1
0 (130)
24
58/M
3
L
CLS
Co
BX*1
TO
Patent
DSA (12)
TO
Patent
2
1 (112)
25 26
67/M 53/M
3 1
L R
CLS CLS
LVA RVA
BX*1 NF*2
PO TO
Patent Patent
TO TO
Patent Patent
2 1
0 (105) 0 (107)
27
52/F
2
L
CLS
Co
LEO*2
TO
Patent
TO
Patent
1
0 (97)
TO
Patent
0
0 (94)
TO
Patent
1
0 (47)
TO
Patent
1
0 (37)
MRA (91) MRA (36) DSA (18) MRA (62) DSA (18) MRA (36) 28
41/F
1
R
CLS
RVA
NF*1
PO
Patent
DSA (23) MRA (73)
29
52/F
2
L
CLS
LVA
NF*1
PO
Patent
DSA (6) MRA (42)
30c
43/F
2
R
DIS
Co
EP*3
PO
Patent
DSA (6) MRA (33)
31
54/M
4
R
DIS
Co
EP*3
TO
Patent
–
–
–
6
–
32
52/F
2
R
CLS
Co
EP*3
TO
Patent
DSA (6) MRA (18)
TO
Patent
3
0 (37)
33
38/F
1
L
DIS
LVA
EP*1
PO
Patent
DSA (15)
TO
Patent
1
0 (34)
TO
Patent
1
0 (34)
MRA (28) 34
37/M
2
L
CLS
LVA
EP*2
PO
Patent
DSA (6) MRA (30)
35
49/F
2
R
CLS
Co
EP*2
TO
Patent
MRA (23)
TO
Patent
1
0 (31)
36
46/F
3
L
CLS
Co
EP*3
PO
Patent
DSA (9)
TO
Patent
4
2 (26)
37
46/F
1
L
DIS
Co
EP*2
TO
Patent
DSA (9)
TO
Patent
1
0 (22)
38
47/M
1
L
DIS
Co
EP*2
PO
Patent
DSA (7)
TO
Patent
3
2 (21)
TO
Patent
3
1 (20)
MRA (25)
MRA (18) 39
43/M
1
L
DIS
LVA
EP*2
PO
Patent
DSA (8)
L left; R right; Co comparable; TO total occlusion; PO partial occlusion; mRS modified Rankin Scale; AD at discharge; FU follow-up; mo months; NA not applicable a
Distance between the VADA and the PICA. ‘‘DIS’’ indicates that the VAD was derived at a distance from the PICA, and ‘‘CLS’’ indicates that the VAD was derived close to the PICA
b
‘‘MRA’’ indicates contrast enhanced magnetic resonance angiography
c
Accompanying ICA dissection was treated during a second session
which resulted in an irritating cough due to the reflux of liquids. In above-mentioned two cases, the PICAs were quite close to the dissecting aneurysms. In case 9, a newly derived right-sided facial numbness caused by brain stem infarction was detected one month after the treatment, which may be related to the delayed occlusion of the PICA confirmed by DSA.
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Angiographic Results In the trapping group, the immediate total occlusion rate was 80 % (16/20) (Table 1), which improved to 88.9 % (16/18) at the angiographic follow-ups at 2 to 109 months postoperatively (45 months on average). Two VADAs, which failed to be totally occluded, required a second
Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ?
Fig. 1 Case 10. A Left VA angiography detected a pearl-and-string sign distal to the PICA origin with a local artery vasospasm. B The VADA was not completely trapped by the platinum coils (Microplex 5/20, 3/10, 3/8,3/8, 2/8, 2/6, 2/3), and the proximal VA was dilated using a balloon (AQUA 2.5/20 4 atm). C The follow-up angiography
at 2 months revealed the incomplete occlusion of the VADA. D Total occlusion was obtained in the retreatment (Microplex 2/2, 2/2). E Recanalization was detected at further angiographic follow-ups. The patient refused further treatment and died 1 month later
Table 3 Procedure and non procedure related morbidity/mortality in this case series No.
H&H Grade
VADA to PICAa
strategy
Morbidity/ mortality
procedurerelated
Clinical symptoms
CT/MR
DSA
8
3
CLS
Internal trapping
Permanent morbidity
Yes
Wallenberg syndrome
Acute infarction at PICA territory
Immediate PICA occlusion
9
1
DIS
Internal trapping
Permanent morbidity
Yes
Right-sided facial numbness
Brain stem infarction
Delayed PICA occlusion
10
3
CLS
Internal trapping
Mortality
Yes
Sudden onset of headache and unconsciousness
NA
Recanalization of the VADAb
11
2
CLS
Internal trapping
Permanent morbidity
Yes
Irritating cough due to the reflux of liquids
Brain stem infarction
PICA is patent
31
4
DIS
SAC
Mortality
No
Deteriorating neurological condition
Diffuse infarction of the right hemisphere
Severe vasospasm
CT computed tomography; MR magnetic resonance image; NA not applicable a
Distance between the VADA and the PICA. ‘‘DIS’’ indicates that the VAD was derived at a distance from the PICA, and ‘‘CLS’’ indicates that the VAD was derived close to the PICA
b
This case is illustrated in Fig. 1
endovascular procedure. Recanalization was detected in one of them upon further angiographic follow-ups (Fig. 2). Angiographic occlusion of the PICA was revealed in 3 cases (16.7 %), one of which was related to newly derived neurological deficits (case 8). These 5 VADAs were all quite close to the PICA. In the stenting group, the immediate total occlusion rate was 47.4 % (9/19) (Table 2), which improved to 100 % (18/18) at the angiographic follow-ups at 8 to 91 months postoperatively (39 months on average). The PICAs remained patent in all of the cases. The total occlusion of the VADAs were more frequently obtained in the trapping group (p \ 0.05) immediately after the treatment and was comparable between the two groups (p [ 0.05) in the long-term follow-up.
