Panacea or problem: flow diverters in the treatment of symptomatic large or giant fusiform vertebrobasilar aneurysms

Clinical article

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Object

The use of flow-diverting stents has gained momentum as a curative approach in the treatment of complex proximal anterior circulation intracranial aneurysms. There have been some reported attempts of treating formidable lesions in the posterior circulation. Posterior circulation giant fusiform aneurysms have a particularly aggressive natural history. To date, no one approach has been shown to be comprehensively effective or low risk. The authors report the initial results, including the significant morbidity and mortality encountered, with flow diversion in the treatment of large or giant fusiform vertebrobasilar aneurysms at Millard Fillmore Gates Circle Hospital.

Methods

The authors retrospectively reviewed their prospectively collected endovascular database to identify patients with intracranial aneurysms who underwent treatment with flow-diverting devices and determined that 7 patients had presented with symptomatic large or giant fusiform vertebrobasilar aneurysms. The outcomes of these patients, based on the modified Rankin Scale (mRS), were tabulated, as were the complications experienced.

Results

Among the 7 patients, Pipeline devices were placed in 6 patients and Silk devices in 1 patient. At the last follow-up evaluation, 4 patients had died (mRS score of 6), all of whom were treated with the Pipeline device. The other 3 patients had mRS scores of 5 (severe disability), 1, and 0. The deaths included posttreatment aneurysm ruptures in 2 patients and lack of improvement in neurological status related to presenting brainstem infarcts and subsequent withdrawal of care in the other 2 patients.

Conclusions

Whether flow diversion will be an effective strategy for treatment of large or giant fusiform vertebrobasilar aneurysms remains to be seen. The authors' initial experience suggests substantial morbidity and mortality associated with the treatment and with the natural history. As outcomes data slowly become available for patients receiving these devices for fusiform posterior circulation aneurysms, practitioners should use these devices judiciously.

Abbreviations used in this paper:BA = basilar artery; mRS = modified Rankin Scale; PITA = Pipeline embolization device for the Intracranial Treatment of Aneurysms; SAH = subarachnoid hemorrhage; VA = vertebral artery.

Article Information

Address correspondence to: Elad I. Levy, M.D., University at Buffalo Neurosurgery, Millard Fillmore Gates Hospital/Kaleida Health, 3 Gates Circle, Buffalo, New York 14209. email: elevy@ubns.com.

Please include this information when citing this paper: published online March 9, 2012; DOI: 10.3171/2012.2.JNS111942.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 3. A: Anteroposterior view of left VA angiogram demonstrating a vertebrobasilar fusiform aneurysm. B: Anteroposterior and lateral views of a left VA angiogram revealing a vertebrobasilar fusiform aneurysm after placement of the first Pipeline device. C: Anteroposterior and lateral views after the second Pipeline deployment. D: Anteroposterior and lateral views of the right VA occluded by a balloon during the balloon test occlusion procedure. E: Anteroposterior and lateral views of coil embolization of the distal right VA. F: Anteroposterior and lateral views of the final angiogram after treatment.

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    Case 2. A: Anteroposterior view of a VA angiogram showing a fusiform BA aneurysm originating from the left vertebrobasilar junction. B: Lateral views demonstrating overlapping Pipeline embolization devices within the aneurysm. C: Posttreatment anteroposterior view of the right VA injection showing coil sacrifice of the left VA and reconstruction of the BA. D: Schematic illustration of Pipeline construct through a fusiform vertebrobasilar aneurysm. The stent construct involves overlapping Pipeline stents (dotted lines) introduced from a VA, and it also involves coil occlusion of the contralateral VA. The construct is analogous to endoluminal repair technique for an abdominal aortic aneurysm, with similar concern for branches (or perforators) at the periphery of the aneurysm wall. The number of stents used may be lessened with the more recent availability of longer Pipeline devices (up to 35 mm).

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    Case 6. A: Anteroposterior view of a left VA angiogram demonstrating a large vertebrobasilar fusiform aneurysm. B: Posttreatment anteroposterior angiogram. C–F: Magnetic resonance images demonstrating numerous areas of positive diffusion-weighted imaging changes in the bilateral occipital lobes (C), bilateral cerebellum (D), large thrombosed aneurysm compressing the brainstem (E), and medial left occipital mild diffusion positivity (F). G: Quantitative MR angiography demonstrating nearly symmetrical cerebral blood flow in both posterior cerebral arteries despite the absence of flow detection in the BA, presumably due to artifact. H: Final anteroposterior angiographic view (early filling) of left VA injection. I: Final anteroposterior view (early filling) of left VA injection. LACA = left anterior cerebral artery; LMCA = left middle cerebral artery; LPCA = left posterior cerebral artery; LVA = left VA; RACA = right anterior cerebral artery; RMCA = right middle cerebral artery; RPCA = right posterior cerebral artery; RVA = right VA.

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