Maus Volker, Mpotsaris Anastasios, Dorn Franziska, Möhlenbruch Markus, Borggrefe Jan, Stavrinou Pantelis, Abdullayev Nuran, Barnikol Utako Birgit, Liebig Thomas, Kabbasch Christoph
Department of Neuroradiology, University Hospital Cologne, Cologne, Germany.
Department of Neuroradiology, University Hospital Aachen, Aachen, Germany.
World Neurosurg. 2018 Mar;111:e424-e433. doi: 10.1016/j.wneu.2017.12.095. Epub 2017 Dec 23.
Acute dissecting aneurysms of the posterior circulation are a rare cause of subarachnoid hemorrhage. Established endovascular treatment options include parent artery occlusion and stent-assisted coiling, but appear to be associated with an increased risk of ischemic stroke. Vessel reconstruction with flow diverters is an alternative treatment option; however, its safety and efficacy in the acute stage remains unclear.
This is a multicentric retrospective analysis of 15 consecutive acutely ruptured dissecting posterior circulation aneurysms treated with flow diverters. The primary end point was favorable aneurysm occlusion, defined as OKM C1-3 and D (O'Kelly Marotta scale). Secondary end points were procedure-related complications and clinical outcome.
Nine of 15 aneurysms (60%) arose from the intradural portion of the vertebral artery, 3 were located on the posterior inferior cerebellar artery and 1 each on the anterior inferior cerebellar artery, posterior cerebral artery, and basilar artery. Flow diverter placement was technically successful in 14 of 15 cases (93%). After endovascular treatment, none of the ruptured aneurysms rebled. Median clinical follow-up was 217 days and median angiographic follow-up was 203 days. Favorable occlusion was observed in 7 of 14 aneurysms (50%) directly after flow diverter placement; of those, 5 were completely occluded (36%). Seven patients (47%) with poor-grade subarachnoid hemorrhage died in the acute phase. Favorable clinical outcome (modified Rankin scale ≤2) was observed in 4 of 15 patients (27%) and a moderate outcome (modified Rankin scale 3/4) was observed in 5 of 15 patients (33%). All aneurysms showed complete occlusion at follow-up.
Flow diverters might be a feasible, alternative treatment option for acutely ruptured dissecting posterior circulation aneurysms and may effectively prevent rebleeding. Larger cohort studies are required to validate these results.
后循环急性夹层动脉瘤是蛛网膜下腔出血的罕见病因。既定的血管内治疗选择包括载瘤动脉闭塞和支架辅助弹簧圈栓塞，但似乎与缺血性卒中风险增加有关。使用血流导向装置进行血管重建是一种替代治疗选择；然而，其在急性期的安全性和有效性仍不明确。
这是一项多中心回顾性分析，对连续15例使用血流导向装置治疗的急性破裂后循环夹层动脉瘤进行研究。主要终点是动脉瘤的良好闭塞，定义为OKM C1 - 3级和D级（奥凯利·马罗塔分级）。次要终点是与手术相关的并发症和临床结局。
15例动脉瘤中有9例（60%）起源于椎动脉硬膜内段，3例位于小脑后下动脉，1例分别位于小脑前下动脉、大脑后动脉和基底动脉。15例中有14例（93%）血流导向装置置入在技术上成功。血管内治疗后，破裂动脉瘤均未再出血。临床随访中位数为217天，血管造影随访中位数为203天。血流导向装置置入后直接观察到14例动脉瘤中有7例（50%）实现良好闭塞；其中5例完全闭塞（36%）。7例（47%）蛛网膜下腔出血分级较差的患者在急性期死亡。15例患者中有4例（27%）获得良好临床结局（改良Rankin量表评分≤2），15例患者中有5例（33%）获得中度结局（改良Rankin量表评分3/4）。所有动脉瘤在随访时均显示完全闭塞。
血流导向装置可能是急性破裂后循环夹层动脉瘤的一种可行替代治疗选择，且可能有效预防再出血。需要更大规模的队列研究来验证这些结果。
