Patients with subarachnoid haemorrhage from vertebrobasilar dissection: treatment with stent-in-stent technique

Bhogal, Pervinder; Brouwer, Patrick A.; Söderqvist, Åsa Kuntze; Ohlsson, Marcus; Andersson, Tommy; Holmin, Staffan; Söderman, Michael

doi:10.1007/s00234-015-1505-9

Cited by 15 publications

(11 citation statements)

References 55 publications

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“…In patients where the dissected V4 segment is rated hemodynamically indispensable, for example if the contralateraI V4 is terminating as PICA or it is significantly narrower than the affected vessel (18), reconstruction of the primary brain stem supplying V4 segment is inevitable (especially if no strong posterior communicating artery ensuring midbrain perfusion in case of vertebrobasilar occlusion is present). In scenarios of this sort, restoration can be achieved using a stent-in-stent technique, stent assisted coiling or the application of flow diverters (10, 19–22), notwithstanding that the use of the latter is most favorable, as increased endovascular surface coverage has been demonstrated to be associated with lower rates of re-bleeding and recurrence of dissecting aneurysms (20–22).…”

Section: Discussionmentioning

confidence: 99%

“…If the intimal tear primarily affects the intracranial segment or continues intra-cranially through the dural entry point and then further extends sub-adventitially, a dissecting aneurysm evolves and may rupture primarily or secondarily, thus leading to subarachnoid hemorrhage (SAH) (9). Mortality in these patients can be dramatically high, with rates up to 83% (10). Also, early rebleeding has been reported to occur in 9 of 10 patients within 24 h after the initial hemorrhagic event (11).…”

Section: Introductionmentioning

confidence: 99%

“…Unfortunately, this approach carries a significant risk of ischemic stroke related to perforators of the occluded segment and to hemodynamic changes in the dependent PICA territory (14, 18). Therefore, endovascular reconstruction of dissected vertebral arteries has been performed more recently, using a stent-in-stent technique, stent-assisted coiling or employing flow diverting stents with the aim to prevent ischemic sequelae whilst restoring original hemodynamics (10, 19–22). As a limitation, all of the reconstructive techniques require a relevant period of dual antiplatelet therapy in the setting of SAH, which may jeopardize further neurosurgical interventions, such as external ventricular drainage or craniectomy.…”

Section: Introductionmentioning

confidence: 99%

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Segment Occlusion vs. Reconstruction—A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms

et al. 2019

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Objective: Ruptured dissecting aneurysms of the intracranial vertebral arteries exhibit an extraordinarily high risk for morbidity and mortality and are prone to re-rupture. Therefore, early treatment is mandatory to induce stagnation of the critical dynamic mural process. Appropriate endovascular approaches are segment sacrifice and reconstruction, however, both carry specific risks and benefits. To date most studies discuss only one of these approaches and focus on one specific device or technique. Therefore, our study aimed to present our experiences with both techniques, providing a considered approach on when to perform endovascular reconstruction or sacrifice.Materials and Methods: We retrospectively reviewed patients with subarachnoid hemorrhage in our database, suffering from dissecting aneurysms of the intradural vertebral arteries and treated endovascularly in the acute setting. A total of 16 cases were included. Clinical history, radiologic findings and outcomes were analyzed.Results: In 7 patients a reconstructive approach was chosen with 4 of them receiving stent-assisted coiling as primary strategy. One of the 7 patients suffered early re-bleeding due to progression of the dissection and therefore treatment was augmented with implantation of 2 flow diverters. The remaining 2 patients were primarily treated with flow diverters in telescoping technique. In 9 patients a deconstructive approach was followed: 6 patients were treated with proximal coil-occlusion of the V4 segment, 3 patients received distal coiling of the V4 segment. Two patients died (GOS 1) in the subacute stage due to sequelae of recurrent episodes of raised intracranial pressure and parenchymal hemorrhage. Two patients kept severe disability (GOS 3), six patients had moderate disability (GOS 4) and seven patients showed full recovery (GOS 5). None of the patients suffered from a procedural or postprocedural ischemic stroke.Conclusions: In patients with good collateral vascularization, proximal, or distal partial segment sacrifice via with endovascular coil occlusion seems to yield the best risk-benefit ratio for treatment of ruptured dissecting V4 aneurysms, especially since no continued anticoagulation is required and possibly essential surgery remains feasible in this scenario. If possible, PICA occlusion should be avoided—although even proximal PICA occlusion can become necessary, when weighing against the risk of an otherwise untreated ruptured V4 dissecting aneurysm. Contrarily, if the dominant V4 segment is affected, the hemodynamic asymmetry prohibits occlusion and necessitates reconstruction of the respective segment. For this, implants with high metal coverage treating the entire affected segment appear to be the most promising approach.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Segment Occlusion vs. Reconstruction—A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms

et al. 2019

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“…Ruptured intracranial vertebral artery dissection (VAD) is one of the causes of non-traumatic subarachnoid hemorrhage (SAH) [1–4]. Because rebleeding from VAD may occur at an early stage [1], urgent intervention will be considered [2].…”

Section: Introductionmentioning

confidence: 99%

“…Moreover, PAO has a risk of postoperative medullary infarction, which results from occlusion of perforators branching from the vertebral artery [3]. With recent improvement of intracranial stents, reconstructive therapies are increasingly emerging [4–6]. Multiple overlapping stent-assisted coiling is an adjunctive technique in treatment of complex cerebral aneurysms [7].…”

Section: Introductionmentioning

confidence: 99%

Overlapping stent-assisted coil embolization for a ruptured intracranial vertebral artery dissection

Asai

Nakamura

Nishida

et al. 2017

Journal of Surgical Case Reports

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Ruptured intracranial vertebral artery dissection is a cause of non-traumatic subarachnoid hemorrhage. Urgent intervention should be considered to prevent fatal rebleeding. Endovascular parent artery occlusion, which is the initial treatment of choice, is not suitable for patients with a hypoplastic or occlusive contralateral vertebral artery. We report a case of ruptured vertebral artery dissection, which was successfully treated with double overlapping stent-assisted coiling.

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Intracranial Dissection

Bhogal¹,

Pérez²,

Bäzner³

et al. 2017

Textbook of Catheter-Based Cardiovascular Interventions

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Patients with subarachnoid haemorrhage from vertebrobasilar dissection: treatment with stent-in-stent technique

Abstract: The stent-in-stent technique represents a viable reconstructive endovascular surgical technique with a low risk of intra-procedural complication and post-operative repeat haemorrhage.

Cited by 15 publications

References 55 publications

Segment Occlusion vs. Reconstruction—A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms

Segment Occlusion vs. Reconstruction—A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms

Overlapping stent-assisted coil embolization for a ruptured intracranial vertebral artery dissection

Intracranial Dissection

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