Clinical Follow-ups Thirty-eight patients were clinically followed-up from 3 to 156 months. Twenty patients in the trapping group were clinically followed-up for 75 months on average, and the mRS score was 0 in 7 cases, 1 in 7 cases, 2 in 3 cases, 3 in 2 cases, and 6 in 1 case. One patient (case 9) suffered newly derived right-sided facial numbness. One patient (case 10, illustrated in Fig. 2) died 1 month after the recanalization of the lesion. Eighteen patients in the stenting group were clinically followed-up for 69 months on average, and the mRS score was 0 in 14 cases, 1 in 2 cases, and 2 in 2 cases. No newly derived neurological deficits were detected. Favorable outcomes (mRS scores of 0 and 1) were obtained in 70 % of the cases in the trapping group and in
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Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ?
Fig. 2 Case 23 A The right vertebral angiography at admission showed a supra-PICA VADA, with the PICA located at the edge of the lesion. B The immediate angiographic result was incomplete occlusion of the VADA. C The plain radiography in the lateral view reveals the positions of the stent and coils. D Total occlusion was
detected at the 6-month follow-up. E The angiographic follow-up at 66 months showed no signs of the lesion. F A healing line was detected between the stent and the blood flow on the plain radiography, which demonstrated the cure of the lesion
88.9 % of the cases in the stenting group; there was no statistically significant difference (p [ 0.05).
techniques based on stents for VADAs have increasingly emerged as a promising alternative to deconstructive techniques [5–7]. In this context, whether it is appropriate for the parent artery to be sacrificed as a first choice and when to occlude a vessel are questions that need to be answered. Intradual VADAs are usually classified into the following 4 types according to the location of the aneurysmal dilation to the PICA: the supra-PICA type, PICA-involved type, infra-PICA type, and non-PICA type [9]. The supraPICA type is the most common subgroup, comprising 56 % of all VADAs [9]. The PICA-involved type is primarily contraindicated for internal trapping, and the infraand non-PICA types are relatively rare. Therefore, we selected the supra-PICA VADAs to compare the efficacy of the two different treatment strategies. Although internal trapping has been widely used and is thought to be effective in the treatment of ruptured VADAs [3, 17–19], immediate total occlusion is not always possible, and early rebleeding is not uncommon [21–23]. In our series, 20 % of the cases in the trapping group failed to be
Discussion Intracranial spontaneous vertebral artery dissecting aneurysms are increasingly diagnosed as the cause of SAH, particularly in young to middle-aged adults [9, 10]. It is believed that a cerebral dissecting aneurysm is formed by the sudden widespread disruption of the internal elastic lamina [11, 12], which results in a high risk of rebleeding in the acute stage [3, 9, 13]. Surgical trapping may be the most reliable method to prevent rerupture and was widely used before endovascular treatment was available [14, 15]. However, this treatment is quite invasive, may precipitate the Wallenberg syndrome or other disastrous events [9, 16], and has been replaced gradually by internal trapping [3, 17–19]. Moreover, there are still some limitations for such deconstructive approaches. With the continued advances in stent technology [20], reconstructive
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Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ?
