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

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

Jens Maybaum¹, Hans Henkes², Marta Aguilar-Pérez², Victoria Hellstern², Georg Alexander Gihr², Wolfgang Härtig³, André Reisberg⁴, Dirk Mucha⁵, Marie-Sophie Schüngel¹, Richard Brill⁶, Ulf Quäschling¹, Karl-Titus Hoffmann¹ and Stefan Schob^6*

• ¹Institute of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
• ²Neuroradiological Clinic, Katharinenhospital Stuttgart, Stuttgart, Germany
• ³Paul Flechsig Institute for Brain Research, University of Leipzig, Leipzig, Germany
• ⁴Department of Diagnostic Imaging and Interventional Radiology, Bergbau-Berufsgenossenschaft Hospital Bergmannstrost Halle, Halle, Germany
• ⁵Department of Radiology, Interventional Radiology and Neuroradiology, Heinrich-Braun-Klinikum, Zwickau, Germany
• ⁶Department of Neuroradiology, Radiology and Policlinic of Radiology, University Hospital Halle (Saale), Halle, Germany

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.

Introduction

Intracranial dissections of the vertebral artery (VA) represent rare but potentially critical cerebrovascular lesions associated with a significant variety of unspecific symptoms (1). The dissection of an intracranial VA may remain clinically silent but more frequently manifests with posterior circulation stroke, subarachnoid hemorrhage (SAH), or, less frequently, spinal ischemia (2, 3). More than 80% of patients with intracranial VA dissections of the steno-occlusive type develop posterior circulation stroke. However, the majority of those improve without the imperative for endovascular treatment (4, 5).

Ruptured dissecting aneurysms of the intracranial VA are associated with worse outcomes. Between 24 and 72 h after the segmental vascular injury, frequently indicated by a characteristic occipital and nuchal headache, severe SAH manifests in almost every case (6). Subsequently, re-hemorrhage occurs in more than 70% of patients, culminating in mortality rates of ~50% (7). As a consequence, early and sufficient therapy of ruptured dissecting aneurysms of the intracranial VA is mandatory.

Depending on the hemodynamic situation in the posterior circulation and the localization of the ruptured dissecting aneurysm, different endovascular approaches must be considered (8, 9). In case the rupture site is associated with a hypoplastic VA, segmental sacrifice, ideally sparing the posterior inferior cerebellar artery (PICA) orifice, has shown promising results (8, 10). However, segmental sacrifice and proximal VA occlusion carry significant risk for ischemia and, in some cases, re-bleeding (11).

In particular, if the ruptured dissecting aneurysm arises from a dominant VA or involves the PICA origin, a reconstructive technique is recommendable (11, 12). Reconstruction can be achieved with different approaches, for example, stent-in-stent implantation, stent-assisted coiling, and flow-diverting stents (12–16). However, related to the rarity of the condition, only retrospective reports on the different strategies exist, and the most suitable treatment remains to be determined (17).

Flow-diverting stents offer several advantages over the alternative endovascular techniques; most importantly, they allow the reconstruction of the vessel without primary catheterization of the highly fragile dissecting aneurysm, and their increased surface coverage provides a superior seal of the potentially extensive intimal tear in comparison to conventional, low-porosity laser-cut stents. However, reports on flow diversion (FD) in this specific context are lacking.

This study, therefore, aims to report our multicenter experience of FD for the reconstruction of acutely ruptured, dissecting aneurysms of the dominant intracranial VA, including clinical and procedural aspects as well as follow-up data in order to present feasibility, safety, and effectiveness of this approach.

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