Introduction: Dissecting aneurysms of the posterior circulation present a unique challenge for neurosurgeons and interventionalists: avoidance of re-bleeding while preserving the patency of the vertebral artery. The mortality rate is around 46%, often from recurrent hemorrhage, which occurs in 24% to 70% of cases. Flow diverters, such as Pipeline Endovascular Devices (PEDs) (Covidien, Irvine, CA), have emerged as a potential treatment option. We present our experience with patients treated at our institution with PED’s for dissecting distal vertebral artery (V4 segment) aneurysms.
Methods: We performed a retrospective search of our prospectively kept database between January 2014 and July 2016 to identify all patients who presented with V4 dissecting aneurysms and treated with PED. The protocol was approved by the Duke Institutional Review Board. Electronic records and images were accessed and information was gathered, including demographics, the location and morphology of the aneurysm, the clinical presentation, specific form of treatment, complications, anti-platelet medication regimen, and follow-up time.
Results: There were a total of eight patients with dissecting V4 aneurysms treated with PED during the study period. All were treated with an average of 1.25 PEDs. Follow-up angiograms were obtained in seven of the eight patients, and no residual aneurysm was seen in five patients and only minimal residual filling seen in the other two. In those that presented with neurologic deficits, there was an average improvement in Modified Rankin Scale (MRS) of 3.33 points, and all patients at follow up had an MRS of either 0 or 1.
Overall, there were no serious complications related to the procedure and no patient developed any new or worsening neurologic deficits.
Conclusions: PED is a safe and effective tool that can be used to treat dissecting aneurysms of the posterior circulation, but it does require close management of anti-platelet therapy in the setting of subarachnoid hemorrhage.
Patient Care: This research will improve patient care because it presents a novel therapeutic option for dissecting aneurysms of the distal vertebral artery, which historically have been very difficult to treat and cary high morbidity and mortality when left untreated.
Learning Objectives: By conclusion of this session, participants should be able to 1) Describe the natural history of ruptured dissecting V4 aneurysms, 2) Identify different modalities of treatment, 3) Understand the use of PED for dissecting V4 aneurysms