immediately totally occluded, and the proportion decreased to 11.1 % (2/18) at the follow-ups, which is comparable to the published results [2, 3]. One patient suffered recanalization after a retreatment and had to forego further treatment for financial reasons. The patient died 1 month later after the sudden onset of a headache, which may have been caused by rebleeding. The actual reported risk of rebleeding after internal trapping reaches to 8.3 % in VADAs [2]. Despite a lower immediate total occlusion rate, progressive occlusion was detected in all of the cases in the stenting group without immediate total occlusion. This progressive occlusion may result from the flow diversion and scaffolding effects of the stents. Similar results also have been reported in aneurysms in other locations [24, 25]. Considering that the risk of rebleeding for untreated ruptured VADAs can reach 70 %, our results showed that internal trapping and SAC were both effective treatments for these lesions [9]. Ischemic complications continue to be important causes of disability, which most frequently results from the compromised blood flow in the PICA. The total incidence of symptomatic ischemic events in our series was 10.3 % (4/39) and occurred primarily in the trapping group (3/4). One of the ischemic events was not related to the PICA, and it may have been caused by the occlusion of the perforators supplying the brainstem after the VA occlusion. Even when performed on the nondominant side or following a negative result on a balloon occlusion test (BOT), internal trapping may still cause ischemic complications [1]. We did not routinely perform DW-MRI scanning after the operations in this series, and the risk of a subsequent silent infarction therefore may be underestimated. In the trapping group, an incomplete obliteration of the VADA or the occlusion of the PICA was detected in the VADAs closest to the origin of the PICA. Furthermore, early ischemic complications also occurred primarily in this subgroup (2/2). The primary cause of complications may be that the length of the VA that requires occlusion is not always controllable and often is longer than anticipated when performing internal trapping. For the cases harboring VADAs close to the origin of the PICA, the risk of unwanted coil herniation into the PICA or coil packing below the PICA is always present. Moreover, total occlusion is not always possible when the PICA needs to be protected. The procedure-related complications appear to be increased in this subgroup (Table 3). When PICA was close to the dissecting aneurysms, we attempted to use a stent or microwire to protect the PICA when trapping the VADAs. This technique has been reported to be feasible and efficacious in small case series
[26, 27], but we prefer to protect both the VA and the PICA, with a similar risk of antiplatelet therapy. In contrast, when the VADAs close to the PICA are treated using SAC, the only difference may be the increased potential to cover the origin of the PICA by the stent struts, which has proven to be safe in most cases [28, 29]. In our stenting group, the orifice of the PICA was covered in 15 cases by 1 to 3 (overlapping) stent(s), and there were no perforator-related ischemic complications. The only lethal complication in the stenting group was a severe vasospasm, as confirmed by a DSA in case 31, which resulted in a diffuse infarction of the right hemisphere and the death of the patient. The primary limitation of using SAC to treat ruptured aneurysms is the increased risk of hemorrhagic complications because of peri-operative antiplatelet medication. In our series, loading doses of dual antiplatelet drugs were administered shortly before stenting in all of the cases, and no rebleeding was detected. Administering loading doses of antiplatelet drugs has proven to be essential and safe according to our preliminary published results on the application of stents in treating ruptured VADAs [8]. Because of the high risk of intracerebral hematomas, SAC was not the first choice for the cases requiring external ventricle drainage.
Limitations This series has some limitations, including its retrospective design, patient selection bias, and limited cases in a single institution.
Conclusions Our preliminary results showed that internal trapping and stent-assisted coiling are both technically feasible for treating ruptured supra-PICA VADAs. Although ischemic complications occurred more frequently in the trapping group, the differences were not statistically significant. When the VADAs are close to the PICA, it is preferable to treat the lesions using SAC. Acknowledgments The study was supported by the National Natural Science Foundation of China (No. 81301004, 81271271), the Foundation of Shanghai Public Health Bureau (No. 20114232), and the Shanghai Science and Technology Development Funds (No. 13140903201). Conflict of interest Yi-Bin Fang, Kai-Jun Zhao, Yi-Na Wu, Yu Zhou, Qiang Li, Peng-Fei Yang, Qing-Hai Huang, Wen-Yuan Zhao, Yi Xu, and Jian-Min Liu have no conflicts of interest.
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16. Yasui T, Yagura H, Komiyama M, Fu Y, Nagata Y, Tamura K (1993) Surgical treatment of ruptured dissecting aneurysms: proximal clipping vs trapping. No Shinkei Geka 21(5):395–401 17. Shibukawa M, Sakamoto S, Kiura Y, Matsushige T, Kurisu K (2009) Ruptured vertebral artery dissecting aneurysms treated with endovascular treatment. Hiroshima J Med Sci 58(2–3): 55–60 18. Ryu CW, Koh JS, Kim EJ (2010) Dissection of the distal vertebral artery treated by modified parent artery trapping and a contralateral stent barricade: a case report. Interv Neuroradiol 16(2):171–174 19. Rabinov JD, Hellinger FR, Morris PP, Ogilvy CS, Putman CM (2003) Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 24(7):1421–1428 20. Krischek O, Miloslavski E, Fischer S, Shrivastava S, Henkes H (2011) A comparison of functional and physical properties of self-expanding intracranial stents [Neuroform3, Wingspan, Solitaire, Leo ? , Enterprise]. Minim Invasive Neurosurg 54(1): 21–28 21. Takai N, Ezuka I, Sorimachi T, Kumagai T, Sano K (1993) Vertebral artery dissecting aneurysm rebleeding after proximal occlusion–case report. Neurol Med Chir (Tokyo) 33(11):765–768 22. Sugiu K, Tokunaga K, Ono S, Nishida A, Date I (2009) Rebleeding from a vertebral artery