Retreatment and Outcomes of Recurrent Intracranial Vertebral Artery Dissecting Aneurysms after Stent Assisted Coiling: A Single Center Experience

<div><p>Background and purpose</p><p>The retreatment of recurrent intracranial vertebral artery dissecting aneurysms (VADAs) after stent assisted coiling (SAC) has not yet been studied. The purpose of this study was to evaluate the strategies and outcomes for retreatment of recurrent VADAs after SAC.</p><p>Methods</p><p>Between September 2009 and November 2013, six consecutive patients presenting with recurrent intracranial VADAs after SAC were enrolled in this study. They were all male with age ranging from 29 to 54 years (mean age, 46.2 years). The procedures of treatments and angiographic and clinical follow-up were reviewed retrospectively. Retreatment modalities were selected individually according to the characteristics of recurrence. The outcomes of retreatment were evaluated by angiographic and clinical follow-up.</p><p>Results</p><p>Six patients with recurrent intracranial VADAs after SAC were retreated, with second SAC in three patients, coil embolization, double overlapping stents placement and endovascular occlusion with aneurysm trapping in one patient, respectively. Immediate angiographic outcomes of retreatment were: complete occlusion in three patients, nearly complete occlusion in two patients, and contrast medium retention in dissecting aneurysm in one patient. All cases were technically successful. No complications related to endovascular procedures occurred. Angiographic follow-up was available in all five patients treated with second SAC or double overlapping stents, which was complete occlusion in four patients, obliteration of parent artery in one patient, showing no recurrence at 4–11 months (mean: 8.6 months). Clinical follow-up was performed in all six patients at 11–51 months after initial endovascular treatment and at 9–43 months after retreatment. The mRS of last clinical follow-up was excellent in five patients and mild disability in only one patient.</p><p>Conclusions</p><p>Endovascular retreatment is feasible and effective for recurrent intracranial VADAs after SAC. Individualized strategies of retreatment should be enacted according to the characteristics and reasons for the recurrence.</p></div

Retreatment with a second stent assisted coiling was performed for recurrent intracranial VADA after SAC.

<p>A 43-year old male presented with severe headache. CT scan showed subarachnoid hemorrhage and intraventricular hemorrhage (A). MR imaging showed intramural hematoma (B). Right vertebral angiograms of oblique view showed a dissecting aneurysm involving PICA (C). SAC were performed with near complete occlusion (D). Follow up angiography after eight months revealed regrowth of dissecting aneurysm on the opposite side and in a different location from the original dissecting aneurysm (black arrow) (E). Retreatment by SAC (white arrows) (F) was performed with complete occlusion (G). Follow up angiography after ten months of retreatment showed not only complete occlusion of dissecting aneurysm, but also patency of parent artery (H).</p

Retreatment with endovascular occlusion with aneurysm trapping was performed for recurrent huge intracranial VADA after multiple stents assisted coiling.

<p>A 54-year old male presented with headache and dysphagia. MR imaging showed huge onion skin-like thrombus (black arrowhead), intramural hematoma and compression to brain stem (A). Right vertebral angiograms of frontal (B) and lateral (C) view showed a dissecting aneurysm. Multiple stents assisted coiling (D) were performed with complete occlusion (E, F). Follow up angiography (G) after three months revealed regrowth of original dissecting aneurysm (black arrow). Retreatment by endovascular occlusion with aneurysm trapping (white arrow) (H) was performed. Collateral blood flow could be seen from contralateral VA (I) and left posterior communicating artery (J).</p

Demographic, angiographic and clinical characteristics on admission.

<p>IVH = intraventricular hemorrhage; SAH = subarachnoid hemorrhage; VA = vertebral artery; PICA = posterior inferior cerebellar artery; IMH = intramural hematoma; IF = Intimal flap; ME = Mass effect.</p><p>Demographic, angiographic and clinical characteristics on admission.</p

Initial endovascular treatment results and angiographic and clinical follow-up.

<p>SAC = stent assisted coiling; FU = follow up; EN = Enterprise; CO = complete occlusion; NC = nearly complete; PO = partial occlusion.</p><p>Initial endovascular treatment results and angiographic and clinical follow-up.</p

Retreatment with coil embolization was performed for recurrent intracranial VADA after SAC.

<p>A 29-year old male presented with dizziness and hemiplegia. Sagittal view of MR imaging showed intramural hematoma and compression to brain stem (A). Right vertebral angiograms showed a dissecting aneurysm involving PICA (B). SAC (C) were performed with nearly complete occlusion (D). Follow up angiography after three months revealed recanalization of the dissecting aneurysm (black arrow) (E). Retreatment was performed by coil embolization (F, G). Follow up angiography after 7 months of retreatment showed complete occlusion of right vertebral dissecting aneurysm (H).</p