Angiographic and Clinical re-sult of Endovascular Treat-ment of Isolated Dissecting

Aneurysm of the Posterior In-ferior Cerebellar Artery

Yon Kwon Ihn1, Byung-Hee Lee2 , Sang Heum Kim3

1Department of Radiology, St.Vincent’s Hospital, The Catholic University of Korea2Department of Radiology, Chungmu Hospital, Chonan, Korea

3Department of Radiology, Bundang CHA Hospital, CHA University College of medicine, Seongnam, Korea

EP - 98

Disclosure

We don’t have any significant finan-cial interest or other relationship with manufacturer of any commer-cial products or services discussed in the exhibit.

PURPOSE

Isolated dissecting aneurysm of the pos-terior inferior cerebellar artery (PICA) Rare but has a high risk of re-bleeding

Recently, endovascular treatment has been proposed as an alternative to surgery, but still they present a therapeutic challenge

To report results of various endovascular treatments in patients with isolated dissect-ing aneurysms of the PICA

METHODS

March 2005 and May 2012 11 patients (M:F=5:6) Mean age: 44.4 years (range: 15-58 years)

Clinical presentations Acute subarachnoid hemorrhage (n= 7, 64%)

▪ 6 Spontaneous, 1 Traumatic Ischemia (n=2, 18%) Severe headache (n=1, 9%) Ruptured anterior choroidal aneurysm (n=1,

9%)

METHODS

Location Anterior medullary segment (n=7, 64%)) Lateral medullary segment (n=2, 18%) Tonsillomedullary segment (n=2,18%)

Shape Saccular (n=8, 72%) Fusiform (n=2, 18%) Pearl and string (n=1, 10%)

Size Mean 4.4mm (range: 2.5-8mm)

METHODS

Angiographic evaluation Balloon occlusion test (n=5)

▪ Neurologic symptom / EEG abnormality▪ Aneurysm sac or distal PICA filling from collateral vessels

Presence of collaterals of the PICA (n=6)▪ PICA-PICA ▪ Ipsilateral SCA/AICA – PICA▪ Ipsilateral VA – PICA▪ Contralateral VA –PICA

METHODS

Endovascular treatment Coiling of aneurysmal sac with/without assisted balloon

(n=4) Coiling of aneurysmal sac with assisted stent ( n=2)

Graft stent insertion (n=3)▪ High risk of re-rupture during super-selection of

aneurysm sac▪ Acute angle▪ Severe stenosis just proximal to aneurysmal sac

▪ Little difference of proximal and distal diameter of VA

Occlusion of vertebral artery by using coils (n=2)

METHODS

Medication Preprocedural & during procedure

▪ Heparinized flushing system without systemic hep-arinization

Post-procedure ▪ Low molecular weight heparin for 3 days in all patients▪ Clopidogrel loading (300mg) just after procedure and

daily clopidogrel 75mg , aspirin 100mg for 3 months▪ Graft stent cases (n=3)

METHODS

Angiographic follow up Around 10 days after procedure 2-4 months & 12 months after procedure Annual angiographic FU

RESULTS - Immediate

Technical success rate - 100% Total occlusion (n=10) Near-total occlusion (n=1)

PICA flow well preserved (n=9) sluggish PICA flow (n=2)

MR or DWI follow up No infarction (n=4) PICA territory embolic infarct (n=1)

Characteristics of 11 patients with isolated dissecting PICA aneurysm

Case

No

Patient

Sex/age

(yr)

Side Site Signs & Symptoms CT-MRI

findings

Endovascular

Procedure

Treatment related

complication

Follow up

Angiography

(months)

1 M/35 R TM Vertigo, nausea Cerebellar infarction

VA sacrifice None 5

2 F/57 R AM Neck pain, LOC

Headache SAH Graft stent insertion None 4

3 M/15 L AM LOC, Headache SAH, IVH Graft stent insertion None 45

4 F/50 L AM Neck pain, Headache Incidental aneurysm

BAC Coil protrusion

Thrombus fomtation 34

5 M/34 L LM Severe headache

Transient LOC SAH BAC

Coil protrusion Thrombus fomtation

3

6 F/58 L AM Severe occipital

headache SAH Graft stent insertion None 32

7 F/56 L AM Headache,

Heaviness of occipital region

Incidental aneurysm

BAC None 12

8 M/39 R LM Ataxia, dizziness,

Wallenberg’s syndrome

Lateral medullary infarction

BAC None 15

9 F/45 R AM Occipital headache,

transient LOC SAH VA sacrifice None 12

10 M/50 L TM Severe headache Transient LOC

SAH SAC None 28

11 F/49 L AM LOC, Headache SAH SAC None 3

Note.- M indicates male; F, female; R, right; L, left; AM, anteromedullary segment; LM, lateral medullary segment, TM, tonsilomedullary segment; VA, vertebral artery; LOC, loss of consciousness; SAH, subarachnoid hemorrhage; IVH, intraventricular hemorrhage; BAC, balloon assisted coil embolization; SAC , stent assisted coil embolization

RESULTS - Immediate

Periprocedural complication Acute thrombosis (n=2)

▪ Complete resolution with IA infusion of Reo-pro®

▪ No neurologic complication

Subacute embolic infarction (n=1) resulting in minor stroke ▪ Delayed anticoagulation medication▪ Full recovery (mRS 0) at 4 months

RESULTS - Follow up

Angiographic follow up (n=11) mean: 18.0 months (range: 4-45Mo) No recanalization or regrowth of aneurysm Well preserved PICA flow by collaterals in all

patients

Clinical follow up (n=11) mean: 40.3 months (range: 6-60 Mo) No newly developed neurologic event or re-

bleeding mRS 0 in all patients

Aneurysmal sac coiling – balloon as-sisted

39/M, severe-headache

Occlusion test

15 Mo

10 days

Graft stent15/MDrowsy mentality after traumaSAH, HH3

7 days Occlusion test

6 days 45 Mo

initial

Vertebral artery oc-clusion

Occlusion test

4 Mo, mRS 0Delayed anticoagula-tion

45/FSevere headache with N/VSAH, HH2

CONCLUSION

Various endovascular approach tailored to the specific aneurysm in the specific patient seems even more appropriate than for aneurysms at other location aneurysm under careful angiographic evaluation.

Further studies are necessary to make a strategy for endovascular treatment of the PICA dissecting aneurysms.