dissecting aneurysm after endovascular internal trapping: adverse effect of intrathecal urokinase injection or incomplete occlusion? case report. Neurol Med Chir (Tokyo) 49(12):597–600 23. Nakatomi H, Nagata K, Kawamoto S (1999) Persistent patent pseudolumen of ruptured dissecting aneurysm involving the posterior inferior cerebellar artery after proximal clipping. Acta Neurochir (Wien) 141(5):533–536 24. Chalouhi N, Starke RM, Koltz MT, Jabbour PM, Tjoumakaris SI, Dumont AS et al (2013) Stent-assisted coiling versus balloon remodeling of wide-neck aneurysms: comparison of angiographic outcomes. AJNR Am J Neuroradiol 34(10):1987–1992 25. Kulcsar Z, Goricke SL, Gizewski ER, Schlamann M, Sure U, Sandalcioglu IE et al (2013) Neuroform stent-assisted treatment of intracranial aneurysms: long-term follow-up study of aneurysm recurrence and in-stent stenosis rates. Neuroradiology 55(4):459–465 26. Chung J, Kim BS, Lee D, Kim TH, Shin YS (2010) Vertebral artery occlusion with vertebral artery-to-posterior inferior cerebellar artery stenting for preservation of the PICA in treating ruptured vertebral artery dissection. Acta Neurochir (Wien) 152(9):1489–1492 27. Kim MJ, Chung J, Kim SL, Roh HG, Kwon BJ, Kim BS et al (2011) Stenting from the Vertebral Artery to the Posterior Inferior Cerebellar Artery. AJNR Am J Neuroradiol 33(2):348–352 28. Hong B, Wang K, Huang Q, Xu Y, Fang X, Li Z et al (2012) Effects of metal coverage rate of flow diversion device on neointimal growth at side branch ostium and stented artery: an animal experiment in rabbit abdominal aorta. Neuroradiology 54(8):849–855 29. Masuo O, Terada T, Walker G, Tsuura M, Matsumoto H, Tohya K et al (2002) Study of the patency of small arterial branches after stent placement with an experimental in vivo model. AJNR Am J Neuroradiol 23(4):706–710
CLINICAL INVESTIGATION
Treatment of Ruptured Vertebral Artery Dissecting Aneurysms Distal to the Posterior Inferior Cerebellar Artery: Stenting or Trapping? Yi-Bin Fang • Kai-Jun Zhao • Yi-Na Wu • Yu Zhou Qiang Li • Peng-Fei Yang • Qing-Hai Huang • Wen-Yuan Zhao • Yi Xu • Jian-Min Liu
•
Received: 21 March 2014 / Accepted: 27 July 2014 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2014
Abstract Purpose The treatment of ruptured vertebral artery dissecting aneurysms (VADAs) continues to be controversial. Our goal was to evaluate the safety, efficacy, and long-term outcomes of internal trapping and stent-assisted coiling (SAC) for ruptured VADAs distal to the posterior inferior cerebellar artery (supra-PICA VADAs), which is the most common subset. Methods A retrospective review was conducted of 39 consecutive ruptured supra-PICA VADAs treated with internal trapping (n = 20) or with SAC (n = 19) at our institution. The clinical and angiographic data were retrospectively compared. Results The immediate total occlusion rate of the VADAs was 80 % in the trapping group, which improved to 88.9 % at the follow-ups (45 months on average). Unwanted occlusions of the posterior inferior cerebellar artery (PICA) were detected in three trapped cases. Incomplete obliteration of the VADA or unwanted occlusions of the PICA were detected primarily in the VADAs closest to the PICA. Yi-Bin Fang and Kai-Jun Zhao are co-first authors.
In the stenting group, the immediate total occlusion rate was 47.4 %, which improved to 100 % at the follow-ups (39 months on average). The immediate total occlusion rate of the VADAs was higher in the trapping group (p \ 0.05), but the later total occlusion was slightly higher in the stenting group (p [ 0.05). Conclusions Our preliminary results showed that internal trapping and stent-assisted coiling are both technically feasible for treating ruptured supra-PICA VADAs. Although not statistically significant, procedural related complications occurred more frequently in the trapping group. When the VADAs are close to the PICA, we suggest that the lesions should be treated using SAC. Keywords Vertebral artery dissecting aneurysm Internal trapping Stent-assisted coiling Abbreviations VA VADAs PICA
Vertebral artery Vertebral artery dissecting aneurysms Posterior inferior cerebellar artery
Y.-B. Fang K.-J. Zhao Y.-N. Wu Y. Zhou Q. Li P.-F. Yang Q.-H. Huang W.-Y. Zhao Y. Xu (&) J.-M. Liu (&) Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai 200433, China e-mail: [email protected]
Y.-N. Wu e-mail: [email protected]
J.-M. Liu e-mail: [email protected]
P.-F. Yang e-mail: [email protected]
Y.-B. Fang e-mail: [email protected]
Q.-H. Huang e-mail: [email protected]
K.-J. Zhao e-mail: [email protected]
W.-Y. Zhao e-mail: [email protected]
Y. Zhou e-mail: [email protected] Q. Li e-mail: [email protected]
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Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ?
supra-PICA VADAs SAH mRS
VADAs distal to the posterior inferior cerebellar artery Subarachnoid hemorrhage Modified Rankin Scale score
clinical follow-up. A total of 39 consecutive patients (M:F = 22:17; median age, 48.3 years; range, 29–67 years) with 39 VADAs (Hunt-Hess grades: I in 15, II in 17, III in 6, IV in 1; Tables 1 and 2) were identified and enrolled in this study. Nineteen cases treated with endovascular SAC also were enrolled in our prior publication [8].
Introduction
Internal Trapping
The rupture of intradural vertebral artery dissecting aneurysms (VADA) is an important cause of subarachnoid hemorrhages (SAH), which result in a high risk of subsequent rebleeding and a poor prognosis. Although a high risk of postprocedural ischemic complications have been reported [1], the internal trapping has been effective in controlling rebleeding and has been considered the first choice of treatment for ruptured VADAs [2–4]. With the development of self-expandable stents for the reconstructive treatment of intracranial aneurysms, endovascular reconstruction has shown favorable safety and efficacy in treating VADAs [5–7]. In this context, whether it is reasonable to consider parent artery occlusion the preferred treatment is an important question to answer. In this study, we compared the safety and efficacy of internal trapping and stent-assisted coiling in the treatment of ruptured vertebral artery dissecting aneurysms distal to the posterior inferior cerebellar artery (supra-PICA VADAs), for which internal trapping has been thought to be the most suitable method.
