Treatment of Ruptured Anterior Choroidal Artery Aneurysms by Acute Coiling Followed by Flow Diversion.

BACKGROUND: Flow-diverter treatments are successful endovascular treatments in protecting important perforating branches during aneurysm treatments. Because these treatments are performed under antiplatelet therapy, acute flow-diverter treatments in ruptured aneurysms are still controversial. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured anterior choroidal artery aneurysm treatment. As a single-center retrospective case series study, this study reported the clinical and angiographic results of staged endovascular treatment in patients with a ruptured anterior choroidal aneurysm. METHODS: This is a single-center retrospective case series study between March 2011 and May 2021. Patients with ruptured anterior choroidal aneurysm received flow-diverter therapy in a different session after acute coiling. Patients treated with primary coiling or only flow diversion were excluded. Preoperative demographic and presenting symptoms, aneurysm morphology, perioperative and postoperative complications, and long-term clinical and angiographic outcome as measured using the modified Rankin Scale and O'Kelly Morata Grading scale and also Raymond-Roy occlusion classification respectively. RESULTS: Sixteen patients underwent coiling in the acute phase to undergo flow diversion later. The mean maximum aneurysm diameter is 5.44 ± 3.39 mm. All patients had a subarachnoid hemorrhage and were treated acutely between days 0 and 3 of acute bleeding. The mean age at the presentation was 54.12 ± 12 years (32-73 years). Two patients (12.5%) had minor ischemic complications, which are seen on magnetic resonance angiography as clinically silent infarcts, after the procedure. One patient (6.2%) had a technical complication with the flow-diverter shortening and deployed a second flow diverter telescopically. No mortality or permanent morbidity was reported. The mean interval time between the 2 treatments was 24.06 ± 11.83 days. All patients were followed up with digital subtraction angiography; 14/16 patients (87.5%) had aneurysms that were completely occluded and 2/16 (12.5%) showed near-complete occlusion. Mean follow-up was 16.62 ± 3.22 months; all patients had modified Rankin Scale scores ≤2; 14/16 (87.5%) had a total occlusion 14/16 (87.5%) had near-complete occlusion. None of the patients had retreatment or rebleeding. CONCLUSIONS: Staged treatment of ruptured anterior choroidal artery aneurysms with acute coiling and flow-diverter treatment after recovery from subarachnoid hemorrhage is safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. Staged treatment should be considered a valid option in patients with challenging ruptured anterior choroidal aneurysms.

Craniovertebral junction aneurysms.

OBJECTIVE: The course of the vertebral artery and its relationship to the C0-1-2 structures render it particularly vulnerable to mechanical trauma. In the present study, we investigated the course of vertebral arteries along the craniovertebral junction (CJ) to cast light on the biomechanical aspects of aneurysm formation, focusing mainly on the relation of the vertebral artery injuries to the CJ bony landmarks. Herein, we report our experience with fourteen cases of craniovertebral junction vertebral artery (CJVA) aneurysms and their presentations, management, and outcomes. MATERIALS AND METHODS: We extracted from 83 vertebral artery aneurysms only those 14 cases whose aneurysms were located at the C0-1-2. We reviewed all medical records, including operative reports and radiologic images. We divided the CJVA into 5 segments and then carefully reviewed the cases, largely focusing on the CJVA segments involved in the aneurysm. Angiographic outcomes were determined by angiography, which was scheduled at 3-6 months, 1, 2.5, and 5 years postoperatively. RESULTS: A total of 14 patients with CJVA aneurysms were included in the present study. 35.7 % had cerebrovascular risk factors, while 23.5 % had other predisposing factors such as an AVM, an AVF, or a foramen magnum tumor. Predisposing factors in the form of neck trauma, both direct and indirect, were identified in 50 % of cases. The segmental distribution of aneurysms was as follows: three (21.4 %) at CJV 1, one (7.1 %) at CJV 2, four (28.6 %) at CJV 3, two (14.3 %) at CJV 4, and four (28.6 %) isolated to the CJV 5 segment. Of the 6 indirect traumatic aneurysms, 1 (16.7 %) was located at CJV 1, 4 (66.7 %) were located at CJV 3 and 1 (16.7 %) was located at CJV 5. The 1/1 direct traumatic aneurysm (100 %) from the penetrating injury was located at CJV 1. 100 % of cases with cerebrovascular risk factors, the affected vessels were on the dominant side. 42.9 % of cases presented symptoms of a vertebrobasilar stroke. All 14 aneurysms were managed only endovascularly. 85.8 % of patients we implemented flow diverters only. 57.1 % of follow-up cases were completely occluded angiographically, and 42.9 % of cases were near-completely or incompletely occluded at 1, 2.5, and 5-year follow-ups. CONCLUSIONS: The current article is the first report of a series of vertebral artery aneurysms located in CJ. Herein, the association of vertebral artery aneurysm, hemodynamics, and trauma is well established. We clarified all segments of the CJVA and showed that the segmental distribution of CJVA aneurysms significantly differs between traumatic and spontaneous cases. We showed that treatment with flow diverters should be the mainstay of CJVA aneurysm treatment.