The Role of the Pipeline Embolization Device for the Treatment of Dissecting Intracranial Aneurysms

Abstract

SUMMARY:Intracranial dissecting aneurysms constitute rare lesions with complex management and elevated morbidity and mortality. Results of 23 patients harboring such lesions treated with the PED are reported. Standard dual antiplatelet therapy was instituted. Neurologic and angiographic assessments were obtained at 3, 6, and 12 months. Clinical presentation included SAH (52%), symptoms of mass effect (22%), ischemia (4%), and incidental finding (22%). The posterior circulation was affected in 91% of cases. Total occlusion was demonstrated in 69.5% of patients, with an increment to 87.5% considering only patients with at least 3 months of follow-up. Small aneurysms demonstrated higher rates of total occlusion (6/7) compared with large (5/7) and giant (5/9) ones. Good clinical outcome was achieved in 74% of patients. Reconstructive endovascular treatment of intracranial dissecting aneurysms with the PED provided good clinical and angiographic results with acceptable risks, representing an attractive therapeutic option for this complex disease, especially when parent vessel preservation is mandatory.ABBREVIATIONS: DSA ϭ digital subtraction angiography; GOS ϭ Glasgow Outcome Score; ICA ϭ internal carotid artery; PED ϭ Pipeline Embolization Device; PICA ϭ posterior inferior cerebellar artery; SAH ϭ subarachnoid hemorrhage D issecting aneurysms of the intracranial circulation are uncommon, accounting for 3% of all cerebral aneurysms.

Pipeline Embolization Device in Aneurysmal Subarachnoid Hemorrhage

“…34,35 The PED has been reported as a treatment alternative in acutely ruptured dissecting and blister aneurysms with good results, though the number of cases continues to be small. [2][3][4][5][6][7][8] The aneurysm occlusion is not immediate compared with coiling and surgical clipping; still, no rehemorrhages have been reported to date. Although there are minimal immediate angiographic changes, the PED may provide some immediate protection by reducing the aneurysm inflow, 36 with reconstruction of the parent vessel in the long term (Fig 1).…”

Safety of the Pipeline Embolization Device in Treatment of Posterior Circulation Aneurysms

“…Three of the 5 serious clinical complications were in patients with posterior circulation aneurysms: 2 acute cerebellar hemorrhages within 24 hours of elective basilar artery aneurysm treatment and a fatal basilar artery thrombosis after clopidogrel cessation. De Barros Faria et al 10 published a series of 23 dissecting aneurysms treated with PEDs, 11 after SAH. Twenty-one were posterior circulation lesions, with 10 in the basilar artery.…”

“…Six of the 21 (29%) patients with posterior circulation aneurysms had complete aneurysm closure. 10 A report of 3 patients treated with PEDs in the setting of recent aneurysm rupture included 1 basilar artery aneurysm. MR imaging in this patient documented a clinically silent pontine infarct.…”

“…25 Severe and bilateral disabling brain stem infarcts can be caused by occlusion of a single perforator that is invisible on angiography. 3,10,11,[20][21][22][23][24] Perforator infarction has also been reported after overlapped PED constructs in the anterior cerebral artery A1 and middle cerebral artery M1 segments. 6,26 A series of 26 flow-diverter treatments in the anterior, middle, and posterior cerebral arteries recorded ischemic events that were reversible in 7.4% and permanent in 3.7%.…”

Current Trends and Results of Endovascular Treatment of Unruptured Intracranial Aneurysms at a Single Institution in the Flow-Diverter Era

“…11 These devices are being used in greater numbers of patients with various aneurysm locations and morphologies. 6,[12][13][14] While observing the changing endovascular treatment trends is interesting, it is crucial to assess the risk-benefit ratio for treatment by flow diverters (FDs) compared with coiling. The current single-center study presents results and trends of endovascular treatment with flow diversion and coil embolization in a group of unselected patients with unruptured intracranial aneurysms in a "real world" setting.…”