Platinum coils were used to trap the vessel from the distal VA through the aneurysmal dilation to the proximal VA. When necessary, a microwire or stent was introduced from the proximal VA into the PICA, which followed the VA coil trapping outside the stent. Total occlusion was defined as no contrast medium filling in the aneurysmal dilation on a bilateral VA angiogram. Stent-Assisted Coiling In the early period, the balloon-expandable stent (BX) was employed. Recently, self-expanding neurovascular stents (e.g., Neuroform III, Leo, Enterprise, and Solitaire) have been preferred for reconstructing the entire dissected segment based on the operator’s experience, anatomical characteristics of the affected and contralateral segments, and the hemodynamic modification status after the deployment of the first stent. The perioperative antiplatelet and anticoagulation strategies for the endovascular stenting were the same as those used in our published data [8]. Follow-up
Materials and Methods The institutional review board approved this retrospective study, and the requirement for informed consent was waived. Patient Population A retrospective review of intradural VADAs that had been managed using endovascular modalities from October 2000 to March 2011 was performed at our institution. All of the cases met the following inclusion criteria: (1) a history of SAH relevant to intracranial VADAs, as confirmed by angiography; (2) the VADAs were located distal to the PICA and proximal to the basilar artery (BA); and (3) the initial treatment was either internal trapping or stentassisted coiling. The exclusion criteria included the following: (1) a traumatic and iatrogenic history; (2) unruptured lesions; (3) bilateral VADAs; and (4) patients without
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A follow-up angiography was performed 6 months after the embolization. Contrast enhanced magnetic resonance angiography (MRA) and MRI were performed at 3 months and 1 year after treatment and annually thereafter. The clinical outcomes at discharge and at the follow-ups were assessed using the modified Rankin Scale (mRS) score through either a neurological examination or a telephone interview, and the results were based on the most recent clinical follow-up at the time of the study. Statistical Analysis The baseline demographics, procedural complications, and clinical and angiographic results were retrospectively compared between the trapping group and the stenting group. All of the statistical analyses were performed using SPSS for the MAC (SPSS 20.0); p \ 0.05 was considered statistically significant.
Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ? Table 1 Angiographic and clinical results in 20 ruptured supra-VADAs treated with internal trapping No.
1
Age (yr)/ sex
H&H grade
Side
58/M
1
L
VADA to PICAa
Dominant vessel
Immediate results
Angiographic FU
mRS score
VADA
PICA
Method (mo)
VADA
PICA
AD
FU (mo)
DIS
Co
TO
Patent
DSA (24)
TO
Patent
1
0 (143)
MRAb (109) 2
46/F
1
R
CLS
Co
PO
Patent
MRA (62)
TO
Patent
2
0 (136)
3
60/F
1
L
CLS
LVA
TO
Patent
DSA (26)
TO
Patent
1
1 (115)
MRA (68) 4
57/F
2
R
DIS
Co
TO
Patent
NA
NA
NA
3
2 (103)
5 6
43/F 50/M
2 2
R R
DIS CLS
Co Co
TO TO
Patent Patent
MRA (58) NA
TO NA
Patent NA
1 2
1 (98) 1 (92)
7
46/M
2
R
DIS
Co
TO
Patent
MRA (36)
TO
Patent
2
2 (86)
8
29/M
3
L
CLS
LVA
TO
Occluded
DSA (9)
TO
Occluded
3
2 (85)
TO
Occluded
1
1 (83)
MRA (71) 9
49/M
1
R
DIS
Co
TO
Patent
DSA (7) MRA (53)
10
41/M
3
L
CLS
Co
PO
Patent
DSA (2)
Progression
Patent
4
6 (3)
11
50/F
2
L
CLS
Co
TO
Patent
DSA (6)
TO
Patent
4
3 (79) 0 (75)
MRA (43) 12c
49/M
1
R
DIS
Co
TO
Patent
MRA (42)
TO
Patent
1
13
39/M
2
R
CLS
Co
PO
Patent
MRA (36)
TO
Patent
2
1 (65)
14
40/M
2
R
DIS
LVA
TO
Patent
DSA (18)
TO
Patent
1
0 (62)
15
47/M
2
L
DIS
Co
TO
Patent
DSA (37)
TO
Patent
1
0 (62)
16c 17c
51/F 55/M
2 1
R R
CLS DIS
LVA Co
PO TO
Patent Patent
DSA (28) DSA (12)
Progression TO
Patent Patent
2 1
1 (56) 1 (55)
MRA (49)
MRA (37) 18
53/M
2
R
DIS
Co
TO
Patent
MRA (22)
TO
Patent
1
0 (38)
19
34/M
2
R
CLS
Co
TO
Patent
DSA (26)
TO
Occluded
1
0 (37)
20c
57/F
1
R
CLS
Co
TO
Patentd
DSA (11)
TO
Patent
1
3 (25)
