external ventricular drain placement, shunting, and decompressive craniectomy). ,, Potential risks of DAPT following SAH include an increased risk of re-rupture and bleeding complications in the event of additional surgical procedures (i.e. ,, FD stents require at least 6 months of dual-antiplatelet therapy (DAPT) to allow for endothelialization, which has limited their utility in the setting of acute hemorrhage. ,, ,, ,, ,, , However, significant debate remains in relation to their application in the setting of subarachnoid hemorrhage (SAH). ,, There is a growing body of literature highlighting the successful treatment of dolichoectasia, fusiform aneurysms, and intracranial dissections with FD. ,, In addition to providing durable long-term aneurysm occlusion, these properties also allow FDs to reconstruct the vessel anatomy, thus making them useful in addressing pathology of the vessel walls. Flow-diverting stents rely on increased metal coverage to restrict flow into the aneurysm, promote thrombosis, and provide a scaffold for endothelialization across the neck. ,, In the United States, the primary experience has been with the pipeline embolization device (PED), however, a number of additional devices have now begun to enter the market. , When occurring in the posterior circulation, these lesions may be particularly devastating due to their inclusion of brainstem perforators and the need for advanced skull base techniques to access the pathology.įlow diversion (FD) technology, initially introduced for the management of large unruptured aneurysms of the petrous to communicating segments of the internal carotid artery (ICA), has been increasingly and successfully applied to off-label indications. ,, , Thus, traditional open and endovascular techniques have relied on vessel deconstruction with or without bypass. As a result, IPs are generally not amenable to clip ligation or coil embolization, as any manipulation usually leads to disruption of the contained thrombus and potentially catastrophic bleeding. Lesions result from disruption of the vessel wall and are contained by only thin friable intima. Available from: ĭissecting intracranial pseudoaneurysms (IPs) are relatively rare lesions that are associated with a high risk of rupture and significant morbidity and mortality. Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature.
Pica artery dissection survival how to#
How to cite this URL: Scullen T, Mathkour M, Werner C, Zeoli T, Amenta PS. How to cite this article: Scullen T, Mathkour M, Werner C, Zeoli T, Amenta PS. Keywords: Endovascular surgery, flow diversion, pseudoaneurysm, subarachnoid hemorrhage We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.
The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The use of FD and DAPT in the setting of acute SAH remains controversial. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. The patient was treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes.
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