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Endovascular Treatment of Complex Aneurysms at the Vertebrobasilar Junction With Flow-Diverting Stents: Initial Experience

Meckel, Stephan MD*; McAuliffe, William MD; Fiorella, David MD§; Taschner, Christian A. MD*; Phatouros, Constantine MD; Phillips, Timothy John MD; Vasak, Paul; Schumacher, Martin MD*; Klisch, Joachim MD

doi: 10.1227/01.neu.0000431472.71913.07
Research-Human-Clinical Studies

BACKGROUND: Large or giant complex vertebrobasilar junction aneurysms have a dismal natural history and are often challenging to treat with standard endovascular or neurosurgical techniques.

OBJECTIVE: To report initial experience with endovascular treatment of these aneurysms using flow-diverting stents (FDS).

METHODS: Ten patients with FDS treatment of complex vertebrobasilar junction aneurysms were collected from 4 large cerebrovascular centers. Clinical/angiographic presentation and outcome were retrospectively analyzed.

RESULTS: Of 10 aneurysms, 7 presented with brainstem compression, 2 with ischemia, and 1 with subarachnoid hemorrhage, and 3 were recurrent after stent-assisted treatments. Eight were giant. Morphology was fusiform in 5, fusiform dissecting in 1, and multilobulated saccular in 4. Six were partially thrombosed. In addition to FDS (mean number of devices, 3.9; range, 1-9), contralateral vertebral artery sacrifice and adjunctive coiling were performed in 9 and 5 of the 10 patients, respectively. At follow-up, 5 of 10 were completely occluded, 4 showed minimal residual filling, and 1 was retreated with an additional FDS. Postinterventionally, worsening mass effect and ischemic complications were seen in 2 and 4 of 10, respectively. Clinical outcome was good in 6 (modified Rankin Scale score, 0-2). Four fatalities were related to sequelae of subarachnoid hemorrhage, late FDS thrombosis, progressive mass effect, and delayed intracranial hemorrhage.

CONCLUSION: FDS may be used to treat complex vertebrobasilar junction aneurysms with overall good angiographic outcome. A combined reconstructive/deconstructive approach appears useful to avoid endoleaks. FDS strategies, like other endovascular and neurosurgical approaches to these lesions, are associated with significant risk and therefore should be reserved for those cases in which alternative approaches either are deemed unsafe or are likely to be ineffective.

ABBREVIATIONS: FDS, flow-diverting stent

PED, Pipeline Embolization Device

SAH, subarachnoid hemorrhage

VA, vertebral artery

VBJ, vertebrobasilar junction

*Department of Neuroradiology, University Hospital Freiburg, Freiburg, Germany;

Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner & Royal Perth Hospitals, Perth, Australia;

§Department of Neurological Surgery, Health Sciences Center T-12080, Stony Brook University Medical Center, Stony Brook, New York;

Institute of Diagnostic und Interventional Radiology and Neuroradiology, HELIOS Klinikum Erfurt, Erfurt, Germany

Correspondence: Stephan Meckel, MD, Department of Neuroradiology, Neurocenter, University Hospital Freiburg, Breisacher Strasse 64, D-79106 Freiburg, Germany. E-mail: stephanmeckel@gmail.com

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Received November 23, 2012

Accepted May 1, 2013

Copyright © by the Congress of Neurological Surgeons