MRA (24) L left; R right; Co comparable; TO total occlusion; PO partial occlusion; mRS modified Rankin Scale; AD at discharge; FU follow-up; NA not applicable a
Distance between the VADA and the PICA. ‘‘DIS’’ indicates that the VAD was derived at a distance from the PICA, and ‘‘CLS’’ indicates that the VAD was derived close to the PICA
b
‘‘MRA’’ indicates contrast enhanced magnetic resonance angiography
c
Accompanying ICA aneurysm was treated during a second session
d
VADA was treated with internal trapping under the protection of a microwire, which was deployed from the VA into the PICA
Results All of the results are detailed in Tables 1 and 2. Twenty lesions were treated using endovascular coil trapping, in which the PICA was protected by the deployment of a stent in 1 case and by a microwire in another case. Nineteen VADAs were successfully treated by stent-assisted coiling (Fig. 1). Complications In the stenting group, one patient (case 31, Table 3) who was successfully treated using triple stents and coils
suffered a severe vasospasm and died from a right hemispheric brain infarction (5.3 %, 1/19). The other 18 patients experienced an uneventful postoperative procedure. Three treatment-related complications occurred in the trapping group (15 %, 3/20), all of which were ischemic complications (Table 3). In case 8, coil trapping was performed successfully for a dissecting aneurysm located at the dominant VA. However, an immediate PICA occlusion was detected on the post-operative angiogram that resulted in an acute infarction at PICA territory (mRS, 3). In case 11, a newly derived brain stem infarction was detected after the total occlusion of the VA despite the patent PICA,
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Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ? Table 2 Angiographic and clinical results in 19 ruptured supra-VADAs treated with stent-assisted coiling No.
21
Age (yr)/ sex
H&H grade
Side
50/M
1
R
VADA to PICAa
Dominant vessel
Stents
DIS
Co
BX*1
Immediate results
Angiographic FU
mRS score
VADA
PICA
Method (mo)
VADA
PICA
AD
FU (mo)
PO
Patent
DSA (20)
TO
Patent
1
0 (156)
TO
Patent
1
0 (131)
MRAb (62) 22
58/M
3
L
DIS
Co
BX*1
TO
Patent
DSA (48)
23
44/F
1
R
CLS
Co
BX*1
TO
Patent
DSA (66)
TO
Patent
1
0 (130)
24
58/M
3
L
CLS
Co
BX*1
TO
Patent
DSA (12)
TO
Patent
2
1 (112)
25 26
67/M 53/M
3 1
L R
CLS CLS
LVA RVA
BX*1 NF*2
PO TO
Patent Patent
TO TO
Patent Patent
2 1
0 (105) 0 (107)
27
52/F
2
L
CLS
Co
LEO*2
TO
Patent
TO
Patent
1
0 (97)
TO
Patent
0
0 (94)
TO
Patent
1
0 (47)
TO
Patent
1
0 (37)
MRA (91) MRA (36) DSA (18) MRA (62) DSA (18) MRA (36) 28
41/F
1
R
CLS
RVA
NF*1
PO
Patent
DSA (23) MRA (73)
29
52/F
2
L
CLS
LVA
NF*1
PO
Patent
DSA (6) MRA (42)
30c
43/F
2
R
DIS
Co
EP*3
PO
Patent
DSA (6) MRA (33)
31
54/M
4
R
DIS
Co
EP*3
TO
Patent
–
–
–
6
–
32
52/F
2
R
CLS
Co
EP*3
TO
Patent
DSA (6) MRA (18)
TO
Patent
3
0 (37)
33
38/F
1
L
DIS
LVA
EP*1
PO
Patent
DSA (15)
TO
Patent
1
0 (34)
TO
Patent
1
0 (34)
MRA (28) 34
37/M
2
L
CLS
LVA
EP*2
PO
Patent
DSA (6) MRA (30)
35
49/F
2
R
CLS
Co
EP*2
TO
Patent
MRA (23)
TO
Patent
1
0 (31)
36
46/F
3
L
CLS
Co
EP*3
PO
Patent
DSA (9)
TO
Patent
4
2 (26)
37
46/F
1
L
DIS
Co
EP*2
TO
Patent
DSA (9)
TO
Patent
1
0 (22)
38
47/M
1
L
DIS
Co
EP*2
PO
Patent
DSA (7)
TO
Patent
3
2 (21)
TO
Patent
3
1 (20)
MRA (25)
MRA (18) 39
43/M
1
L
DIS
LVA
EP*2
PO
Patent
DSA (8)
L left; R right; Co comparable; TO total occlusion; PO partial occlusion; mRS modified Rankin Scale; AD at discharge; FU follow-up; mo months; NA not applicable a
Distance between the VADA and the PICA. ‘‘DIS’’ indicates that the VAD was derived at a distance from the PICA, and ‘‘CLS’’ indicates that the VAD was derived close to the PICA
b
‘‘MRA’’ indicates contrast enhanced magnetic resonance angiography
c
Accompanying ICA dissection was treated during a second session
which resulted in an irritating cough due to the reflux of liquids. In above-mentioned two cases, the PICAs were quite close to the dissecting aneurysms. In case 9, a newly derived right-sided facial numbness caused by brain stem infarction was detected one month after the treatment, which may be related to the delayed occlusion of the PICA confirmed by DSA.
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Angiographic Results In the trapping group, the immediate total occlusion rate was 80 % (16/20) (Table 1), which improved to 88.9 % (16/18) at the angiographic follow-ups at 2 to 109 months postoperatively (45 months on average). Two VADAs, which failed to be totally occluded, required a second
Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ?
Fig. 1 Case 10. A Left VA angiography detected a pearl-and-string sign distal to the PICA origin with a local artery vasospasm. B The VADA was not completely trapped by the platinum coils (Microplex 5/20, 3/10, 3/8,3/8, 2/8, 2/6, 2/3), and the proximal VA was dilated using a balloon (AQUA 2.5/20 4 atm). C The follow-up angiography
at 2 months revealed the incomplete occlusion of the VADA. D Total occlusion was obtained in the retreatment (Microplex 2/2, 2/2). E Recanalization was detected at further angiographic follow-ups. The patient refused further treatment and died 1 month later
Table 3 Procedure and non procedure related morbidity/mortality in this case series No.
H&H Grade
VADA to PICAa
strategy
Morbidity/ mortality
procedurerelated
Clinical symptoms
CT/MR
DSA
8
3
CLS
Internal trapping
Permanent morbidity
Yes
Wallenberg syndrome
Acute infarction at PICA territory
Immediate PICA occlusion
9
1
DIS
Internal trapping
Permanent morbidity
Yes
Right-sided facial numbness
Brain stem infarction
Delayed PICA occlusion
10
3
CLS
Internal trapping
Mortality
Yes
Sudden onset of headache and unconsciousness
NA
Recanalization of the VADAb
11
2
CLS
Internal trapping
Permanent morbidity
Yes
Irritating cough due to the reflux of liquids
Brain stem infarction
PICA is patent
31
4
DIS
SAC
Mortality
No
Deteriorating neurological condition
Diffuse infarction of the right hemisphere
Severe vasospasm
CT computed tomography; MR magnetic resonance image; NA not applicable a
Distance between the VADA and the PICA. ‘‘DIS’’ indicates that the VAD was derived at a distance from the PICA, and ‘‘CLS’’ indicates that the VAD was derived close to the PICA
b
This case is illustrated in Fig. 1
endovascular procedure. Recanalization was detected in one of them upon further angiographic follow-ups (Fig. 2). Angiographic occlusion of the PICA was revealed in 3 cases (16.7 %), one of which was related to newly derived neurological deficits (case 8). These 5 VADAs were all quite close to the PICA. In the stenting group, the immediate total occlusion rate was 47.4 % (9/19) (Table 2), which improved to 100 % (18/18) at the angiographic follow-ups at 8 to 91 months postoperatively (39 months on average). The PICAs remained patent in all of the cases. The total occlusion of the VADAs were more frequently obtained in the trapping group (p \ 0.05) immediately after the treatment and was comparable between the two groups (p [ 0.05) in the long-term follow-up.
Clinical Follow-ups Thirty-eight patients were clinically followed-up from 3 to 156 months. Twenty patients in the trapping group were clinically followed-up for 75 months on average, and the mRS score was 0 in 7 cases, 1 in 7 cases, 2 in 3 cases, 3 in 2 cases, and 6 in 1 case. One patient (case 9) suffered newly derived right-sided facial numbness. One patient (case 10, illustrated in Fig. 2) died 1 month after the recanalization of the lesion. Eighteen patients in the stenting group were clinically followed-up for 69 months on average, and the mRS score was 0 in 14 cases, 1 in 2 cases, and 2 in 2 cases. No newly derived neurological deficits were detected. Favorable outcomes (mRS scores of 0 and 1) were obtained in 70 % of the cases in the trapping group and in
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Y.-B. Fang et al.: Ruptured Vertebral Artery Dissecting Aneurysms: Stenting or Trapping ?
Fig. 2 Case 23 A The right vertebral angiography at admission showed a supra-PICA VADA, with the PICA located at the edge of the lesion. B The immediate angiographic result was incomplete occlusion of the VADA. C The plain radiography in the lateral view reveals the positions of the stent and coils. D Total occlusion was
detected at the 6-month follow-up. E The angiographic follow-up at 66 months showed no signs of the lesion. F A healing line was detected between the stent and the blood flow on the plain radiography, which demonstrated the cure of the lesion
88.9 % of the cases in the stenting group; there was no statistically significant difference (p [ 0.05).
techniques based on stents for VADAs have increasingly emerged as a promising alternative to deconstructive techniques [5–7]. In this context, whether it is appropriate for the parent artery to be sacrificed as a first choice and when to occlude a vessel are questions that need to be answered. Intradual VADAs are usually classified into the following 4 types according to the location of the aneurysmal dilation to the PICA: the supra-PICA type, PICA-involved type, infra-PICA type, and non-PICA type [9]. The supraPICA type is the most common subgroup, comprising 56 % of all VADAs [9]. The PICA-involved type is primarily contraindicated for internal trapping, and the infraand non-PICA types are relatively rare. Therefore, we selected the supra-PICA VADAs to compare the efficacy of the two different treatment strategies. Although internal trapping has been widely used and is thought to be effective in the treatment of ruptured VADAs [3, 17–19], immediate total occlusion is not always possible, and early rebleeding is not uncommon [21–23]. In our series, 20 % of the cases in the trapping group failed to be
Discussion Intracranial spontaneous vertebral artery dissecting aneurysms are increasingly diagnosed as the cause of SAH, particularly in young to middle-aged adults [9, 10]. It is believed that a cerebral dissecting aneurysm is formed by the sudden widespread disruption of the internal elastic lamina [11, 12], which results in a high risk of rebleeding in the acute stage [3, 9, 13]. Surgical trapping may be the most reliable method to prevent rerupture and was widely used before endovascular treatment was available [14, 15]. However, this treatment is quite invasive, may precipitate the Wallenberg syndrome or other disastrous events [9, 16], and has been replaced gradually by internal trapping [3, 17–19]. Moreover, there are still some limitations for such deconstructive approaches. With the continued advances in stent technology [20], reconstructive
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immediately totally occluded, and the proportion decreased to 11.1 % (2/18) at the follow-ups, which is comparable to the published results [2, 3]. One patient suffered recanalization after a retreatment and had to forego further treatment for financial reasons. The patient died 1 month later after the sudden onset of a headache, which may have been caused by rebleeding. The actual reported risk of rebleeding after internal trapping reaches to 8.3 % in VADAs [2]. Despite a lower immediate total occlusion rate, progressive occlusion was detected in all of the cases in the stenting group without immediate total occlusion. This progressive occlusion may result from the flow diversion and scaffolding effects of the stents. Similar results also have been reported in aneurysms in other locations [24, 25]. Considering that the risk of rebleeding for untreated ruptured VADAs can reach 70 %, our results showed that internal trapping and SAC were both effective treatments for these lesions [9]. Ischemic complications continue to be important causes of disability, which most frequently results from the compromised blood flow in the PICA. The total incidence of symptomatic ischemic events in our series was 10.3 % (4/39) and occurred primarily in the trapping group (3/4). One of the ischemic events was not related to the PICA, and it may have been caused by the occlusion of the perforators supplying the brainstem after the VA occlusion. Even when performed on the nondominant side or following a negative result on a balloon occlusion test (BOT), internal trapping may still cause ischemic complications [1]. We did not routinely perform DW-MRI scanning after the operations in this series, and the risk of a subsequent silent infarction therefore may be underestimated. In the trapping group, an incomplete obliteration of the VADA or the occlusion of the PICA was detected in the VADAs closest to the origin of the PICA. Furthermore, early ischemic complications also occurred primarily in this subgroup (2/2). The primary cause of complications may be that the length of the VA that requires occlusion is not always controllable and often is longer than anticipated when performing internal trapping. For the cases harboring VADAs close to the origin of the PICA, the risk of unwanted coil herniation into the PICA or coil packing below the PICA is always present. Moreover, total occlusion is not always possible when the PICA needs to be protected. The procedure-related complications appear to be increased in this subgroup (Table 3). When PICA was close to the dissecting aneurysms, we attempted to use a stent or microwire to protect the PICA when trapping the VADAs. This technique has been reported to be feasible and efficacious in small case series
[26, 27], but we prefer to protect both the VA and the PICA, with a similar risk of antiplatelet therapy. In contrast, when the VADAs close to the PICA are treated using SAC, the only difference may be the increased potential to cover the origin of the PICA by the stent struts, which has proven to be safe in most cases [28, 29]. In our stenting group, the orifice of the PICA was covered in 15 cases by 1 to 3 (overlapping) stent(s), and there were no perforator-related ischemic complications. The only lethal complication in the stenting group was a severe vasospasm, as confirmed by a DSA in case 31, which resulted in a diffuse infarction of the right hemisphere and the death of the patient. The primary limitation of using SAC to treat ruptured aneurysms is the increased risk of hemorrhagic complications because of peri-operative antiplatelet medication. In our series, loading doses of dual antiplatelet drugs were administered shortly before stenting in all of the cases, and no rebleeding was detected. Administering loading doses of antiplatelet drugs has proven to be essential and safe according to our preliminary published results on the application of stents in treating ruptured VADAs [8]. Because of the high risk of intracerebral hematomas, SAC was not the first choice for the cases requiring external ventricle drainage.
Limitations This series has some limitations, including its retrospective design, patient selection bias, and limited cases in a single institution.
Conclusions Our preliminary results showed that internal trapping and stent-assisted coiling are both technically feasible for treating ruptured supra-PICA VADAs. Although ischemic complications occurred more frequently in the trapping group, the differences were not statistically significant. When the VADAs are close to the PICA, it is preferable to treat the lesions using SAC. Acknowledgments The study was supported by the National Natural Science Foundation of China (No. 81301004, 81271271), the Foundation of Shanghai Public Health Bureau (No. 20114232), and the Shanghai Science and Technology Development Funds (No. 13140903201). Conflict of interest Yi-Bin Fang, Kai-Jun Zhao, Yi-Na Wu, Yu Zhou, Qiang Li, Peng-Fei Yang, Qing-Hai Huang, Wen-Yuan Zhao, Yi Xu, and Jian-Min Liu have no conflicts of interest.
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